ESSAY
Discuss in brief the modifiable & non-modifiable risk factors in Coronary Heart
Community Medicine
Epidemiology of Chronic Non-
Communicable Diseases and
Conditions
[Document subtitle]
Atul K Shankar
31
Disease. Explain some of the steps taken to prevent Coronary Heart Disease.
Modifiable Risk Factors for Coronary Heart Disease
The modifiable risk factors for CHD are:
- Cigarette smoking
- High Blood Pressure
- Elevated serum cholesterol
- Diabetes
- Obesity
- Sedentary habits
- Stress
Non-modifiable Risk Factors for Coronary Heart Disease
The non-modifiable risk factors for coronary heart disease are:
- Age
- Sex
- Family history
- Genetic factors
- Personality
Prevention of Coronary Heart Disease
Population Strategy:
- CHD is a mass disease and thus the strategy should be based on mass approach focusing
mainly on the control of underlying causes in the whole populations
- This approach is based on the principle that small changes in risk factor levels in total
populations can achieve the biggest reduction in mortality
- The aim should be to shift the whole risk-factor distribution in the direction of “biological
normality”
- The specific interventions are
o Dietary changes
 Reduction of fat intake to 20-30% of total energy intake
 Consumption of saturated fat is limited to 10% of total energy intake
 Reduction of dietary cholesterol
 Increase in complex carbohydrate consumption
 Avoidance of alcohol consumption
o Smoking
 To achieve the goal of smoke-free society, comprehensive health
programmes would be required
o Blood Pressure
 Small reduction of blood pressure by even 2-3mmHg would produce a large
reduction in the incidence of cardiovascular complications
 The goal would be to reduce the mean population blood pressure levels
 This involves a multifactorial approach based on a prudent diet
 o Physical Activity SHORT NOTES
 Regular physical activity should be a part of normal daily life
 It is important to encourage children to take up physical activities that they Diet in Coronary Heart Disease
can continue throughout their life The dietary changes required in Coronary Heart disease is a principal preventive strategy in the
prevention of CHD.
High-Risk Strategy:
WHO consider the following dietary changes to be appropriate for high incidence populations:
- Identifying Risk
o High risk intervention can only start one those at high risk is identified - Reduction of Fat Intake to 20-30% of total energy intake
o By means of measuring blood pressure and serum cholesterol, it is possible to - Consumption of Saturated fats must be limited to less than 10% of total energy intake
identify individuals at special risk o Some of the reduction in saturated fat may be made up by mono- and poly-
o Individuals at special risk include unsaturated fats
 Smokers - Reduction of dietary cholesterol to below 100 mg per 1000 kcal per day
 Familial history of CHD - An increase in complex carbohydrate consumption (i.e. vegetables, fruits, whole grains,
 Diabetes legumes)
 Obesity - Avoidance of alcohol consumptions; reduction of salt intake to 5 grams daily or less
 Young women using oral contraceptives
Risk Factors of Diabetes Mellitus
- Specific Advice
- Agent Factors
o Having identified the high-risk group, next step is to bring them under
o Pancreatic disorders
preventative care and motivate them to take positive action against all the
o Defects in the formation of insulin
identified risk factors
o Destruction of beta cells
o High risk approach suffers from disadvantage that the intervention may be
o Decreased insulin reactivity
effective in reducing the disease to the same extent in the general population
o Genetic defects
Secondary Prevention: - Host Factors
o Age – prevalent in middle years of life
- Must be seen as a continuation of primary prevention
o Sex – equal male to female ratio
- It forms an important part of an overall strategy
o Genetic factors and markers
- The aim is to prevent the recurrence and progression of CHD
o Immune mechanisms
- It is a rapidly expanding field with much research in progress
o Obesity
o Drug trials
o Maternal diabetes
o Coronary surgery
- Environmental Risk Factors
o Use of Pacemakers
o Sedentary Lifestyle
- The principles are same as those set out for the population and high-risk strategy
o Diet
- Most promising results have come from beta-blockers which appear to reduce the risk of
o Dietary Fibre
CHD mortality
o Malnutrition
- Despite advances in treatment, mortality of an acute heart attack is still high
o Alcohol
Vision 2020 o Viral infections
- Known as ‘VISION 2020 : The Right to Sight o Chemical Agents
- It is a global initiative to eliminate avoidable blindness o Stress
- It was launched by WHO on 18th February 1999 - Social Factors
- One significant way in which this initiative differs from previous ones is that the concept o Occupation
centres around Rights issues o Marital status
- Recognition of sight as a fundamental human right by all countries can be an important o Religion
catalyst of initiatives for prevention and control of blindness o Economic status
- The objective is to assist member countries in developing sustainable systems which will o Education
enable them to eliminate avoidable blindness from major causes o Urbanization
o Cataract o Lifestyle changes
o Xerophthalmia
 Avoidable Blindness
- The concept of avoidable blindness has gained increasing recognition during the years
- Many causes of blindness lend themselves to prevention or control by treating the cases of
infectious diseases, or by controlling the organisms which cause the infection, or by
improving safety conditions
- The components for action in national programmes include
o Initial Assessment
 First step is to assess the magnitude, geographic distribution and causes
of blindness within the country
 This is essential for setting the priorities and development of appropriate
intervention programmes
o Methods of Intervention
 Primary Eye Care
 Essential drugs such as topical tetracycline, vitamin A capsules,
eye bandages, shields, are provided to locally trained primary
health workers
 These aid in first line, grassroot health care of eye conditions
 Secondary Care
 Definitive management of common blinding conditions
 This is provided in PHCs and district hospitals
 May involve the use of mobile eye clinics
 Tertiary Care
 Services are established in the national or regional capitals
 Provides sophisticated eye care such as retinal detachment
surgery, corneal grafting and other complex forms of
management
 Other measures of rehabilitation include education of the blind in
special schools and utilization of there services
 Specific Programmes
 Trachoma control
 School eye health services
 Vitamin A prophylaxis
 Occupational eye health services
o Long Term Measures
 Aimed at improving the quality of life and modifying or attacking the
factors responsible for persistent eye health problems
 health education is an important long-term measure in order to
 create community awareness of the problem
 motivate community
 accept total eye health care programmes
 secure community participation
o Evaluation
 Integral part of intervention programmes
 Measures the extent to which ocular diseases and blindness have been
alleviated, assess the manner and degree to which programmes are
carried out, and determine the nature of changes produced
Obesity
Obesity is defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell
size or an increase in fat cell number or a combination or both.
It is expressed in terms of BMI (body mass index), with overweight is usually due to obesity but
can arise from other causes such as abnormal muscle development or fluid retention.
- Prevalence
o Obesity is the most prevalent form of malnutrition
o As a chronic disease, it is prevalent in both developed and underdeveloped
countries, and increasingly affecting children
o One of the most significant contributors to ill health
- Epidemiology
o Age
 Obesity can occur at any age, and increases with age
 Most adipose cells are formed early in life and obese infant lays down more
of these cells than the normal infant
o Sex
 Women generally have a higher rate of obesity than men
o Genetic Factors
 There is a genetic component to the etiology of obesity
o Physical Inactivity
 Regular physical exercise is protective against unhealthy weight gain
 Major reduction in activity without the relative reduction in energy intake
is a major cause of increased obesity
o Socio-economic Status
 Relationship of obesity to social class is well established
 Obesity has been found to be more prevalent in the lower socio-economic
groups
o Eating habits
 Eating habits are established very early in life
 Diet containing more energy than needed leads to prolonged post-
prandial hyperlipidaemia and to the deposition of triglycerides in the
adipose tissue
o Psychological Factors
 Overeating can be a symptom of depression, anxiety, frustration and
lonliness in childhood as it is in adult life
- Assessment of Obesity
o Body Weight
 Body Mass Index = Weight/Height
 Ponderal Index = Height / Cube root of body weight
 Brocca Index = height - 100
𝐻𝑒𝑖𝑔ℎ𝑡−150
 Lorentz’s Formula = Height – 100 - 2 (𝑤𝑜𝑚𝑒𝑛) 𝑜𝑟 4 (𝑚𝑒𝑛)
 Corpulence Index = Actual weight / desirable weight
 Should not exceed 1.2
o Skinfold Thickness
o Waist Circumference and Waist Hip Ratio
 Danger Signals of Cancer Importance of Tracking of Blood Pressure
The early warning signs, or ‘danger signals’ of cancer are: - If blood pressure levels of individuals were followed up over a period of years from early
childhood into the adult life, then those individuals whose pressure were high in the
- Lump or hard area in the breast
distribution, would continue in the same track as adults
- Change in a wart or mole
- Low blood pressure levels tend to remain low, and high levels tend to become higher as
- Persistent change in digestive and bowel habits
individuals grow older
- Persistent cough or hoarseness
- this phenomenon of persistence of rank order is described as tracking
- Excessive loss of blood at a monthly period or a loss of blood outside of the usual cycle
- this knowledge can be applied in identifying children and adolescents at risk of
- Blood loss from any natural orifice
developing hypertension at a future date.
- Swelling or sore that does not get better
- Unexplained loss of weight Assessment of Obesity
Body Weight
Screening Methods for Cancer
Screening for Cancer Cervix: - Body Mass Index = Weight/Height
- Ponderal Index = Height / Cube root of body weight
- Prolonged early phase of cancer in situ is detected by the Pap smear
- Brocca Index = height – 100
- This requires excessive resources in terms of labs, equipment and personnel 𝐻𝑒𝑖𝑔ℎ𝑡−150
- This has led to an alternative screening methods - Lorentz’s Formula = Height – 100 – 2 (𝑤𝑜𝑚𝑒𝑛) 𝑜𝑟 4 (𝑚𝑒𝑛)
o Visual Inspection with Acetic Acid (VIA) - Corpulence Index = Actual weight / desirable weight
o VIA with Magnification (VIAM) o Should not exceed 1.2
o Visual Inspection Post-application of Lugol’s Iodine (VILI)
Skinfold Thickness
Screening for Breast Cancer:
- Large proportion of total body fat is located just under the skin
- The basic techniques for early detection of breast cancer are: - The method most used is measurement of skinfold thickness
o Breast Self-examination by the patient - It is a rapid and non-invasive method for assessing body fat
 Probably the only feasible approach to wide population coverage - The measurement may be taken at all the 4 sites – mid-triceps, biceps, subscapular,
o Palpation by a physician suprailiac regions
 Unreliable for large fatty breasts - The sum of measurements should be less than 40 mm in boys and 50 mm in girls
o Thermography - In extreme obesity, measurements may not be impossible
 Has the advantage that patient is not exposed to radiation - The main drawback is poor repeatability
o Mammography
Waist Circumference and Waist Hip Ratio
- The use of mammography has 3 potential drawbacks;
o Exposure to radiation - Waist Circumference
o Mammography requires technical equipment of a high standard and radiologists o Measured at the mid-point between the lower border of the rib cage and the iliac
with very considerable experience crest
o Biopsy from a suspicious lesion may end up as a false-positive in as many as 5-10 o It is a convenient and simple measurement that is unrelated to height, correlates
cases closely with BMI and WHR
o It is an appropriate index of intra-abdominal fat mass and total body fat
Screening for Lung Cancer:
- There is an increased risk of metabolic complications for men with a waist circumference
- At present there is only 2 techniques for screening for lung cancer or more than 102 cm and women with a circumference of more than 88 cm
o Chest Radiograph
Other Measures:
o Sputum Cytology
- Mass radiography has been suggested for early diagnosis at six monthly intervals - Total body water
- It is doubtful whether the disease satisfies the criteria of suitability for screening - Total body potassium
- Total body density
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Epidemiology of Communicable Diseases
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ESSAY
Describe the natural history of Tuberculosis. Discuss the control of
tuberculosis. Add a note on Directly Observed Treatment Short Course
NATURAL HISTORY OF TUBERCULOSIS
(DOTS)
- Agent Factors
o Agent
 the causative agent of tuberculosis is Mycobacterium tuberculosis
 it is a facultative intracellular parasite
 it is readily ingested by phagocytes and is resistant to intracellular
killing
o Source of Infection
 there are 2 sources of infection – human and bovine
 the most common source of infection in humans is in a patient whose
sputum is positive for tubercle bacilli and who has either received
no treatment or has not been treated fully
 they can discharge the bacilli in their sputum for years
 some bacilli multiply quickly and some slowly
 more rapid multipliers are more susceptible to bactericidal drugs
 the slow multipliers are the source of dormant bacilli
 dormant bacilli can stay alive but does not cause infection to
the human until the conditions are favourable when they
multiply again and cause infection
 the bovine source is usually infected milk
 no definite evidence that bovine TB is a problem due to
practice of boiling milk before consumption
o Communicability
 patients are infective as long as they remain untreated
 effective anti-microbial treatment reduces infectivity
- Host Factors
o Age
 tuberculosis affects all ages
 developing countries show a sharp rise in infection rates from
childhood to adolescence
o Sex
 more prevalent in males
o Hereditary
 not a hereditary disease
 twin studies show that inherited susceptibility is an important risk
factor
o Nutrition
 malnutrition is believed to predispose to tuberculosis
 it affects the development, outcome and spread of disease
o Immunity
  man has no inherited immunity but is acquired by BCG vaccine or
natural infection
Target Group
- Social Factors
o TB is a social disease with medical aspects - overwhelming majority of patients of pulmonary TB have one or more of the
o considered a barometer for social welfare symptoms referable to chest
o social factors include
- the chest symptoms develop early before the disease has gone onto advanced stage
 poor quality of life
 poor housing and overcrowding - this is the most fertile group for case-finding
 population explosion Intensified TB Case Finding
 malnutrition
 smoking and alcohol abuse - primary objective of detecting TB cases early by active case finding in targeted
 lack of education groups and to initiate treatment promptly
 large families - it can target people who anyway have sought health care with or without
 early marriages symptoms of TB
o these factors are interrelated and contribute to occurrence and spread of TB
- decisions on when and how to screen for TB will depend on the vulnerable group,
- Mode of Transmission
capacity of the health system and availability of resources
o TB is transmitted by droplet infection and droplet nuclei generated by
sputum positive patients with pulmonary tuberculosis Screening Strategies
o to transmit infection, particles must be fresh enough to carry viable
organisms 1) Community screening is done by
o coughing generates the highest number of droplets o inviting people to attend screening at a mobile facility or a fixed facility
 frequency and vigour and ventilation of environment influences o invitations may target specifically people within a given group
transmission of infection 2) Institutional Screening
o TB is not transmitted by fomites o health care facilities
o Patients with extrapulmonary TB constitute a minimal hazard of  systematically performing active screening of vulnerable individuals
transmission of infection o congregate settings
 systemically perform active screening of vulnerable individuals in
- Incubation period
shelters, old age homes, refugee camps, correctional facilities
o the time from receipt of infection to the development of positive
tuberculin test ranges from 3-6 weeks Case Finding Tools
o the development of disease is dependent on closeness of contact, extent
of disease and sputum positivity of source - Sputum Examination
o incubation period may be weeks, months or years. o sputum examination by direct microscopy is the method of choice
o it enables us to discover the epidemiologically most important cases of
CONTROL OF TUBERCULOSIS
pulmonary TB
Tuberculosis control means the reduction in the prevalence and incidence of disease in the
Tuberculin Test
community. The basic principles of prevention and control are the same as for any infectious
disease. - test to diagnose tuberculosis in a suspected patient
The control measures consist of a: - discovered by Von Pirquet in 1907
- positive result is accepted as evidence of past or present TB infection
- Curative Component – case finding and treatment - only means of estimating the prevalence of infection in a population
- Preventive component – BCG vaccination
Directly Observed Treatment Short Course (DOTS) Chemotherapy:
Case Finding
- strategy to ensure cure by providing the most effective medicine and confirming
- the first step in a TB control programme is early detection of sputum positive that it is taken
cases - only strategy to be documented to be effective worldwide on a programme basis
- this should be an intensive, ongoing programme
 - health worker watches the patient swallow the drug in his presence, after which - Immunity
the patient is given a multiblister combipack to consume at home. o maternal antibodies disappear during the first 6 months of life
- The patient must return with an empty combipack when they come to collect the o immunity following infection is solid although reinfection can occur as
medicine for the next week immunity for one type of polio does not protect the patient from the
other 2 types
Describe the epidemiology of Poliomyelitis. Add a note on the ‘Pulse o type 2 virus antigen is the most effective
Polio Immunization Programme’. Environmental Factors
Agent Factors
- polio is more likely to occur during the rainy monsoon season
- Agent - 60% of cases recorded were during July and September
o the causative agent of poliomyelitis is poliovirus which has 3 serotypes; 1, 2
- environmental sources include
and 3
o Contaminated water, food and flies
o most outbreaks of paralytic polio are due to type 1 virus
- Polio survives for a long time in cold conditions
o poliovirus can survive for long periods in the external environment
 in a cold climate, it can survive for 4 months in water and 6 months in - Overcrowding and poor sanitation provide opportunities for exposure to infection
faeces
Mode of Transmission
o it is well adapted for the faeco-oral route of transmission
o virus is rapidly deactivated by pasteurisation - Faeco-oral Route
- Reservoir of Infection o main route of spread in developing countries
o man is the only known reservoir of infection o the infection may spread directly through contaminated fingers where
o most infections are subclinical hygiene is poor, or indirectly through contaminated water, milk, foods,
o it is mild and subclinical cases play a dominant role in the spread of flies and articles of daily use
infection - Droplet Infection
o they constitute the submerged portion of the iceberg (see ICEBERG o this may occur in acute phase of disease when the virus occurs in the
PHENOMENON) throat
o there are no chronic carriers o close personal contact with an infected person facilitates droplet spread
o no animal source has yet been demonstrated o this mode of transmission may be more important in developed countries
- Infectious Material where faecal transmission is remote
o virus is found in faeces and oropharyngeal secretions of an infected
person Incubation Period
- Period of communicability
- usually 7-14 days
o the cases are most infectious from 7-10 days before and after onset of
symptoms Clinical Spectrum
Host Factors - Inapparent Infection
o there are no presenting symptoms
- Age
o recognition only by virus isolation or rising antibody titres
o disease occurs in all age groups
- Abortive Polio
o children are usually more susceptible than adults
 due to acquired immunity of the adult population o causes only a mild or self-limiting illness due to viraemia
o in India, polio is a disease of infancy and childhood o the patient recovers quickly
 most vulnerable age is between 6 months and 3 years o diagnosis is not made clinically as recognition is only made by viral
isolation or rising antibody titres
- Sex
- Non-Paralytic Polio
o more prevalent in males than females
 3:1 ratio o presenting features are stiffness and pain in the neck and back
o disease lasts 2-10 days
- Risk Factors
o recovery is rapid
o fatigue, trauma, intramuscular injections, operative procedures
 o disease is synonymous with aseptic (viral) meningitis Enumerate the Sexually Transmitted Diseases (STDs). Describe the
- Paralytic Polio
syndromic management of STDs in detail.
o virus invades the CNS and causes varying degrees of paralysis
Classification of Sexually Transmitted Diseases
o there is history of fever at time of onset of paralysis which is suggestive of
polio
- Bacterial Agents
o other associated symptoms are malaise, anorexia, nausea, vomiting,
o Neisseria gonorrhoeae
headache, sore throat, constipation, abdominal pain
o Chlamydia Trachomatis
o paralysis is characterized as descending
o Treponema pallidum
Pulse Polio Immunization Programme o Haemophilus ducreyi
o Mycoplasma hominis
- Government of India conducted the first round of PPI consisting of 2 immunization o Ureaplasma urealyticum
days 6 weeks apart on 9th December 1995 and 20th January 1996 o Calymmatobacterium granulomatis
- the first PPI targeted all children under 3 years irrespective of immunisation o Shigella
schedule o Campylobacter
o Group B Streptococci
- later, it was decided to extend the age group from under 3 to under 5
o Bacterial vaginosis-associated organisms
- the term ‘pulse’ is used to describe the sudden, simultaneous, mass
- Viral Agents
administration of OPV on a single day during the low transmission period
o Herpes Simplex Virus
(November to February)
o Human Herpes Virus type 5 (Cytomegalovirus)
- the dose of OPV during PPIs are extra doses to supplement and not replace the
o Hepatitis B Virus
doses already received
o Human Papilloma Virus (HPV)
- children including 0-1 should receive their routine immunization and their PPI o Molluscum contagiosum virus
- important improvement is the use of vaccine vial monitors o Human Immunodeficiency Virus (HIV)
o Colour monitors are put on the vaccine bottles - Protozoal Agents
o each label has a circle of deep blue colour o Entamoeba histolytica
o inside the circle there is white square which gradually changes to blue, if the o Giardia lamblia
vaccine bottle is exposed to higher temperatures o Trichomonas vaginalis
o when the colour of the white square becomes blue, vaccine should be
- Fungal Agents
considered ineffective
o Candida albicans
o this quality assurance ensures that the children will have better protection
- Ectoparasites
against polio
o Phthirus pubis
- AFP Surveillance
o Sarcoptes scabiei
o PPI is supported by AFP surveillance system since 1997
o it is being conducted through network of surveillance medical officers Syndromic Approach to Sexually Transmitted Diseases
 SMOs are specially trained and responsible for a defined area
 they are located at the state HQ and at regional places in cases of - syndromic approach is scientifically derived and offers accessible and immediate
larger states treatment, that is effective and efficient
- management of STDs using flowcharts is more cost-effective than diagnosis based
on lab tests
- many different agents cause STDs, however, some agents give rise to similar or
overlapping clinical manifestations
- e.g.
o Urethral discharge in males
o Vaginal Discharge
o Lower abdominal pain in females
o genital ulcers
 o scrotal swelling o treat female partners on same lines after ruling out pregnancy and history
o inguinal bubo of allergies
o advise sexual abstinence during the course of treatment
SYNDROMIC MANAGMENT OF URETHRAL DISCHARGE IN MALES o provide condoms, educate about correct and consistent use,

Urethral discharge confirmed by
clinician
- Treatment for gonorrhoea and
chlaymidial infection
- Health education and counselling
- Examine and treat sexual
partners
Follow up, 7-14 days after treatment
Discharge persists
Assess: treatment compliance
good and re-infection unlikely
Refer
Lab Investigations include SYNDROMIC MANAGEMENT OF VAGINAL DISCHARGE
- Gram stain examination of urethral smear will show Causative Organisms
gram negative intracellular diplococci in gonorrhoea
- in non-gonococcal cases, more than 5 neutrophils per Vaginitis: T. vaginalis, C.albicans, G. vaginalis
oil immersion field in the smear, or more than 10
Cervicitis: N. gonorrhoeae, C. Trachomatis, T.
neutrophils per high power field in the sediment of the
vaginalis, HSV
first void urine are observed
History Examination
Lab Investigations
- Menstrual history to rule out - Per speculum examination to
pregnancy differentiate between vaginitis - wet mount microscopy of
Clinical Cure - Nature and type of discharge and cervicitis discharge for T vaginalis and
- Genital Itching - cervical erosion/ cervical clue cells
- Burning micturition and ulcer/ Mucopurulent cervical - 10% KOH mount for C.
Assess: treatment compliance increased frequency discharge albicans
poor and re-infection likely - Presence of ulcer or swelling - Bimanual pelvic examination - Gram’s stain for clue cells in
- Genital complaints in sexual to rule out PID bacterial vaginosis
partners - If speculum examination is not - Gram’s stain of endocervical
Restart the treatment protocol - Low backache possible, treat for both vaginitis smear to detect Gonococci
and cervicitis

Treatment
- Notification and treatment of sexual partners of men with Urethritis are the
highest priority - Vaginitis
- Treatment o Tab. Secnidazole 2 gm orally, single dose OR Tab. Tinidazole 500mg
o as dual infection is common, treatment should cover therapy for both orally, twice daily for 5 days
gonorrhoeal and chlamydial infections o Tab. Metoclopramide 30 mins before Tab. Secnidazole, to prevent
o Uncomplicated infection regimen gastric intolerance
 Tab. Cefixime 400mg orally, single dose + Tab. Azithromycin 1gm o Treat for candidiasis with Tab. Fluconazole 150mg orally single
orally, single dose UNDER SUPERVISION dose or local Clotrimazole 500 mg vaginal pessaries once
 advise the patient to return after 7 days of start of therapy for follow - Cervical Infection
up o Tab. Cefixime 400mg orally, single dose
o if symptoms persist, patient should be treated for Trichomonas vaginalis o PLUS Azithromycin 1 gram, 1 hour before lunch
 If discharge or only dysuria persists after 7 days, Tab. Secnidazole 2 o if vomiting within 1 hour, given anti-emetic and repeat
gm orally, single dose
o if symptoms still persist, refer to higher centre ASAP
o If individual is allergic to Azithromycin, give Erythromycin 500mg 4 times a Management in Pregnant Women Specific Guidelines for Partner Managment
day for 7 days
- Per speculum examination should be done to - Treat current partner only if no improvement
- Syndrome specific guidelines for partner management rule out pregnancy complications after treatment
o treat all recent partners - Treatment for vaginitis - If partner is symptomatic, treat client and
o In 1st trimester, local treatment with partner using the protocols
Clotrimazole for candidiasis and - Advise sexual abstinence during course of
Metronidazole for Trichomonas or BV treatment
o In 2nd and 3rd trimesters, oral - Provide condoms, educate about proper and
Metronidazole is given consistent use
 o transfusion recipients of blood and blood products
o haemophiliacs
o clients of STD

Discuss the epidemiology & clinical course of AIDS. Mention the

preventive measures for the same. Mode of Transmission
Agent Factors
- Sexual Transmission
- Agent o AIDS is a sexually transmitted disease
o HIV virus is a protein capsule containing 2 short strands of genetic material o it can spread via unprotected vaginal, oral or anal sex
and enzymes o size of risk is affected by number of factors
o the virus replicates in actively dividing T4 lymphocytes and like other  presence of STD
retroviruses, it remains in the latent state that can be activated  sex and age of uninfected partner
o the virus has the ability to destroy human T4 helper cells  type of sexual act
o it is able to spread throughout the body and can pass through the blood-  stage of illness of the infected partner
brain barrier and can then destroy some brain cells  virulence of the HIV strain
o the virus is easily killed by heat and is readily inactivated by ether, o anal intercourse carries a higher risk of transmission than vaginal
acetone, ethanol and beta-propriolactone intercourse because it is more likely to injure tissues of the receptive
- Reservoir of Infection partner
o these are cases and carriers o the risk of transmission is greater where there are abrasions of the skin or
o once a person is infected, virus remains in the body lifelong mucous membrane
o the risk of developing AIDS increases with time o exposed adolescent girls and women are more prone to HIV
o since HIB infection can take years to manifest itself, the symptomless o HIV infected people are more infectious to others in the very early stages,
carrier can infect other people for years before the antibody production and when the infection is well advanced, as
- Source of Infection the level of virus in the blood is higher than at other times
o the virus has been found in greatest concentration in blood, semen and - Blood Contact
CSF o AIDS is also transmitted by contaminated blood
o lower concentration has been detected in tears, saliva, breast milk. urine o it is highly infective when introduced in large quantities directly into the
and cervical and vaginal secretions blood stream
o HIV has been isolated in brain tissue, lymph nodes, bone marrow cells o the risk of contracting HIV infection is estimated to be over 95%
and skin o this route of transmission is common among recreational drug users who
inject drugs into their system
Host Factors
- Maternal-Foetal Transmission
- Age o HIV may pass from an infected mother to her foetus, through the placenta
o most cases have occurred among sexually active persons aged 20-49 or to her infant during delivery or by breastfeeding
years o transmission accounts for 1/3 to 2/3 of overall numbers infected
o this group represents the most productive members of society o risk of infection is higher in newly infected, or if she has already developed
AIDS
- Sex
o HIV infected infants progress rapidly to AIDS
o In North America, Europe and Australia, 51% of cases are homosexual or
o can be prevented entirely by anti-retroviral drug prophylaxis
bisexual
o no evidence of spread to health care workers in their professional contact
o In Africa, sex ratio is equal
with AIDS patients
o Certain sexual practices increase the risk of infection more than others
- High Risk Groups Clinical Manifestations
o male homosexuals and bisexuals,
o heterosexual partners - Initial Infection
o IV drug abusers - Asymptomatic Carrier State
 - AIDS-related complex o material should be made widely available
- AIDS - Combination HIV Prevention
o combination prevention uses a mix of biomedical, behavioural and
structural interventions to meet the current HIV prevention
o ARV drugs play a key role in HIV prevention
- Prevention of Blood-borne HIV Transmission
Initial Infection: o high risk people should refrain from donating blood, body organs, sperm
or other tissues
- infected people have no symptoms for the first 5 years
- they appear healthy Discuss the epidemiology and control of Acute Diarrhoeal Diseases
- once infected, people are infected for life Agent Factors
- HIV antibodies take between 2-12 weeks to appear in the blood
- Viruses
o this period is known as WINDOW PERIOD
o many have been identified as causative organisms.
Asymptomatic Carrier State: o most prevalent of which are rotaviruses
 first discovered in 1973 and has emerged as the leading cause of
- infected people have antibodies, but no overt signs of disease severe, dehydrating diarrhoea in children aged less than 5 years
- there is persistent generalized lymphadenopathy globally
- it is not clear how long the carrier state lasts  rotavirus reinfection is common although the primary infection is
usually the most significant clinically
AIDS-related Complex  they are shed in very high concentrations and for many days in the
stools and vomit of infected individuals
- person with ARC has illnesses caused by damage to the immune system  transmission occurs primarily by faecal-oral route, directly from
- they may exhibit one or more of the clinical signs person to person or indirectly via contaminated fomites
o Unexplained diarrhoea for more than a month - Bacterial
o Fatigue o V.cholerae, Salmonella, Shigella, enterotoxic E. coli and Campylobacter
o Malaise jejuni
o Loss of more than 10% body weight o they produce potent Enterotoxins similar to that produced by V. cholerae
o fever o the lesser-known pathogens which causes diarrhoea are Yersinia
o Night sweats enterocolitica and V. parahaemolyticus
- patients with 2 or more of these manifestations and a decreased number of T- o ETEC is an important cause of acute watery diarrhoea in adults and
helper lymphocytes are considered to have AIDS-related complex children in developing countries.
 most common cause of Traveller’s diarrhoea
AIDS: o salmonella causes inflammation of the bowel epithelium
o Shigella accounts for high percentage of mortality due to diarrhoeal
- the end-stage of HIV infection
disease
- opportunistic infections commonly occur at this stage o the estimate suggest that is causes about 1 million deaths every year in
- death is due to uncontrolled or untreatable infection children aged under 5
- TB and Kaposi Sarcoma is usually seen early
Reservoir of Infection
- Serious fungal infections such as Candida, Cryptococcus, Penicillosis, and
parasitic infections such as Pneumocystis carinii pneumonia or Toxoplasma - for some enteric pathogens, man is the principal reservoir and thus most
gondii encephalitis tends to occur transmission originates from human factors
Prevention of HIV - examples are enterotoxic E. coli, Shigella species, V. cholerae, Giardia lamblia
and E. histolytica
- Education - animals are important reservoirs and transmission originates from both human
o only means at present is health education to enable people to make life- and animal faeces
saving choices
Host Factors
- diarrhoea is most common in children especially between 6 months and 2 years
- incidence is highest in age of 6-11 months, when weaning occurs
- it reflects the combined effects of declining levels of maternally acquired
antibodies, the lack of active immunity in the infant, the introduction of
contaminated food, and direct contact with human or animal faeces, when
infant starts to crawl
- Diarrhoea is more common in patients with malnutrition
o Malnutrition – Infection – Diarrhoea
o two live, oral attenuated rotavirus vaccines were licensed in 2006; Rotarix
and Rota Teq
o both vaccines have demonstrated very good safety and efficacy profiles in
large clinical trials
o the vaccines are now introduced for routine use in the number of
industrialized and developing countries
- Control and Prevention of Diarrhoeal Epidemics
- Integrated Global Action Plan for the Prevention and Control of Pneumonia and
Diarrhoea

Environmental Factors

- distinct seasonal patterns of diarrhoea occur in many geographical area

- in temperature climates, bacterial diarrhoea occurs more frequently during the
warm season, whereas viral diarrhoea, particularly diarrhoea caused by rotavirus
peak during the winter
- in tropical areas, rotavirus diarrhoea occurs throughout the year, increasing in
frequency during the drier, cool months, whereas bacterial diarrhoeas peak
during the warmer, rainy season
Describe in detail the epidemiology of leprosy. Add a note on the
National Leprosy Eradication Programme
Leprosy or ‘Hansen’s disease’ is a chronic infectious disease caused by Mycobacterium
leprae. It mainly affects the peripheral nerve, skin, muscles, eyes, bones, testes and
internal organs. it manifests itself in two polar forms, namely the Lepromatous leprosy
and Tuberculoid leprosy, lying at the 2 ends of a long-spectrum of the disease

Mode of Transmission Leprosy is clinically characterized by one or more of the following cardinal features

- most organisms that causes diarrhoea are transmitted primarily or exclusively by - Hypopigmented patches
the faecal-oral route - Partial or total loss of cutaneous sensation in the affected areas
- may be water-borne, food borne, or direct transmission which implies an array of - Presence of thickened nerves
other faecal-oral routes such as via fingers, fomites, dirt - Presence of acid-fast bacilli in the skin and nasal smears
Control of Diarrhoeal Diseases Agent Factors

- Appropriate Clinical Management - Agent

o Oral Rehydration Therapy o leprosy is caused by Mycobacterium leprae
o Intravenous Rehydration Therapy o they are acid fast and occur in the human host both intracellularly and
- Better MCG care Practices extracellularly
o Maternal Nutrition o they occur characteristically in clumps or bundles
 improving prenatal nutrition will reduce the low birth weight problem o they have a particular affinity for Schwann cells and cells of the RES
 prenatal and postnatal nutrition will improve the quality of breast milk o they remain dormant in various sites and cause a relapse
o Child Nutrition o bacterial load is highest in Lepromatous cases
 promotion of breast-feeding - Source of Infection
 appropriate weaning practices o it is generally agreed that multibacillary cases are the most important
 supplementary feeding sources of infection in the community
 Vitamin A supplementation o patients with active leprosy must be considered ‘infectious’
- Preventative Strategies - Portal of Exit
o sanitation o widely accepted that the portal of exit is through the Nose
o Health education  Lepromatous cases harbour millions of M. leprae in their nasal
o Immunization mucosa which are discharged when sneezing or blowing the nose
- Rotavirus vaccine  bacilli also exit through ulcerated or broken skin of bacteriologically
positive cases of leprosy
 - Infectivity
o leprosy is highly infectious but of low pathogenicity
o it is claimed that an infectious patient is rendered non-infectious by treatment
with Dapsone for 90 days, or with rifampicin for 3 weeks
o local application of rifampicin might destroy all bacilli within 8 days
- Attack Rates
o among the household contacts of lepromatous cases, 4.4% - 12% is expected
to show signs of leprosy within 5 years
o this occurs despite treatment of the index case
Host Factors
- Age
o Leprosy is not associated with children
o Can take place at any time depending upon the opportunities for exposure
o Disease is acquired commonly during childhood in endemic areas
o Presence of leprosy in child population is of epidemiological significance
- Sex
o Both incidence and prevalence of leprosy is higher in males than females
o Excess of male cases is attributed to greater motility and increased
opportunities for contact in many populations
- Migration
o Leprosy is considered to be a rural problem
o However, due to movement of population from the rural to urban areas,
leprosy is slowly developing into an urban problem
- Prevalence Pool
o Prevalence pool is in a constant flux resulting from inflow and outflow of
cases
- Inactivation of Disease
o Where leprosy treatment facilities exist, inactivation or cure due to specific
treatment is an important mode of elimination of cases from the prevalence
pool
- Immunity
o It is well-established that only few persons exposed to infection develop
disease
o Large proportion of early lesions of lesion heal spontaneously
 Suggesting immunity acquired through these lesions
o Subclinical infections are far more common than what was believed
 Believed to contribute to active immunity
- Genetic Factors
o There is now evidence that Human Lymphocyte Antigen (HLA) linked
genes influence the type of immune response that develops as a result of
infection
Environmental Factors
- The presence of infectious cases in that environment
o There is evidence that humidity favours the survival of M. leprae
o M. leprae can remain viable in dried nasal secretions for at least 9 days and
in moist soil at room temperature for 46 days
- Overcrowding and Lack of ventilation within households
Incubation Period
- Leprosy has a long incubation period of an average of 3-5 years for lepromatous
cases
- Tuberculoid leprosy has a shorter incubation period
o Symptoms can take up to 20 years to manifest
- Failure to recognise the early symptoms or signs may contribute to an assumed
prolonged incubation period in some patients
- Leprologists prefer the term latent period to incubation period due to the long
duration
Mode of Transmission
- Droplet Transmission
o There is growing evidence that leprosy is transmitted by droplet infection
o With this realization, there has been increased emphasis on the respiratory
tract as the portal of entry
o The possibility of this route of transmission is based on
 Inability of the organisms to be found on the surface of the skin
 Demonstration of a large number of organisms in the nasal
discharge
 The high proportion of morphologically intact bacilli in the nasal
secretions
 The evidence that M. leprae could survive outside the human host
for several hours or days
- Contact Transmission
o Numerous studies indicate that leprosy is transmitted from person-to-
person by close contact between an infectious patient and a healthy but
susceptible person
o This contact may be direct or indirect
- Other routes
o Insect vectors
o Tattooing needles
National Leprosy Eradication Programme
The “National Leprosy Control Programme” (NLCP) was started in 1955 as a programme
to achieve control of leprosy through early detection of cases and DDS monotherapy
on an ambulatory basis. In 1980, the government constituted a ‘Working Group’ who
advised a revised strategy based on ‘multidrug chemotherapy aimed at leprosy
eradication through reduction in the sources of infection, and breaking the chain of
transmission of disease. The “National Leprosy Eradication Programme” (NLEP) was
formed in 1983 to combat leprosy and aim for eradication by the turn of the century.
The components of the programme are:
- Decentralized integrated leprosy services through general health care system
- Capacity building of all general health services functionaries
- Intensified information, education and communication
- Prevention of disability and medical rehabilitation
- Intensified monitoring, supervision and surveillance
After the introduction of multidrug therapy, recorded case load of leprosy came down
from 57.6 per 10,000 in 1981 to less than 1 at a national level in 2005. 34 states have
declared leprosy elimination with only 2 yet to declare elimination; Chhattisgarh and Dadra
& Nagar Haveli.
Describe the epidemiology and control of Malaria in India.
Agent Factors
Host Factors
- Agent
o Malaria in man is caused by 4 distinct species of Plasmodium; P. vivax, P.
falciparum, P. ovale, P. malariae
o P. vivax has the widest geographic distribution throughout the world
o In India, the most prevalent species are P. falciparum and P. vivax
o The largest focus of P. malariae is in the Tumkur and Hassan Districts of
Karnataka
o P. ovale is a rare species in man and many restricted to tropical regions and
Africa.
 Cases have also been reported in Vietnam
o Severity of malaria is related to the species of Plasmodium.
o Plasmodium undergoes 2 cycles; Asexual and Sexual
o During the asexual cycle (Schizogony), it undergoes multiplication in the
liver parenchymal cells (Hepatic Phase), and maturation and
differentiation in the red blood cells (Erythrocytic Phase) into micro- and
macrogametocyte
o These gametocytes enter the Sexual Cycle (Sporogony) when they are
taken up by mosquitoes during blood meal, and undergo sexual replication
and development into an oocyst which bursts releasing sporozoites. These
sporozoites enter the salivary gland and are discharged into the human
during the next blood meal and the cycle continues
- Reservoir of Infection
o With the exception of chimpanzees in tropical Africa, there is no other
animal reservoir of human plasmodia
o Patient can be carrier of several plasmodial species at the same time
o Children are more likely to carry the gametocyte form and are therefore
better reservoirs than adults,
o Certain conditions must be satisfied to make an ideal reservoir
 Both sexes of gametocytes must be present for further
development to occur
 Gametocytes must be mature
 Gametocytes must be viable
 Gametocytes must be present in sufficient density to infect the
mosquitos
- Period of Communicability
o Malaria is communicable as long as the mature, viable gametocytes exist
in the circulating blood in sufficient density to infect vector mosquitoes
o In vivax infections, gametocytes appear in the blood 4-5 days after the
appearance of the asexual parasites
o Gametocytes are the most numerous during the early stages of the infection
o RELAPSES
 Usual for vivax and ovale to relapse more than 3 years after the
patients first attack
 Recurrences of falciparum disappear within 1-2 years
 P. malariae cause prolonged, low-level asymptomatic
parasitaemia
- Age
o Malaria affects all ages
o New-borns are considerably resistant to P. falciparum
 Due to high concentration of foetal haemoglobin during the first
months of life, suppressing the development of P. falciparum
- Sex
o Males are more frequently exposed to risk of acquiring malaria due to their
‘outdoor lifestyle’
- Race
o Individuals with sickle cell trait are have a milder infection of P. falciparum
than those with normal haemoglobin
o Persons with Duffy negative are resistant to P. vivax infection
- Pregnancy
o Increases the risk of malaria in women
o Malaria during pregnancy causes intrauterine death of the foetus
o It may also cause premature labour or abortion
o Primigravid mothers are at greatest risk
- Socioeconomic development
o Malaria is more prevalent in under developed societies
- Housing
o Ill-ventilated and ill-lit houses provide ideal indoor resting places for
mosquitos
 o Malaria is acquired by mosquito bites inside the house
- Population Mobility
o People migrating from one place to another may import malarial parasites
to a place where it has been controlled and reintroduce malaria into
these areas
- Occupation
o Malaria is predominantly a rural disease and as such is common seen
among individuals in the agricultural industry
- Human Habits
o Sleeping outdoors, nomadism, refusal to accept spraying of houses,
replastering of walls and personal protection measures (nets, bug spray)
o These measures influence the man-vector contact
- Immunity
o Epidemic of malaria is influenced by the immunity of the population
o Immunity is only acquired after repeated infections and exposure to the
parasite
o Therefore, in endemic areas, a state of collective immunity develops
slowly
 As a result, only infants, children, new-borns, travellers and
migrants are affected the most.
o Infants born to immune mothers are protected during the first 3-5 months due
to the presence of maternal IgG antibody
o Active immunity is species-specific; immunity to one species does not
protect you from the other species of plasmodia.
Environmental Factors
- Season
o Malaria is a seasonal disease
o Maximum prevalence is during July – November
- Temperature
o Optimum temperature for the development of the malarial parasite in the
mosquito is between 20°C - 30°C
o Temperatures below 16°C causes development to cease
o Temperatures above 30°C is lethal to the parasite
- Humidity
o Atmospheric humidity has a direct effect on the life span of the vector but has
no effect on the parasite itself
o When relative humidity is high, mosquitoes are more active and feed more
voraciously
o If humidity is low, mosquitoes do not live very long
- Rainfall
o Rain provides opportunities for the breeding of mosquitoes
o Heavy rain may have the adverse effect and flush out any breeding spots
o Epidemics of malaria has also followed periods of drought
 This produce small pools of water which served as active breeding
spots for mosquitoes
- Altitude
o Anophelines are not found at altitudes above 2000-2500 metres
 Due to unfavourable climatic conditions
- Man-made malaria
o Burrow pits, garden pools, irrigation channels and engineering projects have
led to the breeding of malarial vectors and subsequent increase in malaria
o Malaria consequent of such endeavours is known as man-made malaria
Mode of Transmission
- Vector Transmission
o Malaria is transmitted by bite of certain species of infected, female,
anopheline mosquitoes
o Single infected vector may infect several persons
o Mosquitoes are not infective until the sporozoites are present in its salivary
gland
- Direct Transmission
o Malaria may be induced by hypodermic intramuscular and intravenous
injections of blood or plasma
o Blood transfusions poses a problem as the parasites keep their infective
activity for at least 14 days in blood bottles stored at 4°C
o Persons living in endemic areas or has had malaria should not be accepted
as blood donor until 3 years after recovery
- Congenital Malaria
o Congenital infection of a new-born from the blood of the mother may also
occur, but rare due to the effect of the foetal haemoglobin
Clinical Features
- Primary fever is marked by paroxysms which correspond to the development of the
parasites in the RBCs
- The peaks of fever coincide with the release into the blood stream of successive
broods of merozoites
- Typical attack consists of 3 stages; cold stage, hot stage, sweating stage,
followed by an afebrile period in which the patient feels relieved
Cold Stage:
- The onset is with lassitude, headache, nausea and chilly sensation followed by
rigors
- The temperature rises rapidly to 39-41°C
- Headache is often severe and commonly there is vomiting associated.
- In early parts, skin feels cold; later it becomes hot
- Parasites are usually demonstrable in the blood
- The pulse is rapid and may be weak
- This stage may last 15 minutes to 1 hour
Hot Stage o Capacity building
o Behavioural change communication
- The patient feels burning hot and casts off their clothes o Intersectoral collaboration
- The skin is hot and dry to touch o Monitoring and evaluation
- Headache is intense but nausea commonly diminishes o Operational research and applied field research
- Pulse is full and respiration is rapid
Early diagnosis and treatment of malaria aims at:
- This stage lasts 2-6 hours
- Complete cure
Sweating Stage
- Prevention of progression of uncomplicated malaria to severe disease
- Fever comes down with profuse sweating - Prevention of deaths
- Temperature drops rapidly to normal and skin is cool and moist - Interruption of transmission
- The pulse rate becomes slower and patient feels relieved and often falls asleep - Minimising risk of selection and spread of drug resistant malaria parasite
- This stage lasts for 2-4 hours
National Malaria Control Programme
Complications of Malaria
- Began in 1953 during the First Five Year Plan
- P. falciparum - Due to spectacular success, the ‘control’ plan was converted to ‘eradication’ plan
o Cerebral malaria in 1958
o Acute renal failure - The main activities of the programme are:
o Liver damage o Formulating policies and guidelines
o GI symptoms o Technical guidance
o Dehydration o Planning and Logistics
o Collapse o Monitoring and evaluation
o Anaemia o Coordination of activities
o Blackwater fever o Collaboration with international organizations
- P. vivax, P. ovale and P. malariae o Training
o Anaemia o Facilitating research
o Splenomegaly and Hepatomegaly o Coordinating control activities in the interstate and intercountry border
o Herpes areas

Control of Malaria in India

The Strategic Action Plan for malarial control in India was developed by the Directorate of Describe the epidemiology of Dengue Fever. Mention the measures to
National Vector Borne Disease Control Programme.
control and prevent the epidemic of Dengue Fever.
The strategies for prevention and control of malaria and its transmission are: Dengue Fever is a self-limiting disease and represents the majority of cases of dengue
infection. A prevalence of Aedes aegyptii and Aedes albopictus with the circulation of
- Surveillance and Case Management dengue virus of more than one type tends to be associated with outbreaks of DHF/DSS
o Case detection (passive and active)
o Early diagnosis and complete treatment Agent Factors
o Sentinel surveillance
- Agent
- Integrated Vector Management
o The dengue virus forms a distinct complex within the flavivirus genus
o Indoor residual spray (IRS)
based on antigenic and biological characteristics
o Insecticide treated bed nets (ITNs) and long-lasting insecticidal nets
o There are 4 serotypes which are designated as DENV-1, DENV-2, DENV-3,
o Anti-larval measures including source reduction
and DENV-4
- Epidemic preparedness and early response o Infection with one serotype confers lifelong immunity to that specific
- Supportive interventions serotype
 o All 4 serotypes are similar antigenically but different enough to elicit cross-
protection for only a few months after infection by any one serotype
o Pathogenesis of severe syndrome involves pre-existing dengue antibody
 Virus antibodies are formed within a few days of second dengue
infection and that the non-neutralizing antibodies promote infection of
higher numbers of mononuclear cells, followed by the release of
cytokines, vasoactive mediators and procoagulants
 Leading to DIC seen in haemorrhagic fever syndrome
- Vector
o Aedes aegyptii and Aedes albopticus are two most important vectors of
dengue
o They both carry high vectorial competency for dengue virus
o Aedes aegyptii is highly domesticated, strongly anthropophilic, nervous
feeder (It bites more than one person to complete its blood meal) and is a
discordant species (requires more than one feed to complete the
gonotropic cycle)
o This habit results in the generation of multiple cases and clustering of
dengue cases in the cities.
o Aedes albopticus partly invades peripheral areas of the urban cities
 It is an aggressive feeder
 Concordant species
 Does not require a second blood meal to complete the
gonotropic cycle
Transmission of Disease
- Aedes mosquito becomes infective by feeding on a patient from the day before
onset to 5th day of illness (Viraemia stage)
- After an incubation period of 8-10 days, the mosquito becomes infective and is able
to transmit the infection
- Once it is infective, it remains so for life
- The genital tract gets infected and transovarian transmission of dengue virus
occurs when the virus enters the fully developed eggs at the time of oviposition.
Environmental Factors
- Population of Aedes mosquitos fluctuates with rainfall and water storage
- Its life span is influenced by temperature and humidity
- It breeds in the containers in and around the house
- It is a domestic breeder and there endophagic and endophilic
- An increase of 2°C will shorten the extrinsic incubation period of the DENV
- Mosquitos will tend to bite more frequently due to dehydration and thus increases
the man-mosquito contact
- Failure of the urban authorities to provide civil amenities and poor public health
infrastructure increases the potential for vector breeding and makes the
environment transmission conducive
- The rural spread of the vector is associated with development of rural water
supply schemes, improved transport systems, scarcity of water and lifestyle
changes
Control of Dengue Fever
- Mosquito Control
o Vectors of DF and DHF breed in and around houses
o In principle, it can be controlled by individual and community action,
using anti-adult and antilarval measures
- Vaccines
o CYD-TDV
 Prophylactic, tetravalent, live attenuated viral vaccine
 Developed by Sanofi Pasteur in December 2015
 Consists of 3 injections of 0.5 mL administered at 6-month intervals
 Available as a single dose vial or in a multidose (5-dose) vial
 It is a freeze-dried product to be reconstituted before injection
with sterile solution of 0.4% Sodium Chloride (single dose) or 0.9%
Sodium Chloride (multidose)
 It is administered subcutaneously
 It is contraindicated in
 Individuals with severe allergy to dengue vaccine
 Individuals with congenital or acquired immune deficiency
 Individuals with HIV, asymptomatic or symptomatic
 Pregnant or breastfeeding women
- Other measures
o Isolation of patient under bed nets during the first few days
o Individual protection against mosquitoes
Global Strategy for Dengue Protection and Control: 2012-2020
- The Global Strategy promotes coordination and collaboration among multisectoral
partners on integrated vector management
- The goals are
o To reduce dengue mortality by at least 50% by 2020
o To reduce dengue morbidity by at least 25% by 2020
o To estimate the true burden of the disease by 2015
SHORT NOTES
Multidrug Therapy of Leprosy
Objectives:
- To interrupt transmission of the infection in the community by sterilizing infectious
patients as rapidly as possible with bactericidal drugs
- To ensure a rapidly detection and treatment of cases to prevent deformities
 - To prevent drug resistance
Drugs used:
- Rifampicin
o Only drug that is highly bactericidal against M. leprae
o Single dose of 1500mg can kill up to 99% of viable organisms
o It is now an essential drug in chemotherapy of leprosy
o When given alone, resistance to the drug develops and is hence given in
combination with other drugs
- Dapsone
o Has been in use globally for control of leprosy for more than 30 years
o It is an important drug in the MDT of leprosy
o It is cheap and effective in the correct dosage (1-2mg/kg body weight)
o When given orally, it is completely absorbed from the gut and fairly well
tolerated
o Shown to have a weak bactericidal action against M. leprae
- Clofazimine
o Originally synthesised for treatment of TB, but was found to be more effective
against leprosy
o Has both anti-leprosy and anti-inflammatory properties
o Has the added advantage in suppressing and preventing reactions
- Ethionamide and Protionamide
o Bactericidal drugs killing 98% of organisms in 4-5 days
o Virtually interchangeable and gives rise to cross-resistance with each other
o Both more expensive and more toxic than dapsone
- Quinolones
o Ofloxacin is the most preferred
o 22 doses can kill 99.9% of viable organism
- Minocycline
o Most lipid soluble of the tetracyclines
o Inhibits bacterial protein synthesis
o May strengthen the MDT and thereby shorten the duration of treatment
needed for leprosy
- Clarithromycin
o Member of the macrolide group of antibiotics
o Displays a significant bactericidal activity
o Daily administration of 500mg killed 99% of viable organisms within 28
days in lepromatous leprosy
WHO Recommended Chemotherapy Regimens:
- For multibacillary Leprosy in adults
o Rifampicin – 600mg once monthly, under supervision
o Dapsone – 100mg daily, self-administered
o Clofazimine – 300mg once monthly supervised, and 50mg daily self-
administered
 If clofazimine is unacceptable, ethionamide 250-375 mg self-
administered is suggested
- For Paucibacillary Leprosy in adults
o Rifampicin – 600mg once monthly, supervised
o Dapsone – 100mg (1-2mg/kg bodyweight) daily, self-administered
- For multibacillary leprosy in children
o Rifampicin – 450mg once monthly, supervised
o Dapsone – 50mg daily, self-administered
o Clofazimine – 150mg once a month, supervised, 50 mg every other day
- For paucibacillary leprosy in children
o Rifampicin – 450mg once monthly supervised
o Dapsone – 50mg daily, self-administered
Pulse Polio Immunisation Programme
- Government of India conducted the first round of PPI consisting of 2 immunization
days 6 weeks apart on 9th December 1995 and 20th January 1996
- the first PPI targeted all children under 3 years irrespective of immunisation
schedule
- later, it was decided to extend the age group from under 3 to under 5
- the term ‘pulse’ is used to describe the sudden, simultaneous, mass
administration of OPV on a single day during the low transmission period
(November to February)
- the dose of OPV during PPIs are extra doses to supplement and not replace the
doses already received
- children including 0-1 should receive their routine immunization and their PPI
- important improvement is the use of vaccine vial monitors
o Colour monitors are put on the vaccine bottles
o each label has a circle of deep blue colour
o inside the circle there is white square which gradually changes to blue, if the
vaccine bottle is exposed to higher temperatures
o when the colour of the white square becomes blue, vaccine should be
considered ineffective
o this quality assurance ensures that the children will have better protection
against polio
Classification and Management of Acute Respiratory Infection in a young
infant under 2 months of age.
SIGNS - stopped feeding well
- convulsions
- abnormally sleepy or difficult to wake
- stridor in calm child
- wheezing
- fever or low body temperature
CLASSIFY AS: VERY SEVERE DISEASE
TREATMENT - refer urgently to the hospital
- Keep the young infant warm
- Give the first dose of antibiotic
SIGNS - Severe chest indrawing
- Fast breathing (60 breaths per
minute)
CLASSIFY AS: SEVERE PNEUMONIA
TREATMENT - Refer urgently to the hospital
- Keep the young infant warm
- Give the first dose of an antibiotic
- If referral is not feasible, administered
antibiotic and follow closely
SIGNS - No severe chest indrawing
- No fast breathing (less than 60
breaths per minute)
CLASSIFY AS: NO PNEUMONIA: COUGH OR COLD
TREATMENT - Advise the mother to give the
following home care; keep infant
warm, frequent feeding, clear nose
if it interferes with feeding
- Return quickly if; breathing
becomes difficult, breathing
becomes fast, feeding becomes a
problem, young infant becomes
sicker
Treatment of Pneumonia in Young Infants
- Child must be hospitalized
- Treatment with cotrimoxazole may be started by the health worker before referring
the child
- If pneumonia is suspected, child is treated with IM injections of Benzyl penicillin or
injection ampicillin, along with injection Gentamicin
- Chloramphenicol is not recommended as the first line
- Besides antibiotics, therapy for associated conditions should be set immediately
o Child should be kept warm and dry
o Breast feeding should be promoted to reduce risk of developing diarrhoea
Control Measures for Typhoid Fever
Control of Reservoir
- Cases
o Early diagnosis
 Vital importance as early symptoms are non-specific
 Culture of blood and stools are important investigations in diagnosis
o Notification
 Done where such notification is necessary
o Isolation
 Cases are better transferred to a hospital for proper treatment as well
as to prevent the spread of disease
 Cases should be isolated until 3 bacteriologically negative stool
and urine samples are produced on 3 separate days
o Treatment
 FQs are the drug of choice
 They are relatively inexpensive, well-tolerated and more rapidly and
reliably effective than the former first-line drugs (chloramphenicol,
ampicillin, amoxicillin, trimethoprim-sulfamethoxazole)
o Disinfection
 Stools and urine are sole sources of infection
 They should be received in closed containers and disinfected
 Soiled clothes should be soaked in a solution of 2% chlorine and
steam-sterilized.
 Nurse and doctors should not forget to disinfect their hands
- Carriers
o Identification
 Carriers are identified by cultural and serological examination
 Duodenal drainage establishes salmonella presence
o Treatment
 Ampicillin or amoxicillin with probenecid for 6 weeks
o Surgery
 Cholecystectomy with concomitant ampicillin therapy
o Surveillance
 Carriers are kept under surveillance
o Health education
 Washing hands with soap, after defaecation or urination
Control of Sanitation
- Protection and purification of drinking water supplies, improvement of basic sanitation
and promotion of food hygiene
- Sanitation combined with health education produces cumulative effects, resulting in a
steady reduction of typhoid morbidity
Immunization
- Immunization against typhoid does not give 100% protection but does lower
incidence and seriousness of the infection
Nosocomial Infections
- Nosocomial Infections are infections acquired during hospital care which are not
present or incubating at admission.
- Infections occurring more than 48 hours after admission are usually nosocomial
- May also be considered either endemic or epidemic
o Endemic infections are most common
o Epidemic infections occur during outbreaks, defined as an unusual
increase above the baseline of a specific infection or infecting organism
- Changes in healthcare delivery have resulted in shorter hospital stays and
increased outpatient care
- It is suggested that nosocomial infections should encompass infections occurring in
patients receiving treatment in any health care setting
- Hospital acquired infections may be considered from 3 angles;
o Source
 Patients – patients suffering from infectious diseases are sources of
infection
 Staff – hospital staff in close contact with other patients may be an
important source of cross-infection
 Environment – hospital environment is laden with microbes and thus
is important source of infection
o Routes of Spread
 Common routes of spread are
 Direct Contact
 Droplet Infection
 Release of Hospital Dust
 Airborne particles
 Through hospital procedures
o Recipients
 All patients in hospital are potential recipients of cross-infection
 Some patients are more susceptible than others, especially those
who are severely ill and those under corticosteroid therapy
 Cross infection is greater in intensive care units, urological and
geriatric wards and in special baby care units.
o Those who are suffering from skin diseases, sore throat, common cold,
ear infection, diarrhoea or dysentery and other infectious ailments should
be kept away from work until completely cured
- Hand Washing
o Most common route of infection is via the hands
o When dealing with patients, hand washing must be thorough
o When hand washing with soap and water is insufficient, disinfected is used
Control of Dengue Fever
- Mosquito Control
o Vectors of DF and DHF breed in and around houses
o In principle, it can be controlled by individual and community action,
using anti-adult and antilarval measures
- Vaccines
o CYD-TDV
 Prophylactic, tetravalent, live attenuated viral vaccine
 Developed by Sanofi Pasteur in December 2015
 Consists of 3 injections of 0.5 mL administered at 6-month intervals
 Available as a single dose vial or in a multidose (5-dose) vial
 It is a freeze-dried product to be reconstituted before injection
with sterile solution of 0.4% Sodium Chloride (single dose) or 0.9%
Sodium Chloride (multidose)
 It is administered subcutaneously
 It is contraindicated in
 Individuals with severe allergy to dengue vaccine
 Individuals with congenital or acquired immune deficiency
 Individuals with HIV, asymptomatic or symptomatic
 Pregnant or breastfeeding women
- Other measures
o Isolation of patient under bed nets during the first few days
o Individual protection against mosquitoes

Preventive Measures

- Isolation
o Infectious patients must be isolated
o Patients who are susceptible to infection should not be placed in beds next to
patients who are a source of infection
- Hospital Staff
 o Rash
o Impaired kidney and liver functions
Grading of Deformities in Leprosy - There is no specific treatment for this disease
- Mortality can be reduced and spread of disease can be prevented by instituting
specific infection control measures
- There is no vaccine against the Ebola virus

Investigations for HIV

TEST SIGNIFICANCE
ELISA Screening test for HIV infection; sensitivity >
99.9%.
Western Blot Confirmatory test for HIV
Complete Blood Count Anaemia, Neutropenia, Thrombocytopenia is
common with advanced HIV
Absolute CD4 Lymphocyte Count Most widely used predictor for HIV
progression
CD4 Lymphocyte Percentage Percentage may be more reliable than the
CD4 count
HIV viral load tests Test that measure the amount of actively
replicating HIV virus; Correlates with disease
progression and response to anti-retroviral
drugs
B2 – Microglobulin Cell surface protein indicative of macrophage
– monocyte stimulation; not useful with IV
drug users
P24 Antigen Indicates Active HIV replication; tends to be
positive prior to seroconversion and with
advanced disease
Ebola
- Ebola is a new breed of deadly haemorrhagic fever which appeared for the first
time in Zaire and Sudan in 1976. Post-exposure Prophylaxis of Rabies
- It has an incubation period of 2-21 days and is not infective during this period General Consideration
- Asymptomatic cases are also not infective - The vast majority of persons requiring anti-rabies treatment are those bitten by a
- The virus is transmitted through direct contact with the blood, organs, body suspected rabid animal
secretions or other body fluids of infected animals like chimpanzees, gorillas, - The aim is to neutralize the inoculated virus before it can enter the nervous system
monkeys, fruit bats
- It is well established that combination of single dose of rabies immunoglobulin
- Human to human transmission is through blood or bodily fluids of an infected with local treatment of the wound
symptomatic person or through exposure to objects
- It is not transmissible through air, water or food Local Treatment of Wound
- Characteristic features include
- Prompt and adequate local treatment is the first requisite and is of utmost
o Sudden onset of fever
importance
o Intense weakness
o Muscle pain - Purpose is to remove as much virus as possible from the site of inoculation
o Headache before it can be absorbed on nerve endings.
o Sore throat - Is of maximal value when applied immediately after exposure but it should not be
o Vomiting and diarrhoea neglected if time has elapsed
- Measures include
 o Cleansing
o Chemical Treatment
o Suturing
o Antibiotics and anti-tetanus measures

Immunization

- Concentrated and purified cell-culture vaccine and embryonated egg-based

vaccine are proved to be safe and effective in preventing rabies
- Rabies viruses has been propagated in cell substrates such as
o human diploid cells,
o foetal rhesus diploid cells,
o Vero cells,
o Primary Syrian hamster kidney cells
o Primary chick embryo cells
o Embryonated duck eggs
- Rabies vaccines prequalified by WHO do not contain preservatives

WHO Guidelines for Post-Exposure Treatment

CATEGORIES OF CONTACT WITH POST-EXPOSURE PROPHYLAXIS

SUSPECT RABID ANIMAL MEASURES
Category I – touching or feeding animals, None
licks on intact skin
Category II – nibbling of uncovered skin, Immediate vaccination and local treatment of
minor scratches or abrasions without the wound
bleeding
Category III – single or multiple transdermal Immediate vaccination and administration of
bites or scratches, licks on broken skin; rabies immunoglobulins; local treatment of
contamination of mucous membrane with the wound
saliva from licks, contacts with bats

Oral Rehydration Therapy

- It is well established that oral rehydration treatment can be safely and successfully
used in treating acute diarrhoeas due to aetiologies, in all age groups
- The aim is to prevent dehydration and reduce mortality
- ORT is based on observation that glucose given orally enhances the intestinal
absorption of salt and water, and is capable of correcting the electrolyte and
water deficit
- Composition of Reduced Osmolarity ORS
o Sodium Chloride – 2.6 grams/litre
o Glucose, anhydrous – 13.5 grams/litre
o Potassium Chloride – 1.5 grams/litre
o Trisodium Citrate, Dihydrate – 2.9 grams/litre
ESSAY  man has no inherited immunity but is acquired by BCG vaccine or
natural infection
Describe the natural history of Tuberculosis. Discuss the control of - Social Factors
o TB is a social disease with medical aspects
tuberculosis. Add a note on Directly Observed Treatment Short Course o considered a barometer for social welfare
(DOTS) o social factors include
NATURAL HISTORY OF TUBERCULOSIS  poor quality of life
 poor housing and overcrowding
- Agent Factors  population explosion
o Agent  malnutrition
 the causative agent of tuberculosis is Mycobacterium tuberculosis  smoking and alcohol abuse
 it is a facultative intracellular parasite  lack of education
 it is readily ingested by phagocytes and is resistant to intracellular  large families
killing  early marriages
o Source of Infection o these factors are interrelated and contribute to occurrence and spread of TB
 there are 2 sources of infection – human and bovine - Mode of Transmission
 the most common source of infection in humans is in a patient whose o TB is transmitted by droplet infection and droplet nuclei generated by
sputum is positive for tubercle bacilli and who has either received sputum positive patients with pulmonary tuberculosis
no treatment or has not been treated fully o to transmit infection, particles must be fresh enough to carry viable
 they can discharge the bacilli in their sputum for years organisms
 some bacilli multiply quickly and some slowly o coughing generates the highest number of droplets
 more rapid multipliers are more susceptible to bactericidal drugs  frequency and vigour and ventilation of environment influences
 the slow multipliers are the source of dormant bacilli transmission of infection
 dormant bacilli can stay alive but does not cause infection to o TB is not transmitted by fomites
the human until the conditions are favourable when they o Patients with extrapulmonary TB constitute a minimal hazard of
multiply again and cause infection transmission of infection
 the bovine source is usually infected milk - Incubation period
 no definite evidence that bovine TB is a problem due to o the time from receipt of infection to the development of positive
practice of boiling milk before consumption tuberculin test ranges from 3-6 weeks
o Communicability o the development of disease is dependent on closeness of contact, extent
 patients are infective as long as they remain untreated of disease and sputum positivity of source
 effective anti-microbial treatment reduces infectivity o incubation period may be weeks, months or years.
- Host Factors
o Age CONTROL OF TUBERCULOSIS
 tuberculosis affects all ages
Tuberculosis control means the reduction in the prevalence and incidence of disease in the
 developing countries show a sharp rise in infection rates from
community. The basic principles of prevention and control are the same as for any infectious
childhood to adolescence
disease.
o Sex
 more prevalent in males The control measures consist of a:
o Hereditary
 not a hereditary disease - Curative Component – case finding and treatment
 twin studies show that inherited susceptibility is an important risk - Preventive component – BCG vaccination
factor
o Nutrition Case Finding
 malnutrition is believed to predispose to tuberculosis
- the first step in a TB control programme is early detection of sputum positive
 it affects the development, outcome and spread of disease
cases
o Immunity
- this should be an intensive, ongoing programme
 - health worker watches the patient swallow the drug in his presence, after which
the patient is given a multiblister combipack to consume at home.
Target Group
- The patient must return with an empty combipack when they come to collect the
- overwhelming majority of patients of pulmonary TB have one or more of the medicine for the next week
symptoms referable to chest
- the chest symptoms develop early before the disease has gone onto advanced stage
Describe the epidemiology of Poliomyelitis. Add a note on the ‘Pulse
- this is the most fertile group for case-finding Polio Immunization Programme’.
Agent Factors
Intensified TB Case Finding
- Agent
- primary objective of detecting TB cases early by active case finding in targeted o the causative agent of poliomyelitis is poliovirus which has 3 serotypes; 1, 2
groups and to initiate treatment promptly and 3
- it can target people who anyway have sought health care with or without o most outbreaks of paralytic polio are due to type 1 virus
symptoms of TB o poliovirus can survive for long periods in the external environment
- decisions on when and how to screen for TB will depend on the vulnerable group,  in a cold climate, it can survive for 4 months in water and 6 months in
capacity of the health system and availability of resources faeces
o it is well adapted for the faeco-oral route of transmission
Screening Strategies o virus is rapidly deactivated by pasteurisation
1) Community screening is done by - Reservoir of Infection
o inviting people to attend screening at a mobile facility or a fixed facility o man is the only known reservoir of infection
o invitations may target specifically people within a given group o most infections are subclinical
2) Institutional Screening o it is mild and subclinical cases play a dominant role in the spread of
o health care facilities infection
 systematically performing active screening of vulnerable individuals o they constitute the submerged portion of the iceberg (see ICEBERG
o congregate settings PHENOMENON)
 systemically perform active screening of vulnerable individuals in o there are no chronic carriers
shelters, old age homes, refugee camps, correctional facilities o no animal source has yet been demonstrated
- Infectious Material
Case Finding Tools o virus is found in faeces and oropharyngeal secretions of an infected
person
- Sputum Examination
- Period of communicability
o sputum examination by direct microscopy is the method of choice
o the cases are most infectious from 7-10 days before and after onset of
o it enables us to discover the epidemiologically most important cases of
symptoms
pulmonary TB
Host Factors
Tuberculin Test
- Age
- test to diagnose tuberculosis in a suspected patient
o disease occurs in all age groups
- discovered by Von Pirquet in 1907 o children are usually more susceptible than adults
- positive result is accepted as evidence of past or present TB infection  due to acquired immunity of the adult population
- only means of estimating the prevalence of infection in a population o in India, polio is a disease of infancy and childhood
 most vulnerable age is between 6 months and 3 years
Directly Observed Treatment Short Course (DOTS) Chemotherapy:
- Sex
- strategy to ensure cure by providing the most effective medicine and confirming o more prevalent in males than females
 3:1 ratio
that it is taken
- Risk Factors
- only strategy to be documented to be effective worldwide on a programme basis
o fatigue, trauma, intramuscular injections, operative procedures
 - Immunity o disease is synonymous with aseptic (viral) meningitis
o maternal antibodies disappear during the first 6 months of life - Paralytic Polio
o immunity following infection is solid although reinfection can occur as o virus invades the CNS and causes varying degrees of paralysis
immunity for one type of polio does not protect the patient from the o there is history of fever at time of onset of paralysis which is suggestive of
other 2 types polio
o type 2 virus antigen is the most effective o other associated symptoms are malaise, anorexia, nausea, vomiting,
headache, sore throat, constipation, abdominal pain
Environmental Factors o paralysis is characterized as descending
- polio is more likely to occur during the rainy monsoon season Pulse Polio Immunization Programme
- 60% of cases recorded were during July and September
- environmental sources include - Government of India conducted the first round of PPI consisting of 2 immunization
o Contaminated water, food and flies days 6 weeks apart on 9th December 1995 and 20th January 1996
- Polio survives for a long time in cold conditions - the first PPI targeted all children under 3 years irrespective of immunisation
schedule
- Overcrowding and poor sanitation provide opportunities for exposure to infection
- later, it was decided to extend the age group from under 3 to under 5
Mode of Transmission - the term ‘pulse’ is used to describe the sudden, simultaneous, mass
administration of OPV on a single day during the low transmission period
- Faeco-oral Route (November to February)
o main route of spread in developing countries
- the dose of OPV during PPIs are extra doses to supplement and not replace the
o the infection may spread directly through contaminated fingers where
doses already received
hygiene is poor, or indirectly through contaminated water, milk, foods,
- children including 0-1 should receive their routine immunization and their PPI
flies and articles of daily use
- Droplet Infection - important improvement is the use of vaccine vial monitors
o this may occur in acute phase of disease when the virus occurs in the o Colour monitors are put on the vaccine bottles
throat o each label has a circle of deep blue colour
o close personal contact with an infected person facilitates droplet spread o inside the circle there is white square which gradually changes to blue, if the
o this mode of transmission may be more important in developed countries vaccine bottle is exposed to higher temperatures
where faecal transmission is remote o when the colour of the white square becomes blue, vaccine should be
considered ineffective
Incubation Period o this quality assurance ensures that the children will have better protection
against polio
- usually 7-14 days - AFP Surveillance
o PPI is supported by AFP surveillance system since 1997
Clinical Spectrum
o it is being conducted through network of surveillance medical officers
- Inapparent Infection  SMOs are specially trained and responsible for a defined area
o there are no presenting symptoms  they are located at the state HQ and at regional places in cases of
o recognition only by virus isolation or rising antibody titres larger states
- Abortive Polio
o causes only a mild or self-limiting illness due to viraemia
o the patient recovers quickly
o diagnosis is not made clinically as recognition is only made by viral
isolation or rising antibody titres
- Non-Paralytic Polio
o presenting features are stiffness and pain in the neck and back
o disease lasts 2-10 days
o recovery is rapid
 Enumerate the Sexually Transmitted Diseases (STDs). Describe the o scrotal swelling
o inguinal bubo
syndromic management of STDs in detail.
Classification of Sexually Transmitted Diseases SYNDROMIC MANAGMENT OF URETHRAL DISCHARGE IN MALES

- Bacterial Agents Urethral discharge confirmed by Lab Investigations include

o Neisseria gonorrhoeae clinician - Gram stain examination of urethral smear will show
o Chlamydia Trachomatis
gram negative intracellular diplococci in gonorrhoea
o Treponema pallidum
- in non-gonococcal cases, more than 5 neutrophils per
o Haemophilus ducreyi - Treatment for gonorrhoea and
oil immersion field in the smear, or more than 10
o Mycoplasma hominis chlaymidial infection
neutrophils per high power field in the sediment of the
o Ureaplasma urealyticum - Health education and counselling
first void urine are observed
o Calymmatobacterium granulomatis - Examine and treat sexual
o Shigella partners
o Campylobacter
o Group B Streptococci Follow up, 7-14 days after treatment
o Bacterial vaginosis-associated organisms
- Viral Agents Clinical Cure
o Herpes Simplex Virus
Discharge persists
o Human Herpes Virus type 5 (Cytomegalovirus)
o Hepatitis B Virus Assess: treatment compliance
o Human Papilloma Virus (HPV) Assess: treatment compliance poor and re-infection likely
o Molluscum contagiosum virus good and re-infection unlikely
o Human Immunodeficiency Virus (HIV)
- Protozoal Agents Restart the treatment protocol
o Entamoeba histolytica
o Giardia lamblia Refer
o Trichomonas vaginalis
- Fungal Agents - Notification and treatment of sexual partners of men with Urethritis are the
o Candida albicans highest priority
- Ectoparasites - Treatment
o Phthirus pubis o as dual infection is common, treatment should cover therapy for both
o Sarcoptes scabiei gonorrhoeal and chlamydial infections
o Uncomplicated infection regimen
Syndromic Approach to Sexually Transmitted Diseases
 Tab. Cefixime 400mg orally, single dose + Tab. Azithromycin 1gm
orally, single dose UNDER SUPERVISION
- syndromic approach is scientifically derived and offers accessible and immediate
 advise the patient to return after 7 days of start of therapy for follow
treatment, that is effective and efficient
up
- management of STDs using flowcharts is more cost-effective than diagnosis based
o if symptoms persist, patient should be treated for Trichomonas vaginalis
on lab tests
 If discharge or only dysuria persists after 7 days, Tab. Secnidazole 2
- many different agents cause STDs, however, some agents give rise to similar or gm orally, single dose
overlapping clinical manifestations o if symptoms still persist, refer to higher centre ASAP
- e.g. o If individual is allergic to Azithromycin, give Erythromycin 500mg 4 times a
o Urethral discharge in males day for 7 days
o Vaginal Discharge - Syndrome specific guidelines for partner management
o Lower abdominal pain in females o treat all recent partners
o genital ulcers
 o treat female partners on same lines after ruling out pregnancy and history
of allergies
o advise sexual abstinence during the course of treatment
o provide condoms, educate about correct and consistent use,
Discuss the epidemiology & clinical course of AIDS. Mention the
SYNDROMIC MANAGEMENT OF VAGINAL DISCHARGE preventive measures for the same.
Causative Organisms Agent Factors

Vaginitis: T. vaginalis, C.albicans, G. vaginalis - Agent

o HIV virus is a protein capsule containing 2 short strands of genetic material
Cervicitis: N. gonorrhoeae, C. Trachomatis, T.
and enzymes
vaginalis, HSV
o the virus replicates in actively dividing T4 lymphocytes and like other
retroviruses, it remains in the latent state that can be activated
History Examination o the virus has the ability to destroy human T4 helper cells
Lab Investigations o it is able to spread throughout the body and can pass through the blood-
- Menstrual history to rule out - Per speculum examination to brain barrier and can then destroy some brain cells
pregnancy differentiate between vaginitis - wet mount microscopy of o the virus is easily killed by heat and is readily inactivated by ether,
- Nature and type of discharge and cervicitis discharge for T vaginalis and acetone, ethanol and beta-propriolactone
- Genital Itching - cervical erosion/ cervical clue cells - Reservoir of Infection
- Burning micturition and ulcer/ Mucopurulent cervical - 10% KOH mount for C. o these are cases and carriers
increased frequency discharge albicans o once a person is infected, virus remains in the body lifelong
- Presence of ulcer or swelling - Bimanual pelvic examination - Gram’s stain for clue cells in o the risk of developing AIDS increases with time
- Genital complaints in sexual to rule out PID bacterial vaginosis o since HIB infection can take years to manifest itself, the symptomless
partners - If speculum examination is not - Gram’s stain of endocervical carrier can infect other people for years
- Low backache possible, treat for both vaginitis smear to detect Gonococci - Source of Infection
and cervicitis o the virus has been found in greatest concentration in blood, semen and
CSF
o lower concentration has been detected in tears, saliva, breast milk. urine
Treatment
and cervical and vaginal secretions
- Vaginitis o HIV has been isolated in brain tissue, lymph nodes, bone marrow cells
o Tab. Secnidazole 2 gm orally, single dose OR Tab. Tinidazole 500mg and skin
orally, twice daily for 5 days
Host Factors
o Tab. Metoclopramide 30 mins before Tab. Secnidazole, to prevent
gastric intolerance - Age
o Treat for candidiasis with Tab. Fluconazole 150mg orally single
o most cases have occurred among sexually active persons aged 20-49
dose or local Clotrimazole 500 mg vaginal pessaries once
years
- Cervical Infection
o this group represents the most productive members of society
o Tab. Cefixime 400mg orally, single dose
- Sex
o PLUS Azithromycin 1 gram, 1 hour before lunch
o In North America, Europe and Australia, 51% of cases are homosexual or
o if vomiting within 1 hour, given anti-emetic and repeat
bisexual
o In Africa, sex ratio is equal
Management in Pregnant Women Specific Guidelines for Partner Managment o Certain sexual practices increase the risk of infection more than others
- High Risk Groups
- Per speculum examination should be done to - Treat current partner only if no improvement o male homosexuals and bisexuals,
rule out pregnancy complications after treatment o heterosexual partners
- Treatment for vaginitis - If partner is symptomatic, treat client and o IV drug abusers
o In 1st trimester, local treatment with partner using the protocols
Clotrimazole for candidiasis and - Advise sexual abstinence during course of
Metronidazole for Trichomonas or BV treatment
o In 2nd and 3rd trimesters, oral - Provide condoms, educate about proper and
Metronidazole is given consistent use
 o transfusion recipients of blood and blood products - AIDS-related complex
o haemophiliacs - AIDS
o clients of STD

Mode of Transmission
- Sexual Transmission
o AIDS is a sexually transmitted disease
o it can spread via unprotected vaginal, oral or anal sex
o size of risk is affected by number of factors
 presence of STD
 sex and age of uninfected partner
 type of sexual act
 stage of illness of the infected partner
 virulence of the HIV strain
o anal intercourse carries a higher risk of transmission than vaginal
intercourse because it is more likely to injure tissues of the receptive
partner
o the risk of transmission is greater where there are abrasions of the skin or
mucous membrane
o exposed adolescent girls and women are more prone to HIV
o HIV infected people are more infectious to others in the very early stages,
before the antibody production and when the infection is well advanced, as
the level of virus in the blood is higher than at other times
- Blood Contact
o AIDS is also transmitted by contaminated blood
o it is highly infective when introduced in large quantities directly into the
blood stream
o the risk of contracting HIV infection is estimated to be over 95%
o this route of transmission is common among recreational drug users who
inject drugs into their system
- Maternal-Foetal Transmission
o HIV may pass from an infected mother to her foetus, through the placenta
or to her infant during delivery or by breastfeeding
o transmission accounts for 1/3 to 2/3 of overall numbers infected
o risk of infection is higher in newly infected, or if she has already developed
AIDS
o HIV infected infants progress rapidly to AIDS
o can be prevented entirely by anti-retroviral drug prophylaxis
o no evidence of spread to health care workers in their professional contact
with AIDS patients
Initial Infection:
- infected people have no symptoms for the first 5 years
- they appear healthy
- once infected, people are infected for life
- HIV antibodies take between 2-12 weeks to appear in the blood
o this period is known as WINDOW PERIOD
Asymptomatic Carrier State:
- infected people have antibodies, but no overt signs of disease
- there is persistent generalized lymphadenopathy
- it is not clear how long the carrier state lasts
AIDS-related Complex
- person with ARC has illnesses caused by damage to the immune system
- they may exhibit one or more of the clinical signs
o Unexplained diarrhoea for more than a month
o Fatigue
o Malaise
o Loss of more than 10% body weight
o fever
o Night sweats
- patients with 2 or more of these manifestations and a decreased number of T-
helper lymphocytes are considered to have AIDS-related complex
AIDS:
- the end-stage of HIV infection
- opportunistic infections commonly occur at this stage
- death is due to uncontrolled or untreatable infection
- TB and Kaposi Sarcoma is usually seen early
- Serious fungal infections such as Candida, Cryptococcus, Penicillosis, and
parasitic infections such as Pneumocystis carinii pneumonia or Toxoplasma
gondii encephalitis tends to occur

Clinical Manifestations Prevention of HIV

- Initial Infection - Education

- Asymptomatic Carrier State o only means at present is health education to enable people to make life-
saving choices
 o material should be made widely available Host Factors
- Combination HIV Prevention
o combination prevention uses a mix of biomedical, behavioural and - diarrhoea is most common in children especially between 6 months and 2 years
structural interventions to meet the current HIV prevention - incidence is highest in age of 6-11 months, when weaning occurs
o ARV drugs play a key role in HIV prevention - it reflects the combined effects of declining levels of maternally acquired
- Prevention of Blood-borne HIV Transmission antibodies, the lack of active immunity in the infant, the introduction of
o high risk people should refrain from donating blood, body organs, sperm contaminated food, and direct contact with human or animal faeces, when
or other tissues infant starts to crawl
- Diarrhoea is more common in patients with malnutrition
Discuss the epidemiology and control of Acute Diarrhoeal Diseases o Malnutrition – Infection – Diarrhoea
Agent Factors
Environmental Factors
- Viruses
- distinct seasonal patterns of diarrhoea occur in many geographical area
o many have been identified as causative organisms.
o most prevalent of which are rotaviruses - in temperature climates, bacterial diarrhoea occurs more frequently during the
 first discovered in 1973 and has emerged as the leading cause of warm season, whereas viral diarrhoea, particularly diarrhoea caused by rotavirus
severe, dehydrating diarrhoea in children aged less than 5 years peak during the winter
globally - in tropical areas, rotavirus diarrhoea occurs throughout the year, increasing in
 rotavirus reinfection is common although the primary infection is frequency during the drier, cool months, whereas bacterial diarrhoeas peak
usually the most significant clinically during the warmer, rainy season
 they are shed in very high concentrations and for many days in the
stools and vomit of infected individuals Mode of Transmission
 transmission occurs primarily by faecal-oral route, directly from
- most organisms that causes diarrhoea are transmitted primarily or exclusively by
person to person or indirectly via contaminated fomites
the faecal-oral route
- Bacterial
- may be water-borne, food borne, or direct transmission which implies an array of
o V.cholerae, Salmonella, Shigella, enterotoxic E. coli and Campylobacter
other faecal-oral routes such as via fingers, fomites, dirt
jejuni
o they produce potent Enterotoxins similar to that produced by V. cholerae Control of Diarrhoeal Diseases
o the lesser-known pathogens which causes diarrhoea are Yersinia
enterocolitica and V. parahaemolyticus - Appropriate Clinical Management
o ETEC is an important cause of acute watery diarrhoea in adults and o Oral Rehydration Therapy
children in developing countries. o Intravenous Rehydration Therapy
 most common cause of Traveller’s diarrhoea - Better MCG care Practices
o salmonella causes inflammation of the bowel epithelium o Maternal Nutrition
o Shigella accounts for high percentage of mortality due to diarrhoeal  improving prenatal nutrition will reduce the low birth weight problem
disease  prenatal and postnatal nutrition will improve the quality of breast milk
o the estimate suggest that is causes about 1 million deaths every year in o Child Nutrition
children aged under 5  promotion of breast-feeding
 appropriate weaning practices
Reservoir of Infection
 supplementary feeding
- for some enteric pathogens, man is the principal reservoir and thus most  Vitamin A supplementation
transmission originates from human factors - Preventative Strategies
- examples are enterotoxic E. coli, Shigella species, V. cholerae, Giardia lamblia o sanitation
and E. histolytica o Health education
o Immunization
- animals are important reservoirs and transmission originates from both human
- Rotavirus vaccine
and animal faeces
 o two live, oral attenuated rotavirus vaccines were licensed in 2006; Rotarix
and Rota Teq
o both vaccines have demonstrated very good safety and efficacy profiles in
large clinical trials
o the vaccines are now introduced for routine use in the number of
industrialized and developing countries
- Control and Prevention of Diarrhoeal Epidemics
- Integrated Global Action Plan for the Prevention and Control of Pneumonia and
Diarrhoea
Describe in detail the epidemiology of leprosy. Add a note on the
National Leprosy Eradication Programme
Leprosy or ‘Hansen’s disease’ is a chronic infectious disease caused by Mycobacterium
leprae. It mainly affects the peripheral nerve, skin, muscles, eyes, bones, testes and
internal organs. it manifests itself in two polar forms, namely the Lepromatous leprosy
and Tuberculoid leprosy, lying at the 2 ends of a long-spectrum of the disease
Leprosy is clinically characterized by one or more of the following cardinal 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 skin and nasal smears
Agent Factors
- Agent
o leprosy is caused by Mycobacterium leprae
o they are acid fast and occur in the human host both intracellularly and
extracellularly
o they occur characteristically in clumps or bundles
o they have a particular affinity for Schwann cells and cells of the RES
o they remain dormant in various sites and cause a relapse
o bacterial load is highest in Lepromatous cases
- Source of Infection
o it is generally agreed that multibacillary cases are the most important
sources of infection in the community
o patients with active leprosy must be considered ‘infectious’
- Portal of Exit
o widely accepted that the portal of exit is through the Nose
 Lepromatous cases harbour millions of M. leprae in their nasal
mucosa which are discharged when sneezing or blowing the nose
 bacilli also exit through ulcerated or broken skin of bacteriologically
positive cases of leprosy
- Infectivity
o leprosy is highly infectious but of low pathogenicity
o it is claimed that an infectious patient is rendered non-infectious by treatment
with Dapsone for 90 days, or with rifampicin for 3 weeks
o local application of rifampicin might destroy all bacilli within 8 days
- Attack Rates
o among the household contacts of lepromatous cases, 4.4% - 12% is expected
to show signs of leprosy within 5 years
o this occurs despite treatment of the index case
Host Factors
- Age
o Leprosy is not associated with children
o Can take place at any time depending upon the opportunities for exposure
o Disease is acquired commonly during childhood in endemic areas
o Presence of leprosy in child population is of epidemiological significance
- Sex
o Both incidence and prevalence of leprosy is higher in males than females
o Excess of male cases is attributed to greater motility and increased
opportunities for contact in many populations
- Migration
o Leprosy is considered to be a rural problem
o However, due to movement of population from the rural to urban areas,
leprosy is slowly developing into an urban problem
- Prevalence Pool
o Prevalence pool is in a constant flux resulting from inflow and outflow of
cases
- Inactivation of Disease
o Where leprosy treatment facilities exist, inactivation or cure due to specific
treatment is an important mode of elimination of cases from the prevalence
pool
- Immunity
o It is well-established that only few persons exposed to infection develop
disease
o Large proportion of early lesions of lesion heal spontaneously
 Suggesting immunity acquired through these lesions
o Subclinical infections are far more common than what was believed
 Believed to contribute to active immunity
- Genetic Factors
 o There is now evidence that Human Lymphocyte Antigen (HLA) linked
genes influence the type of immune response that develops as a result of
infection
Environmental Factors
- The presence of infectious cases in that environment
o There is evidence that humidity favours the survival of M. leprae
o M. leprae can remain viable in dried nasal secretions for at least 9 days and
in moist soil at room temperature for 46 days
- Overcrowding and Lack of ventilation within households
Incubation Period
- Leprosy has a long incubation period of an average of 3-5 years for lepromatous
cases
- Tuberculoid leprosy has a shorter incubation period
o Symptoms can take up to 20 years to manifest
- Failure to recognise the early symptoms or signs may contribute to an assumed
prolonged incubation period in some patients
- Leprologists prefer the term latent period to incubation period due to the long
duration
Mode of Transmission
- Droplet Transmission
o There is growing evidence that leprosy is transmitted by droplet infection
o With this realization, there has been increased emphasis on the respiratory
tract as the portal of entry
o The possibility of this route of transmission is based on
 Inability of the organisms to be found on the surface of the skin
 Demonstration of a large number of organisms in the nasal
discharge
 The high proportion of morphologically intact bacilli in the nasal
secretions
 The evidence that M. leprae could survive outside the human host
for several hours or days
- Contact Transmission
o Numerous studies indicate that leprosy is transmitted from person-to-
person by close contact between an infectious patient and a healthy but
susceptible person
o This contact may be direct or indirect
- Other routes
o Insect vectors
o Tattooing needles
National Leprosy Eradication Programme
The “National Leprosy Control Programme” (NLCP) was started in 1955 as a programme
to achieve control of leprosy through early detection of cases and DDS monotherapy
on an ambulatory basis. In 1980, the government constituted a ‘Working Group’ who
advised a revised strategy based on ‘multidrug chemotherapy aimed at leprosy
eradication through reduction in the sources of infection, and breaking the chain of
transmission of disease. The “National Leprosy Eradication Programme” (NLEP) was
formed in 1983 to combat leprosy and aim for eradication by the turn of the century.
The components of the programme are:
- Decentralized integrated leprosy services through general health care system
- Capacity building of all general health services functionaries
- Intensified information, education and communication
- Prevention of disability and medical rehabilitation
- Intensified monitoring, supervision and surveillance
After the introduction of multidrug therapy, recorded case load of leprosy came down
from 57.6 per 10,000 in 1981 to less than 1 at a national level in 2005. 34 states have
declared leprosy elimination with only 2 yet to declare elimination; Chhattisgarh and Dadra
& Nagar Haveli.
Describe the epidemiology and control of Malaria in India.
Agent Factors
- Agent
o Malaria in man is caused by 4 distinct species of Plasmodium; P. vivax, P.
falciparum, P. ovale, P. malariae
o P. vivax has the widest geographic distribution throughout the world
o In India, the most prevalent species are P. falciparum and P. vivax
o The largest focus of P. malariae is in the Tumkur and Hassan Districts of
Karnataka
o P. ovale is a rare species in man and many restricted to tropical regions and
Africa.
 Cases have also been reported in Vietnam
o Severity of malaria is related to the species of Plasmodium.
o Plasmodium undergoes 2 cycles; Asexual and Sexual
o During the asexual cycle (Schizogony), it undergoes multiplication in the
liver parenchymal cells (Hepatic Phase), and maturation and
differentiation in the red blood cells (Erythrocytic Phase) into micro- and
macrogametocyte
o These gametocytes enter the Sexual Cycle (Sporogony) when they are
taken up by mosquitoes during blood meal, and undergo sexual replication
and development into an oocyst which bursts releasing sporozoites. These
sporozoites enter the salivary gland and are discharged into the human
during the next blood meal and the cycle continues
- Reservoir of Infection
o With the exception of chimpanzees in tropical Africa, there is no other
animal reservoir of human plasmodia
 o Patient can be carrier of several plasmodial species at the same time
o Children are more likely to carry the gametocyte form and are therefore
better reservoirs than adults,
o Certain conditions must be satisfied to make an ideal reservoir
 Both sexes of gametocytes must be present for further
development to occur
 Gametocytes must be mature
 Gametocytes must be viable
 Gametocytes must be present in sufficient density to infect the
mosquitos
- Period of Communicability
o Malaria is communicable as long as the mature, viable gametocytes exist
in the circulating blood in sufficient density to infect vector mosquitoes
o In vivax infections, gametocytes appear in the blood 4-5 days after the
appearance of the asexual parasites
o Gametocytes are the most numerous during the early stages of the infection
o RELAPSES
 Usual for vivax and ovale to relapse more than 3 years after the
patients first attack
 Recurrences of falciparum disappear within 1-2 years
 P. malariae cause prolonged, low-level asymptomatic
parasitaemia
Host Factors
- Age
o Malaria affects all ages
o New-borns are considerably resistant to P. falciparum
 Due to high concentration of foetal haemoglobin during the first
months of life, suppressing the development of P. falciparum
- Sex
o Males are more frequently exposed to risk of acquiring malaria due to their
‘outdoor lifestyle’
- Race
o Individuals with sickle cell trait are have a milder infection of P. falciparum
than those with normal haemoglobin
o Persons with Duffy negative are resistant to P. vivax infection
- Pregnancy
o Increases the risk of malaria in women
o Malaria during pregnancy causes intrauterine death of the foetus
o It may also cause premature labour or abortion
o Primigravid mothers are at greatest risk
- Socioeconomic development
o Malaria is more prevalent in under developed societies
- Housing
o Ill-ventilated and ill-lit houses provide ideal indoor resting places for
mosquitos
o Malaria is acquired by mosquito bites inside the house
- Population Mobility
o People migrating from one place to another may import malarial parasites
to a place where it has been controlled and reintroduce malaria into
these areas
- Occupation
o Malaria is predominantly a rural disease and as such is common seen
among individuals in the agricultural industry
- Human Habits
o Sleeping outdoors, nomadism, refusal to accept spraying of houses,
replastering of walls and personal protection measures (nets, bug spray)
o These measures influence the man-vector contact
- Immunity
o Epidemic of malaria is influenced by the immunity of the population
o Immunity is only acquired after repeated infections and exposure to the
parasite
o Therefore, in endemic areas, a state of collective immunity develops
slowly
 As a result, only infants, children, new-borns, travellers and
migrants are affected the most.
o Infants born to immune mothers are protected during the first 3-5 months due
to the presence of maternal IgG antibody
o Active immunity is species-specific; immunity to one species does not
protect you from the other species of plasmodia.
Environmental Factors
- Season
o Malaria is a seasonal disease
o Maximum prevalence is during July – November
- Temperature
o Optimum temperature for the development of the malarial parasite in the
mosquito is between 20°C - 30°C
o Temperatures below 16°C causes development to cease
o Temperatures above 30°C is lethal to the parasite
- Humidity
o Atmospheric humidity has a direct effect on the life span of the vector but has
no effect on the parasite itself
o When relative humidity is high, mosquitoes are more active and feed more
voraciously
o If humidity is low, mosquitoes do not live very long
- Rainfall
o Rain provides opportunities for the breeding of mosquitoes
o Heavy rain may have the adverse effect and flush out any breeding spots
o Epidemics of malaria has also followed periods of drought
 This produce small pools of water which served as active breeding
spots for mosquitoes
 - Altitude Hot Stage
o Anophelines are not found at altitudes above 2000-2500 metres
 Due to unfavourable climatic conditions - The patient feels burning hot and casts off their clothes
- Man-made malaria - The skin is hot and dry to touch
o Burrow pits, garden pools, irrigation channels and engineering projects have - Headache is intense but nausea commonly diminishes
led to the breeding of malarial vectors and subsequent increase in malaria - Pulse is full and respiration is rapid
o Malaria consequent of such endeavours is known as man-made malaria - This stage lasts 2-6 hours

Mode of Transmission Sweating Stage

- Vector Transmission - Fever comes down with profuse sweating

o Malaria is transmitted by bite of certain species of infected, female, - Temperature drops rapidly to normal and skin is cool and moist
anopheline mosquitoes
- The pulse rate becomes slower and patient feels relieved and often falls asleep
o Single infected vector may infect several persons
- This stage lasts for 2-4 hours
o Mosquitoes are not infective until the sporozoites are present in its salivary
gland Complications of Malaria
- Direct Transmission
o Malaria may be induced by hypodermic intramuscular and intravenous - P. falciparum
injections of blood or plasma o Cerebral malaria
o Blood transfusions poses a problem as the parasites keep their infective o Acute renal failure
activity for at least 14 days in blood bottles stored at 4°C o Liver damage
o Persons living in endemic areas or has had malaria should not be accepted o GI symptoms
as blood donor until 3 years after recovery o Dehydration
- Congenital Malaria o Collapse
o Congenital infection of a new-born from the blood of the mother may also o Anaemia
occur, but rare due to the effect of the foetal haemoglobin o Blackwater fever
- P. vivax, P. ovale and P. malariae
Clinical Features o Anaemia
o Splenomegaly and Hepatomegaly
- Primary fever is marked by paroxysms which correspond to the development of the
o Herpes
parasites in the RBCs
- The peaks of fever coincide with the release into the blood stream of successive Control of Malaria in India
broods of merozoites
The Strategic Action Plan for malarial control in India was developed by the Directorate of
- Typical attack consists of 3 stages; cold stage, hot stage, sweating stage,
National Vector Borne Disease Control Programme.
followed by an afebrile period in which the patient feels relieved
The strategies for prevention and control of malaria and its transmission are:
Cold Stage:
- Surveillance and Case Management
- The onset is with lassitude, headache, nausea and chilly sensation followed by
o Case detection (passive and active)
rigors
o Early diagnosis and complete treatment
- The temperature rises rapidly to 39-41°C
o Sentinel surveillance
- Headache is often severe and commonly there is vomiting associated.
- Integrated Vector Management
- In early parts, skin feels cold; later it becomes hot o Indoor residual spray (IRS)
- Parasites are usually demonstrable in the blood o Insecticide treated bed nets (ITNs) and long-lasting insecticidal nets
- The pulse is rapid and may be weak o Anti-larval measures including source reduction
- This stage may last 15 minutes to 1 hour - Epidemic preparedness and early response
- Supportive interventions
 o Capacity building o All 4 serotypes are similar antigenically but different enough to elicit cross-
o Behavioural change communication protection for only a few months after infection by any one serotype
o Intersectoral collaboration o Pathogenesis of severe syndrome involves pre-existing dengue antibody
o Monitoring and evaluation  Virus antibodies are formed within a few days of second dengue
o Operational research and applied field research infection and that the non-neutralizing antibodies promote infection of
higher numbers of mononuclear cells, followed by the release of
Early diagnosis and treatment of malaria aims at: cytokines, vasoactive mediators and procoagulants
 Leading to DIC seen in haemorrhagic fever syndrome
- Complete cure
- Vector
- Prevention of progression of uncomplicated malaria to severe disease
o Aedes aegyptii and Aedes albopticus are two most important vectors of
- Prevention of deaths
dengue
- Interruption of transmission o They both carry high vectorial competency for dengue virus
- Minimising risk of selection and spread of drug resistant malaria parasite o Aedes aegyptii is highly domesticated, strongly anthropophilic, nervous
feeder (It bites more than one person to complete its blood meal) and is a
National Malaria Control Programme discordant species (requires more than one feed to complete the
gonotropic cycle)
- Began in 1953 during the First Five Year Plan
o This habit results in the generation of multiple cases and clustering of
- Due to spectacular success, the ‘control’ plan was converted to ‘eradication’ plan
dengue cases in the cities.
in 1958 o Aedes albopticus partly invades peripheral areas of the urban cities
- The main activities of the programme are:  It is an aggressive feeder
o Formulating policies and guidelines  Concordant species
o Technical guidance  Does not require a second blood meal to complete the
o Planning and Logistics gonotropic cycle
o Monitoring and evaluation
o Coordination of activities Transmission of Disease
o Collaboration with international organizations
o Training - Aedes mosquito becomes infective by feeding on a patient from the day before
o Facilitating research onset to 5th day of illness (Viraemia stage)
o Coordinating control activities in the interstate and intercountry border - After an incubation period of 8-10 days, the mosquito becomes infective and is able
areas to transmit the infection
- Once it is infective, it remains so for life
- The genital tract gets infected and transovarian transmission of dengue virus
occurs when the virus enters the fully developed eggs at the time of oviposition.
Describe the epidemiology of Dengue Fever. Mention the measures to
control and prevent the epidemic of Dengue Fever. Environmental Factors
Dengue Fever is a self-limiting disease and represents the majority of cases of dengue
- Population of Aedes mosquitos fluctuates with rainfall and water storage
infection. A prevalence of Aedes aegyptii and Aedes albopictus with the circulation of
dengue virus of more than one type tends to be associated with outbreaks of DHF/DSS - Its life span is influenced by temperature and humidity
- It breeds in the containers in and around the house
Agent Factors
- It is a domestic breeder and there endophagic and endophilic
- Agent - An increase of 2°C will shorten the extrinsic incubation period of the DENV
o The dengue virus forms a distinct complex within the flavivirus genus - Mosquitos will tend to bite more frequently due to dehydration and thus increases
based on antigenic and biological characteristics the man-mosquito contact
o There are 4 serotypes which are designated as DENV-1, DENV-2, DENV-3, - Failure of the urban authorities to provide civil amenities and poor public health
and DENV-4 infrastructure increases the potential for vector breeding and makes the
o Infection with one serotype confers lifelong immunity to that specific environment transmission conducive
serotype
 - The rural spread of the vector is associated with development of rural water
supply schemes, improved transport systems, scarcity of water and lifestyle
changes
Control of Dengue Fever
- Mosquito Control
o Vectors of DF and DHF breed in and around houses
o In principle, it can be controlled by individual and community action,
using anti-adult and antilarval measures
- Vaccines
o CYD-TDV
 Prophylactic, tetravalent, live attenuated viral vaccine
 Developed by Sanofi Pasteur in December 2015
 Consists of 3 injections of 0.5 mL administered at 6-month intervals
 Available as a single dose vial or in a multidose (5-dose) vial
 It is a freeze-dried product to be reconstituted before injection
with sterile solution of 0.4% Sodium Chloride (single dose) or 0.9%
Sodium Chloride (multidose)
 It is administered subcutaneously
 It is contraindicated in
 Individuals with severe allergy to dengue vaccine
 Individuals with congenital or acquired immune deficiency
 Individuals with HIV, asymptomatic or symptomatic
 Pregnant or breastfeeding women
- Other measures
o Isolation of patient under bed nets during the first few days
o Individual protection against mosquitoes
Global Strategy for Dengue Protection and Control: 2012-2020
- The Global Strategy promotes coordination and collaboration among multisectoral
partners on integrated vector management
- The goals are
o To reduce dengue mortality by at least 50% by 2020
o To reduce dengue morbidity by at least 25% by 2020
o To estimate the true burden of the disease by 2015
SHORT NOTES
Multidrug Therapy of Leprosy
Objectives:
- To interrupt transmission of the infection in the community by sterilizing infectious
patients as rapidly as possible with bactericidal drugs
- To ensure a rapidly detection and treatment of cases to prevent deformities
- To prevent drug resistance
Drugs used:
- Rifampicin
o Only drug that is highly bactericidal against M. leprae
o Single dose of 1500mg can kill up to 99% of viable organisms
o It is now an essential drug in chemotherapy of leprosy
o When given alone, resistance to the drug develops and is hence given in
combination with other drugs
- Dapsone
o Has been in use globally for control of leprosy for more than 30 years
o It is an important drug in the MDT of leprosy
o It is cheap and effective in the correct dosage (1-2mg/kg body weight)
o When given orally, it is completely absorbed from the gut and fairly well
tolerated
o Shown to have a weak bactericidal action against M. leprae
- Clofazimine
o Originally synthesised for treatment of TB, but was found to be more effective
against leprosy
o Has both anti-leprosy and anti-inflammatory properties
o Has the added advantage in suppressing and preventing reactions
- Ethionamide and Protionamide
o Bactericidal drugs killing 98% of organisms in 4-5 days
o Virtually interchangeable and gives rise to cross-resistance with each other
o Both more expensive and more toxic than dapsone
- Quinolones
o Ofloxacin is the most preferred
o 22 doses can kill 99.9% of viable organism
- Minocycline
o Most lipid soluble of the tetracyclines
o Inhibits bacterial protein synthesis
o May strengthen the MDT and thereby shorten the duration of treatment
needed for leprosy
- Clarithromycin
o Member of the macrolide group of antibiotics
o Displays a significant bactericidal activity
o Daily administration of 500mg killed 99% of viable organisms within 28
days in lepromatous leprosy
WHO Recommended Chemotherapy Regimens:
- For multibacillary Leprosy in adults
o Rifampicin – 600mg once monthly, under supervision
o Dapsone – 100mg daily, self-administered
 o Clofazimine – 300mg once monthly supervised, and 50mg daily self- Classification and Management of Acute Respiratory Infection in a young
administered
 If clofazimine is unacceptable, ethionamide 250-375 mg self- infant under 2 months of age.
administered is suggested SIGNS - stopped feeding well
- convulsions
- For Paucibacillary Leprosy in adults - abnormally sleepy or difficult to wake
o Rifampicin – 600mg once monthly, supervised - stridor in calm child
o Dapsone – 100mg (1-2mg/kg bodyweight) daily, self-administered - wheezing
- fever or low body temperature
CLASSIFY AS: VERY SEVERE DISEASE
- For multibacillary leprosy in children
TREATMENT - refer urgently to the hospital
o Rifampicin – 450mg once monthly, supervised
- Keep the young infant warm
o Dapsone – 50mg daily, self-administered
- Give the first dose of antibiotic
o Clofazimine – 150mg once a month, supervised, 50 mg every other day

- For paucibacillary leprosy in children SIGNS - Severe chest indrawing

o Rifampicin – 450mg once monthly supervised - Fast breathing (60 breaths per
o Dapsone – 50mg daily, self-administered minute)
CLASSIFY AS: SEVERE PNEUMONIA
TREATMENT - Refer urgently to the hospital
Pulse Polio Immunisation Programme - Keep the young infant warm
- Government of India conducted the first round of PPI consisting of 2 immunization - Give the first dose of an antibiotic
days 6 weeks apart on 9th December 1995 and 20th January 1996 - If referral is not feasible, administered
antibiotic and follow closely
- the first PPI targeted all children under 3 years irrespective of immunisation
schedule
- later, it was decided to extend the age group from under 3 to under 5 SIGNS - No severe chest indrawing
- the term ‘pulse’ is used to describe the sudden, simultaneous, mass - No fast breathing (less than 60
administration of OPV on a single day during the low transmission period breaths per minute)
(November to February) CLASSIFY AS: NO PNEUMONIA: COUGH OR COLD
- the dose of OPV during PPIs are extra doses to supplement and not replace the
TREATMENT - Advise the mother to give the
following home care; keep infant
doses already received warm, frequent feeding, clear nose
- children including 0-1 should receive their routine immunization and their PPI if it interferes with feeding
- important improvement is the use of vaccine vial monitors - Return quickly if; breathing
o Colour monitors are put on the vaccine bottles becomes difficult, breathing
o each label has a circle of deep blue colour becomes fast, feeding becomes a
problem, young infant becomes
o inside the circle there is white square which gradually changes to blue, if the
sicker
vaccine bottle is exposed to higher temperatures
o when the colour of the white square becomes blue, vaccine should be
considered ineffective Treatment of Pneumonia in Young Infants
o this quality assurance ensures that the children will have better protection
against polio - Child must be hospitalized
- Treatment with cotrimoxazole may be started by the health worker before referring
the child
- If pneumonia is suspected, child is treated with IM injections of Benzyl penicillin or
injection ampicillin, along with injection Gentamicin
- Chloramphenicol is not recommended as the first line
- Besides antibiotics, therapy for associated conditions should be set immediately
 o Child should be kept warm and dry Immunization
o Breast feeding should be promoted to reduce risk of developing diarrhoea
- Immunization against typhoid does not give 100% protection but does lower
Control Measures for Typhoid Fever incidence and seriousness of the infection
Control of Reservoir
Nosocomial Infections
- Cases - Nosocomial Infections are infections acquired during hospital care which are not
o Early diagnosis present or incubating at admission.
 Vital importance as early symptoms are non-specific - Infections occurring more than 48 hours after admission are usually nosocomial
 Culture of blood and stools are important investigations in diagnosis
- May also be considered either endemic or epidemic
o Notification
o Endemic infections are most common
 Done where such notification is necessary
o Epidemic infections occur during outbreaks, defined as an unusual
o Isolation
increase above the baseline of a specific infection or infecting organism
 Cases are better transferred to a hospital for proper treatment as well
- Changes in healthcare delivery have resulted in shorter hospital stays and
as to prevent the spread of disease
 Cases should be isolated until 3 bacteriologically negative stool increased outpatient care
and urine samples are produced on 3 separate days - It is suggested that nosocomial infections should encompass infections occurring in
o Treatment patients receiving treatment in any health care setting
 FQs are the drug of choice - Hospital acquired infections may be considered from 3 angles;
 They are relatively inexpensive, well-tolerated and more rapidly and o Source
reliably effective than the former first-line drugs (chloramphenicol,  Patients – patients suffering from infectious diseases are sources of
ampicillin, amoxicillin, trimethoprim-sulfamethoxazole) infection
o Disinfection  Staff – hospital staff in close contact with other patients may be an
 Stools and urine are sole sources of infection important source of cross-infection
 They should be received in closed containers and disinfected  Environment – hospital environment is laden with microbes and thus
 Soiled clothes should be soaked in a solution of 2% chlorine and is important source of infection
steam-sterilized. o Routes of Spread
 Nurse and doctors should not forget to disinfect their hands  Common routes of spread are
- Carriers  Direct Contact
o Identification  Droplet Infection
 Carriers are identified by cultural and serological examination  Release of Hospital Dust
 Duodenal drainage establishes salmonella presence  Airborne particles
o Treatment  Through hospital procedures
 Ampicillin or amoxicillin with probenecid for 6 weeks o Recipients
o Surgery  All patients in hospital are potential recipients of cross-infection
 Cholecystectomy with concomitant ampicillin therapy  Some patients are more susceptible than others, especially those
o Surveillance who are severely ill and those under corticosteroid therapy
 Carriers are kept under surveillance  Cross infection is greater in intensive care units, urological and
o Health education geriatric wards and in special baby care units.
 Washing hands with soap, after defaecation or urination
Preventive Measures
Control of Sanitation
- Isolation
- Protection and purification of drinking water supplies, improvement of basic sanitation o Infectious patients must be isolated
and promotion of food hygiene o Patients who are susceptible to infection should not be placed in beds next to
- Sanitation combined with health education produces cumulative effects, resulting in a patients who are a source of infection
steady reduction of typhoid morbidity - Hospital Staff
 o Those who are suffering from skin diseases, sore throat, common cold,
ear infection, diarrhoea or dysentery and other infectious ailments should
be kept away from work until completely cured Grading of Deformities in Leprosy
- Hand Washing
o Most common route of infection is via the hands
o When dealing with patients, hand washing must be thorough
o When hand washing with soap and water is insufficient, disinfected is used

Control of Dengue Fever

- Mosquito Control
o Vectors of DF and DHF breed in and around houses
o In principle, it can be controlled by individual and community action,
using anti-adult and antilarval measures
- Vaccines
o CYD-TDV
 Prophylactic, tetravalent, live attenuated viral vaccine
 Developed by Sanofi Pasteur in December 2015
 Consists of 3 injections of 0.5 mL administered at 6-month intervals
 Available as a single dose vial or in a multidose (5-dose) vial
 It is a freeze-dried product to be reconstituted before injection
with sterile solution of 0.4% Sodium Chloride (single dose) or 0.9%
Sodium Chloride (multidose)
 It is administered subcutaneously
 It is contraindicated in
 Individuals with severe allergy to dengue vaccine
 Individuals with congenital or acquired immune deficiency
 Individuals with HIV, asymptomatic or symptomatic
 Pregnant or breastfeeding women Ebola
- Other measures - Ebola is a new breed of deadly haemorrhagic fever which appeared for the first
o Isolation of patient under bed nets during the first few days time in Zaire and Sudan in 1976.
o Individual protection against mosquitoes
- It has an incubation period of 2-21 days and is not infective during this period
- Asymptomatic cases are also not infective
- The virus is transmitted through direct contact with the blood, organs, body
secretions or other body fluids of infected animals like chimpanzees, gorillas,
monkeys, fruit bats
- Human to human transmission is through blood or bodily fluids of an infected
symptomatic person or through exposure to objects
- It is not transmissible through air, water or food
- Characteristic features include
o Sudden onset of fever
o Intense weakness
o Muscle pain
o Headache
o Sore throat
o Vomiting and diarrhoea
 o Rash o Cleansing
o Impaired kidney and liver functions o Chemical Treatment
- There is no specific treatment for this disease o Suturing
- Mortality can be reduced and spread of disease can be prevented by instituting o Antibiotics and anti-tetanus measures
specific infection control measures Immunization
- There is no vaccine against the Ebola virus
- Concentrated and purified cell-culture vaccine and embryonated egg-based
Investigations for HIV vaccine are proved to be safe and effective in preventing rabies
- Rabies viruses has been propagated in cell substrates such as
o human diploid cells,
TEST SIGNIFICANCE
o foetal rhesus diploid cells,
ELISA Screening test for HIV infection; sensitivity >
99.9%. o Vero cells,
Western Blot Confirmatory test for HIV o Primary Syrian hamster kidney cells
Complete Blood Count Anaemia, Neutropenia, Thrombocytopenia is o Primary chick embryo cells
common with advanced HIV o Embryonated duck eggs
Absolute CD4 Lymphocyte Count Most widely used predictor for HIV - Rabies vaccines prequalified by WHO do not contain preservatives
progression
CD4 Lymphocyte Percentage Percentage may be more reliable than the
CD4 count WHO Guidelines for Post-Exposure Treatment
HIV viral load tests Test that measure the amount of actively
replicating HIV virus; Correlates with disease CATEGORIES OF CONTACT WITH POST-EXPOSURE PROPHYLAXIS
progression and response to anti-retroviral SUSPECT RABID ANIMAL MEASURES
drugs Category I – touching or feeding animals, None
B2 – Microglobulin Cell surface protein indicative of macrophage licks on intact skin
– monocyte stimulation; not useful with IV Category II – nibbling of uncovered skin, Immediate vaccination and local treatment of
drug users minor scratches or abrasions without the wound
P24 Antigen Indicates Active HIV replication; tends to be bleeding
positive prior to seroconversion and with Category III – single or multiple transdermal Immediate vaccination and administration of
advanced disease bites or scratches, licks on broken skin; rabies immunoglobulins; local treatment of
contamination of mucous membrane with the wound
saliva from licks, contacts with bats
Post-exposure Prophylaxis of Rabies
General Consideration
Oral Rehydration Therapy
- The vast majority of persons requiring anti-rabies treatment are those bitten by a - It is well established that oral rehydration treatment can be safely and successfully
suspected rabid animal used in treating acute diarrhoeas due to aetiologies, in all age groups
- The aim is to neutralize the inoculated virus before it can enter the nervous system - The aim is to prevent dehydration and reduce mortality
- It is well established that combination of single dose of rabies immunoglobulin - ORT is based on observation that glucose given orally enhances the intestinal
with local treatment of the wound absorption of salt and water, and is capable of correcting the electrolyte and
Local Treatment of Wound water deficit
- Composition of Reduced Osmolarity ORS
- Prompt and adequate local treatment is the first requisite and is of utmost o Sodium Chloride – 2.6 grams/litre
importance o Glucose, anhydrous – 13.5 grams/litre
- Purpose is to remove as much virus as possible from the site of inoculation o Potassium Chloride – 1.5 grams/litre
before it can be absorbed on nerve endings. o Trisodium Citrate, Dihydrate – 2.9 grams/litre
- Is of maximal value when applied immediately after exposure but it should not be
neglected if time has elapsed
- Measures include