COMMED T-02 (2nd Edition)

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Community Medicine
2nd Term
Card - 07: Basic concept on Behavior Science
Item 01: Definitions, concept & component behavioral science. Definition of

anthropology, psychology & sociology. Society & community. Family: definition,
types limitation & functions. Culture. Social factors affecting health
Behavioral Science - it is the branch of science which deals with human behavior. There are 3
important components of behavioral science named -
1. Medical Anthropology - is the subject which deals all aspects of human being from its
origin of a species to its modern position. It has many sub branches, one of which is
medical anthropology. Medical Anthropology deals with that part of anthropology which
is related to medical science, mainly structural and functional aspect of man, grossly
Anatomy and Physiology.
2. Sociology - is the subject which deals human being as a social animal
3. Psychology - is the subject which deals mental aspect of human being. It is also called
study of human behavior. It has many sub branches like child psychology, adult
Psychology, social psychology, psychiatry etc.
Shahriar Hossain Rudro (JRRMC/26th/58)

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Family - family is a biological related group of people living together in a house and eating from
a common kitchen. There are 3 main types of family -
1. Nuclear Family - The nuclear or elementary family consists of a married couple and their
children.
➢ Merits - husband-wife relationship is likely to be more intimate in the nuclear
family than a joint family
➢ Demerits - absence of grandparents, uncles, aunts and near relatives places a
greater burden on the nuclear family in terms of responsibilities for child
bearing. It is also true in case of illness of any member of the family
2. Joint Family - the joint extended family consists of more than one married couple and
their children
3. Three-generation Family - The three-generation family consists of a grandparent’s
parents and their children that is there are represent its of three generation

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Item 02: Behavior: definition, types & determinants. Behavioral patterns & it’s
importance. Personality: definitions, determinants, types. Psychosexual
Development of personality. Defense Mechanism
Behavior - it is the observable expression of an organism to any internal or external stimuli. The
observable expression is made by voluntary movements of the body or its part generally
according to motives and decision. Behavior can be classified in many ways like the following -
• Overt Behavior- the behavior and individual generally shows to a particular stimulus is
called overt behavior e.g. smiling after listening of a joke
• Covered Behavior - the hidden behavior an individual only shows in special situation to a
particular stimulus is called covered behavior e.g. burst into fire instead of smiling after
listening of the same joke
• Health-illness & Treatment Behavior - it is of 2 types
i. Compliance Behavior - is the result of motives that moves toward a desired
action e.g. brushing tooth, taking nutritious food, accepting immunization etc.
ii. Avoidance Behavior - is the result of motives that moves away from disliked
situation e.g. quitting smoking, avoiding fast food etc.
• Individual Behavior
• Group Behavior etc.
Behavioral Patterns - there are 2 main behavioral patterns

1. Type A Behavioral Pattern - is positively associated with her diseases. It consists of
aggressive behavior. The person always fights for the best and takes risk for that. He/she
believes in ‘no risk no gain’
2. Type B Behavioral Patterns
Personality - the consistent behavioral pattern of a person in his personality. It implies some
physical and mental traits, which are characteristics of the person.
• Types - Carl Jung (Swiss psychiatrist) divided personality into two types
➢ Extrovert - A person who is dashing, practical, active, showing of and easily mixes
with people is called extrovert
➢ Introvert - A person who is reserved shy and generally keeps to himself is called
introvert

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• Elements/Components - important elements and components of personality are

physical, emotional, intelligence and behavioral. Physical component includes height,
weight, color, facial expression, physical health etc.
Emotional component includes love, jealous, fear, anger, guilt, worries etc.
Intelligence may be dull or bright.
Behavioral component includes affectionate, gentle, kind etc.
• Personality Traits - human personality is a bundle of traits. Important personality traits

are kindliness, consciousness, thoroughness, patience, tolerance, preservance, honesty,
reality, reliability, loyalty, good manner, sense of humor, tactfulness, willing to help
others, cheerfulness, dignity, courage

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Item 03: Intelligence: definition & level. IQ. Mental Retardation. Autism
Intelligence - it is the ability of an individual to see meaningful relationships between different

things. Includes perceiving, knowing, reasoning and remembering.
Intelligence Quotient (IQ) - IQ is the measurement of the quality and potential of Intelligence.
The higher the IQ, the more brilliant the man is. IQ test is done by considering his actual age
and levels of performance in a test for mental age. IQ is calculated by dividing the mental age
by chronic chronological age and multiplying by 100.
𝑀𝑒𝑛𝑡𝑎𝑙 𝐴𝑔𝑒
𝐼𝑄 = × 100
𝐶ℎ𝑟𝑜𝑛𝑜𝑙𝑜𝑔𝑖𝑐𝑎𝑙 𝐴𝑔𝑒
• Important levels of IQ - normal IQ is (100 ± 10); above this level is called superior and
then genius (140+) and IQ below 25 and 25 to 50 is called idiot and imbecile respectively
Levels of Intelligence IQ Range

Idiot 0 to 24
Imbecile 25 to 49
Moron 50 to 69
Borderline 70 to 79
Low Normal 80 to 89
Normal 90 to 109
Superior 110 to 119
Very Superior 120 to 139
Near Superior 140 & over

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Item 04: Learning: definition, types, methods, principles. Memory & forgetting.
Concept of perception, emotions & motivation. Learning of a new thing.
Knowledge, attitude & practice (KAP)
Learning - is a process resulting in relatively permanent change in behavior of the individual by

the way of thinking, feeling and doing that occurs as a result of practice or experience. It means
acquiring something new - new knowledge, new techniques, new skills etc. Learning largely
depends upon intelligence of learner. It also depends upon motivation and motivation depends
upon felt need of the learner.
• Types of learning (KAP or KAPS) - 3 types

➢ Cognitive learning (knowledge)
➢ Effective learning (attitude)
➢ Psychomotor learning (practice or skill)
In practice, these are expressed as KAP (Knowledge → Attitude → Practice)

Or
KAPS (Knowledge → Attitude → Practice → Skill)
• Conditions Affecting Learning - IQ, age, learning situation, motivation, physical health,
mental health. Ability of learning is peak age around 22 to 25 years and there is sharp
decline in after the age of 30. Learning situation includes institution, classroom,
teachers, textbook, audio visual AIDS etc. Learning requires some basic ingredients -
stimulus, a trial response and a rewarding consequence of trial response. Learning
environment encourages people to be active in learning process.

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Item 05: Importance of human interpersonal relationship. IPC. Doctor-Patient

relationship & relationship of doctor with other health personnel. BCC
Doctor-patient Relationship - it is an important form of interpersonal communication in which

complex social factors are implicated. A successful doctor is one who knows how well to
communicate with his or her patient. Presently, doctor-patient relationship is becoming worse.
We can improve this by communicating them by 3 levels of communication -
1. Communication on Emotional Plane - giving sympathetic ear to the complaints made by
the patients and their relatives. It also helps in quick rapport building
2. Communication on Cultural Plane - be aware of the general concepts of culture and
social organization of the community so as to be flexible in dealing with patients
3. Communication on Intellectual Plane - there may exist an enormous social distance
between doctor and patient party. A successful doctor is one who reduces the distance
anyway and able to communicate with his patient freely and wins his confidence. A
most important way of breaking ice is making humor, it can warm up the patient frozen
by fear and anxiety
Motive - it is an internal force/source of energy that compel one to action towards the
achievement of desired goal.
• Types - 2 types
➢ Primary Motives - related to man as animal that is to fulfill the basic needs e.g.
thirst, hunger, sex etc.
➢ Secondary Motives - related to man as a member of society that is to fulfill the
social needs e.g. love, recognition, belongingness etc.
Motivation - motivation means a process of stimulating people to action to accomplish desired
goals (William Scott). It is an awakening of an intra-psychic force. Generally awakening depends
on motive of particular reason
Maslow’s Hierarchy of Need for Motivation - Abraham H. Maslow discusses the motivation for
change in terms of a 'Hierarchy of Needs’. Basic needs must be satisfied before the individual
takes action to fulfill higher order need

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Behavioral Change Communication (BCC) - is the strategic communication for get a change in
human behavior. It takes in consider many important things like need or motive of the people,
modern technology of learning, different methods and media of communication etc. in nice
way.

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Card - 08: Biostatistics & Demography
Item 01: Definition & simple understanding about Statistics, Biostatistics & Vital
statistics. Sources & uses of vital statistics. Variables: definition & classification.
Attribute
Statistics - Statistics may be defined as the science which deals with systematic collection,
processing, analysis and interpretation of data from which an inference may be drawn.
Or, Statistics is a field of study concerned with classification, summarization, and analysis of
data and the drawing of inference about a body of data when only a part of the data is
observed.
Biostatistics - Biostatistics is a special branch of statistics, which deals with different types of
data pertaining to biological sciences. Biostatistics also deals with different types of data
related to medicine, epidemiology, research studies in different aspects of medical and health
sciences, community health, planning, organization and management of health services.
• Function - All these are mandatory for understanding & conducting a research and
computing various demographic & biophysical data in medical science
➢ Data collection
➢ Data processing
➢ Data analysis
➢ Interpretation
➢ Drawing up inference
• Use
➢ Collection of information
➢ Simplification of huge & complex sets of data
➢ Elucidation of ideas, information of hypothesis
➢ Identification of health problems, health resources &health services utilization
➢ Measurement of association between two or more variables
➢ Prediction & forecasting a disease magnitude
➢ Designing a research or study
➢ Planning, management, monitoring & evaluation of health services or
programmes

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Vital Statistics - Vital statistics is the ongoing collection by government agencies of data related
to vital events, including natality (births), morbidity (sickness), mortality (death), fertility,
marriage and divorce.
Information - Data needs to be transformed into information by reducing them, summarizing
them and adjusting them for variations, such as age, sex composition of the population so that
comparison over time and place are possible.
Intelligence - It is transformation of information through integration and processing with
experience and perception based on social and political values that produces intelligence.
Hypothesis - A hypothesis may be defined simply as a statement about one or more
populations. It is of 2 types -
1. Research Hypothesis - is the conjuncture or supposition that motivates the research.
2. Statistical Hypothesis - are hypothesis that are stated in such a way that may be
evaluated by appropriate statistical techniques.
Variable - A variable is a characteristic or condition that can change or take on different values.
Example: sex, age, education level, income, parity etc. Most research begins with a general
question about the relationship between two variables for a specific group of individuals. If we
observe a characteristics, we find that it takes on different values in different persons, places
and things, we label the characteristics a variable.
• Types -
A. For research purpose, variables can be classified into 3 types-
a. Independent variable - which influences the dependent variable, e.g.
smoking
b. Dependent variable - which is influenced by the independent variable,
e.g. cancer)
c. Confounding variable - which influences both of independent and
dependent variables, e.g. age influences smoking and cancer both
B. Types according to nature 2 types -
a. Qualitative variable - outcome of this type of variable is narrative This
variables take non numeric narrative values. Also called categorical
variables e.g. sex, occupation, nationality
b. Quantitative variable - Here the expression is numerical e.g. age, height,
weight, income, parity,

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C. Variables can be classified as discrete or continuous 2 types -

a. Discrete variables - can only have a finite number of isolated values
within its domain. This values are usually whole numbers. No fractions
possible e.g. parity, family size, number of beds in hospital
b. Continuous variables - is one with potentially an infinite number of
possible values in any interval. Fraction possible e.g. age, height, weight
income etc.
*Qualitative variables are always discrete e.g. sex, occupation, religion

*Quantitative variables may be discrete or continuous e.g. parity (discrete), income
(continuous)
• Measurement of Variables - To establish relationships between variables, researchers

must observe the variables and record their observations. This requires that the
variables be measured. The process of measuring a variable requires a set of categories
called a scale of measurement and a process that classifies each individual into one
category. There are 4 principal scales of measurement:
1. Nominal Scale - is an unordered set of categories identified only by name.
Nominal measurements only permit you to determine whether two individuals
are the same or different, that are only distinguished by their name and labels
and cannot be classified one above another e.g. race, name, sex, name of
country, name of crops, type of blood. In this type of data there is no implication
of order or ratio. Nominal data that falls into two groups are called dichotomous
data e.g. male/ female, black/white, rural/ urban.
2. Ordinal Scale - is an ordered set of categories. Ordinal measurements tell you the
direction of difference between two individuals. When the categorical data can
be placed in meaningful order on the basis of their quality, it is known as ordinal
data. In this the exact difference between the two groups cannot be estimated
e.g. pain categorized as mild, moderate and severe. Similarly scoring of students
categorized as A (70% and above), B (60 to 69 %), C (50 to 59 %). In this the exact
difference between the students placed in grade A and B cannot be estimated.
3. Interval Scale - is an ordered series of equal-sized categories. Interval
measurements identify the direction and magnitude of a difference. The zero
point is located arbitrarily on an interval scale. Interval scale data are like ordinal
data in that they can be placed in a meaningful order. The categories are
arranged in equally spaced units and there is no absolute zero point e.g.
temperature where 0˚ C does not mean no temperature but is equal to 32˚ F or
273 K (Kelvin scale). In addition they have meaningful intervals between items,
which are usually measured quantities. For example on the Celsius scale the
difference between 100˚ C and 90˚ C is the same as the difference between 50˚ C
and 40˚ C.

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However because interval scales do not have an absolute zero, ratio of scores
are not meaningful e.g. 100˚ C is not twice as hot as 50˚ C, because 0˚ C does not
indicate a complete absence of heat. Difference between any two
measurements is known in terms of an interval between two points of the scale.
Numbers are assigned so that equal differences on the scale reflect equal
differences in the amounts of the attribute measured. In this scale there is no
true zero e.g. Temp and pressure. Here zero temp or zero pressure does not
mean absence of temp or pressure.
4. Ratio Scale - is an interval scale where a value of zero indicates none of the
variable. Ratio measurements identify the direction and magnitude of
differences and allow ratio comparisons of measurements. A ratio scale has the
same properties as an interval scale; however, because it has an absolute zero,
meaningful ratios do exist. Most biomedical variables form a ratio scale e.g.
weight in grams or pounds, time in seconds or days, blood pressure in
millimeters of mercury, and pulse rate in beats per minute are all ratio scale
data. The only ratio scale of temperature is the Kelvin scale, in which zero degree
indicates an absolute absence of heat, just as a zero-pulse rate indicates an
absolute lack of heartbeat. Therefore it is correct to say that a pulse rate of 120
beats/min is twice as fast as pulse rate of 60 beats/min, or that 300 K is twice as
hot as 150 K.
Attribute - A variable is called attribute when it describes characteristics in terms of a category,

or property or quality. Example - occupation, sex, access to safe water etc.
Observation - an event & it’s measurement such as blood pressure (event) & 180mm of Hg
(measurement). Observational units are -
1. Data (details in Item:02) - A set of values recorded on one or more observational units. It
is a collection of facts such as values or measurements. Data are basic building blocks of
statistics & refers to the individual values presented, measured or observed.
2. Population - The entire group of individuals is called the population. For example, a
researcher may be interested in the relation between class size (variable 1) and
academic performance (variable 2) for the population of third grade children
3. Sampling Unit (details in Item:04) - Usually populations are so large that a researcher
cannot examine the entire group. Therefore, a sample is selected to represent the
population in a research study. The goal is to use the results obtained from the sample
to help answer questions about the population

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THE POPULATION
The sample is
[All of the selected from the
individuals of population
interest]
THE SAMPLE
The results from
the sample are [The individuals
generalized to selected to
the population participate in the
research study]
Statistical Inference - is the act of generalizing from a sample to a population with calculated
degree of certainty.

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Parameters & Statistics - it is essential that we draw distinctions between parameters &
statistic.
Parameters Statistics
Source Population Sample
Calculated? No Yes
Constant? Yes No
Examples µ, σ, p x̅, s, p̂
We are going to illustrate inferential by considering how well a given sample mean ‘X-Bar’
reflects an underling population mean µ -

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Item 02: Data - definition & types. Different data collection instruments,
methods of data collection & presentations. Data Management (classification,
analysis, result, interpretation etc.)
Data - A set of values recorded on one or more observational units. It is a collection of facts
such as values or measurements. Data are basic building blocks of statistics & refers to the
individual values presented, measured or observed.
• Types -
i. Measurement
ii. Counting
• Classification -
➢ According to Source
i. Primary - freshly collected data (by study, survey, observation, from
census)
ii. Secondary - already collected by some other but not published (from
primary source - hospital records, vital statistics record)
iii. Tertiary - already collected & published (from text books, journal &
internet)
➢ According to Arrangement
i. Ungrouped - e.g. weight of 6 men in Lbs. 130, 140, 160, 150, 150
ii. Grouped - e.g. height of 10 boys in feet. 4×4 boys, 5×5 boys, 4.5×1 boy
➢ According to Characteristics
i. Discreate - e.g. number of members in a family
ii. Continuous - e.g. weight, height
➢ According to Nature
i. Qualitative - e.g. religion, occupation, sex
ii. Quantitative - e.g. age, height in cm, weight in kg, BP

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• Methods of Data Collection -

➢ Interview - done by directly asking questions to get information e.g. history
taking of patients, face to face, in depth interview, over phone interview etc.
➢ Observation - observing the respondents indirectly to obtain information e.g.
caring for the patients by the nurse (injections, bed making), people washing
hands before taking meals. It could be participatory or non-participatory
➢ Questionnaire - done by format of questions that have to be filled up by the
respondents to obtain information
➢ Examination & Experiment - done by direct intervention methods e.g. blood
grouping, blood test, dose response of drugs etc.
➢ Records - from hospital records
➢ Focus Group Discussion (FGD)
➢ Case Study
➢ Document Review
➢ Survey
• Tools & Instruments - means or materials by which we collect data. Tools is a broader
term (instrument + others). Instruments are -
➢ Instruments -
▪ Questionnaire - All information is collected by putting questions to the
person from whom the data are to be collected. It is of 5 types -
1. Structured: all possible answers are listed alongside the questions.
2. Unstructured: blank space is provided for writing answers, these
are also known as open-ended questionnaire.
3. Semi-structured:
a. Open Ended - here options or answers not given,
respondents have to answer in his/her own way. Usually
respondents do not like to answer open-ended
questionnaires. They feel that they taking the
examination. It gives multiple responses, which makes
statistical analysis difficult. For Example -
Please answer the following questions:

➢ Give your opinion on the issue of salt iodization law
➢ What is its advantage?
➢ What are its disadvantages?

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b. Close Ended - here options or answers are given or

enumerated. The respondents simply check or encircle
his/her answer. It’s easy to answer, easy to analyze,
objective is high & subjectivity is low or absent. For
Example -
English should be used as a medium of instruction in all

subjects. Encircle the number of the best answer
➢ Strongly Agree
➢ Agree
➢ Not Agree
➢ Disagree
➢ Strongly Disagree
[5 point Likert scale and 4 point modified Likert scale]

4. Interviewer administered questionnaire
5. Self-administered questionnaire
▪ Check List
▪ Forms
▪ Modules
• Others - paper, pen, smart phone, measuring tape, BP machine, weighing machine etc.
Data Presentation - In order to make the data easily understandable, the first task of the
presenter is to condense the data and simplify them.
• Principles -
➢ Data should be arranged in such a way that it will arouse interest in reader
➢ The data should be made sufficiently concise without losing important details
➢ The data should be presented in simple form to enable the reader to form quick
impressions and to draw some conclusion, directly or indirectly
➢ Should facilitate further statistical analysis
➢ It should define the problem and suggest its solution
• Methods - 3 methods
1. Array
2. Tabulation
3. Graph/Drawing

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Array - simply means arranging in order. For example -
• Ascending
➢ From lowest to highest e.g. 1 2 3 4 5
• Descending
➢ From highest to lowest e.g. 5 4 3 2 1
Tabulation -
A. Principles -
1. A table should be clear & simple, several comparisons of different nature should
not be put in one table
2. A table should be numbered e.g. table 1, table 2
3. A title must be given to each table. The title must be brief & self-explanatory
4. The headings of the columns or rows should be clear & concise
5. The data must be presented according to size or importance, chronologically,
alphabetically or geographically
6. If percentage or average are to be compared, they should be placed as close as
possible
7. No table should be too large
8. Most people find vertical arrangement better than a horizontal one, because it is
easier to scan data from top to bottom, then from left to right
9. Foot notes maybe given, where necessary, providing explanatory notes or
additional information
10. The groups in the tables should be such that main groups are separated by thick
lines
11. Unimportant data may be grouped together & placed
12. The column heading should indicate the units used (height in centimeter, weight
in grams)
13. Source should be mentioned when data is taken from a secondary source
B. Types - 3 types
i. Univariate Table - presenting one variable at a time. For example -
Age Groups (years) Number (frequency) %
0 to 9 7 19.0
10 to 19 10 27.0
20 to 29 10 27.0
30 to 39 4 10.8
40 & above 6 16.2
Total 37 100.0

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ii. Bivariate Table - presenting two variable at a time. For example -

Sex
Age (years) Total
Male Female
0 to 9 4 3 7
10 to 19 6 4 10
20 to 29 7 3 10
30 to 39 3 1 4
40 & above 2 4 6
Total 22 15 37
iii. Multivariate Table - presenting three or more variables at a time. For example -
Name of the Marital Status
Service Types Total
course Married Single
M.Phill 1 0 1
CM 2 0 2
Epidemiology 3 0 3
Government Hm 1 0 1
HP & HE 8 3 11
RCH 1 0 1
Total 16 3 19
M.Phill 2 0 2
CM 9 0 9
Epidemiology 5 2 7
Hm 4 1 5
Non- HP & HE 7 2 9
Government/Private Nutri 1 0 1
OEH 7 2 9
PHA 9 0 9
RCH 9 1 10
Total 53 8 61
Total 69 11 80

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C. Another Types - 3 types

1. Simple Table - for example, a table showing sex distribution among students of
JRRMC
Year Male Female
st
1 Year 40 25
nd
2 Year 45 55
rd
3 Year 40 35
4th Year 35 30
th
5 Year 25 20
Total 185 165
2. Frequency Distribution Table - for example, a table showing percent distribution

of WBC’s of blood of a patient
Cell Tally Total %
|||| |||| |||| ||||
|||| |||| |||| ||||
Neutrophil 65%
|||| |||| |||| ||||
||||
|||| |||| |||| ||||
Lymphocyte 37%
|||| |||| ||
Monocyte | 01%
Eosinophil || 02%
Basophil 00%
Total 100
3. Complex Table - for example, a table showing sex & marital status distribution
among students of JRRMC
Male Female
Year
Married Unmarried Married Unmarried
st
1 Year 2 38 5 20
2nd Year 5 40 10 45
rd
3 Year 5 40 8 27
th
4 Year 3 32 10 20
th
5 Year 2 23 10 10
Total 17 173 43 122

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D. Parts of Table - 8 components

1. Table Number
2. Title
3. Caption/Column Heading
4. Stub/Row Heading
5. Body
6. Head Note
7. Foot Note
8. Reference/Source Note
Drawings/Charts/Graphs -
A. For qualitative, discrete, categorical data presentation - 4 types
1. Bar Diagram - It is a graphical representation of discrete data. Different
categories or classifications are represented on one axis (i.e. x axis), and the
frequency count (or%) is represented on the other (i.e. y axis). The lengths of the
bars are proportional to the frequencies. The widths of the bars should be equal.
The gap between the bars should be 50-99% of the width of the bar. It is of 3
types -
a. Simple Bar
Number of Distribution of Students of JRRMC
160
155
150
145
140
135
130
1st year 2nd year 3rd year 4th year 5th year

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b. Multiple Bar
Number distribution of students of JRRMC during the year

2000, 2001, 2002
145
140
135
130
125
120
115
110
105
2000 2001 2002
c. Component/Proportional Bar
Number distrituion of students of JRRMC during the year

2000, 2001, 2002
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2000 2001 2002

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2. Pie/Sector Diagram - it is a circular diagram divided into sectors, illustrating

proportion. In a pie chart, the arc length of each sector (and consequently its
central angle & are) is proportional to the quantity it represents. It is 360° and
shows 100%. So 1% = 3.6°. It starts from 12 o’clock position.
Distribition of students of JRRMC
3. Pictogram/Picture Diagram - means presentation of data in the form of picture

= 500 visitors
January
February
March
April
May

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4. Map/Spot Diagram - Spot maps are used to show geographical distribution of

frequencies of variable. In spot map single color or multiple color dots are used
to indicate various data
B. For quantitative, continuous data presentation - 6 types

1. Histogram - is a graphical representation of a frequency distribution by means of
rectangles whose widths represent class intervals & whose areas are
proportional to the corresponding frequencies. For constructing histogram
variable is taken on X-axis (class interval) & frequencies on y-axis. The histogram
is 2 dimensional, both length & width of the bar are important. For example -

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Difference between bar & histogram -

Bar Histogram
for qualitative data for quantitative data
gap between 2 bar no gap
height of the bar proportional to
area is proportional to frequency
relative frequency
2. Frequency Polygon - is a figure with many angles. It is an area diagram of

frequency distribution developed over a histogram. If we join the midpoints of
class interval at height of frequency by straight lines it gives a polygon. For
example -
3. Frequency Curve - when number of observations are very large & group interval
is small, the frequency polygon tends to loosen its angulations giving place to a
smooth curve known as frequency curve. For example -

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4. Line Chart - For example -
5. Cumulative Frequency diagram or ogive - is a graph of the cumulative relative

frequency distribution. An ogive when drawn, is in the form of curve. To draw an
ogive, an ordinary frequency distribution table in a quantitative data has to be
converted into a relative cumulative frequency table. For Example -

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6. Scatter or dot diagram - it examines the relationships between data collected for
2 different characteristics. Although the scatter diagram cannot determine the
cause of such a relationship, it can show whether or not such a relationship
exists & if so, just how strong it is. The analysis produced by scatter diagram is
called regression analysis. For Example -

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Item 03: Central tendency & Dispersion - definition & measures, calculation of
mean, mode, median, range & standard deviation. Population, parameter,
sample & statistics, Normal distribution curve.
Central Tendency - In case of large number of observations, there is generally a tendency of the
observations to cluster around a central point. This is known as central tendency.
• Measures of Central Tendency (Average) - information from a series of observations

presented by rank in simple or frequency distribution table is summarized by an
observer to get answers of the following 3 questions -
➢ What is its average/central value?
➢ How are the other values dispersed around this value or what is the degree of
scatter?
➢ What is the shape of the distribution? Is it normal?
Average value of a characteristics is the one central value around which all other
observations are dispersed. In any large series, nearly 50% observations lie above while
remaining 50% lie below the central value. It indicated how the values lie near the
center. In other words, it is a measure of central tendency or concentration of all other
observations around the central value. Thus an average value helps -
➢ Firstly: to find that most of the normal observations lie close to the central value
while few of the too large or too small lie far away at both ends.
➢ Secondly: to find out which group is better off by comparing the average of one
group with that of the other
• Types - 3 types
1. Mean - it is the sum of all values in a series divided by the actual numbers of
values in the series.
▪ Types - 4 types
a. Arithmetic Mean
b. Geometric Mean
c. Harmonic Mean
d. Weighted Mean
▪ Formula -
∑𝑥
𝑀𝑒𝑎𝑛 = =𝑥
𝑛

P a g e | 29
2. Median - median is the value that divides the series into equal groups so that
half of the values are greater than & half are less than the median.
▪ Methods of Determination - 2 methods
a. If number of observation (n) is odd, the value in the middle
position is the median
b. In case of even, there are 2 middle positions. The arithmetic mean
of 2 middle values is the median
▪ Formula -
a. For ODD number series
𝑛+1
𝑀𝑒𝑑𝑖𝑎𝑛 = 𝑣𝑎𝑙𝑢𝑒 𝑖𝑛 𝑡ℎ 𝑝𝑜𝑠𝑖𝑡𝑖𝑜𝑛
2
For Example -
4, 5, 7, 8, 10, 11, 12, 13, 14
So (9+1)/2 =5th position is the median. So median is 10
b. For EVEN number series

𝑛 𝑛
𝑀𝑒𝑑𝑖𝑎𝑛 = 𝑎𝑟𝑖𝑡ℎ𝑚𝑒𝑡𝑖𝑐 𝑚𝑒𝑎𝑛 𝑜𝑓 𝑡ℎ𝑒 2 𝑣𝑎𝑙𝑢𝑒𝑠 𝑖𝑛 𝑡ℎ & ( + 1)𝑡ℎ 𝑝𝑜𝑠𝑖𝑡𝑖𝑜𝑛
2 2
For example -
4, 5, 7, 8, 10, 11, 12, 13, 14, 15
So value of 10/2 = 5th position is 10 & (10/2) + 1 = 6th position is
11. So median is (10+11)/2 = 10.5
3. Mode - the mode is the most commonly occurring value in a series of values. For
example -
11, 16, 13, 17, 13, 18, 20. Here 13 is the most commonly occurring value. So
mode is 13

30 | P a g e
Measures of Location - 4 types

1. Percentile - is a value or point in a data series which divides the entire data set into two
parts in percentage. The part below the percentile contains a particular part of the
values in percentage and the part above the percentile contains the rest of the values.
For example, 30th percentile is the value which divides the entire data set into 2 parts.
30% values are lower than it & the rest 70% values are higher than it.
*There are 99% percentiles in a data series
*Median is the 50th percentile
2. Deciles - are the locations which divides the distribution into 10 equal parts. First deciles
is the 10th percentile. It divides the distribution into 10% & 90%. 10% values are below it
& 90% values are above it.
*Deciles are 9 in number
3. Quartiles - are the locations which divide the distribution into 4 equal parts. First
quartile (Q1) is the 25th percentile. It divides the distribution into 25% & 75%. 25% values
are below it and 75% values are above it.
*Quartiles are 3 in number
4. Quintiles - are the locations which divide the distribution into 5 equal parts. First quintile
is the 20th percentile. It divides the distribution into 20% and 80%. 20% values are below
it & 80% values are above it.
*Quintiles are 4 in number
Dispersion - the term dispersion means scattering of value of the variable. It measures the
variation of the observations. In other words, measured of dispersion are the measures of
extent of deviation of individual value from the central value (mean).
1. Measures of Dispersion - 2 types
1. Absolute - 6 types
a. Range - is the difference between the highest & lowest values of a series.
If we denote range by R, the largest value by XL and the smallest value by
XS, the range is
𝑅 = 𝑋𝐿 − 𝑋𝑆
b. Mean Deviation (MD) - is the measure of absolute deviation from
arithmetic mean. It is the average of differences of the observed value
from their arithmetic mean
∑ |𝑥 − x|
𝑀𝐷 =
𝑛 − 1

P a g e | 31
c. Variance - is the measure of spread. When the values of a set of

observation lie close to their mean, the dispersion or spread is less than
when they are dispersed over a wide range. Sample variance is
symbolically expressed by S2 & Population variance is expressed by σ2.
The variance & standard deviation (square root of the variance) are the
most commonly used measures of spread.
∑(𝑥 − x)2
𝑆2 =
𝑛 − 1
2
Σ(𝑥 − x) is called the sum of the squared deviation from mean
d. Standard Deviation (SD) - is a measure of dispersion and is used most
commonly in statistical analysis. It is the square root of the average of the
squared deviation of the observations from the arithmetic mean. It is
more acceptable than mean deviation, because the algebraic negative
sign is ignored in mean deviation but in standard deviation is not ignored
rather converted into plus sign by squaring deviations. It is denoted as
‘square root of the variance’
∑(𝑥 − x)2
𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝐷𝑒𝑣𝑖𝑎𝑡𝑖𝑜𝑛 (𝑆) 𝑓𝑜𝑟 𝑠𝑎𝑚𝑝𝑙𝑒 = √
𝑛 − 1
∑(𝑥 − x)2
𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝐷𝑒𝑣𝑖𝑎𝑡𝑖𝑜𝑛 (σ) 𝑓𝑜𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 = √
𝑛
∑ 𝑓(𝑥 − x)2
√ 2
𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝐷𝑒𝑣𝑖𝑎𝑡𝑖𝑜𝑛 (σ) 𝑓𝑟𝑜𝑚 𝑓𝑟𝑒𝑞𝑢𝑒𝑛𝑐𝑦 𝑡𝑎𝑏𝑙𝑒 =
𝑛 − 1
e. Interquartile Range
f. Quartile Deviation
2. Relative - 4 types
a. Coefficient of Range
b. Coefficient of Mean Deviation
c. Coefficient of Variation
d. Coefficient of Quartile Deviation

32 | P a g e
Item 04: Sample & Sampling Techniques
Sample - is part of population about which information is actually obtained with a view of
studying the population characteristics. It is the representative of the population whose
variables are under study. There are 2 main characteristics of representative sample.
A. Precision - which implies the size of the sample (precision depends on sample size,
ordinarily it should not be less than 30)
B. Unbiased Character
Sample Size - The number of individuals observed or from whom data is collected in the sample
is the size of sample, usually denoted by ‘n’
𝑧 2 𝑝𝑞
𝐹𝑜𝑟 𝑖𝑛𝑓𝑖𝑛𝑖𝑡𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛, 𝑛 =
𝑑2
ȵ
𝐹𝑜𝑟 𝑓𝑖𝑛𝑖𝑡𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛, 𝑛 =
ȵ − 1
1 + 𝑁
Here,
z = standardized normal deviate, set at 1.96 at 95% C.I
p = proportion having a characteristics
q = proportion without the characteristics (1 - p)
d = degree of allowable error
N = population size
n = calculated sample size
ȵ = sample size of finite population before correction
Sample Bias - bias comes in when the sample from a population are not chosen at random or
samples are not drawn from similar populations

P a g e | 33
Sampling - is the process of selecting the sample from a defined study population. 2 major
objectives of sampling are -
1. To estimate the population parameter (mean, proportion etc.) from the sample
statistics
2. To test the hypothesis about the population from which the sample or samples were
drawn
Sampling Unit - each member of the study population is a sampling unit. For example: a person,
a household, a village etc.
Sampling Frame - is the set of available sampling units from which a sample is to be picked. Or,
when all the members of population are listed by numbering then it is called sample frame
Sampling Interval - it is measured by the following formula

𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑆𝑎𝑚𝑝𝑙𝑖𝑛𝑔 𝐼𝑛𝑡𝑒𝑟𝑣𝑎𝑙 =
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑎𝑚𝑝𝑙𝑒
Methods of Sampling - 2 types

A. Probability Sampling - when each & every member/individual has the equal chance of
being selected, it is called probability sampling. It is of 5 types
1. Simple Random Sampling (SRS) - it is sample in which the sample is drawn in
such a way that each unit has an equal chance of being drawn in the sample. SRS
is generally based on a list of sampling units/sampling frame in the population.
Random numbers are a haphazard collection of certain numbers, arranged in a
manner to eliminate personal selection of unconscious bias in taking out the
sample. It is of 3 types -
▪ Lottery method
▪ Random table method
▪ Calculator method
2. Systematic Random Sampling - in this method, the sampling interval is first

calculated. The selection of the 1st unit is made at random & the subsequent are
selected at a certain interval

34 | P a g e
3. Stratified Sampling - this method is followed when the population is not

homogenous. The population is divided in different homogenous groups on the
basis of certain characteristics. Each group is called a stratum. Then data is
collected either by ‘simple random sampling’ or ‘systematic random sampling’
4. Multistage Sampling - when total population is large it is convenient to consider

it in various geographical levels or stages. Unit at each level are selected using
SRS, till the ultimate sampling units are obtained. For example, if we have to
select a sample for hookworm survey in Bangladesh, 1st select a division
randomly then select one district from the selected division and then Upazilla,
Union, Village respectively.
5. Cluster Sampling - In this type, the population is first divided into clusters. A
sample of such clusters are then selected randomly. All the units in the selected
clusters are then studied or examined. Between the cluster there is
homogenicity but within the cluster heterogenicity exist. It is advantageous but
less accurate
B. Non probability sampling - is a process in which personal judgement determines sample

selection. Thus each & every member/individual doesn’t have the equal chance of being
selected. It is of 4 types
1. Convenience Sampling - researcher have the freedom to choose whomever they
find. It is the simplest, least reliable method. The primary virtue is low cost
2. Purposive/Judgmental Sampling - in this method, the investigator exercises his

judgement in the choice of sample items & includes in the sample, which he
thinks are most representative with regard to the characteristics under
investigation
3. Quota Sampling - in this method, quotas are set up according to a given criteria
but within the quotas the selection of sample items depends on personal
judgement
4. Snowball Sampling - method in which persons chosen for the sample at the
beginning are used as informants to locate the other persons having same
characteristics making them eligible for the sample through referral network

P a g e | 35
Distribution - means how data are arranged. It is the arrangement of certain events.
Arrangement or pattern of data of any variable is called distribution. It is of 2 types
1. Continuous Distribution
➢ Normal Distribution/Gaussian Distribution - is a continuous probability
distribution that describes data that clusters around a mean or average. The
graph of the associated probability density function is bell-shaped, with a peak at
the mean and is known as the gaussian function or bell curve. It has the
following characteristics -
▪ Bilaterally symmetrical, bell shaped, smooth
▪ Mean, median, mode will coincide
▪ Total area under the curve = 1, half the measurement lies above the
mean, half lies below the mean
▪ Continuous random variable
▪ Based on large number of variables
▪ In terms of standard deviation, the limits are
 mean ± 3 times of SD include 99% of all values
2. Discrete Distribution - 2 types

a. Binomial Distribution - has only 2 mutually exclusive outcomes. Probability of
success is p, while probability of failure is 1-p. Examples, smoker/non-smoker,
cured/non-cured, cyanosed/non-cyanosed etc.
b. Poisson Distribution - number of events happening in a fixed time interval.
Examples, number of ambulances coming to our medical college in an hour,
number of days schools remain closed in a year due to natural disaster

36 | P a g e
Item 05: Demography - definition, demographic process & transition

(demographic cycle). Population pyramid & dependency ration
Demography - is that branch of social science, which deals with the statistical study of size,
structure & distribution of populations, along with the spatial & temporal changes in them in
response to birth, migration, aging & death. It is the scientific study of human population.
Demographic analysis can be applied to whole societies or to groups defined by criteria such as
education, nationality, religion & ethnicity. In academia, demography is often regarded as a
branch of either anthropology, economics or sociology.
• Focuses - it focuses its attention on 3 readily observable human phenomena -

i. Changes in population size - growth rate (increase or decrease)
ii. Composition of the population - age, sex, ethnic group etc.
iii. Distribution of the population in space - urban population, rural population
• Demographic Process -
i. Fertility
ii. Mortality
iii. Marriage
iv. Migration
v. Social mobility
• Sources of Demography -
i. National surveys
ii. Registration of vital events like birth, death & marriage registration
iii. Population census
iv. Hospital records
v. Adhoc demographic studies
vi. Sample screening
vii. International statistical records

P a g e | 37
Demographic Cycle - the history of world population since 1950 suggests that there is a
demographic cycle of 5 stages through which a nation passes.
1. First Stage (High Stationary) - it was prevalent in Indian subcontinent till 1920
➢ High birth rate
➢ High death rate
➢ Population static
2. Second Stage (Early Expanding) - many countries of South Asia are in this stage
➢ Birth rate unchanged
➢ Death rate begins to decline
➢ Population rapidly increases
3. Third Stage (Late Expanding) - some of the countries like China, Singapore, India,
Bangladesh is in this stage
➢ Death rate declines still further
➢ Birth rate tends to falls
➢ Population slowly increases
4. Fourth Stage (Low Stationary) - Austria, UK, Denmark, Sweden, Belgium is in this stage
➢ Low birth rate
➢ Low death rate
➢ Population static
5. Fifth Stage (Declining) - Germany & Hungary are experiencing this stage
➢ Birth rate < Death rate
➢ Population decline
Demographic Stage of Bangladesh -
• Past (1974 to 1981) -

o Stage - 2nd stage
o Condition -
▪ Birth rate high
▪ Death rate begins to decline
▪ Population growth rate 2.35%
o Comment - explosive growth
• Present (2001 to 2011) -
o Stage - 3rd stage
o Condition -
▪ Birth rate tends to fall
▪ Death rate declines further
▪ Population growth rate -1.6%
o Comment - rapid growth

38 | P a g e
Population Pyramid - visual representation of population growth in country
• Developing Country -
o Apex - narrow
o Base - wide
• Developed Country - ‘bee hive shape’
o Apex - narrow
o Middle - wide
o Base - narrow
Age-Sex Population Pyramid of Bangladesh -
• Characteristics -
o Apex - Narrow
o Base - Wide, representing children population. Birth rate is very high in
Bangladesh. Thus the age-sex pyramid takes this shape

P a g e | 39
Item 06: Fertility related important rates & ratios. Factors influencing fertility.
Growth rate, population explosion & effects of over population
Fertility - is the ability of a female to actually bear a child. Factors influencing fertility in
Bangladesh are -
➢ Age at marriage
➢ Duration of married life
➢ Spacing of children
➢ Education
➢ Universality of marriage
➢ Economic status
➢ Caste & religion
➢ Family planning
➢ Breast feeding
Total Fertility Rate - represents the average number of children a women would have if she
were to pass through her reproductive years bearing children at the same rates as the women
now in each age group.
Net Reproduction Rate - defined as the number of daughters a newborn girl will bear during
her lifetime assuming fixed age-specific fertility & mortality rates. It is a demographic indicator.
NRR of 1 is equivalent to attaining approximately the 2-child norm. If the NRR is less than 1, the
reproductive performance of population is said to be below replacement level. The
demographic goal of Net Reproduction Rate (NRR) = 1 can be achieved only if CPR exceeds 60%.
CPR is less than 1 in Germany
Growth Rate - when crude death rate is subtracted from the crude death rate, the net residual
is the current annual growth rate.
𝐶𝑟𝑢𝑑𝑒 𝐵𝑖𝑟𝑡ℎ 𝑅𝑎𝑡𝑒 − 𝐶𝑟𝑢𝑑𝑒 𝐷𝑒𝑎𝑡ℎ 𝑅𝑎𝑡𝑒
𝐺𝑟𝑜𝑤𝑡ℎ 𝑅𝑎𝑡𝑒 =
10

40 | P a g e
Doubling Time - it denotes how long a growth rate would take a population to double itself. If
the growth rate of a population is 2, the population double itself in 35 years. The rough formula
for estimating doubling time of population is -
70
𝐷𝑜𝑢𝑏𝑙𝑖𝑛𝑔 𝑇𝑖𝑚𝑒 =
𝐺𝑟𝑜𝑤𝑡ℎ 𝑅𝑎𝑡𝑒 𝑜𝑓 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
Population Explosion - when growth rate is more than 2%, is called population explosion.
Hazards of population explosion are the following -
➢ Physical hazards (housing, environment, pollution)
➢ Psychological hazards
➢ Social hazards (alcoholism, broken homes, corruption, divorces, drug abuses, gambling)
➢ Anti-social activities (theft, murder, sex crimes e.g. rape, prostitution, robbery, child
abuse, juvenile delinquency)
➢ Miscellaneous hazards (STDs, malnutrition, infection, epidemics, HTN due to stress)
Thus population explosion is not only a health problem but a social, economic & demographical
problem also.

P a g e | 41
Item 07: Demographic characteristics of Bangladesh. Census - definitions &

types
Bangladesh Demographic Profile - [Source: CIA World Factbook, September 18, 2021]
• Population: 164,098,818 (July 2021 est.)

• Nationality:
o noun: Bangladeshi(s)
o adjective: Bangladeshi
• Ethnic Groups: Bengali at least 98%, other indigenous ethnic groups 1.1% (2011 est.)
Note: Bangladesh's government recognizes 27 indigenous ethnic groups under the 2010
Cultural Institution for Small Anthropological Groups Act; other sources estimate there
are about 75 ethnic groups; critics of the 2011 census claim that it underestimates the
size of Bangladesh's ethnic population
• Languages: Bangla 98.8% (official, also known as Bengali), other 1.2% (2011 est.)
• Religions: Muslim 89.1%, Hindu 10%, other 0.9% (includes Buddhist, Christian) (2013
est.)
• Age Structure:
o 0-14 years: 26.48% (male 21,918,651/female 21,158,574)
o 65 years and over: 6.82% (male 5,218,206/female 5,879,411) (2020 est.)
• Dependency Ratio:
o total dependency ratio: 47
o youth dependency ratio: 39.3
o elderly dependency ratio: 7.7
o potential support ratio: 13 (2020 est.)
• Median Age:
o total: 27.9 years
o male: 27.1 years
o female: 28.6 years (2020 est.)
• Population growth rate: 0.95% (2021 est.)
• Birth Rate: 17.88 births/1,000 population (2021 est.)
• Death Rate: 5.44 deaths/1,000 population (2021 est.)
• Net Migration Rate: -2.93 migrant(s)/1,000 population (2021 est.)
• Urbanization:
o urban population: 38.9% of total population (2021)
o rate of urbanization: 2.88% annual rate of change (2020-25 est.)

42 | P a g e
• Major Cities Population: (2021)

o 21.741 million DHAKA (capital)
o 5.133 million Chittagong
o 949,000 Khulna
o 924,000 Rajshahi
o 890,000 Sylhet
o 820,000 Bogra
• Sex Ratio:
o at birth: 1.04 male(s)/female
o 0-14 years: 1.04 male(s)/female
o 65 years and over: 0.89 male(s)/female
o total population: 0.97 male(s)/female (2020 est.)
• Mother's Mean Age at First Birth: 18.6 years (2017/18 est.)
Note: median age at first birth among women 20-49

• Maternal Mortality Rate: 173 deaths/100,000 live births (2017 est.)
• Infant Mortality Rate:
o total: 31.13 deaths/1,000 live births
o male: 33.82 deaths/1,000 live births
o female: 28.34 deaths/1,000 live births (2021 est.)
• Life Expectancy at Birth:
o total population: 74.43 years
o male: 72.25 years
o female: 76.7 years (2021 est.)
• Total Fertility Rate: 2.1 children born/woman (2021 est.)
• Contraceptive Prevalence Rate: 62.7% (2019)
• Drinking Water Source:
o improved:
▪ urban: 98.9% of population
▪ rural: 98.4% of population
▪ total: 98.6% of population
o unimproved:
▪ total: 1.4% of population (2017 est.)
• Health Expenditures: 2.3% (2018)
• Physicians’ Density: 0.58 physicians/1,000 population (2018)

P a g e | 43
• Hospital Bed Density: 0.8 beds/1,000 population (2016)

• Sanitation Facility Access:
o improved:
▪ total: 70.9% of population
o unimproved:
▪ total: 29.1% of population (2017 est.)
• HIV/AIDS - adult prevalence rate: <.1% (2018 est.)
• HIV/AIDS - people living with HIV/AIDS: 14,000 (2018 est.)
• HIV/AIDS - deaths: <1000 (2018 est.)
• Major Infectious Diseases
o degree of risk: high (2020)
o food or waterborne diseases: bacterial and protozoal diarrhea, hepatitis A and E,
and typhoid fever
o vector borne diseases: dengue fever and malaria are high risks in some locations
o water contact diseases: leptospirosis
o animal contact diseases: rabies
Note: widespread ongoing transmission of a respiratory illness caused by the novel

coronavirus (COVID-19) is occurring throughout Bangladesh; as of 19 July 2021,
Bangladesh has reported a total of 1,128,889 cases of COVID-19 or 685.47 cumulative
cases of COVID-19 per 100,000 population with 11.13 cumulative deaths per 100,000
population; as of 19 July 2021, 3.54% of the population has received at least one dose of
COVID-19 vaccine
• Obesity - adult prevalence rate: 3.6% (2016)
• Food Insecurity: severe localized food insecurity due to economic constraints - food
insecurity poverty levels have increased due to income losses and a decline in
remittances caused by the effects of the COVID-19 pandemic (2021)
• Children Under the Age of 5 years Underweight: 22.6% (2019)
• Education Expenditures: 1.3% of GDP (2019)
• Literacy:
o definition: age 15 and over can read and write
o total population: 74.7%
o male: 77.4%
o female: 72% (2019)

44 | P a g e
• School Life Expectancy (primary to tertiary education)

o total: 12 years
o male: 12 years
o female: 12 years (2018)
Sources of Population Data -

➢ Census
➢ Registration of Vital Events
➢ Sample Registration Survey
➢ Institutional Records
Census - it is the total process of collecting, compiling and publishing demographic, economic
and social data pertaining at a specific time or times, to all persons in a country or delimited
territory (United Nations)
Census comes from the Latin word ‘sensere’ means value or tax. It is done in every 10-year
interval. It is an important source of health information.
Census is conducted by Bangladesh Bureau of Statistics (BBS). First census was done in 1974.
Then in 1981, 1991, 2001, 2011, 2022
• Methods - 3 methods
a. De facto census (in fact, weather by right or not) - the matter is to list all persons
present in the household or other living quarters at midnight of the census day
or all who passed the night there
b. De jure census (by right) - all persons who usually live in the household are listed
on the form whether they are present or not. Visitors who have a usual
residence elsewhere are excluded from the listing but are counted as their usual
residence
c. Modern Census - Each individual is enumerated separately and characteristics of
each persons are recorded separately. The census covers a precisely defined
territory and includes every person present or residing within its scope.
Population is enumerated with a well-defined time and date is in terms of a well-
defined reference period. Census taken at regular interval
• Uses of Census -
➢ Is the primary source of basic national population data required for
administrative purposes and many aspects of economic and social planning and
research.
➢ Provides information on

P a g e | 45
▪ trends in population growth

▪ Change in age and sex structure
▪ Cause of fertility, mortality, migration and urbanization
➢ Useful for estimating, calculating birth and death rate
➢ Provides information on
▪ Changes in the national occupational and industrial composition
▪ Religion, language and caste/ethnic composition
▪ Analysis of economic development
▪ Future Trends of population growth
▪ National, local, public and private planning
➢ Estimating school going population, military and economic manpower
➢ Future growth of cities and requirement of food, water, housing and health
services
➢ Number of voters present and future and many more
Thus census is contributing to a revolutionary expansion of global economic, sociological

& demographical knowledge.

46 | P a g e
Card - 09: Environmental Health
Item 01: Definition & Simple Understanding about different types of

Environment. Components of physical environment. Role of Environment in
disease causation. Atmosphere & it’s different layer. Global warming & climate
change
Ecology - is the study of structure and functioning of nature. It is the study of structure and
functioning of ecosystem. It is study of natural relationship between living organism and their
environment.
• Components -
1. Atmosphere:
a. Troposphere: Average 12.87 cm from surface. Humidity, cloud, wind
b. Stratosphere: 50 km from troposphere No humidity, little parallel wind
c. Mesosphere: 80 km from stratosphere. Temperature decreased rapidly
d. Thermosphere: High temper true lightening
2. Hydrosphere: Water
a. Oceans – 97%
b. Ice sheets and glaciers – 1.8%
c. Ground water – 0.5%
d. Surface water – 0.01%
e. Soil moist etc. – 0.01%
3. Lithosphere - Soils, rocks
4. Biosphere - Plants, animals
Ecosphere - Ecosphere could be defined biosphere plus those parts of hydrosphere,

atmosphere and lithosphere in which and with which plants and animal interest.

P a g e | 47
Ecosystem - Self-regulating community of living substance (plants and animals) interacting with
one another and with their non-living environment. E.g., lake ecosystem, forest ecosystem.
• Component:
1. Living components
a. Producers (food maker): all green plants, soil and air with energy from
sun forming complex energy rich chemicals.
b. Consumers or eaters: herbivores, carnivores, omnivore.
c. Decomposers: bacteria, fungi etc.
2. Non-living components
a. Physical: wind, soil moisture, water current, temperature and light etc.
b. Chemicals: water, gases, minerals, compounds, complex chemicals.
Ecological Triad - Health and disease are expression of an ecological process, a dynamic
relationship among three ecological factors agent, host and environment. Dynamic equilibrium
between man and his environment or continuous adaptation and adjustment to environment is
health. Maladjustment in the ecosystem of man, i.e. – maladjustment of human organism to
environment may cause disease.

48 | P a g e
Environment - Everything surrounding us collectively be termed as the environment. All

elements of nature including that man-made make the environment.
• Classification - 2 types
1. Internal environment – it comprises various tissue, organs and organ systems
within the human body.
2. External environment – All that which is external to the individual human host,
living and non-living, and with which he is in constant interaction. E.g., air,
waters, food, housing etc.
• Components of Environment:
1. Physical environment: air, water, soil, climate, heat, light, etc.
2. Biological environment: viruses, microbial agents, insects, rodents, animals,
including man, plants, etc.
3. Psychosocial environment: culture, beliefs, habits, attitudes, religion, education,
lifestyles etc.
Environmental Health - Environmental health is the science and art dedicated to preventing,
controlling and reducing environmental pollution. Environmental health has been defined by
the World Health Organization (WHO) in 1999 as, “Those aspects of the human health and
disease that are determined by factors in the environment. It also refers to the theory and
practice of assessing and controlling factors in the environment that can potentially affect
health.”
Influence of Environment on Health - Surrounding or condition in which man, animal or plant

live or operates is called environment. Elements of environment are:
1. External environment:
a. Physical environment: air, water, heat, climate etc.
b. Biological environment: bacteria, virus, plant, animal etc.
c. Psychosocial environment: believe, religion, practice, personality etc.
2. Internal environment: organ, tissue etc.

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If any component of environment is contaminated or polluted, it will affect health in following

ways:
• Air pollution: Droplet infections like TB, pneumonia, bronchial asthma and respiratory
allergies. Inhalation of air pollutants cause pneumoconiosis, lead poisoning etc.
• Water pollution: Water Borne Diseases like, Viral hepatitis, Typhoid and paratyphoid
fever, Schistosomiasis, Fish tape worm, Arsenic poisoning, Minamata disease etc.
• Soil pollution: Tetanus, Anthrax, pneumonic and bubonic plague, fungal infections
• Climate: changes in climate causes global warming which in turn causes several diseases
and spread of vector borne diseases in different parts of world.
Thus, environment influence the health.
Hazards - A hazard is any practice, behavior, substance, condition or combination of these that
can cause injury or illness to people, or damage to property. An inherent physical or chemical
characteristic that has the potential for causing harm to people, the environment or property.
Environmental Hazard - Environmental hazard is the state or events which has the potential to
threaten the surrounding natural environment and adversely affect people’s health.
Environmental hazards can be categorized in the following types:
• Natural hazards
• Cultural hazards
• Chemical
• Physical
• Mechanical
• Biological
• Social
Climate - is the total of all-weather occurring over a period of years in a given place. It is the
average weather conditions of that place.
Weather - is that what is happening outdoors in a place at a given time
Climate Change - refers to significant, long-term changes in the global climate

50 | P a g e
Greenhouse Effect - is the natural warming of the earth that results when gases in the
atmosphere trap heat from the sun that would otherwise escape into space
• Benefits - Due to increased rainfall in the drought affected areas of China, India, Africa,
Australia, and Middle-East countries, the agricultural production will be increased. Due
to melting of ice from Siberia and Canada huge lands will be available for cultivation and
human habitation
• Effect on Bangladesh -
➢ Rise of sea level will inundate land mass of Bangladesh.
➢ The rivers of the remaining area will have saline water and resulting reduced
availability of fresh water due to saltwater intrusion.
➢ There will be more rainfall and increased frequency and severity of natural
calamities such as cyclones, tidal-bore, tornado, flood.
➢ Due to decrease of land area there will be decrease in agricultural land, resulting
shortage of food and feminine.
➢ Due to salinity in the river water the fish production will also decrease and vast
majority of human being will not have any shelter.
➢ There will be an increase in frequency of respiratory diseases from atmospheric
pollution, allergic pollen and also the of spread of vector borne diseases.
Greenhouse Gas - are heat trapping gases in the atmosphere, that has the property of
absorbing heat energy emitted from earths surface & radiating it back to earth’s surface, thus
contributing to the greenhouse effect.
• Types - 2 types
A. Natural e.g. CO2, Methane, NO2, water vapor
B. Synthetic e.g.
▪ HFC (hydrofluorocarbons)
▪ PFC (perfluorocarbons)
▪ SF6 (sulfur hexafluoride)
▪ NF3 (nitrogen trifluoride)
• Source -
➢ Electricity & heat production
➢ Agriculture & land use changes
➢ Industries
➢ Transportation
➢ Operation building

P a g e | 51
• Effect on Climate -
➢ Positive - it traps heat in the atmosphere and warm the planet and keeps the
world habitable for its dwellers. With no green-house gases at all in atmosphere,
the earth’s average atmospheric temperature would be about -18˚C or about
0˚F.
➢ Negative - global warming
Global Warming - is the slow increase in the average temperature of the earth’s atmosphere
because an increased amount of the heat energy striking the earth from the sun is being
trapped by greenhouse gases in the atmosphere and not radiated out into space
• Causes -
➢ Natural e.g. volcanic, ocean currents, solar radiation
➢ Human e.g. greenhouse gas, deforestation, coal mining, burning of fossil fuel,
industrial process, agriculture
• Effects -
➢ Rising sea level
➢ Melting ice
➢ Reduced food security
➢ Pests & diseases
➢ Changing eco system
➢ Effect on human health

52 | P a g e
Item 02: Air Pollution: sources & indicators. Health effects of air pollution.
Prevention of air pollution. Ventilation: definition & types. Air changes of
occupied room. Air conditioning
Air -
• Functions - Air and atmospheric conditions serve several functions.

➢ Supply the life-giving oxygen.
➢ The human body is cooled by the air contact.
➢ The special senses of hearing and smell function through air-transmitted stimuli.
➢ Disease agents may be conveyed by air
• Composition -
➢ Nitrogen – 78.1%
➢ Oxygen – 20.93%
➢ Carbon dioxide – 0.03%
➢ Traces of other gases, e.g., argon, neon, krypton, xenon and helium.
➢ Water vapor
➢ Traces of ammonia
➢ Suspended matter such as dust, bacteria, spores and vegetable debris
• Pure Air - air remails pure by certain self-cleansing natural mechanism. Such as:
➢ Wind - dilutes & sweeps away the impurities by its movement
➢ Sunlight - oxidize impurities & kill bacteria
➢ Rain - remove suspended & gaseous impurities
➢ Plant Life - utilize the carbon dioxide & generate oxygen
• Air of Occupied Room - human occupancy & activity contaminate air in occupied rooms
& give a sense of discomfort to the occupants. The changes in air that takes place in
confined places are both chemical & physical. Such as -
➢ Chemical Changes - CO2 content increases & 02 content decreases in air due to
metabolic processes
➢ Physical Changes -
▪ Rise in Temperature - due to emanation of body heat
▪ Increase in Humidity - due to moisture evaporated from the skin & lungs
▪ Decrease in Natural Movement of air in crowded places
▪ Unpleasant Body Odors - from foul breath, perspiration, bad oral
hygiene, dirty clothes & other sources
▪ Bacterial pollution by the exhaled air containing suspended
microorganisms

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Air Pollution - Air pollution is the presence in the ambient atmosphere of substances generated
by the activities of man in sufficient concentrations and present for sufficient time which
interfere with human health, safety or comfort, or damage to property or injurious to
vegetation and animals and other environmental media.
• Pollutants - 2 types
1. Primary Air Pollutants: those that are emitted into the atmosphere from a source
such as a factory chimney or exhaust pipe, or through suspension of
contaminated dusts by the wind
2. Secondary Air Pollutants: those formed within the atmosphere itself. They arise
from chemical reactions of primary pollutants such as ozone which arises almost
entirely from chemical reactions
• Major health-damaging indoor air pollutants -
1. Fine particles
2. Carbon monoxide
3. Nitrogen oxides
4. Sulphur oxides
5. Volatile organic compounds
6. Lead
7. Radon
8. Asbestos
• Major air pollutants -

Noxious Agent Sources Adverse Effects
Oxides of nitrogen Automobile exhaust, gas Respiratory tract irritation,
stoves and heaters, wood, bronchial hyperactivity,
burning stoves, kerosene impaired lung defenses,
space heaters bronchiolitis obliterans
Hydrocarbons Automobile exhaust, Lung cancer
cigarette smoke
Ozone Automobile exhaust, high Cough,
altitude aircraft cabins bronchoconstriction,
respiratory tract irritation
Sulphur Power plants, smelters, oil Exacerbation of asthma
dioxide refineries, kerosene space and COPD, respiratory
heaters tract irritation, death in
severe
Lead Automobile exhaust using Impaired
leaded gasoline neuropsychological
development in children

54 | P a g e
• Sources -
1. Automobiles: Motor vehicles are a major source of air pollution throughout the
urban areas. They emit hydrocarbons, carbon monoxide, lead, nitrogen oxides
and particulate matter
2. Industries: Combustion of fuel to generate heat and power produces smoke,
sulphur dioxide, nitrogen oxides and fly ash. Petrochemical industries generate
hydrogen fluoride, hydrochloric acid and organic halides. Many industries
discharge carbon monoxide, carbon dioxide, ozone, hydrogen sulphide and
sulphur dioxide
3. Domestic sources: Domestic combustion of coal, wood or oil is a major source of
smoke, dust, sulphur dioxide and nitrogen oxides.
4. Tobacco smoke: The most direct and important source of air pollution affecting
the health of many people.
5. Natural sources: e.g. wind-borne dust, fungi, molds, bacteria.
6. Miscellaneous: Burning refuse, incinerators, pesticide spraying, nuclear energy
programmes
• Effects - 2 ways
1. Health aspect:
a. Droplet infections: TB, diphtheria, pertussis, pneumonia, influenza,
measles, mumps, chicken pox, streptococcal sore throat etc.
b. Delayed effects: chronic bronchitis, lung cancer, bronchial asthma,
emphysema and respiratory allergies
c. Inhalation of air pollutants: pneumoconiosis, lead poisoning etc.
2. Social and economic aspect: These comprise destruction of plant and animal life;
corrosion of metals, damage of buildings, cost of cleaning and maintenance and
repairs and aesthetic nuisance. Air pollution also reduces visibility in towns. It
can damage clothing
• Prevention & Control - The WHO has recommended the following procedures for the
prevention and control of air pollution:
1. Containment: Prevention of escape of toxic substances into the ambient air.
Achieved by a variety of engineering methods such as enclosure, ventilation and
air cleaning
2. Replacement: Replacing a technological process causing air pollution, by a new
process that does not. Increased use of electricity, solar power generation,
natural gas and central heating in place of coal, to reduce lead in petrol
3. Dilution: Some air pollutants are readily removed by vegetation. The
establishment of “green belts” between industrial and residential areas is an
attempt at dilution

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4. Legislation: Controlled by suitable legislation, e.g. clean air acts. Legislation

covers such matters as height of chimneys, powers to local authorities to carry
out investigations, research and education concerning air pollution, creation of
smokeless zones and enforcement of standard for ambient air quality.
5. International action: To deal with air pollution on a world-wide scale, the WHO
has established an international network of laboratories for the monitoring and
study of air pollution. The network consists of 2 international centers at London
and Washington, 3 centers at Moscow, Nagpur and Tokyo and 20 laboratories in
various parts of the world.
Indoor Air Pollution - Indoor can be defined as any nonindustrial indoor space where a person
spends a period of an hour or more in any day. This include the space in the office, classroom,
motor vehicle, shopping centers, hospital and home Indoor air pollution is defined as the
presence of physical, chemical or biological contaminants in high quantities in the air of
confined environments which are not naturally present in the external air of the ecological
systems. Indoor air levels of many pollutants may be 2-5 times higher and the occurrence of ill-
effects are more than 100 times in comparison to outdoor pollutants.
• Sources -
➢ Combustion generated pollutants: Use of traditional fuels for cooking, such as
fire wood, animal dung, coal, gas etc. Common pollutants are particulate matter,
oxide of sulphur, oxides of nitrogen, carbon monoxide and hydrocarbons
➢ Artificial building materials and poor ventilation: Formaldehyde in building
materials such as particle board, plywood etc.
➢ Construction materials: Like rock, sand, bricks, concrete plaster, limestone,
marble, wood, asbestos etc.
➢ Office machines and domestic air cleaners
➢ Biogenic particles: Bacteria, fungi, viruses, amoebae and pollen grains.
Contaminated cooling and heating system in home and public buildings.
➢ Tobacco smoke
➢ Other sources: Emissions from ammoniated cleaning compounds and germicidal
cleaners. Furnishing, adhesive and paints are also sources of pollutants

56 | P a g e
• Major health-damaging indoor air pollutants -

➢ Fine particles - fuel/tobacco combustion, cleaning operation, cooking
➢ Carbon monoxide - fuel/tobacco combustion
➢ Nitrogen oxides - fuel combustion
➢ Sulphur oxides - coal combustion
➢ Volatile organic compounds - fuel/tobacco combustion, construction materials,
cooking
➢ Lead - remodeling/demolition of painted surface
➢ Radon - construction materials
➢ Asbestos - remodeling/demolition of construction materials
Ventilation - The modern concept of ventilation implies the replacement of vitiated air by a
supply of fresh outdoor air and control of the quality of incoming air with regard to its
temperature, humidity and purity with a view to provide a thermal environment that is
comfortable and free from risk of infection.
• Standards -
➢ Cubic space: The minimal fresh air supply ranging from 300 to 3,000 c.ft. per
hour per person.
➢ Air change: In the living rooms, there should be 2 or 3 air changes in one hour; in
work rooms and assemblies 4 to 6 air changes.
➢ Floor space: The optimum floor space requirements per person vary from 50 to
100 sq. ft
• Types -
1. Natural ventilation: Natural ventilation is the simplest system of ventilating small
dwellings, school and offices. The chief drawback of natural ventilation is that it
is not possible to regulate the velocity of the incoming air nor to adjust its
temperature or humidity
a. The wind: An active force in ventilation. Doors and windows facing each
other provide “cross-ventilation”.
b. Diffusion: Air passes through the smallest openings or spaces by diffusion
c. Inequality of temperature: Air flows from high density to low density; it
rises when slightly heated and escapes from openings provided high up in
the room. The outside air which is cooler and denser will enter the room
through inlets placed low These properties of air are utilized to best
advantage by the proper location of windows, doors, ventilators and
skylights

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2. Mechanical ventilation: Mechanical or artificial ventilation may be of the

following 4 types -
a. Exhaust ventilation - Air is extracted or exhausted to the outside by
exhaust fans usually driven by electricity creating a vacuum which
induces fresh air to enter the room through windows, doors and other
inlets. It is negative pressure ventilation. It is generally provided in large
halls and auditoria for removal of vitiated air
b. Plenum ventilation - Fresh air is blown into the room by centrifugal fans
so as to create a positive pressure and displace the vitiated air. It is used
for supplying air to air-conditioned buildings and factories
c. Balanced ventilation - This is a combination of the exhaust and plenum
systems of ventilation
d. Air conditioning - Air conditioning is defined as, “the simultaneous
control of all, or at least the first three of those factors which include
temperature, humidity, air movement, distribution, dust, bacteria, odors
and toxic gases; affecting both the physical and chemical conditions of
the atmosphere within any confined space or room and in greater or
lesser degree the human health and comfort”. The air is filtered when
drawn into an air conditioner system from the room. The temperature
difference between the outside air and the air-conditioned air should not
be more than 20℉. Generally a difference of 10-15 ℉ is maintained. Air
conditioning is popular in large institutions, hospitals, industries and
dwellings.
• Criteria of good ventilation - From the view point of comfortable living & working
conditions, the good and efficient ventilation system should meet the following
functional requirements:
1. Rate of supply of fresh air - It should admit sufficient quantity of fresh air and
remove the contaminated air. It should also properly control the velocity and
quantity of air inside the space.
2. Purity of Air and Humidity - It should admit clean and humid air
3. Air movements or Air Changes - It should continuously change the air inside the
room
4. Temperature of Air - The system should also control the temperature of
admitted air
• Insufficient Ventilation - the occupants in insufficiently ventilated rooms complaints of a
feeling of suffocation or discomfort, headache, drowsiness, inability to concentrate

58 | P a g e
Discomfort - is a subjective sensations which people experience in ill-ventilated & crowded

rooms. It occurs due to physical changes of air which are temperature, humidity, air movement
& heat radiation. These factors determine the ‘cooling power’ of air with respect to human
body. Oxygen content may be reduced to 18% & Carbon-di-Oxide may be raised to over 5%
without adverse effects.
Comfort Zones - may be defined as the range of effective temperatures (ETs) over which the
majority of adults feel comfortable. Comfortable thermal conditions are those under which a
person can maintain normal balance between production & loss of heat at normal body
temperature & without sweating.
Comfort Zones Corrected Effective Temperature (°C)

Pleasant & Cool 20
Comfortable & Cool 20 to 25
Comfortable 25 to 27
Hot & Uncomfortable 27 to 28
Extremely Hot 28+
Intolerably Hot 30
Particulate Matter (PM) - is a mixture of particles that can be solid, liquid or both, are
suspended in the air & represent a complex mixture of organic & inorganic substances. Particles
are categorized according to particle size. They are -
1. PM10 - aerodynamic diameter smaller than 10µm can reach the upper part of the
airway & lung
2. PM2.5 - aerodynamic diameter smaller than 2.5µm can penetrate into lung & may reach
the alveolar region

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Item 03: Water: sources, uses & daily requirement. Safe & wholesome water.
Impurities & methods of purification of water. Biological membrane & BOD.
Water quality standards: WHO bacteriological standard of water. Water borne
& water related diseases.
Water - Our planet has 70% of its surface covered with water. Among the 70% water,
97.5% water is ocean water (salty)
1.725% is in glaciers, snow
0.075% is ground water
0.025% is in the lakes, rivers
Much of the ill health which affects humanity, especially in the developing countries can be
traced to lack of water that is easily accessible, adequate in quantity, free from contamination,
safe and readily available throughout the year
• Fresh Water - is defined as water with a salinity of less than 0.35% of the oceans.
• Safe & Wholesome Water - Safe and wholesome water has been defined as water that is
➢ Free from pathogenic agents
➢ Free from harmful chemical substances
➢ Pleasant to the taste i.e. free from color and odor
➢ Usable for domestic purposes
Water is said to be ‘polluted or contaminated’ when it does not fulfill the above criteria
• Water Requirement -
➢ For drinking water: about 2 liters/head/day
➢ For all urban domestic purpose: 150-200 liters/capita/day
➢ For rural areas: 60-75 liters/capita/day
• Uses of Water -
➢ Domestic use: For drinking, cooking, washing, personal hygiene, gardening etc.
➢ Public purposes: cleaning streets, recreational purposes (swimming pools, public
fountains, ornamental ponds), fire protection and public parks.
➢ Industrial purposes: For processing and cooling.
➢ Agricultural purpose: Irrigation.
➢ Power production from hydropower and steam power
➢ Carrying away waste from all manner of establishments and institutions.
➢ As a thermal transfer agent
➢ Food processing
➢ As a solvent.

60 | P a g e
• Sources of Water Supply -

➢ Rain water:
▪ Purest water in nature
▪ Soft water
▪ Suitable for drinking, cooking, washing and bathing
▪ In some countries (Gibralter), rain is the main source of drinking water
▪ Acid rain
➢ Surface water:
▪ Mostly polluted water
▪ Impounding reservoirs
▪ Rivers and streams
▪ Tanks, ponds and lakes
➢ Impounding reservoirs: These are artificial lakes, where surface water is stored.
The area draining into the reservoir is called catchment area. Water quality is
fairly good but needs purification before drinking
➢ Ground water: usually safe
➢ Water of springs
➢ Wells - may be dug well and tube well (according to method of construction) or
Shallow and deep wells (according to technology)
▪ Shallow wells -
o Taps water from above the first impervious soil stratum
o Open to surface pollution
▪ Deep wells -
o Taps water from below the first impermeable stratum
o Free from pollution and good for drinking
o Safe but hard

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Water Pollution - water is polluted from 2 sources

1. Natural impurities - not essentially dangerous. Natural impurities derived from the
atmosphere, catchment area and soil. These impurities are dissolved gases (nitrogen,
carbon dioxide, hydrogen sulphide, etc. picked up during rainfall from atmosphere),
dissolved minerals (salts of calcium, magnesium, sodium etc. mixed with water during
contact with soil), suspended impurities (e.g. clay, silt, sand and mud) and microscopic
organisms.
2. Manmade Impurities - more serious aspect. It is of 4 types -
i. Sewage/ Municipal wastes: Discharge of sewage and municipal wastes into
water bodies which includes discharges from toilets, washrooms, kitchens etc.
from dwellings, institutions and commercial buildings. The principal pollutants
are pathogenic bacteria, decomposable organic matter and suspended solids.
ii. Industrial and trade waste: Industrial activities generates a wide variety of waste
which are generally discharge into water bodies and may be organic and
inorganic contaminants such as acids, alkalis, dyes, soaps, waxes, suspended
matter, oil, toxic metals, radioactive materials, biological pollutants include
bacteria, viruses, plants and animals.
iii. Agricultural pollutants: fertilizers and pesticides washed out of the soil by rain.
Wastes and waste water from cattle shed, poultry farms.
iv. Physical pollutants: heat (thermal pollution) and radioactive substances.
Purification of Water -
Water
Purification
Large Small
Disinfection
Storage Filtration Disinfection Household
of Well
Slow Sand
Physical Chlorination Boiling Bleeching
Filter
Rapid Sand
Chemical Ozonation Chemical Double Pot
Filter
Ultraviolate
Biological Filtration
Radiation
Ultraviolet
Irradiation
Reverse
Osmosis

62 | P a g e
1. Purification of water on a large scale/ community purpose

a. Storage - it occurs in 3 ways
i. Physical - 90% of suspended impurities settle down in 24 hours by gravity
and reduce the work of filter.
ii. Chemical – certain chemical changes took place and free ammonia is
reduced
iii. Biological – pathogenic organism gradually dies out and tremendous drop
of bacterial count occur
b. Filtration - About 98 to 99% of bacteria are removed by filtration. There are 2
types of filters
i. Slow sand filters - In 1804, first used in Scotland and London but even
today accepted as the standard method of water purification.
▪ Essential elements:
a. Supernatant (raw) water (1 to 1.5 m)
b. A bed of graded sand (1.2 m) supported by a layer of
graded gravel (0.30 m)
c. An under-drainage system; and
d. A system of filter control valves
▪ Vital layer: When the filter is newly laid, it acts merely as a
mechanical strainer. But very soon, the surface of the sand bed
gets covered with a slimy and gelatinous layer consists of
threadlike algae and plankton, diatoms and bacteria. This layer is
known as “Schmutzdecke”, vital layer, zoogleal layer or biological
layer. The formation of vital layer is known as “ripening” of the
filter. It may take several days to be fully formed. Vital layer is the
heart of the slow sand filter. It helps in yielding a bacteria-free
water by holding back bacteria and organic matter.
ii. Rapid sand filter
▪ Types
a. The gravity type – e.g. Paterson‟s filter
b. The pressure type – e.g. Candy‟s filter
▪ Steps - The following steps are involved in the purification of
water by rapid sand filters:
a. Coagulation
b. Rapid mixing
c. Flocculation
d. Sedimentation
e. Filtration

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Difference between Slow Sand Filter & Rapid Sand Filter

Criteria Slow Sand Filter Rapid Sand Filter
Occupies large area Occupies very little
Space
space
Slower, output is 50 Rapid, output is 2500
Rate of Filtration
gallons/sq.ft./day gallons/sq.ft./day
Three folds – physical, Essentially mechanical
Mode of Filtration
chemical & biological
No coagulant is required, Chemical coagulant
Preliminary Treatment
need storage such as alum is needed.
Suitable for clear and Suitable for turbid water
Turbidity of Water
slightly turbid water
Not easy, filter beds are easy (by back washing),
Washing ready after 3 days filter is ready after 15
minutes
Operation Simple to operate Highly skilled
Cheaper than rapid More costly
Cost of Construction
sand filter
Removal of Bacteria 99.9 – 99.99 per cent 98-99 per cen
Bacteriologically water Bacteriologically water is
is almost pure. not safe. Chlorination is
Chlorination
Chlorination of water is necessary
not essential
c. Disinfection - 3 types.
i. Chlorination - is adding chlorine to water as disinfectant. It is supplement,
not a substitute to sand filtration.
▪ Function of Chlorine (mechanism of chlorination):
➢ Chlorine kills pathogenic bacteria, but is has no effect on
spores and certain viruses (e.g., polio, viral hepatitis)
except in high doses.
➢ Apart from its germicidal effect, it oxidizes iron,
manganese and hydrogen sulphide.
▪ Advantage of chlorination:
➢ Powerful germicide and oxidizes iron, manganese and
hydrogen sulphide.
➢ Cheap
➢ Reliable
➢ Efficient
➢ Harmless

64 | P a g e
▪ Disadvantage of chlorination:
➢ Cannot remove hardness
➢ Cannot remove odor
➢ Cannot remove color
➢ Taste of water will be altered
➢ Cannot remove suspended material
▪ Principles of chlorination:
➢ Water should be clear and free from turbidity.
➢ Chlorine Demand - should be estimated. It is the amount
of chlorine that is needed to destroy bacteria, to oxidize all
the organic matter and ammoniacal substances present in
the water. The chlorine demand of water is the difference
between the amount of chlorine added to the water and
the amount of residual chlorine remaining at the end of a
specific period of contact (usually 60 min) at a given
temperature and pH of the water
➢ Contact period - at least one hour is essential.
➢ Concentration of free residual chlorine - 0.5 mg/L for one
hour
➢ Correct dose of chlorine - chlorine demand for specific
water + residual chlorine
▪ Methods of chlorination:
➢ Chlorine gas (first choice because it is cheap, quick in
action, efficient and easy to apply).
➢ Chloramine or
➢ Perchloro
The sum of the chlorine demand of the specific water (at a given
temperature and pH) plus the free residual chlorine of 0.5 mg/L
for one hour constitutes the correct dose of chlorine to be
applied.
▪ Break Point Chlorination: The point at which the chlorine demand
of the water is met and the residual chlorine appears in the water
is called „break point‟. Break point chlorination is the adjustment
of the chlorine dose to a level which will completely oxidize the
organic matter in the water eliminating the total chlorine demand
and keep a slight residual chlorine in the water
ii. Ozonation
iii. Ultraviolet irradiation

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2. Purification of water on a small scale - 2 ways

a. Household purification of water - 5 methods
i. Boiling - Satisfactory method of purifying water. ‘Rolling boil’ for 10 to 20
minutes to be effective. Kills all bacteria, spores, cysts and ova. Removes
temporary hardness. Altered taste but harmless
ii. Chemical disinfection –
▪ Bleaching powder or chlorinated lime
▪ Chlorine solution
▪ High test hypochlorite (HTH) or perchloro
▪ Chlorine tablets (trade name – Halazone tablets) - single tab (0.5g)
for 20 L of water
▪ Iodine
▪ Potassium permanganate (no longer recommended)
iii. Filtration – ceramic filters such as,
▪ Pasteur Chamberland filter
▪ Berkefeld filter
▪ Katadyn filter
iv. Ultraviolet irradiation
v. Multi-stage reverse osmosis purification of water
b. Disinfection of wells - 2 methods
i. By bleaching powder: most effective and cheapest method
ii. The double pot method: during an emergency
Hardness of Water - Hardness is defined as soap destroying power of water. Requires

considerable amount of soap to produce a foam or lather and that also produce scale in
heaters, boilers, hot water pipes. Surface waters are softer than ground water. Drinking water
should be moderately hard. Softening of water is required when hardness exceeds 300mg/l.
• Cause - caused by mainly 4 compounds

1. Calcium bicarbonate
2. Calcium sulfate
3. Magnesium bicarbonate
4. Magnesium sulfate
• Classification - Hardness is classified as
1. Carbonate or temporary hardness
2. Non-carbonate or permanent hardness

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• Classification in terms of presence of CaCO₃ as follows:

1. Soft water ------------------- <50mg/l
2. Moderately hard ----------- 50 – 150mg/l
3. Hard water ------------------150 – 300mg/l
4. Very Hard water ----------- >300mg/l
• Disadvantage -
➢ Consume more soap and detergents
➢ Scaling boilers, water heater etc.
➢ Adversely affects cooking
➢ Shortens the life of fabrics
➢ Shortens the life of industrial
➢ machineries pipes and fixtures
• Removal of hardness:
➢ Temporary -
▪ Boiling
▪ Addition of lime
▪ Addition of sodium carbonate
▪ Permutt process or Base exchange
➢ Permanent -
▪ Addition of sodium carbonate
▪ Permutt process or Base exchange
Q. How to make flood water safe for drinking purpose?

1. First, pass it through a clean cloth
2. Then, do flocculation by adding alum. If alum is not available, the water is allowed to
settle by giving durable time
3. Take supernatant clean water
4. Add Chlorine tablets (trade name – Halazone tablets) - single tab (0.5g) for 20L of water.
Or rolling boiling for at least 10 minutes
5. The water is ready to take after 1 hour of contact with chlorine or being cold after heat

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Quality of Water - it has 4 aspects

1. Acceptability Aspects
a. Physical parameter – Drinking water should be free from turbidity, color and
unusual taste or odor. Cool water is more palatable.
b. Chemical parameter –Chloride (standard level – 200mg/L), hardness, ammonia,
pH (6.5-8.5), hydrogen sulphide etc.
2. Microbiological Aspects
a. Bacteriological standard of drinking water - Ideally drinking water should not
contain any pathogenic microorganism.
i. No sample should contain E. coli in 100ml.
ii. No sample should contain more than 3 coliform organisms per 100ml.
iii. Not more than 5% samples throughout the year should contain coliforms
in 100 ml.
iv. No two consecutive sample should have coliform organisms in 100ml.
In case of small community water supply, no sample should contain more than
10 coliform organisms per 100ml. If E. coli is repeatedly found, the water is unfit
for drinking. The finding of fecal streptococci in water is regarded as an
important confirmatory evidence of recent fecal pollution of water.
b. Viral standard of drinking water - Fecal bacteriophages and enteropathogenic
viruses should be absent.
3. Chemical Aspects - Inorganic chemicals of health significance in drinking water
Constitute Guideline Value (mg/l)

0.01 (WHO)
Arsenic
0.05 (Bangladesh)
Mercury 0.001
Lead 0.01
Fluoride 1.5
Cadmium 0.003
Chromium 0.05
4. Radiological Aspects

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Arsenic Contamination of Water - Arsenic (As) is a naturally occurring metalloid element. It

may be present in inorganic or organic forms in the environment both naturally and due to
certain human activities. In Bangladesh, arsenic contamination of water in tube wells was
confirmed in 1993 at Barogharia union of Chapai Nawabganj district. As per WHO standard, the
recommended arsenic concentration limit in potable water is 0.01mg/liter. In Bangladesh the
limit is set at 0.05 mg/liter.
Arsenicosis - Arsenicosis is defined as the “chronic health condition arising from prolonged
ingestion (not less than 6 months) of arsenic above a safe dose, usually manifested by
characteristic skin lesions, with or without involvement of internal organs”. This manifestations
are slow to develop and chronic in nature. Melanosis and keratosis are the principal features.
• Clinical stages of arsenicosis are - 3 stages

1. Primary stage or stage 1:
▪ Melanosis
▪ Keratosis
▪ Conjunctivitis
▪ Gastroenteritis
▪ Inflammation of respiratory tract
2. Secondary stage or stage 2:
▪ Leucomelanosis
▪ Hyperkeratosis
▪ Non-pitting oedema of feet and legs
▪ Peripheral neuropathy
▪ Liver and kidney disorders
3. Tertiary stage or stage 3:
▪ Gangrene of distal organs or parts of the body
▪ Cancer of skin, lungs, urinary bladder
▪ Kidney and liver failure
• Diagnosis - requires clinical examinations supported by laboratory tests of air, water or
biological specimens like blood, urine, hair and nail. Clinical manifestations of skin
lesions are the commonest and earliest in arsenicosis patients. Arsenic in urine indicates
the recent arsenic exposure whereas arsenic in hair is indicates the past arsenic
exposure.
• Prevention and Control -
➢ Detection of contamination
➢ Identification of cases
➢ Cessations of arsenic contaminated water intake
➢ Provision of safe drinking water
➢ Symptomatic treatment of cases and treatment with specific antidotes.

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• Surface water can be treated by-

➢ Slow sand filter
➢ Pond sand filter
➢ Sono filter
➢ Pressure filter
• Government Strategies -
1. Phase one: to identify the arsenic contaminated tube wells and mark them with
red color and mark the non-contaminated ones with green color.
2. Phase two: to provide deep tube wells as an emergency measures at levels
below 800 feet.
3. Phase three: to provide treated safe surface water to people
Water Borne Diseases - 2 types

1. Disease caused by the presence of an infective agent
i. Viral - Viral hepatitis A, hepatitis E, Poliomyelitis, Rota virus diarrhea in infants
ii. Bacterial - Typhoid and paratyphoid fever, bacillary dysentery, Esch. coli
diarrhea, cholera
iii. Protozoal - Amoebiasis, giardiasis
iv. Helminthic - Round worm, thread worm, hydatid disease
v. Leptospiral - Weil’s disease
2. Those due to the presence of an aquatic host
i. Snail - Schistosomiasis
ii. Cyclops - Guinea worm, Fish tape worm
Water Related Disease -

1. Arsenicosis
2. Rabies

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Chemical Hazards of Water Pollution -

1. Salts of lead, zinc and iron - Constipation
2. Salts of magnesium and aluminum - Diarrhea
3. Deficiency diseases -
a. Iodine deficiency - Goiter
b. Fluoride deficiency - Dental Carries
4. Mercury - Minamata disease
5. Cadmium - Itai Itai disease
6. Poisoning -
a. Excess of phosphorus - Phosphorus poisoning
b. Excess of nitrates - Cyanosis in infant
c. Excess of iron - Dyspepsia
d. Excess of fluoride - Dental Fluorosis
e. Excess of arsenic - Arsenic poisoning
7. Rotten vegetable materials - Diarrhea
8. Prolong use of Lead salt - Plumbism
9. Chromium - Cancer
Q. Why coliform organisms are chosen as indicators for fecal pollution of water?
1. they are constantly present in great abundance in the human intestine.
2. easily detected by culture methods - as small as one bacteria in 100 ml of water
3. survive longer than the pathogens
4. the coliform bacilli have greater resistance to the forces of natural purification than the
water borne pathogens
5. If the coliform organisms are present in a water sample, the assumption is the probable
presence of intestinal pathogens.

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Item 04: Noise: definition, sources & levels. Health effects & control measures.
Light: definition, sources. Public health problems related to light. Criteria of
good lighting. Radiation: definition, sources & types. Radiation hazards &
protective measures
Sound - Sound is a form of energy, which is emitted by vibrating sources and transmitted
through a medium, producing it as the sensation of hearing.
Noise - Wrong sound, which is experienced in a wrong place at the wrong time.
Noise Pollution - is excessive, displeasing human, animal or machine-created environmental
noise that disrupts the activity or balance of human or animal life.
• Sources -
➢ Automobiles
➢ Factories, industries
➢ Air-crafts, airports
➢ Railway junctions
➢ Bus terminals
➢ Use of pressure horns
➢ Recreational noise of loudspeakers
➢ Domestic noises from the radios, T.V sets etc.
• Properties - has 2 important properties
a. Loudness: Loudness or intensity of noise is measured in decibels (dB). “Sound
Level Meter” measures the intensity of sound in dB. The “Audiometer” measures
the hearing ability.
Normal conversation produces 60-65 dB noise.
Whispering produces 20-30 dB.
Heavy street traffic produces 60-80 dB.
Boiler factories produces 120 dB.
A daily exposure up to 85 dB is the recommended maximum limit that people
can tolerate without substantial damage to their hearing.
b. Frequency: The frequency is denoted as Hertz (Hz.). One Hz is equal to one wave
per second. The human ear can hear frequencies from about 20 to 20,000 Hz.
The range of vibrations below 20 Hz are infra-audible. The range above 20,000
Hz is ultra-sonic.

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• Acceptable noise levels (dBA)

Area dBA
Residential Bedrooms 25
Living Room 40
Commercial Office 35 to 45
Conference 40 to 45
Restaurants 40 to 60
Industrial Workshop 40 to 60
Laboratory 40 to 50
Educational Class room 30 to 40
Library 35 to 40
Hospitals Wards 20 to 35
• Effects of noise exposure on health

A. Auditory effects:
▪ Auditory fatigue: It appears in the 90 dB intensity of noise. Whistling,
buzzing in the ears.
▪ Deafness: The hearing loss may be temporary or permanent.
a. Temporary hearing loss: It is reversible, occurs immediately after
exposure to significant loud sound. Disability disappears after a
period of time up to 24 hours following the noise exposure.
Mostly occurs in frequency range between 4,000 to 6,000 Hz.
b. Permanent hearing loss: Repeated or continuous exposure to
noise around 100 dB may result in a permanent hearing loss.
Exposure to noise above 160 dB may rupture the tympanic
membrane and cause permanent loss of hearing.
▪ Acoustic trauma: resulting from explosion or very loud impulse.
B. Non-auditory effects:
▪ Interference with speech
▪ Annoyance
▪ Decreased efficiency due to lower mental concentration
▪ Physiological changes:
➢ Rise in blood pressure
➢ Rise in intracranial pressure
➢ Increase in heart rate and breathing
➢ Increase in sweating
➢ General symptoms such as giddiness, nausea and fatigue
➢ Sleep interference
➢ Visual disturbance – narrowing of pupils, affect color perception
and reduce night vision

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• Prevention and Control -

➢ Careful planning of cities:
▪ Division of the city into zones with separation of areas concerned with
industry and transport.
▪ Separation of the residential areas from the main streets by means of
wide green belts.
▪ Widening of main streets to reduce the level of noise penetration into
dwellings.
➢ Control of vehicles:
▪ Heavy vehicles should not be routed into narrow streets.
▪ Vehicular traffic on residential streets should be reduced.
▪ Use of pressure horn should be prohibited.
➢ To improve acoustic insulation of building: Construction of detached and sound-
proof buildings.
➢ Industries and railways: Special areas like industries, railways must be
earmarked, outside residential areas.
➢ Protection of exposed persons: Hearing protection for all workers who are
consistently exposed to noise louder than 85 dB.
➢ Legislation: Adaptation of legislation of countries for controlling noise pollution
sources.
➢ Health education: Education of people through available media highlighting the
importance of noise as a community hazard

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Radiation -
• Sources - divided into 2 group

A. Natural
▪ Cosmic rays
▪ Environmental:
o Terrestrial
o Atmospheric
▪ Internal radiation:
o Potassium – 40
o Carbon - 14
B. Man-made
▪ Medical and dental: X-Rays, Radio isotopes
▪ Occupational exposure
▪ Nuclear explosion: radioactive fall-out
▪ Miscellaneous: Television sets, Radio-active dial watches, Isotope tagged
products, Luminous markers.
• Types - 2 types
1. Ionizing radiation – radiation which has the ability to penetrate tissues and
deposit its energy with in them. This may be divided into two groups:
▪ Electromagnetic radiations – X-Rays and gamma rays
▪ Corpuscular radiations – alpha particles, beta particles and protons
2. Non-ionizing radiation – Refers to several forms of electromagnetic radiation of
wavelengths longer than those of ionizing radiation. It includes Ultraviolet (UV)
radiation, visible light, infrared radiation, microwave radiation and
radiofrequency radiation
• Biological Effects
A. Somatic effects:
▪ Immediate:
o Radiation sickness
o Acute radiation syndrome
▪ Delayed:
o Leukemia
o Carcinogenesis
o Fetal developmental abnormalities
o Shortening of life
B. Genetic effects
▪ Chromosome mutations
▪ Point mutations

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• Radiation Protection - of the man-made sources, X-Ray constitute the greatest hazard.
➢ Unnecessary X-Ray examinations should be avoided, especially in the case of
children and pregnant women.
➢ Adequate control and surveillance of X-ray installations.
➢ Protection of workers by effective protective measures which includes proper
use of lead shields and lead rubber aprons, wearing film badge or dosimeter.
➢ Improvement in techniques
➢ Improvements leading to dose reduction
➢ Periodic medical examinations of workers
➢ Regular working hours, recreation and holidays must be ensured to workers

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Item 05: Solid Waste: sources, health hazards & methods of disposal. Housing:
housing standard. Overcrowding
Waste - Waste (also known as rubbish, trash, refuse, garbage, junk) is any unwanted or useless
materials. Depending on their physical state they are classified as:
1. Liquid waste
2. Gaseous waste
3. Solid waste
Solid Waste - Solid waste predominantly, is any garbage, refuse or rubbish that we make in our
homes and other places. These include garbage, rubbish, demolition products, sewage
treatment residue, dead animals, manure and other discarded materials. They may include any
waste that is non-liquid. It should not contain night soil.
Thus, solid waste or refuse is unwanted or discarded waste material from houses, street
sweeping, commercial, industrial and agricultural operations arising from man’s activities.
• Health Impacts - solid waste is a health hazard because:

➢ It decomposes and favors fly breeding
➢ It attracts rodents and vermin
➢ The pathogens of solid waste may be conveyed back to man’s food through flies
and dust
➢ There is possibility of water and soil pollution
➢ Piles of refuse present an unsightly appearance and nuisance from bad odors.
• Sources of Refuse -
➢ Street refuse: refuse that is collected by the street cleansing service or
scavenging consisting of leaves, straw, paper, animal droppings and litter of all
kinds.
➢ Market refuse: refuse that is collected from markets containing putrefied
vegetable and animal matter.
➢ Stable litter: refuse that is collected from stables containing animal droppings
and leftover animal feeds.
➢ Industrial refuse: refuse comprises of wastes ranging from completely inert
materials to highly toxic and explosive compounds.

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➢ Domestic refuse: consists of ash, rubbish and garbage.

▪ Ash: the residue from fire used for cooking and heating.
▪ Rubbish: useless waste, rejected or worthless matter like paper, clothing,
bits of wood, metal, glass, dust and dirt.
▪ Garbage: waste matter arising from the preparation, cooking and
consumption of food.
• Storage -
➢ Galvanized steel dustbin with fitting cover
➢ Paper sack
➢ Public bins
• Collection -
➢ House-to-house collection.
➢ Curb-side collection: container, bag collected from curb side or foot path.
➢ Block collection: a collection vehicle travel through a block or road at a definite
time and collect waste.
➢ Community collection: collection of refuse from public bins, street dump, open
space.
• Methods of Refuse Disposal - 6 principal methods
1. Open dumping - refers to low lying uncovered areas that are used to dump solid
waste of all kinds. The waste is untreated and not segregated.
▪ Disadvantage:
o It is the breeding ground for flies, rats and other insects that
spread disease.
o It is the source of nuisance from the smell and unsightly
appearance.
o The loose refuse is dispersed by the action of the wind.
o The rainwater run-off from these dumps contaminates nearby
land and water, thereby spreading disease.
2. Sanitary land-fill - is an economical, sanitary and the most satisfactory method of
refuse disposal where suitable land is available. Sanitary land-fill are designed to
greatly reduce or eliminate the risks that waste disposal may pose to the public
health and environmental quality. Essentially it consists of depositing refuse on
dumps and adequately covering with a layer of earth at the end of each day’s
operation. The refuse is placed in layers, compacted with bulldozers and covered
with earth. In the “modified sanitary land-fill” compaction and covering are done
once or twice a week.

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▪Methods - 3 methods are used in this operation:

a. The trench method – when level ground is available, a long trench
is dug out to place the refuse in the fill.
b. The ramp method – this method is well suited where the terrain is
moderately sloping.
c. The area method – this method is used for filling land
depressions, disused quarries and clay pits
▪ Advantages -
o Simple method
o No costly plant required
o No residues or by products need to be disposed
o Separation not required
o Unused land can be used
o Methane gas can be used as fuel
▪ Disadvantages
o Large land required
o Proper dumping site may not be available
o Odor problem
o Use of insecticides required
o Leachate should be collected regularly
o Methane gas should be collected properly
o Greenhouse gas problem
3. Incineration - is the most common thermal treatment process. It is burning of
the waste at a temperature of 1000℃ + 100℃ in the presence of oxygen. It is the
method of choice where suitable land is not available. Incinerator are particularly
useful for the disposal of hospital refuse. It is practiced in large cities,
industrialized countries due to lack of suitable land
▪ Disadvantage:
o A preliminary separation of dust or ash is needed.
o It involves heavy outlay and expenditure.
o It’s construction and operation involve many engineering
principles.
o Loss to community in terms of manure.
4. Composting - is a method of disposal of refuse along with human excreta or
sludge. In this process the organic matters are broken down by bacterial action
resulting in the formation of “compost” – relatively stable humus like material.
The principal by-products are carbon dioxide, water and heat. The end-product -
compost is a good soil builder containing small amounts of major plant nutrients
such as nitrates and phosphates and can be used as manure in agricultural land.
The methods commonly used are: 2 methods

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a. Hot Fermentation or Anaerobic Composting Method - It has been

recommended as a satisfactory method of disposal of town waste and
night soil. Trenches are dug 3 ft deep, 5-8 ft broad and 15-30 ft long and
the pits should be located not less than ½ miles from city limits. The
composting procedure:
o First a layer of refuse about 6 inch thick is spread at the bottom of
the trench, over this 2-inch-thick night soil is added.
o Then alternate layers of refuse and night soil are added till the
pile rises to 1 ft. above the ground level.
o The top layer should be of refuse, at least 9 inch thick and then
the pile is covered with excavated earth.
In the hot fermentation process, the heat produced (>60° C for several
days) during composting destroys pathogenic organisms and eggs and
larvae of flies. It generally takes 4 to 6 months for the decomposition of
refuse and formation of compost.
b. Mechanical or Aerobic Composting Method - The refuse is first cleared of
salvageable materials such as bones, metal, glass. It is then pulverized in
order to reduce the size of particles to less than 2 inches. The pulverized
refuse is then mixed with sewage, sludge or night soil in a rotating
machine and incubated. The entire process of composting is complete in
4 to 6 weeks. This method is used in Germany, Holland, Switzerland.
5. Manure Pit - Behind any cattle shed village people dig a manure pit to dispose
cow-dung or any animal dropping, left over foods of animal. After one or two
seasons these becomes good organic manures.
6. Burial - Very popular and common in rural areas where people dig ditches, put all
refuses and at the end of the day cover these by earth and ash. When the ditch is
filled, a new one is dug beside it. By this time old ditch ripe to be used as organic
fertilizer. This method is suitable for small camp.
Recycling - is processing used materials into new products. It reduces the consumption of fresh
raw materials, reduce energy usage, reduce air pollution (from incineration) & water pollution
(from landfilling). It is a key component of modern waste reduction & is the 3 rd component of
‘reduce, reuse, recycle’ hierarchy.

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Housing -
• Criteria - an expert committee of the WHO recommended the following criteria for
healthful housing:
➢ Provides physical protection and shelter;
➢ Provides adequately for cooking, eating, washing and excretory functions;
➢ Is designed, constructed, maintained and used in a manner such as to prevent
the spread of communicable diseases.
➢ Provides for protection from hazards of exposure to noise and pollution;
➢ Is free from unsafe physical arrangements due to construction or maintenance
and from toxic or harmful materials;
➢ Encourages personal and community development, promotes social
relationships and by these means promotes mental health.
• Housing Standard
➢ Site: Elevated, independent access from main street, soil dry and safe, subsoil
water table below 10 feet.
➢ Set back: open space all around the house,
▪ Rural area – built up structure should not exceed one third of total area.
▪ Urban area – build up two third of total area.
➢ Floor: Pucca, Impermeable, easily washed, smooth free from cracks, crevices,
damp proof
➢ Walls: reasonably strong, do not absorb heat and conduct the same, unsuitable
for harboring rats, insects etc.
➢ Roof: not less than 10 ft, low heat transmittable.
➢ Rooms: not less than 2.
➢ Floor area: living room at least 120 sq.ft, per person not less than 50 sq.ft.
➢ Windows: living room should have at least two windows, window’s height not
more than 3 ft, windows area should be one fifth of the floor area with door two
fifth of floor area.
➢ Facilities: kitchen, bathroom, toilet.
➢ Utilities: water supply, lighting, fuel, waste disposal, drainage.
• Health Effect of Poor Housing -
➢ Respiratory infections: common cold, TB, influenza, diphtheria, measles,
whooping cough, bronchitis etc.
➢ Skin infections: scabies, ringworm, impetigo
➢ Rat infestations: plague.
➢ Arthropods: houseflies, mosquitoes, fleas and bugs.
➢ Accidents: by some defect in the home and its environment.
➢ High morbidity and mortality.
➢ Psychosocial effects: sense of isolation, neurosis, behavior disorders in people
living densely populated urban area

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Overcrowding - refers to the situation in which more people are living within a single dwelling
than there is space for, so that movement is restricted, privacy secluded, hygiene impossible,
rest and sleep difficult
• Health Problems -
➢ It may promote the spread of infectious diseases, respiratory infections like TB,
influenza and diphtheria.
➢ Psychosocial effects like irritability, frustration, lack of sleep, anxiety, violence
and mental disorder.
• Accepted Standards with Respect to Overcrowding -
➢ Persons per room:
▪ 1 room - 2 persons
▪ 2 rooms - 3 persons
▪ 5 or more rooms - 10 persons (additional 2 or each further room)
➢ Floor space:
▪ 110 sq. ft. or more - 2 persons
▪ 90-100 sq. ft. - 1 ½ persons
▪ 70-90 sq. ft. - 1 person
▪ 50-70 sq. ft. - ½ person
▪ under 50 sq. ft - nil
➢ Sex Separation: overcrowding is considered to exist if 2 persons over 9 years of
age, not husband and wife, of opposite sexes are obliged to sleep in the same
room.

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Item 06: Human Excreta: sanitation barrier. Excreta borne diseases. Methods of
excreta disposal for different areas & purposes (e.g. cities, towns, rural areas, in
festival etc.). Different types of latrine. Definition of sewage, sullage & sludge
Sewerage - refers to entire system of collection, treatment and disposal sewage through a
system of network of sewers.
Sewage - is waste water from a community, containing solid and liquid excreta derived from
houses, street and yard washings, factories and industries
Sewer - is a network of underground pipes which collect and transport excreta and waste water
to place of ultimate disposal.
Sludge - is a solid, semi-solid or liquid thick black mass from a waste treatment plant or water
treatment plant containing 95% water and it has a bad odor
Sullage - liquid discharges from kitchen and wash basin etc. and excludes human excreta.
Leachate - any liquid resulting from contact with or passage through solid wastes landfills. It
may contain hazardous substances
Health Hazards of Improper Excreta Disposal -
• Soil pollution – spread of soil borne diseases.

• Water pollution – spread of waste borne diseases.
• Contamination of foods – spread of food borne diseases.
• Propagation of flies – spread of fly borne diseases.
• Sources of foul smell
Fecal Borne Diseases -
• Diseases resulting from Contamination -

A. Viral:
▪ Viral hepatitis A & E
▪ Poliomyelitis
▪ Rota virus diarrhea in infants
B. Bacterial:
▪ Typhoid & paratyphoid fever
▪ Bacillary dysentery
▪ E. coli diarrhea
▪ Cholera

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C. Protozoal:
▪ Amoebiasis
▪ Giardiasis
D. Helminthic:
▪ Hook worm
▪ Thread worm
▪ Tape worm
• Transmission of diseases - Excreta contains a variety of pathogens bacteria, viruses,
protozoa, fungi and helminths. The human excreta of a sick person or a carrier of
disease is the main focus of infection. The disease agent is transmitted to a new host
through various channels -
a. Water
b. Finger
c. Flies
d. Soil
e. Food
Sanitation Barrier - The barrier approach to sanitation prevents disease agents in feces from
gaining access to new host through various channels such as fingers, flies, fields and fluids.
Through them pathogens are transmitted from feces to food or directly to humans. When feces
contaminate the environment, the vicious cycle of people contaminating the environment and
becoming infected by the contaminated environment continues. Sanitary barrier may be
defined as the sanitary, physical or biological, intervention through proper disposal of excreta
to limit the migration, interbreeding or free movement of harmful disease agents from
environment to human host. Components of sanitation barrier are-
➢ food
➢ fluids
➢ flies
➢ feces
➢ fingers
In order to break the disease cycle of fecal borne diseases, the most effective intervention
would be at the level of segregation of feces by imposing a barrier which is called the sanitation
barrier. It provides a proper sanitary disposal of feces so that the disease agent cannot reach
new host directly or indirectly.

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Methods of Excreta Disposal -

A. Unsewered areas:
i. Service type latrines (conservancy system): Night soil is collected and disposed
manually by human agency.
ii. Non-service type (sanitary latrines) - [details later]
▪ Types - 6 types. At present time, the most suitable method in rural areas
is the hand flushed water seal type of latrines for majority of the families
and for the well-to-do family septic type of latrine.
1. Bore hole latrine
2. Dug well latrine
3. Water seal latrine
4. Septic tank
5. Aqua privy
6. Chemical closet
▪ Criteria -
➢ Excreta in the latrines should not contaminate the ground and
surface water, should be located 50 ft away from source of water
supply.
➢ Excreta should not pollute soil.
➢ Excreta should not be accessible to flies, rodents, animals and
other vehicles for transmission disease agent.
➢ Excreta should not create a nuisance due to odor or unsightly
appearance.
➢ Latrine should have adequate water supply and superstructure for
proper privacy
ii. Shallow trench latrine – temporary type of latrines suitable for camps,
exhibitions and fairs.
B. Sewered areas:
1. Primary treatment –
▪ Screening
▪ Removal of grit
▪ Primary sedimentation
2. Secondary treatment –
▪ Trickling of filters
▪ Activated sludge process
▪ Digestion of sludge

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3. Other methods –
▪ Sea out falls
▪ River outfall
▪ Sewage farming
▪ Oxidation pond
Sanitary Latrines (non-service type) -

1. Bore Hole Latrine -
➢ Criteria:
▪ First introduced by Rockefeller Foundation during 1930 in campaigns of
hook worm control.
▪ The latrine consists of a circular hole (30-40 cm in diameter & 4-8 m in
depth) dug vertically into the ground.
▪ This is for a family of 5-6 members for one year.
▪ The night soil undergoes purification by anaerobic digestion.
➢ Merits:
▪ No need for the services of a sweeper for daily removal of night soil.
▪ Unsuitable for fly breeding.
▪ If located 15 m away from source of water supply, there should be no
danger of water pollution.
➢ Demerits:
▪ Small capacity.
▪ A special equipment, the auger is required for the construction which
may not be readily available.
▪ In many places, the subsoil water is high and the soil loose with the result
it may be difficult to dig a hole deeper than 3m
2. Dug Well Latrine -
➢ Criteria:
▪ A circular pit about 75 cm in diameter and 3-3.5 m deep.
▪ The pits may be lined with pottery rings to prevent caving in of the soil.
▪ A concrete squatting plate is placed on the top of the pit and the latrine is
enclosed with a superstructure to provide privacy.
▪ The night soil undergoes purification by anaerobic digestion.
➢ Advantage:
▪ It is easy to construct and no special equipment is needed to dig the pit.
▪ The pit has a longer life than bore hole latrine because of greater capacity

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3. Water Seal Latrine - it could be used as a sanitary latrine for the rural people. Water seal
latrine is a hand flushed latrine, in this latrine squatting plate is fitted with a trap for
water seal. For rural people, it is more acceptable than bore hole or pit latrine.
➢ Advantage:
▪ Provide sanitary disposal of excreta – It prevents access of flies (i.e. the
night soil is sealed off from flies, by a small depth of water contained in
the bent called the trap), escape of odor and foul gases and thereby
eliminates the nuisance from smell. Once the night soil is flushed, it is no
longer visible.
▪ Prevent pollution of soil
▪ Prevent contamination of water supplies
▪ Can be easily cleaned
▪ Require small quantity of water for flushing
▪ Do not smell so that it can be located near the house
▪ Reasonably cheap
▪ Safe, privacy protected and acceptable to the villagers (Safe for children).
▪ Sludge can be used as fertilizer.
▪ Easy to construct and maintenance.
➢ Demerits:
▪ Risk of polluting ground and surface water and soil.
▪ Cannot be construct where ground water table is high.
▪ Water supply must be available.
▪ Need motivation of the people.
➢ Essential Features -
▪ Location:
 Should be at least 15m (50ft) from water source.
 Should be at lower level than the surface to prevent bacterial
contamination of water supply.
 Should not be located in areas usually subject to flooding.
▪ Squatting plate:
 The squatting plate or slab should be of an impervious material.
 Dimension should be of 90cm² and 5cm thickness at the outer
edge.
 There is a slope towards the pan.
 Raised foot rests are included in the squatting plate.
▪ Pan:
 The pan receives night soil, urine and wash water.
 The length is 42.5cm and the width at its widest portion is 20cm.
 There is a slope towards the back.

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▪ Trap:
 The trap is bent pipe about 7.5cm in diameter and is connected
with the pan.
 It holds water and provides the necessary water seal. The water
seal is the distance between the level of water in the trap and the
lowest point in the concave upper surface of the trap.
 The depth of the water seal in the RCA latrine is 2cm.
▪ Connecting pipe:
 In the indirect type of water seal latrine, connecting pipe is
required.
 It is 7.5cm in diameter and at least 1m in length with a bend at
the end.
▪ Dug well:
 The dug well or pit is usually 75cm in diameter and 3 – 3.5m deep
and is covered.
 A lining of earthen ware or bamboo matting may be used.
▪ Superstructure: The desired type of superstructure may be provided for
privacy and shelter.
▪ Maintenance:
 People should be educated to flush the pan after use with
adequate quantity of water.
 The latrine should not be used for disposal of refuse and debris.
 The squatting plate should be frequently washed kept clean and
dry.
4. Septic Tank - is a water-tight tank into which house hold sewage is admitted for
treatment
➢ Features -
▪ Capacity - at least 500 gallons
▪ Length - usually twice the breadth
▪ Depth - from 1.5 to 2 meter
▪ Liquid Depth - 1.2m
▪ Air Space - 30 cm between the level of liquid in the tank & the
undersurface of cover
▪ Bottom - sloping towards the inlet end
▪ Inlet & Outlet - submerged
▪ Cover - covered by concrete slab of suitable thickness & provided with a
manhole
▪ Retention Period - 24 hours

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➢ Working of Septic Tank - The solid waste settles down to form sludge. The lighter
solids including grease and fat rise to the surface to form scum. The solids are
attacked by anaerobic bacteria and fungi and broken down into simpler chemical
compounds. This is the anaerobic digestion. The liquid passes out the outlet pipe
is called the effluent. It contains numerous bacteria, cysts, helminthic ova and
organic matter in solution or fine suspension. It is allowed to pass through soil. In
the upper layer of soil, it is attacked by millions of aerobic bacteria and oxidized
into stable end products i.e. nitrates, carbon di-oxide and water. This is the
aerobic oxidation
➢ Operation & Maintenance -
▪ The use of soap water & disinfectants such as phenol should be avoided
▪ Content of the septic tank should be removed at least once a year. This
operation is called desludging & it is disposed by trenching,
▪ Newly built septic tanks are first filled with water up to the outlet level &
then seeded with ripe sludge drawn from another septic tank
5. Aqua Privy - it consists of a water tight chamber filled with water A short length of a
drop pipe from the latrine floor dips into the water
6. Chemical Closet - it consists of a metal tank containing a disinfectant fluid. The active
ingredients are formaldehyde, quaternary ammonium compound, a harmless water dye
and a deodorizing substance. The night soil gets diluted, liquefied and sterilized by the
chemical. It is used in ships, boats and aircrafts.
Elements of Water Carriage System -

1. Household sanitary fittings
2. House sewers
3. Street sewers or trunk sewers
4. Sewer appurtenances - manhole, traps etc.
Sewage - is waste water from a community containing solid & liquid excreta. The amount of
sewage which flows through the sewage system in 24 hours is called dry weather flow
• Composition - contains 99.9% water & 0.1% organic and inorganic matters. It is
estimated that 1 gm of feces contain about
o 1,000 million of E. coli
o 10 – 100 million of fecal streptococci
o 1 – 10 million spores of Cl.perfringens.
Average adult person excretes 100 gm of feces/day

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• Strength -
1. Biochemical Oxygen Demand (BOD) - It is the amount of oxygen absorbed by a
sample of sewage during a specified period (generally 5 days) at a specified
temperature (generally 20 ℃) for the aerobic destruction or use of organic
matter by living organisms
2. Chemical Oxygen Demand (COD)
3. Suspended Solids
• Aim of Sewage Purification -
➢ To stabilize the organic matter
➢ To obtain effluent which does not contain pathogenic organisms and does create
nuisance
➢ To utilize liquid and solid without health hazards
Decomposition of Organic Matter - 2 process

1. Aerobic Process: most efficient method, requires continuous supply of oxygen. End
products are CO₂, water, ammonia, nitrites, nitrates and sulphates by the action of
bacteria, fungi and protozoa.
2. Anaerobic Process: effective in highly concentrated solids. End products are methane,
ammonia, CO₂ and H₂

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Card - 10: Principles of Epidemiology
Item 01: Epidemiology: definition, aim and objectives, components, uses.

Measurements in epidemiology and tools of measurement. Morbidity and
Mortality. Epidemiological Approach. Differences between Epidemiology and
Clinical Medicine
Study - is a scientific process of answering a question using data from a population. It includes
surveillance, observation, screening, hypothesis testing, analytic research, experiments &
prediction
Distribution - refers to analysis by time, place or space and population (i.e. classes or subgroups
of persons affected in an organization, population of society, or at regional and global scales)
Determinants - are the geophysical, biological, behavioral, social, cultural, economic and
political factors that influence health.
• Communicable disease - disease agent

• Non-communicable disease - risk factors
Health related Events, States and Processes - includes outbreaks, diseases, disorders, causes of
death, behaviors, environmental and socio-economic process, effects of preventive programs
and use of health and social services. For example -
• Health related States - malnutrition, obesity, arsenicosis, dental fluorosis, IDD etc.
• Health related Events - accident, gas explosion, nuclear explosion, disaster, food
poisoning etc.
Specified Populations - are those with common contexts & identifiable characteristics.
Application to Control - makes explicit the aim of epidemiology, that is to promote, protect &
restore health & advance scientific knowledge

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Epidemiology - EPI means upon or among + DEMOS means people + LOGOS/LOGY means
study. So epidemiology means ‘study upon population’. It derived from the word epidemic.
Epidemiology is the basic science of preventive & social medicine. The foundation of
epidemiology was laid in the 19th century, when a few classic studies made a major contribution
to the saving life.
According to Parkin on 1873, “that branch of medical science which treats epidemics”
According to Frost on 1927, “the science of the mass phenomena of infectious diseases”
According to Greenwood on 1934, “the study of disease, any disease, as a mass phenomenon”
According to McMahon on 1960, “the study of the distribution & determinants of disease
frequency in man”
*According to John M Last on 1998, “the study of the distribution and determinants of health-
related states or events in specified population, and the application of this study to the control
of health problems”
According to Park's Textbook of Preventive and Social Medicine (26th Edition), “the study of the
occurrence & distribution of health-related events, states and processes in specified
population, including the study of the determinants influencing such processes, and the
application of this knowledge to control relevant health problems”
• Components - 3 components
1. Disease Frequency - In epidemiology, measurement of frequency of disease,
disability or that is summarized in the form of rates and ratios (e.g. Prevalence
rate, incidence rate, death rate etc.). These rates are essential for comparing
disease frequency in different population or subgroups of the same population in
relation to respective causal factors giving clues to disease etiology.

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2. The Distribution - Epidemiology is also concerned with the measurement of

health-related events & states in the community (e.g. health needs, demands,
activities, healthcare utilization) and variable (blood pressure, serum cholesterol,
height, weight etc.). These measurements of disease and health related falls in
the domain of biostatistics, which is a basic tool of epidemiology. The
distribution of diseases occurs in patterns in a community which may lead to the
generation of hypothesis about positive or risk factors. An important function of
epidemiology is to study these distribution patterns in the various subgroups of
the population by time, place and person.
The epidemiologic examines whether there has been an increase or decrease of
disease over time span, whether there is a higher concentration of disease in
one geographical area than in others, weather most characteristics or behavior
of those affected are different from those not affected.
An important outcome of this study is formulation of etiological hypothesis. This
aspect of epidemiology is known as descriptive epidemiology.
3. The Determinants - A unique feature of epidemiology is to test it etiological
hypothesis and identify the underlying cause or risk factors of disease. This
aspect of epidemiology is known as analytical epidemiology. Analytical strategies
help in developing scientifically sound health programs, interventions and
policies, understanding the determinants of chronic diseases e.g. lung cancer and
cardiovascular diseases.
• Aims - according to the International Epidemiological Association (IEA), there are 3 main
aims in epidemiology
1. To describe the distribution and magnitude of health and disease problems in
human population
2. To identify the etiological factors (infectious agent or risk factors) in the
pathogenesis of disease
3. To provide the data essential for planning, implementation and evaluation of the
services for the prevention, control and treatment of disease and to setting up of
priorities among those services
3 different types classes of epidemiological studies may be mentioned in order to fulfill

these aims -
1. Descriptive studies
2. Analytical studies
3. Experimental or intervention studies
The ultimate aim of epidemiology is to lead to effective action to

➢ Eliminate or reduce the health problem or its consequences
➢ Promote the health & wellbeing of society as a whole

P a g e | 93
• Measurements -
➢ Types -
a. Measurement of Mortality - commonly used mortality rates & ratios are -
 Crude death rate
 Specific death rate
 Case fatality rate
 Proportional mortality rate
 Survival rate
b. Measurement of Morbidity - defined as any departure, subjective or
objective, from a state of physiological wellbeing e.g. sickness, illness,
disability etc. *Incidence & *Prevalence rates are widely used to describe
the disease occurrence in a community [details in item:02]
c. Measurement of Disability
d. Measurement of Natality
e. Measurement of the presence, absence or distribution of the
characteristic or attributes of the disease
f. Measurement of medical needs, health care facilities, utilization of health
services & other health related events
g. Measurement of the presence, absence or distribution of the
environmental & other factors suspected of causing the disease
h. Measurement of demographic variables
➢ Basic Requirements-
a. Validity
b. Reliability
c. Accuracy
d. Sensitivity
e. Specificity
➢ Basic Tools - 3 tools
a. Rates - a rate measures the occurrence of some particular event in a
population during a given time period. For example, crude death rate is
given bellow -
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑖𝑛 1 𝑦𝑒𝑎𝑟
𝐶𝑟𝑢𝑑𝑒 𝐷𝑒𝑎𝑡ℎ 𝑅𝑎𝑡𝑒 = × 1000
𝑚𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
 Elements -
o Numerator
o Denominator (here numerator is part of denominator)
o Time specification (usually a calendar year)
o Multiplier

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 Categories -
o Crude rates
o Specific rates
▪ Cause specific (e.g. tuberculosis)
▪ Group specific (e.g. age-sex groups)
▪ Time specific (e.g. annual, monthly & weekly rates)
o Standardized rates
b. Ratios - it expresses a relation in size between 2 random quantities. It is

the result of dividing one quantity by another. It is expressed in the form
𝑥
of x:y or . But here, the numerator is not a component of the
𝑦
denominator. For example -
Example 1: the ratio of white blood cells relative to red blood cells is
1:600 or 1/600, meaning that for each WBC there are 600 RBC
Example 2:
𝑡ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑤𝑖𝑡ℎ 𝑠𝑐𝑎𝑏𝑖𝑒𝑠 𝑎𝑡 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑡𝑖𝑚𝑒
𝑡ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑤𝑖𝑡ℎ 𝑚𝑎𝑙𝑛𝑢𝑡𝑟𝑡𝑖𝑜𝑛 𝑎𝑡 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑡𝑖𝑚𝑒
Other Examples: sex ratio, doctor-population ratio, child-women ratio
etc.
c. Proportions - is a ratio which indicated the relation in magnitude of a part

of the whole. It is a fraction in which numerator is always included in the
denominator. It is usually expressed as a percentage. For example -
𝑡ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑤𝑖𝑡ℎ 𝑠𝑐𝑎𝑏𝑖𝑒𝑠 𝑎𝑡 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑡𝑖𝑚𝑒
× 100
𝑡ℎ𝑒 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑖𝑛 𝑡ℎ𝑒 𝑐𝑜𝑚𝑚𝑢𝑛𝑖𝑡𝑦 𝑎𝑡 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒
• Uses -
➢ To study historical does rise and fall of disease in the population
➢ Community diagnosis
➢ Planning and evaluation
➢ Evaluation of individual service and chance
➢ Syndrome identification
➢ Completing the natural history of disease
➢ Searching for cause and risk factors

P a g e | 95
• Epidemiological Approach - the epidemiological approach to problems of health and

disease is based on two major foundations
1. Asking Questions -
▪ related to health events
1. What is the event?
2. What is the magnitude?
3. Where did happen?
4. When did it happen?
5. Who are affected?
6. Why did it happen?
▪ related to health action
1. What can be done to reduce this problem & its consequences?
2. How it can be prevented in future?
3. What action should be taken by the community? By the health
service? By others sectors? Where and for whom these activities
be carried out?
4. What resources are required? How are the activities to be
organized?
5. What difficulty may arise and how might be overcome?
2. Making Comparison - the basic approach in epidemiology is to make comparison

and draw inferences. Comparison is done between two or more groups - one
group having the disease or exposed to risk factors and the other group not
having the disease or not exposed to risk factors or comparison between
individuals. By making comparison, epidemiologists try to find out the crucial
differences in the host and environmental factors between those affected and
not affected. Clues to etiology come from such comparison. In short, the
epidemiologist weighs, balances & contrast. Before making comparisons, it
should be ensured that both the groups should be similar so that like can be
compared with like.

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• Difference between Epidemiology & Clinical Medicine -
Trait Epidemiology Clinical Medicine

1. Unit of Study ‘defined population’ or ‘case’ or cases’
‘population at risk’
2. Objective epidemiologist is concerned physician is concerned with
with disease pattern in the disease in the individual
entire population patient
3. Dealing deals with both the sick & deals with sick only
healthy
4. Action responsible for both responsible for treatment
prevention & treatment
5. Natural History of period of pre-pathogenesis is period of pathogenesis is
Disease important important
6. Approach epidemiologist goes to the the patient goes to the
community/people physician
7. Diagnosis community diagnosis is individual diagnosis is done
possible

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Item 02: Epidemiological methods: classification. Descriptive studies. Definition

and Differences between Cross sectional and Longitudinal study.
Procedure/Steps of a simple descriptive study. Distribution of diseases (time,
place and person). Disease frequency. Incidence, Prevalence, their importance
and relation. Definition of Exotic, Sporadic, Endemic, Epidemic, Pandemic,
Epizootic etc. Types of epidemic and epidemic curves. Investigation of an
epidemic
Epidemiological Methods/Types of Epidemiological Study - 2 types
Cross Sectional
Descriptive
Longtitudinal
Epidemiological Methods
Observational Studies Ecological/Correlational
Cross Sectional/Prevalence
Analytical
Case Control/Case-
reference
Randomized Controlled
Trials/Clinical Trials
Cohort/Follow Up
Experimental
Studies/Intervention Field Trials
Studies
Community Trials
A. Observational Study - where the researcher just describes and analyses objects or
situation but has no control over the exposure or does not intervene
a. Descriptive Studies - descriptive study is usually the first phase in the
epidemiological investigation. These studies are usually concerned with the
observing the distribution of disease or other health related characteristics in
human population and identify the characteristics with which the disease in
question seems to be associated.

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These studies basically ask question -

Where is the disease occurring? (place distribution)
When is it occurring? (time distribution)
Who is getting affected? (person distribution)
Descriptive epidemiology may use a cross-sectional or longitudinal study to
obtain estimates of magnitude of health and disease problems and human
population. Here only one group is studied. So no comparison group is used. The
association between exposure and outcome cannot be seen. In order to see
them, association analytical study is required.
▪ Procedures - 6 procedures
1. Defining the population to be studied
o The total number of the population. It may be the whole
population in a geographical area or a representative
sample
o Composition of population in terms of age, sex,
occupation, cultural characteristics
2. Defining the disease under study
o Case Definition - must be precise & valid, to enable the
researcher to identify those with the disease from those
without disease
o Operational Definition - a definition by which disease or
condition can be identified & measured in the defined
population with the degree of accuracy
3. Describing the disease by time, place and person - the primary
objective is to describe the occurrence & distribution of disease
(or health-related events or characteristics) within populations by
time, place & person and identifying those characteristics
associated with presence or absence of disease in individuals. This
involves systematic collection & analysis of data
o Time Distribution - The pattern of disease may be
described by the time of its occurrence i.e. by week,
month, year, the day of the week, hour of onset etc. 3
kinds of time trends or fluctuations in disease occurrence -
i. Short Term Fluctuations - the short-term
fluctuation in the occurrence of a disease is an
epidemic [details later]
ii. Periodic Fluctuations -
o Seasonal Trend - e.g. upper respiratory
infections during winter months, bacterial
gastrointestinal infections in summer
months

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o Cyclic Trend - e.g. measles in the pre-

vaccination era appeared in cycles with
major peaks every 2 to 3 years
iii. Long Term/Secular Fluctuations - changes in the
occurrence of disease (i.e. a progressive increase or
decrease) over a long period of time, generally
several years or decades. For example, coronary
heart disease, lung cancer & diabetes have shown a
consistent upward trend in the developed
countries during the past 50 years or so, followed
by a decline of tuberculosis, typhoid fever,
diphtheria & polio
o Place Distribution
i. International variation
ii. National variation
iii. Rural variation
iv. Local distribution
o Person Distribution - defining the persons who develop the
disease by some host factors such as
i. Age
ii. Sex
iii. Ethnicity
iv. Marital status
v. Occupation
vi. Social Class
vii. Behavior
viii. Stress
ix. Migration
4. Measurement of disease - disease load in the population in terms
of mortality, morbidity & disability. Morbidity is measured by
o Cross Sectional Study - prevalence can be obtained
o Longitudinal Study - incidence can be obtained

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Cross Sectional Study Longitudinal Study

simplest form of an comprehensive form of an
observational study observational study
observations are repeated in
a single examination of a cross the same population over a
section of population at one prolonged period of time by
point in time is done means of follow-up
examinations
useful for chronic (e.g.
useful for both chronic & acute
hypertension) than short-lived
diseases
diseases
also known as prevalence
known as incidence study
study
gives distribution of disease in identified determinants of
the population disease
usually less time is needed usually more time consuming
less expensive more expensive
gives little information about gives good information about
natural history of disease natural history of disease
5. Comparing with known indices

o Between different population or subgroup of same
population
o Done to get a clue to disease etiology
6. Formulation of an etiological hypothesis
o A hypothesis is a supposition, arrived at from observation
or reflection on
❖ The population
❖ The specific cause being considered
❖ The expected outcome
❖ The dose-response relationship
❖ The time response relationship
e.g. smoking of 30 to 40 cigarettes per day causes lung
cancer in 10% smokers after 20 years of exposure
*Formulation of hypothesis is done only in descriptive

study. But test of hypothesis is done in analytical study

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▪ Uses -
 Provide data regarding the magnitude of the disease load and
types of disease problems in the community in terms of morbidity
and mortality rates and ratios
 Provide clues to disease etiology and help in the formulation of an
etiological hypothesis
 Provide background data for planning, organizing and evaluating
preventive and curative service
 They contribute to research by describing variations in disease
occurrence by time, place and person
b. Analytical Studies [details in item:06] - 4 types
1. Ecological/Correlational
 Unit of Study - populations
2. Cross-sectional/Prevalence - is the simplest form of an observational

study. It measures the prevalence of disease and often called prevalence
studies. This study is based on a single examination of a cross-section of
population where both the exposure and disease are determined
simultaneously for each subject at one point in time or over a short
period of time. The results of which can be projected on the whole
population provided the sampling has been done correctly. Cross
sectional studies are more useful chronic diseases.
 Features -
a. Study at a point in time
b. Useful for investigation of exposure that are fixed
characteristics e.g. blood group
c. Most convenient first step into investigation of sudden
outbreaks
d. Regular cross-sectional survey
e. Not easy to assess associations between the risk factors
and health outcomes
 Unit of Study - individuals
3. Case-control/Case Reference

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4. Cohort/Longitudinal/Follow-up/Prospective Study - in longitudinal studies

observations are prepared in the same population over a prolonged
period of time by means of follow-up examinations. Longitudinal studies
are difficult to organize and more time consuming than cross-sectional
studies. Longitudinal studies are useful to study for natural history of
disease and its future outcome. It is also useful for finding out incidence
rate or rate of occurrence of new cases of disease in the community
Descriptive Study Analytical Study

involve description of the occurrence goes further by analyzing relationship
of a disease in a population between health status & other
variables
comparative group absent comparative group present
hypothesis formulation hypothesis testing
B. Experimental/Intervention Study - where the researchers manipulate/intervenes object

or situations or control the exposure
a. Randomized Controlled Trials/Clinical Trials
 Unit of Study - patients
b. Field Trials
 Unit of Study - healthy people
c. Community Trials/Community Intervention Studies

 Unit of Study - communities
Observational Study Intervention Study

here, the researcher just explores, here, the researcher manipulates objects
describe & analyze the researchable or situations & measures the outcome of
problem but does not intervene his manipulations or intervention
allow nature to take its own course; the involve an active attempt to change a
investigator measures disease determinant or the progress of
the disease

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Epidemic - Epi means upon; demos means people. Epidemic may be defined as the unusual
occurrence in a community or region of disease, specific health related behavior (e.g. smoking)
or other health related events (e.g. traffic accidents) clearly in excess of expected occurrence.
The amount of disease occurring in the past, in the absence of an epidemic, defines the
‘expected’ frequency. Example - gastroenteritis, measles, chickenpox.
• Types - 3 types
1. Common-source Epidemics
i. Single Exposure/Point Source Epidemics - exposure to the disease agent
is brief & essentially simultaneous. All the cases develop within one
incubation period of disease e.g. an epidemic of food poisoning
ii. Continuous/Multiple/Repeated Exposure Epidemics - sometimes the
exposure from the same source may be prolonged (continuous, repeated
or intermittent) but not necessarily at the same time or place e.g. a well
of contaminated water or a nationally distributed brand of vaccine (like
polio vaccine) or food, arsenicosis
2. Propagated Epidemics - is most often of infectious origin & results from person-
to-person transmission of an infectious agent (e.g. epidemics of hepatitis A &
polio)
i. Person to Person
ii. Arthropod Vector
iii. Animal Reservoir
3. Slow/Modern Epidemics - in the modern ‘slow’ epidemics of non-communicable
diseases (e.g. CHD, lung cancer) the time scale of the epidemics is shifted from
days or weeks to years
• Epidemic Curve - a graph of the time distribution of epidemic cases is called the
epidemic curve. It may suggest -
➢ A time relationship with the exposure to a suspected source
➢ A cyclical or seasonal pattern of a particular infection & common source or
propagated spread of the disease
• Investigation of Epidemic - an epidemic cause for a prompt and thorough investigation
to identify the factors responsible and control measures to prevent further spread.
➢ Objectives -
▪ To define the magnitude of epidemic or distribution in terms of time,
place and person
▪ To determine particular conditions and factors responsible for the
occurrence of epidemic
▪ To identify the cause, source of infection and modes of transmission to
determine measures necessary to control the epidemic
▪ To make recommendations to prevent recurrence

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➢ Steps - 10 steps
1. Verification of diagnosis
a. First step in epidemic investigation is to be done on spot
b. A sample of case is to be diagnosed on the basis of clinical
examination and laboratory investigations wherever applicable
2. Confirmation of existence of an epidemic - Done by comparing of disease
frequency during the same period of previous year, number of cases
(observed frequency) is in excess of expected frequency for that
population based on past experience
3. Defining the population at risk
a. Obtaining a map of that area
b. Counting the population
4. Rapid search for all cases and their characteristics -
a. Medical survey - done to identify all cases including who have not
sought medical care and those who are possibly exposed to risk
b. Epidemiological case sheet - to be used for collecting data from
cases and persons exposed to risk but infected
c. Searching for more cases
5. Data analysis - should include time, place and parson distribution. If the
disease agent is known, data can be explained also in agent, host and
environment model
6. Formulation of hypothesis - on the basis of time, place and person
distribution or agent, host, environment model to explain the epidemic in
terms of -
a. Possible source
b. Causative agent
c. Model of spread
d. Environmental factor
7. Testing of hypothesis - reasonable hypothesis should be considered and
tested by analytic study
8. Evaluation of ecological factors
a. Necessary to know to prevent for the transmission of disease
b. Ecological factors related to the disease like status of eating
places, water and milk supply, status of excreta and refusal
disposal, living condition, migration, temperature, humidity etc.
9. Further investigation of population at risk - this may involve medical
examination, screening test, examination of suspected food, samples,
features, blood, biochemical test, assessment of immune status
10. Writing the report - report should be complete and convincing

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Endemic - En means in; demos means people. It may be defined as the constant presence of a
disease or infectious agent or ‘usual’ (or expected) frequency of the disease within a given
geographic area or population group, without importation from outside. Example - common
cold is endemic because somebody always has one. An endemic disease when conditions are
favorable may burst into an epidemic (e.g. hepatitis A, typhoid fever). It is of 2 type -
• Hyperendemic - the disease is constantly present at a high incidence and/or prevalence

rate and affects all age groups equally
• Holoendemic - a high level of infection beginning early in life & affecting most of the
child population, leading to a state of equilibrium such that the adult population shows
evidence of the disease much less commonly than do the children (e.g. malaria)
Sporadic - the word sporadic means scattered about. Irregular, infrequent & isolated
occurrence of a particular disease in a community is called sporadic e.g. cancer.
The cases are so few & separated widely in space & time that they show little or no connection
with each other, nor a recognizable common source of infection. Example - tetanus, herpes-
zoster & meningococcal meningitis
Pandemic - An epidemic usually affecting a large proportion of the population in a wide

geographic area such as a section of a nation, an entire nation, a continent or the world.
Example - AIDS, Covid-19
Exotic - diseases which are imported into a country in which they do not otherwise occur e.g.
rabies in UK
Zoonotic - an infection or infectious disease transmissible under natural conditions from

vertebrate animals to man. Examples - rabies, plague, bovine tuberculosis, anthrax, brucellosis,
salmonellosis, endemic typhus, hydatidosis, monkeypox, lassa fever, etc. It is of 3 types
a. Anthropozoonosis - infectious transmitted to man from vertebrate animal e.g. rabies,
plague
b. Zooanthroponoses - infectious transmitted from man to vertebrate animals e.g.
tuberculosis in cattle
c. Amohixenoses - infectious maintained in both man & lower vertebrate animals that may
be in either direction

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Epizootic - an outbreak or epidemic of disease in an animal population e.g. anthrax, brucellosis,

rabies, influenza
Enzootic - endemic of disease in animal population e.g. anthrax, rabies, bovine tuberculosis
Epornithic - an outbreak (epidemic) of disease in a bird population
Incidence - it is defined as a number of new cases occurring in a defined population during

specified period of time. Incidence rate must include the unit of time. The use of incidence is
generally restricted to acute conditions. It is given by the formula -
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 =
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑎𝑡 𝑝𝑒𝑟𝑖𝑜𝑑
× 1000
For example, there had been 500 new cases of an illness in a population of 30000 in a year. So
incidence = (500/30000) ×1000 = 16.7 per 1000 per year.
• Uses -
➢ Used as a morbidity health status indicator
➢ Used to control disease
➢ Used for research into etiology, pathogenesis, distribution of disease & efficacy
of preventive & therapeutic measures
• Attack Rate - is a special incidence rate. It is used only when the population is exposed
to risk for a limited period of time like epidemic. It is also expressed in percentage

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Prevalence - refers to number of all current cases (old & new) existing at a given point in time,
or over a period of time in a given population. The use of prevalence is generally restricted to
chronic conditions
• Types - 2 types
1. Point Prevalence - the number of all current cases (old & new) of a disease at
one point if time in a defined population. It is given by the following formula
𝑃𝑜𝑖𝑛𝑡 𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑎𝑙𝑙 𝑐𝑢𝑟𝑟𝑒𝑛𝑡 𝑐𝑎𝑠𝑒𝑠 (𝑜𝑙𝑑 & 𝑛𝑒𝑤) 𝑜𝑓 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑒𝑥𝑖𝑠𝑡𝑖𝑛𝑔 𝑎𝑡 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑝𝑜𝑖𝑛𝑡 𝑖𝑛 𝑡𝑖𝑚𝑒
=
𝑒𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑝𝑜𝑖𝑛𝑡 𝑖𝑛 𝑡𝑖𝑚𝑒
× 1000
The ‘point’ in point prevalence may consist of a day, several days or even few
weeks, depending upon the time it takes to examine the population sample.
When the term ‘prevalence rate is used, it is taken to mean ‘point prevalence’
2. Period Prevalence - the number of all current cases (old & new) of a disease in a
defined population during a defined period of a time (e.g. annual prevalence).
Period prevalence is given by the following formula
𝑃𝑒𝑟𝑖𝑜𝑑 𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑥𝑖𝑠𝑡𝑖𝑛𝑔 𝑐𝑎𝑠𝑒𝑠 (𝑜𝑙𝑑 & 𝑛𝑒𝑤) 𝑜𝑓 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
=
𝑒𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑚𝑖𝑑 − 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘
× 1000
1. Uses -
a. Prevalence helps to estimate the magnitude of health/disease problems in the
community & identify potential high-risk populations
b. Prevalence rates are especially useful for administrative & planning purposes,
e.g. hospital beds, manpower needs, rehabilitation facilities etc.

108 | P a g e
In this above picture -

➢ Incidence cases - 3, 4, 5, 8
➢ Point Prevalence (Jan 1) cases - 1, 2, 7
➢ Point Prevalence (Dec 31) cases - 1, 3, 5, 8
➢ Period Prevalence (Jan to Dec) cases - 1, 2, 3, 4, 5, 7, 8
Relationship between Prevalence & Incidence - Prevalence depends upon 2 facotors.

➢ The incidence
➢ Duration of illness
The relationship between incidence & prevalence can be expressed as follows,
𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 = 𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 × 𝑀𝑒𝑎𝑛 𝐷𝑢𝑟𝑎𝑡𝑖𝑜𝑛
Conversely,
𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 =
𝑀𝑒𝑎𝑛 𝐷𝑢𝑟𝑎𝑡𝑖𝑜𝑛
and
𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒
𝐷𝑢𝑟𝑎𝑡𝑖𝑜𝑛 =
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒

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For Example,
Incidence = 10 cases per 1000 population per year
Mean Duration of disease = 5 years
Prevalence = 10×5 = 50 per 1000 population
The equation shows that the longer the duration of the disease, the greater its prevalence.
➢ If the disease is chronic and of long duration (e.g. tuberculosis), prevalence rate will be
high because new cases keep cropping up throughout the year, while the old ones may
persist for months or years.
➢ On the other hand, if the disease is acute and of short duration (e.g. food poisoning)
either because of rapid recovery or death, the prevalence will be relatively low
compared with the incidence rate

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Item 03: Definition of some important terms: Infection, clinical, subclinical,

opportunistic, iatrogenic, nosocomial infection. Infestation. Infectious,
communicable and noncommunicable disease. Infectivity and period of
communicability. Disease cycle. Incubation period (types and importance). Case
and carrier (types and importance). Primary, secondary index case. Reservoir
and source of infection
Infection - the entry and development or multiplication of an infectious agent in an organism,

including the body of a man or animals. An infection does not always cause illness.
Infectious Disease - a clinically manifestation disease of men or animals resulting from an

infection. There are several levels of infection -
• Colonization - e.g. S.aures in skin & normal nasopharynx

• Clinical infection - e.g. measles, diphtheria, chickenpox
• Subclinical or inapparent infection - e.g. polio, mumps
• Latent infection - e.g. virus of herpes simplex
Contamination - the presence of an infectious agent on a body surface; also on or in clothes,

beddings, toys, surgical instrument or dressing, or other inanimate articles or substances
including water, milk and food. Pollution implies the presence of offensive (not necessarily
infectious) matter in the environment.
Infestation - the lodgment, development and reproduction of arthropods on the surface of the
body or in the clothing of persons or animals. (e.g. lice, itch mite). The term is also used to
describe invasion of the gut by parasitic worms e.g. ascariasis
Host - a person or other animal (including birds and arthropods) that affords lodgment to an
infectious agent under natural conditions
• Obligate host - means the only host, e.g. man in measles and typhoid fever
• Primary or definitive host - in which the parasite attains maturity or passes its sexual
stage
• Secondary or intermediate host - in which the parasite is in a level or asexual state
• Transport host - a carrier in which the organism remains alive but does not undergo
development

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Contagious Disease - a disease that is transmitted through contact. Examples - scabies,

trachoma, STD & leprosy
Communicable Disease - an illness due to a specific infectious as agent or its toxic product
capable of being directly or indirectly transmitted from man to man, animal to animal or from
the environment (through air, dust, soil, water, food) to man or animal
• Modes of Transmission - 2 types

➢ Direct -
▪ Direct contact - Direct contact from skin to skin, mucosa to mucosa or
mucosa to skin of the same or another person e.g. STD and AIDS, Leprosy,
skin and eye infections
▪ Droplet infection - Direct projection of a spray of droplets of saliva and
nasopharyngeal secretions during coughing, sneezing, or speaking and
spitting, talking into the surrounding atmosphere. The droplet spread is
usually limited to a distance of 30-60 cm between source and host e.g.
Common cold, Diphtheria, Whooping cough, tuberculosis, meningococcal
meningitis etc.
▪ Contact with soil -Direct exposure of susceptible tissue to the disease
agent in soil, compost or decaying vegetable matter e.g. hookworm,
tetanus, mycosis etc.
▪ Inoculation into skin or mucosa - Inoculated directly into the skin or
mucosa e.g. Rabies virus by dog bite, Hepatitis B virus by contaminated
needles and syringes etc.
▪ Transplacental or vertical e.g. TORCH agents (Toxoplasma gondii, rubella
virus, cytomegalovirus and herpes virus), varicella virus, syphilis, hepatitis
B and AIDS
➢ Indirect - Includes 5 F’s; flies, fingers, fomites, food and fluid. The infectious
agent must be capable of surviving outside the human host in the external
environment retaining its pathogenesis and virulence properties
▪ Vehicle Borne -
 Diseases transmitted by water and food - acute diarrheas, typhoid
fever, cholera, polio, hepatitis A, food poisoning and intestinal
parasites
 Diseases transmitted by blood - hepatitis B, malaria, syphilis,
brucellosis, cytomegalovirus infection
 Organ transplantation - cytomegalovirus infection in kidney
transplant

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▪ Vector-borne -
 Mechanical transmission: by crawling or flying arthropod through
soiling of its feet or proboscis or by passage of organism through
its feces, e.g. housefly carrying dysentery
 Biological transmission: 3 types -
a. Propagative: The agent merely multiplies in vector, but no
change in form, e.g. plague bacilli in rat fleas.
b. Cyclo-propagative: The agent changes in form and
number, e.g. malaria parasite in mosquito.
c. Cyclo-developmental: The agent undergoes inly
development but no multiplication, e.g. microfilaria in
mosquito.
▪ Airborne
 Droplet Nuclei - are tiny particles (1-10 microns) that represent
the dried residue of droplets e.g. tuberculosis, influenza,
chickenpox, measles, Q fever and many respiratory infections.
 Dust - Larger droplets are expelled during talking, coughing or
sneezing, settle down on the floor, carpets, furniture, clothes and
other objects and become part of the dust e.g. Staphylococcal
infection, tuberculosis, pneumonia
▪ Fomite borne - Fomites are inanimate articles or substances other than
water and food contaminated by the infectious agent and capable of
transferring it to a healthy person. Fomite includes soiled clothes, linen,
cups, spoons, pencils, door handles, syringes, surgical instruments etc.
e.g. diphtheria, typhoid fever, bacillary dysentery, hepatitis A, eye and
skin infections.
▪ Unclean hands and fingers e.g. Staphylococcal and streptococcal
infections, typhoid fever, dysentery, hepatitis A and intestinal parasites
Nosocomial Infection (Hospital Acquired Infection) - an infection originating in a patient while

in a hospital or other health care facility. It denotes a new disorder, unrelated to the patient's
primary condition. Example - infection of surgical wounds, hepatitis B and urinary tract
infection, ventilator associated pneumonia
Opportunistic Infection - this is infection by an organism that takes the opportunity provided
by a defect in host defense to infect the host and cause diseases. Example - M. Tuberculosis,
herpes infection, cytomegalovirus pneumonia infection are the opportunities infections in AIDS.

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Iatrogenic Disease - literally doctor generated disease. Any unwanted or adverse consequences
of a preventive, diagnostic or therapeutic regimen or procedure that causes impairment,
handicap, disability or death resulting from a physician's professional activity or from the
professional activity of other health professionals. Example - reactions to penicillin and
immunizing agent, aplastic anemia following the use of chloramphenicol, childhood leukemia
due to prenatal Xray, hepatitis B and AIDS following blood transfusion, hypersensitivity
reactions after chemotherapy etc. These are all preventable. Iatrogenic disease is a hazard of
Health Care.
Disease Cycle - the courses of most communicable disease are going on certain stages, which all
together constitute the disease cycle.
• Stages - there are 6 stages

1. Incubation Period - is the time interval between the entry of the disease agent in
the body & manifestation of clinical signs & symptoms. This period varies from
disease to disease.
2. Prodromal Period - is a short period characterized by vague signs & symptoms
such as headache, fever, body ache & restlessness. Clinical diagnosis is not
possible during this stage because of the vagueness. The patient is nevertheless
infectious to others.
3. Fastigium - in this stage the patient is ill & taken to bed, the signs & symptoms
are clear-cut. Usually there is no difficulty in diagnosing the condition clinically.
4. Defervescence - in this stage body’s defensive mechanism begins to take an
upper hand over the pathogens & the patient starts to feel better
5. Convalescence - during this stage, the patient recovers from disease but may still
harbor the disease agent
6. Defection - during this stage, the individual recovers from illness
• Figure - (collect from guide)

114 | P a g e
Source - defined as the person, animal, object or substances from which disease/infectious
agent can be easily be transmitted to a susceptible host.
Example of Reservoir & Source -
Disease Name Source Reservoir

Hookworm Soil Man
Tetanus Soil Soil
Feces, urine or contaminated
Typhoid Fever case or carrier
food
Cases - defined as a person in the population or study group identified as having the particular
disease, health disorder or condition under investigation.
• Types - 3 types
➢ Clinical Cases
➢ Subclinical Cases
➢ Latent Cases
• Another type - 3 types
1. Primary Cases (first infected) - refers to the first case of a communicable disease
in the population unit
2. Index Cases (first diagnosed) - It is the first case to come to the attention of a
investigator
3. Secondary Cases (first transmitted) - Cases those develop from contact with
primary case
Carrier - defined as an infected person or animal that harbors a specific infectious agent in the
absence of discernible clinical disease & serves as a potential source of infection for other. It
could be classified in following ways -
• Types -
➢ According to type - 3 types
a. Incubatory carriers e.g. Measles, Mumps, Polio, Influenza, Pertussis,
Diphtheria, Hepatitis B
b. Convalescent carriers e.g. Typhoid, Dysentery, Cholera, Diphtheria,
Whooping cough
c. Healthy carriers (emerge from sub clinical state) e.g., Cholera,
Salmonellosis, Diphtheria
➢ According to duration - 2 types
a. Temporary carriers e.g. Incubatory, convalescent and healthy carrier
b. Chronic carriers e.g. Typhoid, Hepatitis-B, Malaria, Gonorrhea, Dysentery

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➢ According to portal of exit -

▪ Urinary carriers
▪ Intestinal carriers
▪ Respiratory carriers
▪ Nasal carriers
▪ Skin eruption
▪ Open wounds
▪ Blood etc.
• Criteria -
➢ Presence of disease agent in the body
➢ Absence of recognizable signs and symptoms of disease
➢ Shedding of the disease agent in the discharges or excretions
• Importance - as a rule, carriers are less infectious than cases. But epidemiologically, they
thy are more dangerous than cases because they escape recognition & continuing as
they do live a normal life among the population or community, they readily infect the
susceptible individuals over a wider area & longer period of time, under favorable
condition
Reservoir - defined as any person, animal, arthropod, plant, soil & substance (or combination of
these) in which an infectious agent lives & multiplies, on which it depends primarily for survival
& where it reproduces itself in such a manner that it can be transmitted to a susceptible host
• Types - 3 types
1. Human Reservoir
▪ Case
▪ Carrier
2. Animal Reservoir
3. Reservoir in non-living things
• Another Type -
1. Homologous - when another member of the same species is the victim
2. Heterologous - when the infection is derived from a reservoir other than man

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Incubation period - The time interval between invasion by an infectious agent and appearance
of the first sign or symptom of the in question. Its importances are -
➢ Tracing the source of infection and contacts: in a disease with short incubation period, it
is simple to trace the source of infection, as in the case of food poisoning, bacillary
dysentery or typhoid fever
➢ Determining the period of surveillance or quarantine
➢ Helps to prevent clinical illness by Human immunoglobulin and Antisera
➢ Identification of point source or propagated epidemics: in a point source epidemic, all
the cases occur within one incubation period of the disease.
➢ Estimating the prognosis of a disease
Latent Period - the term latent period is used in non-infectious diseases. Latent period is the
period from disease initiation to disease detection.
Communicable Period - the time during which an infectious agent is transferred directly or
indirectly from an infected person or animal to another person

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Item 04: Prevention, control, elimination and eradication. Features of necessary

for eradication. Isolation and Quarantine. Chemoprophylaxis. Screening and
surveillance: Definition, types and uses. Criteria of a screening test. Sensitivity
and specificity
Isolation - is the separation of infected persons or animals for the period of communicability
from others in such places and under such conditions, as to prevent or limit the direct or
indirect transmission of the infectious agent from those infected to those who are susceptible
or who may spread the agent to others.
• Purpose / importance of isolation-

➢ To protect the community by preventing transfer of infection from the reservoir
to the possible susceptible host
➢ Isolation has a distinctive value in the control of some infectious diseases e.g.
Diphtheria, cholera, streptococcal respiratory diseases, pneumatic plague
• Types - 4 types
1. Standard
2. Strict
3. Protective
4. High Security
Quarantine - defined as the limitation of freedom of movement of such well persons or

domestic animals exposed to communicable disease for a period of time not longer than the
longest usual incubation period of the disease, in such manner as to prevent effective contact
with those not exposed
• Types - 3 types
1. Absolute Quarantine
2. Modified Quarantine
3. Segregation
Surveillance - surveillance means to watch over with great attention, authority and often with
suspicion. It is defined as the continuous scrutiny of the factors that determine the occurrence
and distribution of disease and other conditions of ill health. Example - epidemiological
surveillance, demographic surveillance, nutritional surveillance, serological surveillance etc.

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Sentinel Surveillance - no routine notification system can identify all cases of infection or
disease. A method for identifying the missing cases and thereby supplementing the notified
cases is required. This is known as sentinel surveillance.
Disease Control - the term describes ongoing operations aimed at reducing -

➢ The incidence of disease
➢ The duration of disease and the risk of transmission
➢ The effects of injection, including both the physical and psychosocial complications
➢ The financial burden to the community
In disease control, the disease agent is permitted to persist in the community at a level that it
will no longer be a public health problem. Example - control of diarrheal diseases, ARI, malaria,
tuberculosis, STD, AIDS
Disease Elimination - the term means the interruption of transmission of disease. Regional
elimination is an intermediate goal between control and eradication and seen every important
precursor of eradication. Example - elimination of measles, polio and diphtheria from large
geographic regions or areas.
Disease Eradication - eradication means to tear out by roots. Eradication of disease implies
termination of all transmission of infection by extermination of the infectious agent. It is an
absolute process and all or none phenomenon. Today, smallpox is the only disease that has
been eradicated globally. Recently, 3 diseases become feasible for global eradication within the
foreseeable future - polio, measles and dracunculiasis. Criteria of disease for eradication -
➢ There must not be any extra human reservoir
➢ The incubation period should be short
➢ There must be an effective vaccine available
Screening - The search for unrecognized disease or defect by means of rapidly applied tests in
apparently healthy individuals.
• Types - 3 types
1. Mass Screening - The screening of a whole population or a sub-group (e.g., all
adults) irrespective of the particular risk individual. Example: screening of
tuberculosis

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2. High-risk or Selective Screening: Applied selectively to high-risk groups. Example:

screening of cancer cervix in the lower social group.
3. Multiphasic Screening - The application of two or more screening tests in
combination to a large number of people at one time. Include a health
questionnaire, clinical examination and investigations.
• Criteria - 2 criteria
➢ The DISEASE to be screened
▪ The condition should be an important health problem (prevalence should
be high)
▪ There should be a latent stage
▪ The natural history of the condition should be known
▪ There is a test that can detect the disease prior to the onset of signs and
symptoms
▪ Facilities should be available for confirmation of the diagnosis
▪ There is an effective treatment
▪ The expected benefits of early detection exceed the risks and cost
▪ Early detection and treatment should reduce morbidity and mortality
➢ The TEST to be applied
▪ Criteria -
 Acceptability
 Repeatability
 Validity (accuracy)
▪ Evaluation -
 Sensitivity
o Sensitivity (True-positive) - The ability of a test to identify
correctly all those who have the disease, that is “true-
positive”. A 90 percent sensitivity means that 90 percent
of the diseased people screened by the test will give a
“true-positive” result and the remaining 10 percent of the
diseased people will give a “false-negative” result.
o Specificity (True-negative) - The ability of a test to identify
correctly those who do not have the disease, that is “true-
negatives”. A 90 percent specificity means that 90 percent
of the non-diseased persons screened by the test will give
a “true-negative” result and the remaining 10 percent of
non-diseased people will give a “false-positive” result
 Specificity
 Predictive value of a positive test
 Predictive value of a negative test
 Percentage of false positive
 Percentage of false negative

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• Uses -
➢ Case detection: It is prescriptive screening. Disease detection is initiated by
medical and public health personnel, does not arise from a patient’s request.
People are screened primarily for their own benefit. Example: screening of
breast cancer, cervical cancer, Diabetes mellitus, Pulmonary tuberculosis,
hemolytic disease of newborn etc.
➢ Control of disease: It is prospective screening. People are examined for the
benefit of others. Example: screening of immigrants from tuberculosis and
syphilis to protect the home population, screening for streptococcal infection to
prevent rheumatic fever.
➢ Research purposes: To obtain the natural history of many chronic diseases, e.g.,
cancer, hypertension.
➢ Educational opportunities: For creating public awareness and for educating
health professionals. Example: screening for diabetes
• Lead Time - Lead time is the advantage gained by screening. The period between
diagnosis by early detection and diagnosis by other means
In the following figure,

A = usual outcome of disease
B = the outcome when disease is detected by screening
B - A = The benefits of the screening program

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• Difference between Screen Test vs. Diagnostic Test
Screening Test Diagnostic Test

Done on apparently healthy Done on sick
Applied to groups Applied to single patients
Test results are final Diagnosis is not final but modified by new
evidence
Based on cut-off point Based on evaluation of signs, symptoms
and laboratory findings
Less accurate More accurate
Less expensive More expensive
Not a basis for treatment Used as a basis for treatment
The initiative comes from the investigator The initiative comes from a patient with a
complaint

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Item 05: Dynamics of disease transmission. Infection chain. Principles of control

of communicable diseases. Notification and notifiable diseases under IHR &
WHO
Dynamics of Disease Transmission -
Source or reservoir
Route of exit
Mode of
transmission
Route of entry
Susceptible host
Infection Chain - there are 3 links in the chain of transmission of disease
Mode of
Source or reservoir The susceptible host
transmission
Principles of Control of Communicable Disease - 3 types

1. Control of reservoir - 8 steps
a. Early diagnosis - The first step in the control of a communicable disease is rapid
identification of cases (and carriers) and their treatment. Early diagnosis is
needed –
i. For the treatment of patients
ii. For epidemiological investigations
iii. To study the time, place and person distribution and
iv. To implement preventive and control measures
b. Notification - Once an infectious disease has been detected, it should be notified
to the local health authority. It helps to adopt immediate control measures,
including the provision of medical care to patients. Diseases which are
considered to be serious threat to public health are the notifiable diseases.

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c. Epidemiological investigations - An epidemiological investigation called for

whenever there is a disease outbreak. Broadly, the investigation covers the
identification of the source of infection and of the factors influencing its spread
in the community
d. Isolation - is the separation of infected persons from those who are not infected
for the period of communicability of the disease in such place and under such
conditions, as to prevent or limit the direct or indirect transmission of the
infectious agent e.g. Covid-19, Diphtheria, Measles, G. measles, Chicken pox,
Mumps
e. Treatment - The object of treatment is to kill the infectious agent when it is still in
the reservoir. Treatment reduces the communicability of disease, cuts short the
duration of illness and prevents development of secondary cases.
f. Quarantine - The restriction of movement of apparently healthy persons who
have been exposed to a communicable disease for the period of time not longer
than the longest incubation period of the disease in order to prevent disease
transmission. There are 3 types of quarantine:
i. Absolute or complete quarantine
ii. Modified quarantine
iii. Segregation
g. Survellieince - surveillance means to watch over with great attention, authority
and often with suspicion. It is defined as the continuous scrutiny of the factors
that determine the occurrence and distribution of disease and other conditions
of ill health. Example - epidemiological surveillance, demographic surveillance,
nutritional surveillance, serological surveillance etc.
h. Disinfection
2. Interruption of transmission:
a. Treatment of water
b. Control of vectors
c. Improvement of sanitation
d. Healthy and clean practices, e.g., hand washing, personal cleanliness, adequate
cooking, prompt refrigeration of prepared food, withdrawal of contaminated
food etc.
e. Use of disposable syringe
f. Healthy sexual practices

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3. Protection of the susceptible host:

a. Active immunization
b. Passive immunization
c. Both active and passive immunization
d. Chemoprophylaxis
e. Non-specific measures:
i. Good housing
ii. Water and sanitation
iii. Education
iv. Nutrition
v. Legislation
vi. Community involvement
vii. Political commitment
viii. Behavioural change

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Item 06: Analytical studies: Types. Case and control in epidemiological studies.
Steps and differences between case control and cohort studies. Experimental
studies: Types. Steps of RCT. Blinding. Concept of risk factors. Relative risk,
attributable risk and odds ratio. Control of NCDs
Analytical Epidemiology - are the second major type of epidemiological studies. It is the
comparative study & identifies the casual factor. The objective is not to formulate but to test
hypothesis. This study determines whether or not a statistical association exists between a
disease & a suspected factor. If exists, the strength of the association between them. There are
2 distinct types of analytical studies.
a. Case Control Study
b. Cohort Study
Case Control study - are a common first approach to test casual hypothesis. It is also called
retrospective studies. Basically comparison studies, involving 2 populations - cases (for diseased
people) & controls (for healthy people).
2. Features - 3 distinct features
a. Both exposure and outcome (disease) have occurred before the start of the
study
b. The study proceeds backwards from effect to cause
c. It uses a control or comparison group to support or refute an inference
3. Unit - individual rather than the group
4. Focus - on a disease or some other health problem that has already developed
5. Use - major use in chronic disease problem

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6. Schematic Design -
Exposed
Population
Cases
(people with disease)
Not Exposed
Exposed
Controls
(people without disease)
Not Exposed
Time
Direction of Inquiry
7. Steps - 4 basic steps

a. Selection of cases & control -
▪ Selection of Controls -
 Criteria -
o Must be free from the disease under study
o Must be similar to the cases as much as possible
 Sources -
o Hospital
o Relatives
o Neighbors
o General population
▪ Selection of Cases -
 Definition - 2 specifications
o Diagnostic Criteria
o Eligibility Criteria

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 Sources -
o Hospital
o General Population (survey, diseases registry, hospital
network etc.)
b. Matching - defined as the process by which one select the controls in such a way
that they are similar to cases with regard to certain selected variables (age &
socio-demographic characteristics)
c. Measurement of exposure - interview, questionnaire, old records - hospitals,
employment area etc.
d. Analysis & Interpretation - has 2 part
▪ Exposure rate among cases & controls of the suspected factor
▪ Estimation of the risk of disease associated with exposure (odds
ratio/cross product ration) - is a measure of the strength of the
association between risk factor & outcome in case control study. The
odds ratio is the cross product of the entries in framework table of case
control study.
For Example, here is a basic framework of a case control study -

Suspected or Risk Control (disease
Cases (disease present)
Factors absent)
Present (exposed) a b
Absent (not exposed) c d
Total a+c b+d
Here,
Cases = a + c
Controls = b + d
𝑎
Exposure rate in cases = 𝑎 + 𝑐
𝑏
Exposure rate in controls = 𝑏 + 𝑑
A case control study of smoking & lung cancer -

Control
Risk Factors Cases (with lung
(without lung Total
(smoking) cancer)
cancer)
Smokers (less 33 (a) 55 (b) 88 (a + b)
than 5 cigarettes a
day)
Non-smokers 2 (c) 27 (d) 29 (c + d)
Total 35 (a + c) 82 (b + d) 117 (a + b + c + d)

128 | P a g e
Exposure Rate (frequency of smoking) -

𝑎 33
Among Cases = 𝑎 + 𝑐 = = 94.2%
35
𝑏 55
Among Controls = 𝑏 + 𝑑 = = 67%
82
Estimation of Risk (odds ratio/cross product ratio) -

𝑎×𝑑 33×27
Odds Ratio = 𝑏×𝑐 = = 8.1
55×2
Interpretation - smokers (less than 5 cigarettes per day) have risk of lung cancer
8.1 times than that of non-smoker
• Advantages -
➢ Relatively easy to carry out
➢ Rapid and inexpensive
➢ Require comparatively few subjects
➢ Particularly suitable to investigate rare diseases
➢ Allows the study of several different etiological factors
➢ Risk factors can be identified
➢ Do not take care follow up of individuals into the future
• Disadvantages -
➢ Problems of recall bias; validation of information obtained is difficult, reliance on
memory or past records, the accuracy of which may be uncertain
➢ Selection of appropriate control group may be difficult
➢ Cannot measure incidence
➢ Do not distinguish between causes & associated factors
• Bias - is any systemic error in the determination of the association between the
exposure & disease.
➢ Sources - 3 sources
a. Subject variation
b. Observer bias
c. Bias in evaluation

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➢ Types -
▪ Bias due to confounding: can be removed by matching of case & control
▪ Memory or recall bias
▪ Selection bias: can be controlled by its prevention
▪ Berkesonian bias
▪ Interviewer’s bias: can be eliminated by double-blinding
• Blinding - in order to reduce bias in case control studies, a technique known as blinding
has been adopted. It can be done in 3 ways
i. Single Blind Trial - the participants are not aware whether he belongs to the
study group or control group
ii. Double Blind Trial - neither the doctor nor the participants are aware of the
group allocation & treatment received
iii. Triple Blind Trial - the participant, the investigator & the person analyzing the
data are all ‘blind’
Cohort/Prospective/Longitudinal/Incidence/Forward-looking Study - usually undertaken to

obtain additional evidence to refute or support the existence of an association between
suspected cause & disease. In a cohort study, incidence rate of disease can be determined.
Cohort is defined as a group of people who share a common characteristics or experience
within a defined time period (e.g. age, occupation, exposure to a drug or vaccine, pregnancy,
insured persons etc.). Example of cohort study are birth cohort, exposure cohort, marriage
cohort etc.
• Distinguishing Features -
➢ The cohorts are identified prior to the appearance of the disease under
investigation
➢ The study groups are observed over a period of time to determine the frequency
of disease among them
➢ The study proceeds forward from cause to effect (the exposure has occurred but
the disease has not)
• Types - 3 types
1. Prospective Cohort Study
2. Retrospective Cohort Study
3. Combination of retrospective & prospective cohort study

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• Schematic Design -
Disease
Population Exposed
No Disease
People without
Disease
Disease
Not Exposed
No Disease
Time
Direction of Inquiry
• Basic Framework -
Disease
Cohort Total
Yes No
Exposed to putative a b a+b
etiological factor
Not exposed to c d c+d
putative etiological
factor
Study Cohort (cohort exposed to etiological factor) = a + b

Control Cohort (cohort not exposed to that factor) = c + d
• Steps -
1. Selection of study subjects
2. Obtaining data on exposure
3. Selection of comparison groups
4. Follow ups
5. Analysis

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• Analysis - data are analyzed in terms of

1. Incidence Rate of outcome among exposed & non-exposed
2. Estimation Risk - done in terms of
▪ Relative Risk - in cohort study, the estimation of disease risk associated
with exposure is obtained by an index known as relative risk or risk ratio.
It is the ratio of the incidence of the disease among exposed & the
incidence among non-exposed. It is given by the formula,
𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝑜𝑟 𝑑𝑒𝑎𝑡ℎ ) 𝑎𝑚𝑜𝑛𝑔 𝑒𝑥𝑝𝑜𝑠𝑒𝑑
Relative Risk = 𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝑜𝑟 𝑑𝑒𝑎𝑡ℎ) 𝑎𝑚𝑜𝑛𝑔 𝑛𝑜𝑛−𝑒𝑥𝑝𝑜𝑠𝑒𝑑
If RR is 1, it indicates no association
▪ Attributable Risk - is the difference in incidence rates of disease between
an exposed group & non-exposed group. It is often expressed as a
percent. It is given by the formula,
Attributable Risk =
𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑟𝑎𝑡𝑒 𝑎𝑚𝑜𝑛𝑔 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 − 𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑟𝑎𝑡𝑒 𝑎𝑚𝑜𝑛𝑔 𝑛𝑜𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
× 100
𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑟𝑎𝑡𝑒 𝑎𝑚𝑜𝑛𝑔 𝑒𝑥𝑝𝑜𝑠𝑒𝑑
A hypothetical cigarette smoking & lung cancer example of cohort study -

Developed Lung Did not develop
Cigarette Smoking Total
Cancer lung cancer
Yes 70 (a) 6930 (b) 7000 (a + b)
No 3 (a) 2997 (d) 3000 (c + d)
Incidence Rate -
𝑎 70
Among exposed (smokers) = 𝑎 + 𝑏 = = 10 𝑝𝑒𝑟 1000
7000
𝑐 3
Among non - exposed (non-smokers) = 𝑐 + 𝑑 = = 1 𝑝𝑒𝑟 1000
3000
10
Relative Risk = = 10. It implies that smokers are 10 times at greater risk of
1
developing lung cancer than non-smokers.
10 − 1
Attribuatble Risk = × 100 = 90%. It implies that 90% lung cancers among
10
smokers was due to their smoking. It indicated that the causal association between
smoking & lung cancer

132 | P a g e
• Advantages -
➢ Incidence can be calculated
➢ Several possible outcomes related to exposure can be studied simultaneously
➢ Provide direct estimation of relative risk
➢ Dose response ratios can also be calculated
➢ Bias like mis-calculation of individuals into exposed & unexposed groups can be
minimized
• Disadvantages -
➢ Involve a large number of people, generally unsuitable for investigating
uncommon diseases
➢ Takes long time to complete the study & obtain results
➢ Loss of experienced staff, loss of funding
➢ Loss of substantial proportion of the original cohort, maybe due to migration,
lose interest in the study etc.
➢ Expensive

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Difference between Case Control & Cohort Study -
Case Control Study Cohort Study

retrospective study prospective study
proceeds from effect to cause proceeds from cause to effect
starts with the disease starts with people exposed to risk factor or
suspected cause (disease occur after the
onset of study)
2 groups are selected. Case (those having the 2 groups are selected. Study group (exposed
disease) & Control (those without that to risk factor) & comparison group (not
particular disease) exposed to risk factors)
tests whether the suspected cause occurs tests whether the disease occurs more
more frequently in those with the disease frequently in those exposed than in those not
than among those without the disease similarly exposed (measure incidence rate
(measure exposure rate among case & among exposed & non-exposed)
control)
usually the first approach to the testing of a reserved for testing of precisely formulated
hypothesis hypothesis
involves fewer number of subjects involves larger number of subjects
yields relatively quick results yields delayed results for long follow up
suitable for the study of rare diseases inappropriate for the rare diseases. But
appropriate for rare exposure
yields only odds ratio yields incidence rates, RR, AR
cannot yield information about diseases can yield information about more than one
other than that selected for study disease outcome
relatively inexpensive expensive
no attrition problem attrition problem is present
ethical problem is minimal more ethical problem
problem of bias is more problem of bias is minimum

134 | P a g e
Experimental Epidemiology - the experimental studies involve some action, intervention or

manipulation in the causative chain in the experimental group. Individuals are randomly
allocated to at least 2 groups - one group is given intervention while the other group is not.
Outcome of the intervention will be obtained by comparing these 2 groups.
• Types - 3 types
1. Randomized Control Trial (RCT) or Clinical Trial
▪ Basic Steps -
 Drawing up a protocol
 Selecting reference & experimental populations
 Randomizations
 Manipulation or intervention
 Follow-up
 Assessment of outcome
▪ Design of a randomized controlled trial -
select suitable
population (reference
or target populatin)
select suitable sample

(experimental or Those not eligible
study population)
make necessary
exclusions
randomize Those who do not wish to

give consent
experimental group & control group
manipulation &
follow up
assessement
2. Field Trial
3. Community Trial

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• Characteristics -
1. Manipulation (intervention) - the researcher does something to one group of
subject in the study
2. Control - the researcher induces one or more group to compare with the
experimental group
3. Randomization - control & experimental groups are selected by randomization. It
is a statistical procedure by which the participants are allocated into groups
usually called study & control groups, to receive or not to receive an
experimental preventive or therapeutic procedure or intervention. It is an
attempt to eliminate ‘bias’ & every individuals gets an equal chance of being
allocated into any of the group.

136 | P a g e
Item 07: Research methodology: Basic concept, research cycle. Designing a

research protocol
[N/A]
.

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Card - 11: Epidemiology of Communicable & Non-

communicable diseases
Item 01: Name of important communicable diseases (viral, bacterial, rickettsia,

protozoal, fungal). Diseases under API coverage. Epidemiology of diphtheria,
pertussis, tetanus, polio
Communicable Disease - An illness due to specific infection as agent or its toxic products
capable of being directly or indirectly transmitted from man to man, animal to animal or from
the environment (through air, dust, soil, water, food etc.) to man or animal
1. Bacterial disease - Diphtheria, enteric fever (typhoid and paratyphoid), pertussis
(whooping cough), plague, anthrax, tuberculosis, leprosy (Hansen’s disease) etc.
2. Viral diseases - poliomyelitis, viral hepatitis, influenza, bird flu, swine flu,
measles, rubella, mums, chicken pox, smallpox, rabies, dengue, yellow fever etc.
3. Protozoan diseases - amoebiasis, giardiasis, trichomoniasis, malaria, kala Azar
etc.
4. Helminthic diseases - ascariasis, ancylostomiasis, filariasis, taeniasis etc.
5. STD - syphilis, gonorrhea, AIDS etc.
6. Zoonotic diseases - rabies, brucellosis, hydatid disease, rickettsia fever etc.
7. Arthropod borne disease - dengue, malaria, kala Bazar etc.
8. Others - acute respiratory infections, SARS, diarrhea, e food poisoning etc.
• Important communicable diseases in Bangladesh -

➢ Chicken pox
➢ Measles
➢ Diphtheria
➢ Whooping cough
➢ Poliomyelitis
➢ Tetanus
➢ Tuberculosis
➢ Rabies

138 | P a g e
• Modes of Transmission - 2 types

➢ Direct -
▪ Direct contact - Direct contact from skin to skin, mucosa to mucosa or
mucosa to skin of the same or another person e.g. STD and AIDS, Leprosy,
skin and eye infections
▪ Droplet infection - Direct projection of a spray of droplets of saliva and
nasopharyngeal secretions during coughing, sneezing, or speaking and
spitting, talking into the surrounding atmosphere. The droplet spread is
usually limited to a distance of 30-60 cm between source and host e.g.
Common cold, Diphtheria, Whooping cough, tuberculosis, meningococcal
meningitis etc.
▪ Contact with soil -Direct exposure of susceptible tissue to the disease
agent in soil, compost or decaying vegetable matter e.g. hookworm,
tetanus, mycosis etc.
▪ Inoculation into skin or mucosa - Inoculated directly into the skin or
mucosa e.g. Rabies virus by dog bite, Hepatitis B virus by contaminated
needles and syringes etc.
▪ Transplacental or vertical e.g. TORCH agents (Toxoplasma gondii, rubella
virus, cytomegalovirus and herpes virus), varicella virus, syphilis, hepatitis
B and AIDS
➢ Indirect - Includes 5 F’s; flies, fingers, fomites, food and fluid. The infectious
agent must be capable of surviving outside the human host in the external
environment retaining its pathogenesis and virulence properties
▪ Vehicle Borne -
 Diseases transmitted by water and food - acute diarrheas, typhoid
fever, cholera, polio, hepatitis A, food poisoning and intestinal
parasites
 Diseases transmitted by blood - hepatitis B, malaria, syphilis,
brucellosis, cytomegalovirus infection
 Organ transplantation - cytomegalovirus infection in kidney
transplant
▪ Vector-borne -
 Mechanical transmission: by crawling or flying arthropod through
soiling of its feet or proboscis or by passage of organism through
its feces, e.g. housefly carrying dysentery
 Biological transmission: 3 types -
a. Propagative: The agent merely multiplies in vector, but no
change in form, e.g. plague bacilli in rat fleas.
b. Cyclo-propagative: The agent changes in form and
number, e.g. malaria parasite in mosquito.

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c. Cyclo-developmental: The agent undergoes inly

development but no multiplication, e.g. microfilaria in
mosquito.
▪ Airborne
 Droplet Nuclei - are tiny particles (1-10 microns) that represent
the dried residue of droplets e.g. tuberculosis, influenza,
chickenpox, measles, Q fever and many respiratory infections.
 Dust - Larger droplets are expelled during talking, coughing or
sneezing, settle down on the floor, carpets, furniture, clothes and
other objects and become part of the dust e.g. Staphylococcal
infection, tuberculosis, pneumonia
▪ Fomite borne - Fomites are inanimate articles or substances other than
water and food contaminated by the infectious agent and capable of
transferring it to a healthy person. Fomite includes soiled clothes, linen,
cups, spoons, pencils, door handles, syringes, surgical instruments etc.
e.g. diphtheria, typhoid fever, bacillary dysentery, hepatitis A, eye and
skin infections.
▪ Unclean hands and fingers e.g. Staphylococcal and streptococcal
infections, typhoid fever, dysentery, hepatitis A and intestinal parasites

140 | P a g e
• Principles of Control -
1. Controlling reservoir/prevention of spread
▪ Early diagnosis
▪ Notification
▪ Epidemiological investigation
▪ Isolation
▪ Treatment
▪ Quarantine
2. Interruption of transmission of disease
▪ Water treatment/ water purification
▪ Control of source of infection
▪ Control of the vector
▪ Practice of safe sex
3. Protection of susceptible host
▪ Immunization
▪ chemoprophylaxis
▪ Nonspecific measures
4. Destruction of microbes
▪ Disinfection
▪ Sterilization

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• Communicable diseases that are under EPI -

➢ Neonatal tuberculosis
➢ Diphtheria
➢ pertussis
➢ Measles
➢ Polio
➢ Tetanus
➢ Hepatitis B
➢ Haemophiles influenzae type-B
Notification of Disease - once an infectious disease has been detected it should be notified to
the local health authority, whose responsibility is to put into operation control measures,
including the provision of medical care to patients
• Notifiable Diseases -
➢ Communicable disease notification-
▪ Cholera
▪ Plague
▪ Yellow fever
▪ Typhoid fever
▪ Relapsing fever
▪ Paralytic polio
▪ Malaria
▪ Viral influenza a
▪ SARS
▪ Smallpox
➢ Non communicable disease notification
▪ Cancer
▪ Congenital defect
▪ Accidents etc.
• Advantages/Benefits -
➢ It is an important source of epidemiological information
➢ Early detection of disease outbreak, which permits immediate action to be taken
by the health authority to control their spread

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Diphtheria - is acute infectious disease caused by toxigenic strains of Corynebacterium

diphtheriae and characterized in its typical form by presence of membrane in the throat and
generalized toxemia.
• Agent - Corynebacterium diphtheriae
• Mode of transmission -
➢ Mainly by droplet infection
➢ From infected cutaneous lesion
• Clinical features -
➢ Respiratory forms -
▪ sore throat
▪ nasal discharge
▪ fever
▪ vomiting
▪ husky voice
▪ high pitch cough
➢ Non-respiratory forms - conjunctivae & the genitals may also be site of infection
➢ Cutaneous forms - appears as secondary infection as an ulcer
• Complications -
➢ Laryngeal obstruction (1st week)
➢ Myocarditis (2nd week)
➢ Peripheral neuropathy (3rd week)
• Management -
➢ Admit to hospital
➢ Administer DPT or DT toxoid antitoxin
➢ give benzylpenicillin I/V
➢ If severe, respiratory obstruction tracheostomy needed
➢ Immunization

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Pertussis - acute infectious disease, usually off young children, caused by B. pertussis, clinically
characterized by an insidious onset and mild fever and an irritating cough, gradually becoming
paroxysmal and characteristic ‘whoop’. The spectrum of disease varies from severe illness to a
atypical and mild illness without hoop. Chinese call it a ‘hundred-day cough’
• Agent - B. pertussis
➢ Contact
➢ Droplet infection
➢ Indirectly contaminated fomite
• Control/Prevention -
➢ Cases & Contacts - early diagnosis, isolation, treatment
➢ Active Immunization - DPT Vaccine
➢ Passive Immunization
Tetanus - acute disease caused by exotoxin of Clostridium tetani and characterized by painful
paroxysmal spasm of the voluntary muscles
• Agent - Clostridium tetani
• Source of Infection - soil, dust/earth, human and animal excreta, contaminated articles
• Mode of Transmission - infection by contamination of wound with tetanus spores, trivial

pinprick, skin abrasion, puncture wound, burns, unsterile surgery, human bite, animal
bite
• Prevention and control-

➢ Immunization of the mother- Tetanus toxoid (TT)
➢ Proper antenatal care
➢ Proper intra-natal care

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Poliomyelitis - is an acute viral infection caused by an RNA virus. It is primarily an infection of

the human alimentary tract but the virus may infect the central nervus system in a very small
percentage (1%) of capes in varying degrees of paralysis & possibly death.
• Agent - poliovirus, member of RNA enterovirus
• Mode of Transmission -
➢ Fecal oral route
1. Inapparent (95%)
2. Abortive (4 to 8%)
3. Non paralytic (1%)
4. Paralytic (<1%)
• Prevention/Control -
➢ Reporting of cases of paralytic poliomyelitis
➢ Isolation of cases is of little value
➢ Disinfection of contaminated articles
• Treatment - OPV (details in 1st term sheet)

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Item 02: Eruptive diseases: Smallpox & chicken pox, measles, mumps & rubella.
Typhus fever, dengue. Zoonotic diseases: Rabies, anthrax, brucellosis, plague,
typhus, yellow fever, Japanese encephalitis
Chicken Pox -
• Agent - varicella zoster
➢ droplet infection
➢ direct contact
➢ air borne
• Complications -
➢ Hemorrhage
➢ Pneumonia
➢ Encephalitis
➢ Acute cerebral ataxia
➢ Skin infection
➢ Septicemia
➢ Septic arthritis
Small Pox - eradicated
Mumps - is an acute infectious & communicable disease characterized by fever, tenderness &
localized swelling of one of more of the salivary glands, usually the parotid & occasionally the
sublingual or sub-maxillary glands & other organs.
• Agent - mumps virus, member of paramyxovirus group
➢ Direct contact
➢ Fomites

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• Complications -
➢ orchitis
➢ ovaritis
➢ pancreatitis
➢ meningo-encephalitis
➢ thyroiditis
➢ neuritis
➢ hepatitis
➢ myocarditis
Measles - an acute highly infectious disease of childhood caused by specific virus of the group
myxoviruses which is clinically characterized by fever & catarrhal symptoms of upper
respiratory tract followed by a typical rash.
• Agent - RNA paramyxo virus
➢ Direct contact
➢ Droplet spread
➢ Fomite
➢ Rarely air borne
• Clinical features - 3 stage

1. Prodromal stage (1 to 2 day) - fever, coryza, sneezing, running nose, red water
eyes, cough, photophobia, kolpik’s spot
▪ Kolpik’s Spot - pathognomonic of measures characterized by small, bluish
white spots on a red base. It is smaller than head of pin. It is found on the
buccal mucosa opposite the 1st & 2nd upper molar teeth. It appears 1 or 2
days before appearance of rash. Its importance is that the diagnosis of
measles is based on typical rash & kolpik’s spot
2. Eruptive Stage (3 to 7 days) - maculo-papular rash, fever & rash begins to fade
3. Post-measles Stage - loss of weight, will remain weak for a number of days

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• Complications -
➢ Effects of measles virus
▪ Stomatitis
▪ Enteritis
▪ Pneumonia
▪ Keratitis
▪ Measles associated diarrhea
➢ Secondary bacterial infection
▪ Otitis media
▪ Bronchopneumonia
▪ Conjunctivitis
➢ Neurological
▪ Post - viral encephalitis
▪ Sub-acute sclerosing panencephalitis (SSPE)
➢ Nutritional
▪ Severe weight loss
▪ Kwashiorkor
▪ Corneal liberation
• Control -
➢ Isolation for 7 days after onset of rash
➢ Immunization of contacts within 2 days of exposure
➢ Prompt immunization at the beginning of an epidemic is essential to limit the
spread
• Prevention -
➢ Active immunization - live attenuated vaccine are recommended for use
➢ Passive immunization - human immunoglobin
Dengue -
• Agent - a virus having 4 immunological types - 1, 2, 3, 4. These are flavivirus
➢ Female Aedes aegypti mosquito transmit the disease
➢ Blood meal is necessary for ovulation
➢ No person-to-person transmission
• Endemic Zone - Dhaka

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Rubella -
• Agent - RNA virus, member of toga virus family
➢ Directly from person to person by droplets from nose & throat & droplet nuclei
➢ Vertical transmission leading to congenital rubella in the new borne. Congenital
infection is considered to have occurred if the infant has IgM rubella antibodies
shortly after birth or if IgG antibodies persist for more than 6 months. Congenital
abnormalities are -
▪ Brain - mental retardation
▪ Eye - Cataract
▪ Ear - deafness
▪ Heart - septal defect
• Diagnosis -
➢ Throat swab culture
➢ Hemagglutination inhibition test
➢ ELISA Test
➢ Radio-immune assay
Rabies -
• Agent - Lyssavirus type I of rhabdoviridiae family
➢ Animal bites
➢ Licks
➢ Non-bite route
• Management -
➢ Post exposure prophylaxis
▪ General consideration - Every instance of human expose should be
treated as an emergency. The aim is to neutralize the inoculated Virus
before it can enter the nervous system
▪ Local treatment of wound
▪ Immediate thorough cleansing and flushing with soap or detergent and
water of all wounds caused by animal bites or scratch
▪ Open wounds should not be closed

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▪ If the wound is severe and near the head, it should be infiltrated with
rabies immunoglobulin (RIG)
▪ Immunization - is the best prophylaxis treatment but once symptoms
have developed vaccine is of no avail. Sheep brain vaccine, suckling
mouse vaccine, inactivated duck embryo vaccine, inactivated chick
embryo vaccine, human diploid cell vaccine (HDCV)
The vaccine previously used widely in Bangladesh is inactivated sheep
brain vaccine
➢ Pre-exposure prophylaxis - required by those who by profession handle
potentially infected animals, work with rabies in laboratory and live at special
risk in rabies-endemic areas. It is done by human diploid cell vaccine (HDCV). 3
doses 1 ml IM on days 0, 7, 21 or 28
➢ Immunization of pet dogs and cats annually
➢ Licensing of dogs
➢ Quarantine measures for entry of dogs in rabies free areas
➢ 10 days detention and observation of dogs and cats known to have bitten a
person or showing suspicious signs of rabies
➢ Unvaccinated dogs or cats bitten by non-rabid animals should be destroyed
➢ Immediate submission of intact head of animal that die of suspected rabies for
laboratory examination
➢ Pre-exposure immunization of high-risk group e.g. Veterinarians, dog handlers,
laboratory workers with HDCV given
• Hydrophobia - rabies in man is called hydrophobia. It means fear of water. It is the

diseased condition in man caused by bite of a rabid animal.
➢ Clinical Feature -
▪ Begins with prodromal symptoms such as headache, malaise, sore throat,
slight fever, pain, tingling at the bite
▪ Wide spread excitation & stimulation of nervous system
▪ At later stage, although the patient is thirsty attempt at drinking become
unsuccessful & thereafter the sight sound of water may precipitate
distressing spasm & attack of panic
➢ Mechanism -
▪ Spasm of muscles of deglutition
▪ Violent contraction of diaphragm and other inspiratory muscles

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Anthrax - disease of wild or domestic animals caused by the bacteria Bacillus anthracis that is
transmitted to man. The characteristic lesion of human anthrax is necrotic cutaneous ulcer
(malignant pustule).
• Agent - Bacillus anthracis
• Modes of Transmission -
➢ Infection of skin is by contact with tissues of animal
➢ Pulmonary Anthrax results from inhalation of sports of the bachelors
➢ Intestinal Anthrax arises from ingestion of contaminated undercooked meat
➢ Accidental infections may occur among laboratory workers
Plague - is an infectious disease of animals, particularly wild and domestic rodents, which is
transmitted to man through the bite of infected ectoparasite, the rat flea. Domestic pets may
carry plague infected rodent fleas into houses.
i. Bubonic plague - It is more common and involves lymphatic system.
Microorganisms multiply in inguinal, axillary lymph node and causes swelling of
lymph node.
ii. Pneumonic plague - It is easily and more commonly spread through respiratory
droplet.
iii. Septicemic plague - It is the most dangerous as it involves blood circulation
• Agent - Yersinia pestis
• Vector - Rat flea
➢ Vector transmission
➢ Mechanical Transmission
➢ Droplet Transmission
Yellow Fever -
• Agent - Flavi virus, formerly classified as a group B arbo-virus

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Item 03: ARI & Diarrheal diseases control programme. Enteric fever. Viral
hepatitis (A & E)
Acute Respiratory Infection (ARI) - is an episode of acute symptoms & signs resulting from
infection of any part of respiratory tract or any related structures including paranasal sinuses,
middle ear & pleural cavity
1. Acute Upper Respiratory Tract Infections
▪ Common cold
▪ Otitis media
▪ Pharyngitis
2. Acute Lower Respiratory Tract Infections
▪ Epiglottis
▪ Laryngitis
▪ Laryngo-tracheitis
▪ Bronchitis
▪ Bronchiolitis
▪ Pneumonia
Diarrhea - defined as the passage of loose, liquid or watery stools more than 3 times a day.
The term ‘diarrheal diseases’ should be considered only as a convenient expression for a group
of disease in which the predominant symptoms is diarrhea.
1. Acute Watery Diarrhea
▪ Lasts several hours to days
▪ Main danger is dehydration
▪ Common cause: Rotavirus, V. cholera, E. coli
2. Acute Bloody Diarrhea
▪ Visible blood in the stool
▪ Main danger is damage in intestinal mucosa, sepsis, malnutrition,
dehydration
▪ Common cause: Shigella
3. Persistent Diarrhea
▪ Lasts 14 days or longer
▪ Common cause: AIDS
4. Diarrhea with severe Malnutrition
▪ Common cause: marasmus & kwashiorkor

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• Classification on the basis of dehydration -
Some Severe
Points No Dehydration
Dehydration Dehydration
lethargic or
appearance well, alert restless, irritable
unconscious
very sunken &
eyes normal sunken
very dry
Looks
tears present absent absent
mouth & tongue moist dry very dry
drinks normally, thirsty, drinks drinks poorly or
thirst
not thirsty eagerly not able to drink
Skin Pinch goes back quickly goes back slowly goes back
Loss of Body Weight <5% 5 to 10% >10%
<50ml/kg body 50 to 100 ml/kg >100 ml/kg body
Fluid Loss
weight body weight weight
• Causes of diarrheal diseases in our country -
Name of the Disease Causative Agent

E. Coli
Rota Virus
Non typhoid salmonella
G. lamblia
Gastroenteritis
Campylobacter
Adenovirus
Norwalk virus
Astro virus
Cholera Vibrio cholerae
Bacillary dysentery Shigella
Amoebic dysentery Entamoeba histolytica

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• Management -
➢ No Dehydration - can be treated in home
▪ ORS packets should be given
▪ Demonstration of how to prepare & give ORS after each loose motion
▪ Give more food & fluid
➢ Some Dehydration
▪ ORS 75ml/kg within 4 hours
▪ Reassess after 4h. If there is no improvement, refer to hospital
➢ Severe Dehydration
▪ Rehydration by I/V fluid such as cholera saline
➢ Sanitation
➢ Breast feeding & weaning practice
➢ Use of sanitary latrine
➢ Personal hygiene
➢ Water for drinking & domestic use
➢ Vaccine against rotavirus
➢ Immunization against measles
➢ Health education
➢ Fly control
Enteric Fever - includes both typhoid and paratyphoid fever.

Typhoid fever is an acute infectious communicable disease caused by Salmonella typhi and is
manifested technically by gradual onset of headache, sustained fever, relative bradycardia, rose
spot on the trunk, and splenomegaly in about 75% of patient.
• Agent - Salmonella typhi
• Mode of Infection -
➢ Fecal oral route
➢ Urine oral route
Viral Hepatitis - inflammation of the liver, which results in damage to hepatocytes with
subsequent cell death

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Hepatitis A -
• Agent - Hepatitis A virus, an enterovirus of the picorna virus family
➢ Fecal-oral route
➢ Parenteral route by blood
➢ Sexual transmission
Hepatitis B - formerly known as ‘serum hepatitis’ is a systemic infection with major pathology in
the liver & transmitted usually by the parenteral route. Persistent hepatitis B virus infection
may cause progressive liver disease including chronic active hepatitis and hepatocellular
carcinoma
• Agent - hepatitis B virus, double stranded DNA virus
➢ Parenteral Transmission e.g. blood injection by contented syringes or needles
➢ Perinatal/Vertical Transmission - mother to fetus
➢ Sexual Transmission
➢ Hepatitis B vaccine
▪ Recombinant DNA yeast derived vaccine
▪ Plasma derived vaccine
➢ Hepatitis B immunoglobulin- used for acutely exposed individuals to HBsAg
positive blood e.g. doctor, nurse, laboratory workers, new born infant of carrier
mothers & sexual contacts
Difference between Hepatitis A & E and Hepatitis B & C -
Traits Hepatitis A & E Hepatitis B & C

Transmission fecal oral parenteral, perinatal, sexual
Chronicity No Yes
Chronic Complications No Yes
Anti-Viral Therapy Not needed Needed

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Item 04: Tuberculosis and Leprosy Control Programme
Tuberculosis - is a chronic infections and communicable granulomatous disease caused by

Mycobacterium tuberculosis and rarely by Mycobacterium bovis which primarily affects lungs &
causes pulmonary tuberculosis as tubercle bacilli grow best in high oxygen content.
• Agent - Mycobacterium tuberculosis & rarely Mycobacterium bovis

• Sites -
➢ Primary -
▪ Lungs
▪ Intestine
▪ Skin
▪ Tonsil
▪ Oropharynx
➢ other sites
▪ Bones
▪ Join
▪ Kidney
▪ Manager
▪ lymph nodes
➢ Airborne, by droplets, droplet nuclei, dust
➢ Injection contaminated milk, infected meat
➢ Inoculation for skin
➢ Transplacental (rare)
• Clinical Features -
➢ Chronic cough for 3 weeks
➢ Fever
➢ Chest pain
➢ Shortness of breath
➢ Loss of weight
➢ Swelling of lymph nodes
➢ Pain and swelling of joints
➢ Tubercular meningitis produce headache, fever, stiffness of neck and late
confusion

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• Investigations -
➢ Chest X Ray - moss miniature radiography
➢ Blood for ESR - raised ESR
➢ Tuberculin Skin Test
➢ Sputum for AFB & culture
➢ Recently advanced ELISA
• Cases -
➢ Open case TB- patient with at least one initial sputum smear is positive for AFB is
called an open case of Tuberculosis. This patient is infectious to others. So it is
epidemiological important cause open cases in tuberculosis are dangerous for
our community as they spread tuberculosis.
➢ Close case TB - patient with at least two negative smears, but tuberculosis
suggestive symptoms and x-ray abnormality or positive culture is called a closed
case of TB
• Treatment -
Treatment Regimen
Category Continuation
Type of Patient
of TB Initial Phase (daily) Phase (3 times
weekly)
new patients with no past
history of taking anti-TB
I drugs or patients who 4 FDC for 2 months 2 FDC for 4 months
have taken anti-TB drugs
for less than a month
4 FDC + Inj.
Streptomycin for 2
patients with past history months 2 FDC + Ethambutol
II of treatment for more for 5 months
than a month followed by
4 FDC for 1 month
Composition of FDC Tablets

4 FDC (HRZE): Isoniazid 75mg + Rifampicin 150mg + Pyrazinamide 400mg + Ethambutol 275 mg
2 FDC (HR) - Isoniazid 75mg + Rifampicin 150mg

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• Control/Prevention -
➢ Curative component
▪ case findings/early detection
▪ isolation
▪ chemotherapy
➢ Preventive component
▪ BCG vaccination
▪ chemoprophylaxis
▪ general health improvement
▪ limitation of disability
▪ rehabilitation
▪ surveillance
• Multidrug-resistant TB (MDR TB) - WHO defines a multidrug resistance strain as one that
is at least resistance to two 1st line drugs: isoniazid & rifampicin. The Consequence are -
➢ It is much more difficult to treat.
➢ It can take at least two years and their results are poor
➢ 2nd line drugs cost 30 times as much as the drugs used in treatment of non-
resistant tuberculosis patients
➢ Patients with MDR tuberculosis may need to be hospitalized and isolated which
adds to the cost of treatment, to prevent transmission of primary resistance
straint to others
• Extensive drug-resistant TB (XDR TB) - causes of tuberculosis that are resistant to almost
all 2nd line drugs are termed extensively drug-resistant tuberculosis and are defined as
occurring when Mycobacterium tuberculosis is resistant to at least rifampicin, isoniazid,
fluroquinolone or injectables such as amikacin, capreomycin, kanamycin
• Directly Observed Treatment Short Course (DOTS) - it means someone, usually a health
worker, takes responsibility for observing the person take each dose of the drugs.
➢ Provider - will be given by peripheral health stuff such as MPWs or through
voluntary workers such as teachers, dais, ex patients, social workers, family
members.

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Leprosy - is a chronic infection cause granulomatous disease caused by Mycobacterium leprae

characterized by skin lesion, involvement of peripheral nerve resulting in an anesthetic patches
hypopigmented areas in the skin, tropic changes for producing defect in mucous membrane,
muscle, bone.
• Agent - Mycobacterium leprae
➢ Droplet of infection
➢ Contact transmission
➢ Others such as insect vectors, tattooing needles
• Clinical features -
➢ Hypopigmented patches
➢ Partial or total loss of cutaneous sensation in the affected areas
➢ Presence of thickened nerves
➢ Presence of acid-fast bacilli in the shin or nasal smears
• Treatment - 2 types
1. Multibacillary (more than 5 skin lesion)
a. Rifampicin 600mg
b. Dapsone 100mg
c. Clofazimine 300mg
2. Paucibacillary (1 to 5 skin lesion)
a. Rifampicin 600mg
b. Dapsone 100mg
• Prevention -
1. Medical measures
▪ Estimation of the problem
▪ Early case detection
▪ Multidrug therapy
▪ Surveillance
▪ Immunoprophylaxis
▪ Chemoprophylaxis
▪ Rehabilitation
▪ Health education
▪ Isolation
▪ Disinfection
▪ Leprosy vaccine

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2. Social measure
▪ Not use of leper food, drink and clothes
▪ Arise in the standard of living
▪ Reduction of overcrowding
3. Planning and Program management is essential ingredients
4. Evaluation
▪ To check whether the desired results are being achieved
▪ To modify program

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Item 05: Parasitic diseases - exo & endo parasites. Scabies and Lice infestation.
Helminthic infestation. Malaria, Filaria, Kala Azar
Scabies - The female parasite burrows into the epidermis where it breeds and causes the
condition known as scabies or itch. Scabies is a contagious, itchy skin condition caused by very
small, wingless insects or mites called Scabies Itch Mite Sarcoptes scabiei hominis.
• Agent - female Sarcoptes scabei hominis. For crusted scabies/secondary infection,
vector is itch mite but agent is Streptococcus
➢ Close Contact - By close contact with an infected person, e.g., sleeping in the
same bed, children playing with each other or nursing an infected person. The
disease tends to spread through families; therefore Scabies is called a familial or
household infection.
➢ Contaminated clothes and bed linen
• Site of lesions - warm places such as

➢ The hands, between the fingers, under fingernails and wrist
➢ The extensor aspect of elbows
➢ The axillae, buttocks, lower abdomen, feet and ankles, palms in infants
➢ Breasts in women and the genitals in men
➢ In babies the neck and head may be affected but not in adults due to more
vascular supply causing more heat and also due to frequent washing of face
• Diagnostic Features -
➢ The patient complains of itching which is worse at night
➢ Examination reveals follicular lesions at the affected site
➢ Secondary infection leads to crusted papules and pustules
➢ The diagnosis is probable if the other members of the household are affected
➢ Confirmation of the diagnosis may be made by searching for the parasite in the
skin debris under microscope

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• Treatment -
➢ It is essential to treat all members of the affected household simultaneously
whether or not they appear to be infested
➢ Before commencing the treatment, the patient is given a good scrub with soap
and hot water
➢ Drug of choice: The 2 most widely used drugs are permethrin cream and
malathion lotion. Both medications contain insecticides that kill the scabies mite.
First-line treatment of scabies is topical permethrin 5% cream.
➢ A thin layer of cream should be applied to every inch of the body below the chin
including the soles of the feet before going to bed and allowed to dry. The cream
should be applied between the fingers and toes and beneath the tips of the
fingernails. In the case of babies, the head must also be treated.
➢ It should be washed off with soap and water 8-12 hours later and repeated after
a week.
➢ All underclothes, clothes and sheets of persons with scabies should be changed
and washed in hot water and dried
• Complications -
➢ Crusted scabies - When large areas of the body, hands and feet are scaly and
crusted the disease is called crusted scabies. When a person itches scabies area,
scraping comes out and streptococcus on skin causes secondary infection which
is the crusted scabies. It is a rare but more severe form of scabies, where a large
number of mites are in the skin. This can develop in older people and those with
a lowered immunity
➢ Acute glomerular nephritis
➢ Rheumatic fever
➢ Urticaria
➢ Eczema

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Malaria - is a serious and sometimes fatal disease caused by a parasite that commonly infects a
certain type of mosquito which feeds on humans. People who get malaria are typically very sick
with high fevers, shaking chills, and flu-like illness. Four kinds of malaria parasites infect
humans: Plasmodium falciparum, P. vivax, P. ovale and P. malariae.
*P. vivax more common in Sylhet but P. ovale is absent in this area.
*P. falciparum is more dangerous as it causes cerebral malaria.
• Clinical Features -
i. Cold stage - headache, nausea, chilly sensation, skin feels cold, rigor an hour
later
ii. Hot stage – burning hot sensation, skin feels dry and hot.
iii. Sweating stage – profuse sweating, skin cool and moist
• Agent -
➢ Plasmodium vivax - causes Malaria
➢ Plasmodium malarie – causes Quartan Malaria (fever occurs every 4th day, 72
hours interval)
➢ P. ovale & P. falciparum – causes Tertian Malaria (fever occurs every 3rd day, 48
hours interval)
• Complications -
➢ Cerebral Malaria
➢ Blackwater Fever - It is the complication of untreated case of malaria in which
RBC is hemolyzed in blood stream in excess amount (Hemoglobinemia), Hb
passes through kidney and appears in urine (Hemoglobinuria), urine looks dark
red or blackish hence called black water fever. It may lead to renal failure
➢ Anemia
➢ Pneumonia
• Endemic Zones - Sylhet hilly area, Chittagong hill track area, Sunamgonj, Tahirpur

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Filariasis - the term ‘lymphatic filariasis’ covers infection with 3 closely related nematode
worms - Wuchereria bancrofti, Brugia malayi & Brugia timori. All 3 infections are transmitted to
man by the bites of infective mosquito
• Agent - mainly Wuchereria bancrofti
• Endemic Zones - Nilfamari, Dinajpiur, Rangpur, Syedpur, Kurigram
Kala Azar - literally means black sickness. Also known as visceral leishmaniasis is a chronic
infection of reticuloendothelial system caused by the protozoa Leishmania donovani. In
Bangladesh it is transmitted by the sand fly named Phlebotomus argentipes. The disease
presents as prolonged fever (>2weeks) with splenomegaly, anemia, weight loss and darkening
of complexion.
• Agent - Leishmania donovani
• Vector - Phlebotomus argentipes
• Endemic Zones - Pabna, Sirajgonj, Dinajpur, Rajshahi, Thakurgaon, Mymensingh,

Netrokona, Tangail, Gazipur, Jamalpur

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Item 06: Emerging and Re-emerging diseases: SARS Avian Flu, NIPAH virus,
MERS corona, ZICA & Ebola Virus
Emerging Diseases - emerging infectious diseases are those whose incidence in humans has
increased during the last two decades or which threaten to increase in the near future. The
term also refers to a newly appearing infection of disease or diseases that are spreading to new
geographical areas such as cholera in South America and yellow fever in Kenya. The most
dramatic example of new disease is AIDS.
Re-emerging Diseases - the term emerging diseases refers to the disease which were previously
easily controlled by chemotherapy and antibiotics, but now they have developed antimicrobial
resistance and are often appearing in epidemic form
Severe Acute Respiratory Syndrome (SARS) - is a communicable viral disease, caused by a new
strain of coronavirus, which differs considerably in genetic structure from previously recognized
coronavirus.
• Clinical Feature -
➢ Fever
➢ Malaise
➢ Chills
➢ Headache
➢ Myalgia
➢ Dizziness
➢ Cough
➢ Sore Throat
➢ Running Nose
➢ close contact with the patient
➢ close contact with the infected material via the eyes, nose & mouth with
infectious respiratory droplets

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Covid-19 - is an infectious disease with a potential to cause severe acute respiratory infection
• Agent - SARS CoV 2 (severe acute respiratory coronavirus 2)
➢ Physical contact with an infected person
➢ Fecal-oral route
➢ Some report suggests of sexual transmission
• Investigation -
➢ RT-PCR
➢ Rapid Antigen Test
➢ CBC
• Treatment -
➢ Home quarantine
➢ O2 Therapy
➢ Paracetamol
➢ Anti-Histamine
➢ Steam inhalation & gurgle with lukewarm water
➢ Antibiotic (azithromycin)
➢ Treatment in severe cases in ICU
• Prevention -
➢ Using medical mask
➢ Social distancing
➢ Frequent hand washing
➢ Vaccination
➢ Maintaining cough etiquette
➢ Rational use of personal protective equipment
• Covid Vaccines -
➢ RNA Vaccine
▪ Pfizer Vaccine
▪ Moderna Vaccine
➢ Adenovirus Vector Vaccine
▪ AstraZeneca Vaccine
▪ Sputnik V

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➢ Inactivated Virus Vaccine

▪ Sinopharm
▪ CoronaVac
▪ Covavaxin
▪ Covivac
➢ Protein Subunit Vaccine
▪ EpiVacCorona

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Zika -
• Agent - Zika virus belonging to genre flavivirus
• Mode of Transmission - female Aedes aegypti mosquito transmit the disease
Ebola -
• Agent - Ebola virus, member of Filoviridae family
➢ through direct contact with blood, organs, body secretions or their body fluids
➢ human to human transmission through blood or body fluids
➢ not transmitted through air, water or food

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Item 07: STDS & HIV AIDS. Viral Hepatitis (B, C & D)
Sexually Transmitted Diseases (STD) - group of communicable disease that are transmitted
predominantly by sexual contact and caused by a wide range of bacterial, viral, protozoal &
fungal agents and ectoparasites.
• Control -
A. Initial planning
▪ Problem definition by
 Prevalence rate
 Geographical distribution
 Population group
 Yearly study
 Factors of STD
▪ Establishment of Priorities which depends on
 Size of the problem
 Consequences of the problem
 Availability of resources
 Political commitment
 Age of the victims
 Sex of the victims
 Occupation of the victims
 Residence of the victims
▪ Setting objectives
▪ Considering the strategies
B. Intervention strategies
▪ Case detection
 Screening
 Contact tracing
 Cluster tracing
▪ Case holding & treatment
▪ Epidemiological treatment
▪ Personal prophylaxis
▪ Health education

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C. Support components
▪ STD clinic
▪ Laboratory services
▪ Primary health care
▪ Information system
▪ Legislation
▪ Social welfare measures
• Prevention -
➢ Health & sex education
➢ Prevention of blood borne STDs transmission
➢ Control of prostitution
➢ Social welfare measures
➢ Abiding by the law of religion
➢ Early diagnosis & treatment
Syphilis -
• Agent - Treponema pallidum
➢ Indirect sexual contact (e.g. kissing)
➢ Blood transfusion
Gonorrhea -
• Agent - Neisseria gonorrhoeae
➢ Sexual activity
➢ From infected mother to the new born

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Acquired Immune Deficiency Syndrome (AIDS) - is a fatal illness caused by human

immunodeficiency virus (HIV), which breaks down the body’s immune system, leaving the
victim vulnerable to a host of life-threatening opportunistic infections, neurological disorders or
unusual malignancies.
• Agent - Human Immunodeficiency Virus (HIV)
▪ Vaginal sex
▪ Anal sex
▪ Oral sex
▪ Homosexual/bisexual/heterosexual contact etc.
➢ Contaminated blood
➢ Maternal fetal transmission
➢ Any skin piercing such as injecting, IV drug abuse, ear & nose piercing, tattooing,
scarification, shared razor etc.
• Control -
➢ Preventive measures
▪ Health & sex education
▪ Prevention of blood borne STD transmission
▪ Control of prostitution
▪ Social welfare measures
▪ Abiding by the law of religion
➢ Antiretroviral treatment - drugs such as zidovudine, stavudine, didanosine
➢ Specific Prophylaxis
➢ Primary health care
• Advice regarding vaccination to a mother -

➢ No symptoms & sign - all vaccination
➢ Symptoms & sings of AIDS - all vaccination except BCG
• High Risk Person -

➢ Prostitutes
➢ Homosexual & bisexual persons
➢ I/V drug abusers
➢ Blood transfusion of the recipients
➢ Lower class people

P a g e | 171
Item 08: CHD, Heart Attack and Stroke, HTN, Rheumatic Fever and Rheumatic
Heart Disease
Non-Communicable Disease - group of chronic disease where the causative agents are not
clearly identified, but a set of risk factors have been identified to be associated. Some common
non-communicable disease of Bangladesh are -
➢ Cardiovascular Diseases -
▪ Coronary Heart Disease (CHD)/Ischemic Heart Disease (IHD)
▪ Hypertension
▪ Rheumatic Heart Disease
➢ Cerebrovascular Disease - Transient Ischemic Attack (TIA), Stroke
➢ Diabetes Mellitus
➢ Cancer
➢ Mental Illness
➢ Blindness
➢ Accidents
Difference between Communicable & Non-communicable Disease -
Traits Communicable Disease Non-communicable Disease

Transmission Transmitted from person to not transmitted person to
person person
Agent/Risk Factor Agent responsible Risk factors responsible
Causative Agent usually single multifactorial
Disease Cycle yes no
incubation period short long
cellular alteration reversible irreversible pathological
alteration occurs
Risk Factors - The term risk factor is used by different authors with at least two meanings -
✓ An attribute or exposure that is significantly associated with development of a disease
✓ A determinant that can be modified by intervention, thereby reducing the possibility of
occurrence of disease or other specific outcomes
Many diseases e.g. coronary heart disease, cancers, peptic ulcers etc. agent is still unidentified.
In this cases, etiology is discussed in terms of risk factor.

172 | P a g e
1. Modifiable risk factors
▪ Smoking
▪ High blood pressure (hypertension)
▪ Elevated blood serum cholesterol (hyperlipidemia)
▪ Physical activity
▪ Obesity
2. Non modifiable risk factors
▪ Age
▪ Sex
▪ race
▪ Family history
▪ Genetic factors
Coronary Heart Disease (CHD) - defined as impairment of heart function due to inadequate
blood flow to the heart compared to its needs, caused by obstructive changes in the coronary
circulation to the heart.
• Risk Factors -
➢ Non-Modifiable/Fixed Factors
▪ Age - increase with age
▪ Sex - more in male
▪ Family history
▪ Genetic factors
▪ Personality (?)
➢ Modifiable Factors
▪ Cigarette smoking
▪ High blood pressure (hypertension)
▪ Elevated blood serum cholesterol (hyperlipidemia)
▪ Diabetes
▪ Obesity
▪ Sedentary habits
▪ Stress

P a g e | 173
• Pathophysiology -
➢ Abnormal lipid metabolism
➢ Excessive intake of cholesterol & saturated fat
➢ Atherosclerosis process initially fatty streaks
➢ Subendothelial accumulation of lipid
➢ LDLs undergo in situ oxidation making them more difficult to mobilize & locally
cytotoxic
➢ Smooth muscle cells migrate to the lesion
➢ Thrombosis formation
➢ Partial or complete occlusion of blood vessels
• Clinical Manifestation -
➢ Angina pectoris of effort
➢ Myocardial infarction
➢ Irregularities of the heart
➢ Cardiac failure
➢ Sudden death
Stroke - according to WHO, rapidly developed clinical signs of focal (or global) disturbance of
cerebral function; lasting more than 24 hours or leading to death, with no apparent cause other
than vascular origin.
• Syndromes -
➢ Ischemic stroke
▪ Lacunar infarct
▪ Carotid circulation obstruction
▪ Vertebrobasilar obstruction
➢ Hemorrhagic stroke
▪ Spontaneous intracerebral hemorrhage
▪ Subarachnoid hemorrhage
▪ Intracranial aneurysm
▪ Arteriovenous malformations

174 | P a g e
• Risk factors -
➢ Hypertension
➢ Other factors
▪ Cardiac abnormalities
▪ Diabetes mellites
▪ Elevated blood lipids
▪ Obesity
▪ Smoking
▪ Glucose intolerance
▪ Blood clotting
▪ Oral contraceptives
Hypertension (HTN) - defined as persistently raised systolic blood pressure 140mmhg or

greater & diastolic blood pressure of 90mmhg or greater in in subjects who are not taking
antihypertensive medication.
• Risk Factors -
➢ Non-modifiable/Fixed Factors
▪ Age - blood pressure rises with age in both sexes
▪ Genetic factors
▪ Family history
➢ Modifiable Factors
▪ Obesity
▪ Salt intake
▪ Saturated fat intake
▪ Alcohol taking
▪ Physical inactivity
▪ Environmental stress
▪ Other factor: OCP, noise, vibration, temperature, humidity
• Complications -
➢ Heart attack
➢ Stroke
➢ Heart failure
➢ Aneurysm
➢ Weakened and narrowed blood vessels
➢ Metabolic syndrome
➢ Dementia

P a g e | 175
• Prevention -
➢ Primary prevention
▪ Population strategy - this involves a multifactorial (non-pharma logical)
approach
 Nutrition
 Reduction of salt intake
 Avoidance of alcohol
 Restriction of energy intake appropriate to body needs
 Weight reduction
 Exercise promotion behavioral changes
 Health education
 Self-care
▪ High risk strategy
➢ Secondary prevention
▪ Early case detection
▪ Treatment
▪ Patient compliance
Rheumatic Fever/Heart Disease - is a febrile disease affecting connective tissues particularly in

the heart & joints initiated by infection of the throat by group-A beta hemolytic streptococci.
• Agent - Streptococcus
• Risk Factors -
➢ Age - typically a disease of childhood & adolescence (5 to 15 years)
➢ Sex - affects both sexes equally
➢ Immunity - group A streptococcus products have certain toxic products &
components of the streptococcus & of host tissues have an antigenic cross-
relationship, leading to immunological processes result in an attack of RF
➢ Socioeconomic Status - linked to poverty, overcrowding, poor housing &
inadequate health services
➢ High Risk groups - school age children between 5 to 15 years, slum dwellers &
those living in a closed community
• Complications/Consequences -
➢ Continuing damage to the heart
➢ Increasing disabilities
➢ Repeated hospitalization
➢ Premature death usually by the age of 35 years or even earlier

176 | P a g e
• Duckett-Jones criteria -
➢ Major criteria
▪ Carditis
▪ Migratory polyarthritis
▪ Sydenham's chorea
▪ Subcutaneous nodules
▪ Erythema marginatum
➢ Minor criteria
▪ Clinical
 Fever
 Arthralgia
 Previous rheumatic fever
▪ Laboratory findings
 Raised ESR
 Leukocytosis
 Prolonged PR interval in ECG
 ASO titer raised
 Positive throat culture
 Recent Scarlet fever

P a g e | 177
Item 09: Obesity, DM & Cancer, Arsenicosis, Geriatric Health Problems,

Substance Abuse
Obesity - may be defined as an abnormal growth of the adipose tissue due to an enlargement
of fat cell size (hypertrophic obesity) and an increase in fat cell number (hyperplastic obesity) or
a combination of both
• Types - 2 types
➢ Hypertrophic (enlargement of fat cell size)
➢ Hyperplastic (increase in fat cell number)
• Risk factors -
➢ Behavioral -
▪ Sedentary worker
▪ Diet: Carbohydrate, fat, energy dense food
▪ Alcohol
▪ Smoking
▪ High blood pressure
➢ Genetic factors - melatonin 4 receptor
• Complications -
➢ Type 2 Diabetes mellitus
➢ Gallstone
➢ Osteoarthritis
➢ Respiratory disorder - obstructive sleep apnea
➢ Cancer
➢ Menstrual irregularities
➢ Stress incontinence
• Prevention -
➢ Primary
▪ Health education among community
▪ Management of risk factors
▪ Management of weight - exercise, diet control
➢ Secondary
▪ Appetite depression drug e.g. sibutramine
▪ Surgery (gastric banding, partial gastrectomy)

178 | P a g e
Diabetes Mellitus - a clinical syndrome characterized by hyperglycemia due to absolute

(reduced insulin secretion) or relative (reduced insulin action) deficiency of insulin
• Types (according to WHO) - 3 types

1. Diabetes Mellitus
a. Insulin dependent diabetes mellitus (IDDM, Type - 1)
b. Non-Insulin dependent diabetes mellitus (NIDDM, Type - 2)
c. Malnutrition related diabetes mellitus (MRDM)
d. Other types (secondary to pancreatic, hormonal, drug-induced, genetic &
other abnormalities)
2. Impaired Glucose Tolerance (IGT)
3. Gestational Diabetes Mellitus (GDM) - diabetes diagnosed during the 1st
trimester of pregnancy
• Difference between Type 1 & Type 2 DM-
Clinical Features Type - 1 Type - 2

Age of onset usually <30 years of age commonly middle aged &
elderly
Onset abrupt onset gradual (insidious) onset
Severity more severe form if not frequently mild in severity
diagnosed
Fate becomes lethal if slow ketosis and long
treatment is late compatible survival
HLA association HLA related HLA relation yet to find
• Risk Factors -
➢ Modifiable
▪ Unhealthy diet
▪ Less physical activity i.e. sedentary lifestyle
▪ Obesity
➢ Non-Modifiable
▪ Family history of DM
▪ Heart disease, valvular disease
▪ Age group 40 years & above
▪ Cataract in relatively early age
▪ Repeated infection, malnutrition in early age
▪ Low socioeconomic condition
▪ Genetic syndrome: down syndrome, Turner’s syndrome, Klinefelter’s
syndrome

P a g e | 179
• Complications -
➢ Acute
▪ Diabetes ketoacidosis
▪ Hypoglycemic coma
▪ Non-ketotic hyperosmolar diabetic coma
▪ Lactic acidosis
➢ Chronic
▪ Microvascular
 Retinopathy, cataract → impaired vision
 Nephropathy → renal failure
 Peripheral neuropathy → sensory loss, motor weakness
 Autonomic neuropathy → postural hypertension, gastroparesis
etc.
 Foot disease → ulceration, arthropathy
▪ Macrovascular
 Coronary circulation → myocardial ischemia/infarction
 Cerebral circulation → transient ischemic attack, stroke
 Peripheral circulation → claudication, ischemia
• Prevention/Care -
➢ Primary
▪ Population strategy -
 Primordial prevention - prevention of emergence of risk factors in
countries in which they have not yet appeared
 Maintenance of normal body weight through adoption of healthy
nutritional habits and physical exercise
 The nutritional habit includes an adequate protein intake, a high
intake of dietary fibers and evidence of sweet foods
 Elimination of protein deficiency and food toxins
▪ High risk strategy
 Avoidance of sedentary lifestyle, overnutrition and obesity
 Avoidance of alcohol
 Evidence of diabetogenic drugs such as oral contraceptives
 Production of factors that promote atherosclerosis e.g. Smoking,
high blood pressure, elevated cholesterol and high triglyceride
levels

180 | P a g e
➢ Secondary prevention
▪ Adequate treatment of diabetes mellitus
▪ Routine checkup of blood sugar, urine for protein and Ketone bodies,
blood pressure, visual acuity, where should be done periodically
▪ There should be an estimation of glycosylated hemoglobin at half yearly
intervals
▪ Selfcare i.e. The diabetic should take a major responsibility for his own
care with medical guidance
▪ Home blood sugar monitoring
➢ Tertiary prevention - Organization of specialized clinics (diabetic clinics) and units
for detection and management of complications of diabetes such as blindness,
kidney failure, coronary thrombosis, gangrene of lower extremities etc.
• Advice - [3 ‘D’s]
➢ Diet -
▪ Less carbohydrate
▪ More dietary fibers & fruits
➢ Drug
▪ Insulin for type 1 diabetic patients
▪ Oral antidiabetic medications (e.g. biguanides, sulfonylureas, meglitinide,
thiazolidinedione (TZD), dipeptidyl peptidase 4 (DPP-4) inhibitors,
sodium-glucose cotransporter (SGLT2) inhibitors, and α-glucosidase
inhibitors) for type 2 diabetic patients
➢ Discipline
▪ Exercise that causes sweating. Exercise is of 2 types
 Aerobic Exercise - is any type of cardiovascular conditioning, or
“cardio.” It can include activities like brisk walking, swimming,
running, or cycling. By definition, aerobic exercise means “with
oxygen.” Breathing and heart rate will increase during aerobic
activities
 Anaerobic Exercise - similar to aerobic exercise but uses a
different form of energy; quickly and immediately. Anaerobic
exercises include high-intensity interval training (HIIT), weight
lifting, circuit training, Pilates, yoga, and other forms of strength
training
▪ Routine work

P a g e | 181
Cancer - may be regarded as a group of diseases characterized by an abnormal growth of cells,

has the ability to invade adjacent tissues & even distant organs, the eventual death of the
affected patient if the tumor has progressed beyond that stage when it can be successfully
removed and can occur at any site or tissue of the body and may involve any type of cells.
• Risk Factors -
➢ Physical agent e.g. UV radiation - development of skin cancer
➢ Mechanical irritation e.g. chronic irritation & trauma to the cervix-uteri from
multiple child birth and chronic cervicitis may lead to cancer of the cervix
➢ Chemical agent e.g. dye workers - bladder cancer, asbestos workers - lung cancer
➢ Viral & Parasitic agent e.g. hepatitis B & C, HIV infection, Epstein Barr virus,
cytomegalovirus, human papilloma virus, human T Cell leukemia virus,
schistosomiasis etc.
➢ Nutrition e.g. smoked fish is related to stomach cancer, dietary fiber to intestinal
cancer, beef consumption to bowel cancer and a high fat diet to breast cancer
• Category -
➢ Carcinomas - arising from epithelial cells lining the internal surfaces of the
various organs (e.g. mouth, esophagus, intestines) and from the skin epithelium
➢ Sarcomas - arising from mesodermal cells constituting the various connective
tissue (e.g. fibrous tissue, fat and bone)
➢ Lymphomas, myeloma & leukemia - arising from the cells of bone marrow and
immune systems
• Warning Sings -
➢ Unusual bleeding or discharge from any natural orifices
➢ A lump or thickening of the breast or elsewhere
➢ A sore that does not heal
➢ Changes in bowel or bladder habit
➢ Hoarseness or persistent cough
➢ Constant investigation or difficulty in swallowing
➢ A change in wart or mole

182 | P a g e
• Common Cancers in Bangladesh -

➢ In Male -
▪ Brain carcinoma
▪ Cancer of eyes & lacrimal gland
▪ Cancer of oral cavity*
▪ Pharyngeal carcinoma*
▪ Laryngeal carcinoma*
▪ Bronchogenic carcinoma* (most common)
▪ Bladder cancer (occurs to the dye or color factory workers)
▪ Bone cancer
▪ Skin cancer
▪ Lymphoma
▪ Carcinoma of unknown primary site
➢ In Female -
▪ Cancer of oral cavity*
▪ Breast Cancer* (most common)
▪ Carcinoma of lungs, esophagus, larynx
▪ Cervical Cancer* (2nd most common)
 Causes -
o Early marriage
o Multiple sexual partner
o Unhygienic lifestyle
o Abortion
o Lack of sex education
 Vaccine - Human Papilloma Virus Vaccine
▪ Ovarian Cancer
▪ Carcinoma of body of uterus
▪ Carcinoma of unknown primary site
• Most Common Cancer in Sylhet - Oral Cancer. Occurs due to chewing of betel leaf with
betel nuts, which remains inside the oral cavity which causes ulcer
• Prevention -
➢ Primary
▪ Lifestyle modification
▪ Chemo-preservation
▪ Screening test
➢ Secondary
▪ Cancer registration
▪ Early diagnosis - by observation, palpation, investigation
▪ Treatment e.g. surgery, radiotherapy, chemotherapy

P a g e | 183
Geriatric Health Problem -
• Problems due to aging process

➢ Dementia
➢ Senile cataract
➢ Glaucoma
➢ Nerve deafness
➢ Osteoporosis affecting mobility
➢ Emphysema
➢ Failure of special senses
➢ Changes in mental outlook
• Problems associated with long term illness
➢ Degenerative disease of heart and blood vessels
➢ Cancer
➢ Accident
➢ Diabetes mellitus
➢ Disease of locomotor system
▪ Gout
▪ Rheumatoid arthritis
▪ Osteoarthritis
▪ Spondylitis of spine
▪ Fibrositis
▪ Myocytis
▪ Neuritis
➢ Respiratory illness
▪ Chronic bronchitis
▪ Asthma
▪ Emphysema
➢ Genitourinary system
▪ Prostatic enlargement
▪ Dysuria
▪ nocturia
▪ Frequency and urgency of micturition
• Psychological problems
➢ Mental changes
➢ Sexual adjustment
➢ Emotional disorder

184 | P a g e
Item 10: Accident - Definition, types, preventive measures. RTA. Snake bite,
drowning, burning
Accidents - is an unexpected, unplanned occurrence which may involve injuries [Hogarth, WHO,
1957]
Unpremeditated event resulting in recognizable damage [Advisory group, WHO, 1957]
An accident is a specific, identifiable, unexpected unusual, and unintended external action
which occurs in a particular time and place, without apparent or deliberate cause but with
marked effects [Wikipedia, 2009]
➢ By physical & non-physical -
▪ Physical accidents include unintended collisions or falls, being injured by
touching something sharp, hot, or electrical, or ingesting poison etc.
▪ Non-physical accidents include unintentionally revealing a secret or
otherwise saying something incorrectly, forgetting an appointment etc.
➢ By activity -
▪ Accidents during the execution of work or arising out of it are called work
accidents
▪ In contrast, leisure related accidents are mainly sports accidents
▪ Drowning
▪ Violence or intentional accidents: Homicide, suicide, and war
➢ By vehicle -
▪ Bike accidents
▪ Car accidents
▪ Sailing Ship accidents
▪ Tram accidents
▪ Railway accidents
▪ Airplane accidents
➢ By place of occurrence -
▪ Road traffic accidents
▪ Industrial accidents
▪ Accidents in public places
▪ Riverine accidents
▪ Household/Domestic accidents

P a g e | 185
• Prevention -
➢ Levels -
1. Primordial Prevention: Avoiding risk behavior, habit & lifestyle lead
causation of accidents in early childhood [drug abuse, obesity, alcohol
consumption]
2. Primary Prevention: Aware people regarding risks of accidents through
health education. Specific protection of potentially vulnerable groups by
suggesting use of PPE [gloves, mask, boot goggles]
3. Secondary Prevention: Early detection of risk factors [agents, host,
vectors & environment] and taking prompt measures to prevent
accidents. Early detection of the victims of accidents & prompt treatment
4. Tertiary Prevention: Disability limitation of the victims of accidents.
Rehabilitation of the accident victims [medical, vocational, social etc.]
➢ Prevention of road traffic accidents -

▪ Study road traffic accidents
▪ Safety education
▪ Promotion of safety measures
 Seat belts
 Safety helmets
 Leather clothing & boots
 Children to be seated
 Others: use door locks, proper vehicle design
 Use of special traffic lights at hazardous intersections
▪ Prohibition of alcohol/ drug use specially during driving
▪ Primary care for the motor workers & emergency care at the time
accidents
▪ Elimination of causative factors
▪ Enforcement of laws
▪ Rehabilitation services
▪ Breath test & revoking driving license of intoxicating drivers
▪ Periodic investigation of fitness of the vehicles, drivers and roads

186 | P a g e
➢ Prevention of industrial accidents -

▪ Carefully planned construction of factory buildings
▪ Specific coloration of ceiling & wall to reflect more light
▪ Adequate lighting and ventilation
▪ Invention of less dangerous machines
▪ Guards & enclosure of machines
▪ Avoiding use of loose clothing
▪ Supply & use of necessary personal protective equipment's
▪ Preplacement medical examinations
▪ Supervision and training of the workers
▪ Adequate rest and food facilities for the workers
▪ Formation of vigilance and safety committee
▪ Easy access of fire extinguishers to the industry
▪ Enforcement of safety laws for industry
▪ Ensure occupational health following “ergonomics” & providing health
care for the workers
➢ Prevention of domestic accidents -

▪ Construction of the house should be in planned
▪ Adult members of the family should aware of first aids use
▪ Sharp and pointed instruments should be kept in safe place
▪ Careful storing of medicine, detergents, insecticides & chemicals remain
out of reach of children
▪ Floor of bathroom should not be slippery and keeping bathroom dry
▪ Telephone numbers of hospital, ambulance, & doctors should be known
and available
▪ Taking protective measures during household works like chopping,
cutting with sharp objects etc.
➢ Research & Interventions -

▪ Accident Research
▪ Evaluation of public health importance of accidents
▪ Specific intervention like
 Engineering
 Economic
 Enforcement
 Education to raise awareness

P a g e | 187
• Accident as a Disease - Accidents represent a major epidemic of non-communicable

disease in the present century. Accidents have their own natural history. It follows the
same epidemiological pattern as any other disease. It occurs by interactions of host,
agent, vector & environment.
➢ Host - An accident results when demand of a task being performed exceeds an

individual’s performance capacity. It varies with physical psychological &
cognitive abilities. Susceptible hosts are
▪ young children, elderly people
▪ poor vision, obese, convulsive disorder
▪ sudden illness, Delay in decision making
▪ lack of experience, poor perception
➢ Environment -
▪ Alteration in the physical environment can reduce/ increase risk of
accidents [e.g. road barrier, insufficient light etc.]
▪ Psychological environment can influence the frequency of industrial
accidents [e.g. dissatisfaction, bad relation etc.]
▪ Psycho-social environment can control events lead to accidents [e.g.
social attitude, laws, regulations]
▪ Cultural environment can control event lead to accidents [e.g. acceptance
the use of alcohol, drug etc.]
➢ Agent - Agent causing accidents is energy. A large amount of energies quickly

transmitted may results in accidents. Agents causing accidents are:
▪ Mechanical energy: automobile crash, sports accidents
▪ Thermal energy: burns, scalds etc.
▪ Electric energy: Electrocution
▪ Radiation energy: radiation burns
▪ Chemical injury: Brain injury due to interference of O2 carrying capacity of
blood by co
▪ Drowning: Interfering of pulmonary function by inhaled water
➢ Vector - Vectors are the factors carries energy and have an influence on
occurrence of accidents. Firearms & automobiles are the vectors of kinetic
energy. Faulty design and of these vectors can initiate accidents. Electric wires
are the vectors of electric energy: Insulated wires is safer than the non-insulated
wire

188 | P a g e
• Bangladesh Profile - Most of the people of the country consider accident as an

occurrence of bad luck or misfortune. National database on accidents is scarce.
Reporting system of accidents is poor.
➢ RTA is the most dominating accidents & it is increasing gradually. Most RTA
occurs due to
▪ Driving negligence
▪ Ignoring traffic signal
▪ Driving under spell of narcotics or alcohol
▪ Untrained drivers & poor physical fitness
▪ Poor legislation: False license
▪ Poor use of PPE
▪ Faulty roads and poor traffic signals
▪ Lack of awareness
▪ Geographical location e.g. Drowning
➢ Riverine accidents like launch accidents are common stormy & cyclonic weather
➢ Factories Act of 1965 is not followed properly by management authority &
results in industrial accidents
➢ Workers are exposed to mechanical, physical & chemical hazards result in
accidents
➢ Many garment factories are located in residential areas which are not built for
the purpose without proper emergency exits
➢ Electric wiring is reported faulty in many industries
➢ Improper housekeeping is the chief cause of domestic accidents
➢ Poor maintenance of sharp objects as well as chemicals & detergents & children
are allowed to play cause in accidents
➢ Unaware about first aid in case of emergencies like burns and injuries
• Management - ABCDE procedure

➢ Airway
➢ Breathing
➢ Circulation
➢ Disability Limitation
➢ Expose

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Page |1

Card - 07: Basic concept on Behavior Science

Item 01: Definitions, concept & component behavioral science. Definition of

Shahriar Hossain Rudro (JRRMC/26th/58)

Shahriar Hossain Rudro (JRRMC/26th/58)

Behavioral Patterns - there are 2 main behavioral patterns

Shahriar Hossain Rudro (JRRMC/26th/58)

• Elements/Components - important elements and components of personality are

• Personality Traits - human personality is a bundle of traits. Important personality traits

Shahriar Hossain Rudro (JRRMC/26th/58)

Intelligence - it is the ability of an individual to see meaningful relationships between different

Levels of Intelligence IQ Range

Shahriar Hossain Rudro (JRRMC/26th/58)

Learning - is a process resulting in relatively permanent change in behavior of the individual by

• Types of learning (KAP or KAPS) - 3 types

In practice, these are expressed as KAP (Knowledge → Attitude → Practice)

Shahriar Hossain Rudro (JRRMC/26th/58)

Item 05: Importance of human interpersonal relationship. IPC. Doctor-Patient

Doctor-patient Relationship - it is an important form of interpersonal communication in which

Shahriar Hossain Rudro (JRRMC/26th/58)

Shahriar Hossain Rudro (JRRMC/26th/58)

Card - 08: Biostatistics & Demography

Shahriar Hossain Rudro (JRRMC/26th/58)

Shahriar Hossain Rudro (JRRMC/26th/58)

C. Variables can be classified as discrete or continuous 2 types -

*Qualitative variables are always discrete e.g. sex, occupation, religion

• Measurement of Variables - To establish relationships between variables, researchers

Shahriar Hossain Rudro (JRRMC/26th/58)

Attribute - A variable is called attribute when it describes characteristics in terms of a category,

Shahriar Hossain Rudro (JRRMC/26th/58)

Shahriar Hossain Rudro (JRRMC/26th/58)

Shahriar Hossain Rudro (JRRMC/26th/58)

Shahriar Hossain Rudro (JRRMC/26th/58)

• Methods of Data Collection -

Please answer the following questions:

Shahriar Hossain Rudro (JRRMC/26th/58)

b. Close Ended - here options or answers are given or

English should be used as a medium of instruction in all

[5 point Likert scale and 4 point modified Likert scale]

Shahriar Hossain Rudro (JRRMC/26th/58)

Array - simply means arranging in order. For example -

Shahriar Hossain Rudro (JRRMC/26th/58)

ii. Bivariate Table - presenting two variable at a time. For example -

Shahriar Hossain Rudro (JRRMC/26th/58)

C. Another Types - 3 types

2. Frequency Distribution Table - for example, a table showing percent distribution

Shahriar Hossain Rudro (JRRMC/26th/58)

D. Parts of Table - 8 components

Number of Distribution of Students of JRRMC

Shahriar Hossain Rudro (JRRMC/26th/58)

Number distribution of students of JRRMC during the year

2000 2001 2002

Number distrituion of students of JRRMC during the year

2000 2001 2002

Shahriar Hossain Rudro (JRRMC/26th/58)

2. Pie/Sector Diagram - it is a circular diagram divided into sectors, illustrating

Distribition of students of JRRMC

3. Pictogram/Picture Diagram - means presentation of data in the form of picture

Shahriar Hossain Rudro (JRRMC/26th/58)

4. Map/Spot Diagram - Spot maps are used to show geographical distribution of

B. For quantitative, continuous data presentation - 6 types

Shahriar Hossain Rudro (JRRMC/26th/58)