VACCINES

• Over the last century, vaccination has been the most effective medical strategy to control
infectious diseases. Vaccination is estimated to save at least 2-3 million lives every year.

• Vaccine is an immuno-biological substance designed to produce specific protection against a

given disease.

• Vaccines may be prepared from live modified organisms, inactivated or killed organisms,
extracted cellular fractions, toxoids or combination of these.

A. Live vaccines : Live vaccines (e.g., BCG, measles, oral polio) are prepared from live or wild
(generally attenuated) organisms. Live vaccines are more potent immunizing agents than killed
vaccines, the reasons being :

• live organisms multiply in the host.

• live vaccines have antigenic components

• live vaccines engage certain tissues of the body.

B. Inactivated or killed vaccines : Inactivated vaccines are produced by growing virus or

bacteria in culture media and then inactivating them with heat or chemicals (usually formalin),
when injected into the body they stimulate active immunity. They are usually safe, less
efficacious than live vaccines.

• Killed vaccines usually require a primary series of 2 or 3 doses of vaccine to produce an adequate
antibody response, and in most cases "booster" injections are required.

C. Subunit vaccines : A vaccine can be made of single or multiple antigenic components of a

microorganism that are capable of stimulating a specific immune response sufficient to protect
from the relevant pathogen infection or from the clinical manifestation of the disease. Different
types of subunit vaccines:

• Toxoids : Certain organisms produce exotoxins, e.g., diphtheria and tetanus bacilli. The toxins
produced by these organisms are detoxicated and used in the preparation of vaccines.
Protein vaccines : In case, immunization with a single protein or a combination of proteins from a
 pathogen is sufficient to stimulate a protective immune response against that particular
microorganism, the approach of a protein-based vaccine is appropriate.

• Recombinant protein vaccines : Development of the recombinant deoxyribonucleic acid (DNA)

technology has made possible the expression of protective protein antigens in heterologous
expression systems such as E. coli, yeast, mammalian cells or baculovirus.

• Polysaccharide-based vaccines : The surface of many pathogenic bacteria is covered by a capsular

shell that is mainly assembled from polymeric glycans.

• Conjugated vaccines : Children under two years of age do not respond well to antigens, such as
polysaccharides, which produce antibodies via a T-cell independent mechanism.

D. Combinations : If more than one kind of immunizing agent is included in the vaccine it is
called a mixed or combined vaccine.

• The aim is to simplify administration, reduce costs minimize the number of contacts of the
patient with the health system, reducing the storage cost, improving timelines of vaccination, and
facilitating the addition of new vaccine into immunization programme. The following are some of
the well-known combinations :

• DPT (Diphtheria-pertussis-tetanus)

• OT (Diphtheria-tetanus)

• DP (Diphtheria-pertussis)

• DPT and typhoid vaccine

• MMR (Measles, mumps and rubella)

• DPTP (DPT plus inactivated polio)

BCG VACCINATION
• Ever since Koch discovered M. tuberculosis, attempts have been made to prepare a prophylactic
vaccine against tuberculosis using either attenuated or killed tubercle bacilli.
AIM :

• The aim of BCG vaccination is to induce a benign, artificial primary infection which will stimulate
an acquired resistance to possible subsequent infection with virulent tubercle bacilli.

VACCINE:

• BCG is the only widely used live bacterial vaccine. It consists of living bacteria derived from an
attenuated bovine strain of tubercle bacilli. The bacilli used for vaccine production are
descendants of the original Calmette strain of BCG.

TYPES OF VACCINE : There are two types of BCG vaccine : The Liquid (fresh) vaccine and
Freeze–Dried vaccine.

Freeze-dried vaccine : is a more stable preparation than liquid vaccine with vastly superior
keeping qualities. The vaccine must be protected from exposure to light during storage (wrapped
up in a double layer of red or black cloth) and in the field. The reconstituted vaccine may be used
up within 3 hours, and the left-over vaccine should be discarded.

• DOSAGE : For vaccination, the usual strength is 0.1 mg in 0.1 ml volume . The dose to newborn
aged below 4 weeks is 0.05 ml.

• ADMINISTRATION The standard procedure recommended by WHO is to inject the vaccine

intradermally using a "Tuberculin" syringe . The site of injection should be just above the
insertion of the left deltoid muscle.

• AGE : the national policy is to administer BCG very early in infancy either at birth or at 6 weeks of
age simultaneously with other immunizing agents such as DPT and polio

• PHENOMENA AFTER VACCINATION : Two to three weeks after a correct intradermal injection of a
potent vaccine, a papule develops at the site of vaccination

• COMPLICATIONS : Prolonged severe ulceration at the site of vaccination, Suppurative

lymphadenitis, Osteomyelitis, Disseminated BCG infection and Death

• PROTECTIVE VALUE : The duration of protection is from 15 to 20 years.

COLD CHAIN
• The "cold chain" is a system of storage and transport of vaccines at low temperature from
the manufacturer to the actual vaccination site.
• The cold chain system is necessary because vaccine failure may occur due to failure to store
and transport under strict temperature controls.

• This is of concern in view of the fairly frequent reports of vaccine- preventable disease
occurrence in populations thought to have been well immunized.
• In other words - the success of national immunization programme is highly dependant on
supply chain system for delivery of vaccines and equipment, with a functional system that
meets 6 rights of supply chain
• The right vaccine in the right quantity at the right place at the right time in the right
condition (no temperature breaks in cold chain) and at the right cost.
• Among the vaccines, polio is the most sensitive to heat, requiring storage at minus 20
degree C. Vaccines which must be stored in the freezer compartment are : polio and
measles.

• Vaccines which must be stored in the COLD PART but never allowed to freeze are : "T series"
vaccines (DPT, tetanus toxoid, DT) hepatitis B, BCG, and diluents.
• If the vials are frozen or contain floccules, discard them. Vaccines must be protected from
sunlight and prevented from contact with antiseptics. At the health centre, most vaccines
(except polio) can be stored up to 5 weeks if the refrigerator temperature is strictly kept
between 2 and S degrees C.

Cold chain equipment

(a) Walk-in cold rooms (WIC) : They are located at regional level, meant to store vaccines upto 3
months and serve 4-5 districts.

(b) Deep freezers : Supplied to all districts (large) and PHCs (small) to store vaccines. The cabinet
temperature is maintained between -15°C to -25°C.

(c) lee-lined refrigerators (ILR) : ILR are kept at the PHC (small) and district level (large). The cabinet
temperature is maintained at +2°C to +S0 C. At the PHC level, ILR are used for storing all UIP
vaccines. A dial thermometer should be kept in the ILR and temperature recorded twice a day.
ISOLATION
• Isolation is the oldest communicable disease control measure. It is defined as "separation,
for the period of communicability of infected persons or animals from others in such places
as to prevent or limit the direct or indirect transmission of the infectious agent from those
infected to those who are susceptible, or who may spread the agent to others".
• In general, infections from human/animal sources can be controlled by physical isolation of
the case or carrier, and if necessary, treatment until free from infection, provided cases and
carriers can be easily identified and carrier rates are low.
• The purpose of isolation is to protect the community by preventing transfer of infection
from the reservoir to the possible susceptible hosts.
• The type of isolation varies with the mode of spread and severity of the disease. There are
several types of isolation - standard isolation, strict isolation, protective isolation, high
security isolation.
• For each patient, the relative risks to the patient and to others should be assessed and the
appropriate type of isolation determined. Hospital isolation, wherever possible, is better
than home isolation.

• Isolation may also be achieved in some diseases by "ring immunization" that is encircling the
infected persons with a barrier of immune persons through whom the infection is unable to
spread. This method when applied worldwide in the 1960s and 1970s eradicated smallpox.
• In North America, ring immunization is being applied in measles control and eradication. The
duration of isolation is determined by the duration of communicability of the disease and
the effect of chemotherapy on infectivity. Isolation has a distinctive value in the control of
some infectious diseases, e.g., diphtheria, cholera, streptococcal respiratory disease,
pneumonic plague, etc.

• In some diseases where there is a large component of subclinical infection and carrier state
(polio, hepatitis A, and typhoid fever), even the most rigid isolation will not prevent the
spread of the disease.

• Isolation has failed in the control of diseases such as leprosy, tuberculosis and STD. In the
control of these diseases, the concept of physical isolation has been replaced by chemical
isolation, i.e. rapid treatment of cases in their own homes and rendering them non -
infectious as quickly as possible. Lastly, cases are usually reported after the disease has
spread widely.
 • Taking all these limitations into consideration, it may be stated that isolation which is a
"barrier approach" to the prevention and control of infectious disease is not as successful as
one would imagine and may well give rise to a false sense of security.
• In modern-day disease control, isolation is more judiciously applied and in most cases
replaced by surveillance because of improvements in epidemiological and disease control
technologies. Today, isolation is recommended only when the risk of transmission of the
infection is exceptionally serious.

QUARANTINE
• Quarantine has been defined as "the limitation of freedom of movement of such well persons or
domestic animals exposed to communicable disease for a period of time not longer than the
longest usual incubation period of the disease, in such manner as to prevent effective contact
with those not so exposed".
• Quarantine measures are also "applied by a health authority to a ship, an aircraft, a train, road
vehicle, other means of transport or container, to prevent the spread of disease, reservoirs of
disease or vectors of disease".
• Quarantine may comprise :

(a) absolute quarantine

(b) modified quarantine (e.g. a selective partial limitation of freedom of movement, such as
exclusion of children from school)

(c) segregation which has been defined as the separation for special consideration, control of
observation of some part of a group of persons (or domestic animals) from the others to facilitate
control of a communicable disease (e.g. removal of susceptible children to homes of immune
persons).

• In contrast to isolation, quarantine applies to restrictions on the healthy contacts of an infectious

disease.
• Quarantine which was once a popular method of disease control has now declined in popularity.
With better techniques of early diagnosis and treatment, quarantine, as a method of disease
control, has become outdated. It has been replaced by active surveillance.
ICEBERG OF DISEASE
• A concept closely related to the spectrum of disease is the concept of the iceberg phenomenon
of disease. According to this concept, disease in a community may be compared with an iceberg.

• The floating tip of the iceberg represents what the physician sees in the community i.e. clinical
cases. The vast submerged portion of the iceberg represents the hidden mass of disease i.e.
latent, inapparent, presymptomatic and undiagnosed cases and carriers in the community.

• The "waterline" represents the demarcation between apparent and inapparent disease. In some
diseases (e.g., hypertension, diabetes, anaemia, malnutrition, mental illness) the unknown
morbidity (i.e. the submerged portion of the iceberg) far exceeds the known morbidity.

• Disease control :The term "disease control" describes (ongoing)

operations aimed at reducing:

• the incidence of disease

• the duration of disease, and consequently the risk of transmission

• the effects of infection, including both the physical and psychosocial complications; and

• the financial burden to the community.

COHORT STUDY
• Cohort study is another type of analytical (observational) study which is usually undertaken to
obtain additional evidence to refute or support the existence of an association between
suspected cause and disease. The distinguishing features of cohort studies are :

A. The cohorts are identified prior to the appearance of the disease under investigation.

B. The study groups, so defined, are observed over a

period of time to determine the frequency of disease among them.

C. The study proceeds forward from cause to effect.

• In epidemiology, the term "cohort" is defined as a group of people who share a common
characteristic or experience within a defined time period (e.g., age, occupation, exposure to a
 drug or vaccine, pregnancy, insured persons, etc). Like birth cohort, marriage cohort, exposure
cohort.
Cohort studies are indicated :

(a) when there is good evidence of an association between exposure and disease.

(b) when exposure is rare, but the incidence of disease high among exposed.

(c) when attrition of study population can be minimized.

• Three types of cohort studies have been distinguished:

1. Prospective cohort studies :

▪ A prospective cohort study (or "current" cohort study)is one in which the outcome (e.g., disease)
has not yet occurred at the time the investigation begins.For example, the long-term effects of
exposure to Uranium was assessing subsequent development of lung cancer.

2. Retrospective cohort studies :

▪ A retrospective cohort study (or "historical" cohortstudy) is one in which the outcomes have all
occurred before the start of the investigation.
▪ The investigator goes back in time, sometimes 10 to30 years, to select his study groups from
existing records of past employment, medical or other records and traces them forward through
time, from a past date fixed on the records, usually up to the present. Eg. study of the role of
arsenic in human carcinogenesis, study of lung cancer in uranium miners.

3. Combination of retrospective and prospective cohort studies :

In this type of study, both the retrospective and prospective elements are combined. The cohort
is identified from past records, and is assessed of date for the outcome.

ELEMENTS OF A COHORT STUDY

• Selection of study subjects

• Obtaining data on exposure

• Selection of comparison groups

• Follow-up
• Analysis

• Selection of study subjects : The subjects of a cohort study are usually assembled in one of two
ways - either from general population or select groups of the population that can be readily
studied (e.g. persons with different degrees of exposure to the suspected causal factor).

• Obtaining data on exposure: Information about exposure may be obtained directly from the

(a) Cohort members

(b) Review of records

(c) Medical examination or special tests

(d) Environmental surveys

Selection of comparison groups:

• Internal comparisons : In some cohort studies, no outside comparison group is required. The
comparison groups are in-built.

• External comparisons : When information on degree of exposure is not available, it is necessary

to put up an external control, to evaluate the experience of the exposed group.

• Comparison with general population rates : If none is available, the mortality experience of the
exposed group is compared with the mortality experience of the general population in the same
geographic area as the exposed people, e.g., comparison of frequency of lung cancer among
Uranium mine workers with lung cancer mortality in the general population.

• Follow-up : One of the problems in cohort studies is the regular follow up of all the participants.
Therefore, at the start of the study, methods should be devised depending upon the outcome to
be determined (morbidity or death), to obtain data for assessing the outcome. The procedures
required comprise :

• Periodic medical examination of each member of the cohort.

• Reviewing physician and hospital records

• Routine surveillance of death records.

• Mailed questionnaires, telephone calls, periodic home visits.

• Analysis : The data are analyzed in terms of :

• Incidence rates of outcome among exposed and non exposed.

• Estimation of risk.

HEALTH INDICATORS
• Health indicator as compared to health index. It has been suggested that in relation to health
trends, the term indicator is to be preferred to index, whereas health index is generally
considered to be an amalgamation of health indicators.

Characteristics of indicators:

• Should be valid i.e. they should actually measure what they are supposed to measure.

• Should be reliable and objective i.e. the answers should be the same if measured by different
people in similar circumstances.

• Should be sensitive i.e. they should be sensitive to changes in the situation concerned.

• Should be specific i.e. they should reflect changes only in the situation concerned.

• Should be feasible i.e. they should have the ability to obtain data needed.

• Should be relevant i.e. they should contribute to the understanding of the phenomenon of
interest.

• Health, like happiness, cannot be defined in exact measurable terms. Its presence or absence is
so largely a matter of subjective judgement.

• Further, health is multidimensional, and each dimension is influenced by numerous factors, some
known and many unknown. This means we must measure health multidimensionally.
RED CROSS
• Red Cross is a non-political non-official international humanitarian organization devoted to the
service of mankind in peace and war.

• It was founded by Henry Dunant, a young Swiss businessman, who when travelling through North
Italy in 1859 happened to be on the scene of one of the most savage battles of history, the battle
of Solferino.

• Dunant urged that voluntary national societies be founded "which in time of war would render
aid to the wounded without distinction of nationality".

• In the beginning, the role of the Red Cross, as conceived by Dunant, was largely confined to
humanitarian service on behalf of the victims of war. Soon thereafter, it was realised that natural
disasters too bring in their wake great human suffering and that on such occasions there is
equally great need for help among nations "as good neighbours".

• Later on the work of the Red Cross was extended to other programmes which would prevent
human suffering.

• The Red Cross Society of India was established by an Act of the Indian Legislature in 1920 with the
three objectives of promoting international friendliness, understanding and cooperation.

• There are numerous other non-governmental organizations (NGO's). Some ofthese are: Oxfam,
Save the Children Fund, International Planned Parenthood Federation, The Population Council,
Voluntary Health Association of India, All India Women's Conference, India Medical Association,
Trained Nurses Association of India, International Agency for the Prevention of Blindness, World
Federation of the Deaf, International Leprosy Association, World Federation of Medical
Education, International Union against Cancer, and so on.

INDIAN RED CROSS

• The Red Cross Society of India was established by an Act of the Indian Legislature in 1920
with the three objectives of the improvement of health, prevention of disease and
mitigation of suffering.

• In peacetime, the Society provides military hospitals with such amenities as newspapers,
periodicals, musical instruments and other comfort goods.
 • The Red Cross Home at Bangalore for disabled ex-servicemen is one of the pioneer
institutions of its kind in Asia.
• Disaster services comprise distribution of milk, medicines, Vitamin tablets, codliver oil and
hundred other items to the famine stricken people and to those who have been hit by the
floods.
• In the development of maternity and child welfare services, the Society has done pioneering
work and has functioned as an auxiliary of the country's health services.
• The JUNIOR RED CROSS is one of the most active sections of the Society. It gives an
opportunity to lakhs of boys and girls all over India to be associated with activities like the
village uplift, first aid, antiepidemic work and building up of an international fraternity of
youth, thus promoting international friendliness, understanding and cooperation.

• There are numerous other non-governmental organizations (NGO's). Some of these are:
Oxfam, Save the Children Fund, International Planned Parenthood Federation, The
Population Council, Voluntary Health Association of India, All India Women's Conference,
India Medical Association, Trained Nurses Association of India, International Agency for the
Prevention of Blindness, World Federation of the Deaf, International Leprosy Association,
World Federation of Medical Education, International Union against Cancer, and so on. Non-
governmental organizations constitute a valuable resource in promoting health care.

UNICEF
• (United Nations International Children's Emergency Fund) is one of the specialized agencies
of the United Nations. In 1953, when the emergency func tions were over, the General
Assembly gave it a new name "U.N. Children's Fund" but retained the initials, UNICEF.
• The headquarters of the UNICEF is at United Nations, New York. UNICEF works in close
collaboration with WHO, and the other specialized agencies of the United Nations like
UNDP, FAO and UNESCO.
• In the early years, UNICEF and WHO worked together on urgent problems such as malaria,
tuberculosis and venereal diseases.
• Greater attention is being given to the concept of the "whole child" meaning that assistance
should hence forward be geared not only to health and nutrition, as before, which are of
immediate benefit to children, but also to their long-term personnel development and to the
development of the countries in which they live. This approach is also known as 'country
 health programming' in which UNICEF is currently interested so as to meet the needs of
children as an integral part of the country's development effort.

Content of services

(a) Child health : UNICEF has provided substantial aid for the production of vaccines and sera in
many countries. UNICEF has supported India's BCG vaccination programme from its inception.
UNICEF is focusing attention on providing primary health care to mothers and children.

(b) Child nutrition : Its aid for child nutrition, which first took the form of supplementing child
feeding began to expand in mid-1950s with the development of low-cost protein-rich food mixtures.

(c) Family and child welfare : The purpose is to improve the ·care of children, both within and
outside their homes through such means as parent education, day-care centres, child welfare and
youth agencies and women's clubs.

(d) Education : Science laboratories' equipment, workshop tools, library books, audiovisual aids are
being made available to educational institutions.

Currently, UNICEF is promoting a campaign known as GOBI campaign to encourage 4 strategies for a
"child health revolution" –

G for growth charts to better monitor child development

O for oral rehydration to treat all mild and moderate dehydration

B for breast feeding

I for immunization against measles, diphtheria, polio, pertussis, tetanus and tuberculosis

CENSUS
• The census is an important source of health information. It is taken in most countries of the
world at regular intervals, usually of 10 years.
• A census is defined by the United Nations as the total process of collecting, compiling and
publishing demographic, economic and social data pertaining at a specified time or times, to
all persons in a country or delimited territory.

• Census is a massive undertaking to contact every member of the population in a given time
and collect a variety of information.
 • It needs considerable organization, a vast preparation and several years to analyse the
results. This is the main drawback of census as a data source i.e. the full results are usually
not available quickly.
• The census is usually conducted at the end of the first quarter of the first year in each
decade, the reason being, most people are usually resident in their own homes during that
period.
• The legal basis of the census is provided by the Census Act of 1948. The supreme officer who
directs, guides and operates the census is the Census Commissioner for India.
• Although the primary function of census is to provide demographic information such as total
count of population and its breakdown into groups and subgroups such as age and sex
distribution, it represents only a small part of the total information collected.
• The census contains a mine of information on subjects not only demographic, but also social
and economic characteristics of the people, the conditions under which they live, how they
work, their income and other basic information.
• These data provide a frame of reference and base line for planning, action and research not
only in the field of medicine, human ecology and social sciences but in the entire
governmental system.
• Population census provides basic data (such as population by age and sex) needed to
compute vital statistical rates, and other health, demographic and socio-economic
indicators.

WHO
• The World Health Organization is a specialized, non- political, health agency of the United
Nations, with headquarters at Geneva. In 1946, the Constitution was drafted by the
"Technical Preparatory Committee" under the chairmanship of Rene Sand, and was
approved in the same year by an International Health Conference of 51 nations in New York.
• The constitution came into force on 7th April, 1948 which is celebrated every year as "World
Health Day". A World Health day theme is chosen each year to focus attention on a specific
aspect of public health.

Objective

• The objective of the WHO is "the attainment by all people's of the highest level of health"
which is set out in the preamble of the Constitution.
 • The current objective of WHO is the attainment by all people of the world a level of health
that will permit them to lead a socially and economically productive life.
• Health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity. The enjoyment of the highest attainable standard of health
is one of the fundamental rights of every human being without distinction of race, religion,
political belief, economic and social condition.
• The achievement of any State in the promotion and protection of health is of value to all.
Healthy development of the child is of basic importance, the ability to live harmoniously in a
changing total environment is essential to such development.

Work of WHO

1. PREVENTION AND CONTROL OF SPECIFIC DISEASES

• Almost all communicable diseases are or have been at sometime the subject of WHO
activities. With the same energy and commitment with which WHO eradicated smallpox, it is
now directing the global battle against poliomyelitis.
• The WHO collects and disseminates epidemiological information on diseases subject to
International Health Regulations and occasionally other communicable diseases of
international importance through an Automatic Telex Reply Service (ATRS) and the "Weekly
Epidemiological Record" (WER).
• Member States can also make use of the "WHO Emergency Scheme for Epidemics"
whenever necessary.
• The aim of International Health Regulations is to ensure maximum security against
international spread of diseases with the minimum interference with world traffic.

2. DEVELOPMENT OF COMPREHENSIVE HEALTH SERVICES

• WHO's most important single function is to promote and support national health policy
development and the development of comprehensive national health programmes.
• Appropriate Technology for Health (ATH) is another new programme launched by the WHO
to encourage self- sufficiency in solving health problems.
• The new programme is part of WHO's efforts to build up primary health care.

3. FAMILY HEALTH
 • Family health is one of the major programme activities of WHO and is broadly subdivided
into maternal and child health care, human reproduction, nutrition and health education.
The chief concern is improvement of the quality of life of the family as a unit.

4. ENVIRONMENTAL HEALTH

• Promotion of environmental health has always been an important activity of WHO. WHO
advises governments on national programmes for the provision of basic sanitary services.
• The activities are directed to protection of the quality of air, water and food; health
conditions of work radiation protection and early identification of new hazard originating
from new technological developments.

5. HEALTH STATISTICS

(a) Weekly Epidemiological Record

(b) World Health Statistics Quarterly

(c) World Health Statistics Annual.

6. BIOMEDICAL RESEARCH

• The WHO does not itself do research, but stimulates and coordinates research work. It has
established a world-wide network of WHO collaborating centres, besides awarding grants to
research workers and research institutions for promoting research.

7. HEALTH LITERATURE AND INFORMATION

• WHO acts as a clearing house for information on health problems. Its publications comprise
hundreds of titles on a wide variety of health subjects.
• The WHO library is one of the satellite centres of the Medical Literature Analysis and
Retrieval System (MEDLARS) of the U.S. National Library of Medicine.

8. COOPERATION WITH OTHER ORGANIZATIONS

• WHO collaborates with the UN and with the other specialized agencies, and maintains
various degrees of working relationships.

Structure

(a) THE WORLD HEALTH ASSEMBLY : The main functions of the Health Assembly are :
(i) to determine international health policy and programmes

(ii) to review the work of the past year

(iii) to approve the budget needed for the following year

(iv) to elect Member States to designate a person to serve for three years on the Executive Board,
and to replace the retiring members

(b) THE EXECUTIVE BOARD : The Board had originally 18 members, each designated ·by a Member
State. Subsequently, the number was raised to 24 and 30. The Health Assembly (1976) increased the
membership from 30 to 31, providing that no fewer than three are to be elected from each of the
WHO regions. The board now has 34 members.

(c) THE SECRETARIAT: The primary function of the WHO secretariat is to provide Member States
with technical and managerial support for their national health development programmes. The WHO
Secretariat comprised of the following divisions:

1. Division of epidemiological surveillance and health situation and trend assessment

2. Division of communicable diseases

3. Division of vector biology and control

4. Division of environmental health

5. Division of public information and education for health

6. Division of mental health

7. Division of diagnostic, therapeutic and rehabilitative technology

8. Division of strengthening of health services

9. Division of family health

10. Division of non-communicable diseases

11. Division of health manpower development

12. Division of information systems support

13. Division of personnel and general services 14. Division of budget and finance
EPIDEMIOLOGY
• Epidemiology is the basic science of preventive and social medicine. The study of the
distribution and determinants of health-related states or events in specified
populations, and the application of this study to the control of health .

Concept Of Epidemiology

1. Disease frequency :

• Measurement of frequency of disease, disability or death, and summarizing this information

in the form of rates and ratios {e.g., prevalence rate, incidence rate, death rate, etc).

• These rates are essential for comparing disease frequency in different populations or
subgroups of the same population in relation to suspected causal factors. Such comparisons
may yield important clues to disease aetiology.

• Epidemiology is also concerned with the measurement of health-related events and states in
the community.

2. Distribution of disease :

• An important function of epidemiology is to study these distribution patterns in the various

subgroups of the population by time, place and person.

• That is, the epidemiologist examines whether there has been an increase or decrease of
disease over time span; whether there is a higher concentration of disease in one
geographic area than in others; whether the disease occurs more often in men o r in a
particular age-group, and whether most characteristics or behaviour of those affected are
different from those not affected.

3. Determinants of disease :

• A unique feature of epidemiology is to test aetiological hypotheses and identify the

underlying causes (or risk factors) of disease.
 Aims of epidemiology

• According to the International Epidemiological Association (IEA), epidemiology has three main
aims :

a. to describe the distribution and magnitude of health and disease problems

b. to identify aetiological factors (risk factors} in the pathogenesis of disease

c. to provide the data essential to the planning, implementation and evaluation of services for the
prevention, control and treatment of disease .

The ultimate aim of epidemiology is to lead to effective action:

a. to eliminate or reduce the health problem or its consequences

b. to promote the health and well-being of society as a whole.

USES OF EPIDEMIOLOGY

• Morris has identified seven distinct uses of epidemiology.

1. To study historically the rise and fall of disease in the population

• It is well known that the health and disease pattern in a community is never constant. There are
fluctuations both over short and long periods of time. Epidemiology provides a means to study
disease profiles and time trends in human population. By a study of these trends, we can make
useful projections into the future and identify emerging health problems and their correlates.

2. Community diagnosis

One of the uses of epidemiology is community diagnosis. Community diagnosis generally refers to the
identification and quantification of health problems in a community in terms of mortality and
morbidity rates and ratios. It helps to identify individuals or groups at risk or those in need of health
care.

3. Planning and evaluation

Planning is essential for a rational allocation of the limited resources. Epidemiologic information
about the distribution of health problems over time and place provides the fundamental basis for
planning and developing the needed health services and for assessing the impact of these services
on the people's problems.

Evaluation is an equally important concern of epidemiology. Any measures taken to control or

prevent a disease must be followed by an evaluation to find out whether the measures undertaken
are effective in reducing the frequency of the disease.

4. Evaluation of individual's risks and chances

One of the important tasks of epidemiologists is to make a statement about the degree of risk in a
population.

5. Syndrome identification

Medical syndromes are identified by observing frequently associated findings in individual patients.
Epidemiological investigations can be used to define and refine syndromes. By observation of
groups, such studies have been able to correct misconceptions concerning many disease syndromes.

6. Completing the natural history of disease

Epidemiology is concerned with the entire spectrum of disease in a population. The epidemiologist
by studying disease patterns in the community in relation to agent, host and environmental factors
is in a better position to fill up the gaps in the natural history of disease than the clinician.

7. Searching for causes and risk factors

• Epidemiology helps to identify the causes and risk factors of disease.

Epidemiology methods

Epidemiological studies can be classified as observational studies and experimental studies with
further subdivisions :

1. Observational studies

a. Descriptive studies

b. Analytical studies

(i) Ecological or Correlational --with populations as unit of study

(ii) Cross-sectional or Prevalence -- with individuals as unit of study

(iii) Case-control or Case-reference -- with individuals as unit of study

(iv) Cohort or Follow-up -- with individuals as unit of study

2. Experimental studies Intervention studies

a. Randomized controlled trials or Clinical trials -- with patients as unit of study

b. Field trials -- with healthy people as unit of study

c. Community trials or Community intervention studies -- communities as unit of study

a. Descriptive epidemiology

The best study of mankind is man. This statement emphasizes the importance of making the best
use of observations on individuals or populations exposed to suspected factors of disease.
Descriptive studies are usually the first phase of an epidemiological investigation. Such studies
basically ask the questions.

a. When is the disease occurring ? time distribution

b. Where is it occurring? - place distribution

c. Who is getting the disease? - person distribution

The various procedures involved in descriptive studies may be outlined as below (Table 8).

1. Defining the population :

Descriptive studies are investigations of populations, not individuals. The first step is, therefore, to
define the "population base" not only in terms of the total number, but also its composition in
terms of age, sex, occupation, cultural characters and similar information needed for the study.
The defined population needs to be large enough so that age, sex and other specific rates are
meaningful. The community chosen should be stable, without migration into or out of the area.

2. Defining the disease under study :

Once the population to be studied is defined or specified, one must then define the disease or
condition being investigated. The clinician may not need a precise definition of disease (e.g.,
migraine) for immediate patient care. If the diagnosis is wrong, he can revise it subsequently.
But the epidemiologist, whose main concern is to obtain an accurate estimate of disease in a
population, needs a definition that is both precise and valid to enable him (or observers working
in field conditions) to identify those who have the disease from those who do not.

The diagnostic methods for use in epidemiological studies must be acceptable to the population to
be studied, and applicable to their use in large populations.

3. Describing the disease :

The primary objective of descriptive epidemiology is to describe the occurrence and distribution of
disease (or health-related events or characteristics within populations) by time, place and person,
and identifying those characteristics associated with presence or absence of disease in
individuals.

Epidemiologists have identified three kinds of time trends or fluctuations in disease occurrence.

a. Short-term fluctuations

b. Periodic fluctuations

c. Long-term or secular trends

4. Measurement of disease :

It is mandatory to have a clear picture of the amount of disease ("disease load") in the population.
This information should be available in terms of mortality, morbidity, disability and so on, and
should preferably be available for different subgroups of the population.

5. Comparing with known indices : The essence of epidemiology is to make comparisons and ask
questions. By making comparisons between different populations, and subgroups of the same
population, it is possible to arrive at clues to disease aetiology. We can also identify or define
groups which are at increased risk for certain diseases.

6. Formulation of a hypothesis :

An epidemiological hypothesis should specify the following :

a. the population the characteristics of the persons to whom the hypothesis applies

b. the specific cause being considered

c. the expected outcome - the disease

d. the dose-response relationship - the amount of the cause needed to lead to a stated incidence of
the effect

e. the time-response relationship the time period that will elapse between exposure to the cause
and observation of the effect.

Uses of descriptive epidemiology:

(a) provide data regarding the magnitude of the disease load and types of disease problems in the
community in terms of morbidity and mortality rates and ratios

(b) provide clues to disease aetiology, and help in the formulation of an aetiological hypothesis.

b. Analytical epidemiology

Analytical studies are the second major type of epidemiological studies. In analytical studies, the
subject of interest is the individual within the population. Analytical studies comprise two distinct
types of observational studies :

A. case control study

The case control method has three distinct features :

a. both exposure and outcome (disease) have occurred before the start of the study

b. the study proceeds backwards from effect to cause

c. it uses a control or comparison group to support or refute an inference.

• By definition, a case control study involves two populations - cases and controls. In case
control studies, the unit is the individual rather than the group.
• Case control studies are basically comparison studies. Cases and controls must be
comparable with respect to known "confounding factors" such as age, sex, occupation, social
status, etc.

• Case control studies have been used effectively for studies of many cancers such as cirrhosis
of the liver, lupus erythematosis and congestive heart failure. There are four basic steps in
conducting a case control study :

1. Selection of cases and controls

2. Matching
3. Measurement of exposure

4. Analysis and interpretation

B. cohort study

The first is to identify a suitable group of cases and a group of controls. While identification of cases
is relatively easy, selection of suitable controls may present difficulties.

1) Selection of cases

(a) Defination of cases :

(i) Diagnostic criteria : The diagnostic criteria of the disease and the stage of disease, if any (e.g.,
breast cancer Stage I) to be included in the study must be specified before the study is
undertaken. Once the diagnostic criteria are established, they should not be altered or changed
till the study is over.

(ii) Eligibility criteria : Only newly diagnosed (incident) cases within a specified period of time are
eligible than old cases or cases in advanced stages of the disease (prevalent cases).

(b) Sources of cases :

The cases may be drawn from

(i) hospitals or (ii) general population

1) Selection of controls

• The controls must be free from the disease under study. Difficulties may arise in the
selection of controls if the disease under investigation occurs in subclinical forms whose
diagnosis is difficult.

Sources of controls :

(i) Hospital controls: The controls may be selected from the same hospital as the cases, but with
different illness other than the study disease.

(ii) Relatives

(iii) Neighbourhood controls

(iv) General population

2) Matching

• Matching is defined as the process by which we select controls in such a way that they are
similar to cases. A "confounding factor" is defined as one which is associated both with
exposure and disease, and is distributed unequally in study and control groups.
• Examples are cited to explain confounding. (a) In the study of the role of alcohol in the
aetiology of oesophageal cancer, smoking is a confounding factor because (i) it is associated
with the consumption of alcohol and (ii) it is an independent risk factor for oesophageal
cancer.

3) Measurement of exposure

Definitions and criteria about exposure (or variables which may be of aetiological importance) are
just as important as those used to define cases and controls. Information about exposure should be
obtained in precisely the same manner both for cases and controls. This may be obtained by
interviews, by questionnaires or by studying past records of cases such as hospital records,
employment records, etc.

4) Analysis

The final step is analysis to find out

(a) Exposure rates among cases and controls to suspected factor : A case control study provides a
direct estimation of the exposure rates (frequency of exposure) to a suspected factor in disease and
non-disease groups.

a. Cases= a/(a+c) = 33/35 = 94.2 per cent

b. Controls= b/(b+d) = 55/82 = 67.0 per cent p < 0.001

(b) Estimation of disease risk associated with exposure : The estimation of disease risk associated
with exposure is obtained by an index known as "Relative Risk" (RR) or "risk ratio", which is defined
as the ratio between the incidence of disease among exposed persons and incidence among non -
exposed.

Relative risk = Incidence among exposed

Incidence among non-exposed

Advantages

1. Easy to carry out

2. Rapid and inexpensive

3. Require few subjects

4. Suitable to investigate rare diseases

5. No risk to subjects

6. Allows the study of several different aetiological factors

7. No attrition problem because case control studies do not require follow-up

8. Ethical problems minimal.

Disadvantages

1. Problems of bias relies

2. Selection of an appropriate control group may be difficult

3. Cannot measure incidence, and can only estimate the relative risk

4. Do not distinguish between causes and associated factors

5. Not suited to the evaluation of therapy or prophylaxis of disease

6. Representativeness of cases and controls

Epidemiological triad
• The germ theory of disease has many limitations. For example, it is well-known, that not
everyone exposed to tuberculosis develops tuberculosis. The same exposure, however, in an
undernourished or otherwise susceptible person may result in clinical disease.
• Similarly, not everyone exposed to beta-haemolytic streptococci develops acute rheumatic
fever. There are other factors relating to the host and environment which are equally
important to determine whether or not disease will occur in the exposed host. This
 demanded a broader concept of disease causation that synthesized the basic factors of
agent, host and environment.
• The above model - agent, host and environment has been in use for many years. It helped
epidemiologists to focus on different classes of factors, especially with regard to infectious
diseases.
• The agent is the cause of disease; the host is an organism, usually a human or an animal,
that harbours the disease, the environment is those surroundings and conditions external to
the human or animal that cause or allow disease transmission; and time accounts for
incubation periods, life expectancy of the host or the pathogen, and duration of the course
of illness or condition.

• Agents of infectious diseases include bacteria, viruses, parasites, fungi, and molds. One or
several agents may contribute to an illness.
• A host offers subsistence and lodging for a pathogen and may or may not develop the
disease. The level of immunity, genetic makeup, level of exposure, state of health, and
overall fitness of the host can determine the effect a disease organism will have on it.

• The makeup of the host and the ability of the pathogen to accept the new environment can
also be a determining factor because some pathogens thrive only under limited ideal
conditions. For example, many infectious disease agents can exist only in a limited
temperature range.
• Environmental factors can include the biological aspects as well as social, cultural, and
physical aspects of the environment. The surroundings in which a pathogen lives and the
effect the surroundings have on it are a part of the environment.

• Environment can be within a host or external to it in the community. Finally, time includes
severity of illness in relation to how long a person is infected or until the condition causes
death or passes the threshold of danger towards recovery.
• Delays in time from infection to when symptoms develop, duration of illness, and threshold
of an epidemic in a population are time elements with which the epidemiologist is
concerned.

DYNAMICS OF DISEASE TRANSMISSION

• Communicable diseases are transmitted from the reservoir/source of infection to
susceptible host. Basically there are three links in the chain of transmission viz, the
reservoir, modes of transmission and the susceptible host.
Sources and reservoir
• The starting point for the occurrence of a communicable disease is the existence of a
reservoir or source of infection.
• The source of infection is defined as "the person, animal, object or substance from
which an infectious agent passes or is disseminated to the host".
• A reservoir is defined as "any person, animal, arthropod, plant, soil or substance {or
combination of these) in which an infectious agent lives and multiplies, on which it
depends primarily for survival, and where it reproduces itself in such manner that it can
be transmitted to a susceptible host". The reservoir may be of three types

1. Human reservoir : By far the most important source or reservoir of infection for humans is
man himself. He may be a case or carrier.

A. Cases : A case is defined as "a person in the population or study group identified as having the
particular disease, health disorder or condition under investigation". A variety of criteria (e.g.,
clinical, biochemical, laboratory) may be used to identify cases.

B. CARRIERS : A carrier is defined as "an infected person or animal that harbours a specific
infectious agent in the absence of discernible clinical disease and serves as a potential source of
infection for others". Carriers may be classified as below :

1. Type (a) lncubatory (b) Convalescent (c) Healthy

2. Duration (a) Temporary (b) Chronic

3. Portal of exit (a) Urinary (b) Intestinal (c) Respiratory (d) Others

2. Animal reservoir : The source of infection may sometimes be animals and birds. These, like
the human sources of infection, may be cases or carriers. The diseases and infections which are
transmissible to man from vertebrates are called zoonoses. The best known examples are rabies,
yellow fever and influenza.

3. Reservoir in non-living things : Soil and inanimate matter can also act as reservoirs of
infection. For example, soil may harbour agents that cause tetanus, anthrax, coccidioidomycosis
and mycetoma.

Modes of transmission
Communicable diseases may be transmitted from the reservoir or source of infection to a
susceptible individual in many different ways, depending upon the infectious agent, portal of
entry and the local ecological conditions.

A. Direct transmission
1) Direct contact :

• Infection may be transmitted by direct contact from skin to skin, mucosa to mucosa, or
mucosa to skin of the same or another person.
 • This implies direct and essentially immediate transfer of infectious agents from the
reservoir or source to a susceptible individual, without an intermediate agency, e.g.,
skin-to-skin contact as by touching, kissing or sexual intercourse or continued close
contact.

2) Droplet infection :

• This is direct projection of a spray of droplets of saliva and nasopharyngeal secretions

during coughing, sneezing, (Fig.17) or speaking and spitting, talking into the surrounding
atmosphere.
• The expelled droplets may impinge directly upon the conjunctiva, oro-respiratory
mucosa or skin of a close contact. Particles of 10mm or greater in diameter are filtered
off by nose. Those 5mm or less can penetrate deeply and reach the alveoli.
• The droplet spread is usually, limited to a distance of 30-60 cm between source and
host.

3) Contact with soil :

• The disease agent may be acquired by direct exposure of susceptible tissue to the
disease agent in soil, compost or decaying vegetable matter in which it normally leads a
saprophytic existence e.g., hookworm larvae, tetanus, mycosis etc.

4) Inoculation into skin or mucosa :

• The disease agent may be inoculated directly into the skin or mucosa e.g., rabies virus by
dog bite, hepatitis B virus through contaminated needles and syringes etc.

5) Transplacental (or vertical) transmission :

• Disease agents can be transmitted transplacentally. Examples include the so-called

TORCH agents (Toxoplasma gondii, rubella virus, cytomegalovirus and herpes virus),
varicella virus, syphilis, hepatitis B, Coxsackie B and AIDS.
• Some of the non-living agents (e.g., thalidomide, diethylstilbestrol) can also be
transmitted vertically.

B. Indirect transmission

• This embraces a variety of mechanisms including the traditional 5 F's - "flies, fingers,
fomites, food and fluid". An essential requirement for indirect transmission is that the
infectious agent must be capable of surviving outside the human host in the external
environment and retain its basic properties of pathogenesis and virulence till it finds a
new host.

1. Vehicle-borne :

• Vehicle-borne transmission implies transmission of the infectious agent through the

agency of water, food (including raw vegetables, fruits, milk and milk products), ice,
blood, serum, plasma or other biological products such as tissues and organs.
• Of these water and food are the most frequent vehicles of transmission, because they
are used by everyone.
 • The infectious agent may have multiplied or developed in the vehicle (e.g. S. aureus in
food) before being transmitted or only passively transmitted in the vehicle (e.g.,
hepatitis A virus in water).
• Diseases transmitted by water and food include chiefly infections of the alimentary tract,
e.g. acute diarrhoeas, typhoid fever, cholera, polio, hepatitis A, food poisoning and
intestinal parasites.
• Those transmitted by blood include hepatitis B, malaria, syphilis, brucellosis,
trypanasomes (Chaga's disease). Organ transplantation may result in the introduction of
the disease agent such as cytomegalovirus in association with kidney transplants.

2. Vector-borne :

• In infectious disease epidemiology, vector is defined as an arthropod or any living carrier

(e.g., snail) that transports an infectious agent to a susceptible individual.

Classification of vector-borne diseases

I. By vector

(a) Invertebrate type :

(1) Diptera - flies and mosquitoes

(2) Siphonaptera fleas

(3) Orthoptera cockroaches

(4) Anoplura - sucking lice

(5) Hemiptera - bugs, including kissing bugs

(6) Acarina - ticks and mites

(7) Copepoda - cyclops

(b) Vertebrate type : Mice, rodents, bats

II. By transmission chain

(a) Man and a non-vertebrate host

(1) Man-arthropod-man (malaria)

(2) Man-snail-man (schistosomiasis)

(b) Man, another vertebrate host and a non-vertebrate host

(1) Mammal-arthropod-man (plague)

(2) Bird-arthropod-man (encephalitis)

(c) Man and 2 intermediate hosts

(1) Man-cyclops-fish-man (fish tape worm)

(2) Man-snail-fish-man (Clonorchis sinensis)

(3) Man-snail-crab-man (Paragonimiasis).

III. By methods in which vectors transmit agent

(a) Biting (b) Regurgitation (c) Scratching-in of infective faeces (d) Contamination of host with
body fluids of vectors

IV. By methods in which vectors are involved in the transmission and propagation of parasites.

3. Airborne :

(1) Droplet nuclei :

• Droplet nuclei are a type of particles implicated in the spread of airborne infection. They
are tiny particles (1-10 microns range) that represent the dried residue of droplets.
• They may be formed by (a) evaporation of droplets coughed or sneezed into the air (b)
generated purposefully by a variety of atomizing devices (aerosols).
• Particles in the 1-5 micron range are liable to be easily drawn into the alveoli of the
lungs and may be retained there.

(2) Dust :

• Some of the larger droplets which are expelled during talking, coughing or sneezing,
settle down by their sheer weight on the floor, carpets, furniture, clothes, bedding, linen
and other objects in the immediate environment and become part of the dust.
• A variety of infectious agents (e.g., streptococci, other pathogenic bacteria, viruses and
fungal spores) and skin squamae have been found in the dust of hospital wards and
living rooms.

4. Fomite-borne :

• Fomites (singular; fomes) are inanimate articles or substances other than water or food
contaminated by the infectious discharges from a patient and capable of harbouring and
transferring the infectious agent to a healthy person.
• Fomites include soiled clothes, towels, linen, handkerchiefs, cups, spoons, pencils, books,
toys, drinking glasses, door handles, taps, lavatory chains, syringes, instruments and surgical
dressings.

5. Unclean hands and fingers :

• Hands are the most common medium by which pathogenic agents are transferred to
food from the skin, nose, bowel, etc as well as from other foods. The transmission takes
place both directly (hand-to-mouth) and indirectly.
 • Examples include staphylococcal and streptococcal infections, typhoid fever, dysentery,
hepatitis A and intestinal parasites. Unclean hands and fingers imply lack of personal
hygiene.
• Lack of personal hygiene coupled with poor sanitation favour person-to-person
transmission of infection, an example is the 1984 dysentery epidemic in India.

CONCEPTS OF PREVENTION
• The goals of medicine are to promote health, to preserve health, to restore
health when it is impaired, and to minimize suffering and distress. These
goals are embodied in the word "prevention".

Levels of prevention

1. Primordial prevention

• In this we prevent emergence of risk factors. Most useful in preventing

chronic diseases (e.g. obesity, hypertension).

• Risk factors like smoking, eating patterns, physical exercise. The main
intervention in primordial prevention is through individual and mass
education.

2. Primary prevention

• Primary prevention can be defined as "action taken prior to the onset of

disease, which removes the possibility that a disease will ever occur".

• It signifies intervention in the pre-pathogenesis phase of a disease or health

problem (e.g., low birth weight) or other departure from health.

• The WHO has recommended the following approaches for the primary
prevention of chronic diseases where the risk factors are established :

a. Population (mass) strategy : Do the intervention to the entire population. E.g. Rubella vaccination
to all children AND Hepatitis B vaccination to everybody.

b. High-risk strategy : The high-risk strategy aims to bring preventive care to individuals at special
risk. This requires detection of individuals at high risk by the optimum use of clinical methods.
3. Secondary prevention

• Secondary prevention can be defined as "action which halts the progress of

a disease at its incipient stage and prevents complications".

• The specific interventions are early diagnosis {e.g., screening tests, case
finding programmes) and adequate treatment.

• Reducing the prevalence of dz by shortening its duration. E.g. DM leading to

Renal failure.

4. Tertiary prevention

• When the disease process has advanced beyond its early stages, it is still
possible to accomplish prevention by what might be called tertiary
prevention.

• For example, treatment, even if undertaken late in the natural history of

disease may prevent sequelae and limit disability.

MODES OF INTERVENTION
• "Intervention" can be defined as any attempt to intervene or interrupt the
usual sequence in the development of disease in man. This may be by the
provision of treatment, education, help or social support.

1. Health promotion

• Health promotion is "the process of enabling people to increase control over

and to improve health".

(i) Health education : A large number of diseases could be prevented with little or no medical
intervention. E.g. Washing hands

(ii) Environmental modifications : A comprehensive approach to health promotion requires

environmental modifications, such as provision of safe water; installation of sanitary latrines;
control of insects and rodents; improvement of housing, etc.
(iii)Nutritional interventions : These comprise food distribution and nutrition improvement of
vulnerable groups; child feeding programmes; food fortification; nutrition education, etc.

(iv)Lifestyle and behavioural changes : The action of prevention in this case, is one of individual and
community responsibility for health , the physician and in fact each health worker acting as an
educator than a therapist.

2. Specific protection

To avoid disease altogether is the ideal but this is possible only in a limited number of cases.

(a) immunization

(b) use of specific nutrients

(c) chemoprophylaxis

(d) protection against occupational hazards

(e) protection against accidents

(f) protection from carcinogens

(g) avoidance of allergens

(h) the control of specific hazards in the general environment

3. Early diagnosis and treatment

• Early detection and treatment are the main interventions of disease

control. The earlier a disease is diagnosed and treated the better it is from
the point of view of prognosis and preventing the occurrence of further
cases (secondary cases) or any long-term disability. It is like stamping out
the "spark" rather than calling the fire brigade to put out the fire.

4. Disability limitation

• When a patient reports late in the pathogenesis phase, the mode of

intervention is disability limitation. The objective of this intervention is to
prevent or halt the transition of the disease process from impairment to
handicap.
 • The sequence of events leading to disability and handicap have been stated
as follows :

Disease ~ impairment ~ disability ~ handicap

5. Rehabilitation

• Rehabilitation has been defined as "the combined and coordinated use of

medical, social, educational and vocational measures for training and
retraining the individual to the highest possible level of functional ability"

• The following areas of concern in rehabilitation have been identified:

(a) Medical rehabilitation - restoration of function

(b) Vocational rehabilitation - restoration of the capacity to earn a livelihood

(c) Social rehabilitation - restoration of family and social relationships

(d) Psychological rehabilitation restoration of personal dignity and confidence

RABIES
• Rabies, also known as hydrophobia is an acute, highly fatal viral disease of
the central nervous system, caused by Lyssavirus type 1.

• It is primarily a zoonotic disease of warm- blooded animals, particularly

carnivorous such as dogs, cats, jackals and wolves.

• It is transmitted to man usually by bites or licks of rabid animals.

Problem statement

• Rabies is an enzootic and epizootic disease of worldwide importance. A

"Rabies-free" area has been defined as one in which no case of indigenously
acquired rabies has occurred in man or any animal species for 2 years.
According to WHO reports, in many countries rabies is spreading inspite of
great advances in research and field control methods.
 • Although all age groups are susceptible, rabies is most common in children
aged less than 15 years; on an average, 40 per cent of post-exposure
immunization are given to children aged 5-14 years, and the majority of
those immunized are male.

Epidemiological determinants

Agent factors

AGENT : The causative agent (Lyssavirus type 1) is a bullet shaped neurotropic RNA containing virus.
nucleoprotein antigen. The presence of neutralizing antibodies in the blood of man and animals is
considered an index of protection against infection with rabies virus.

SOURCE OF INFECTION : The source of infection to man is the saliva of rabid animals. In dogs and
cats, the virus may be present in the saliva for 3-4 days (occasionally 5-6 days) before the onset of
clinical symptoms and during the course of illness till death.

Host factors

• All warm blooded animals including man are susceptible to rabies. Rabies in
man is a dead-end infection, and has no survival value for the virus. The
overwhelming number of victims in India belong to the age group 1 -24
years.

Mode of transmission

People are infected following a deep bite or scratch by an infected animal. Dogs are the main host
and transmitter of rabies. Transmission can also occur when infectious material - usually saliva -
comes into direct contact with human mucosa or fresh skin wounds. Human-to-human
transmission by bite is theoretically possible but has never been confirmed.

Incubation period

• The incubation period in man is highly variable, commonly 1-3 months

following exposure but may vary from 7 days to many years. The incubation
period depends on the site of the bite, severity of the bite, number of
wounds, amount of virus injected.
Pathogenesis

• Rabies virus replicates in muscle or connective tissue cells at or near the site
of introduction before it attaches to nerve endings and enters peripheral
nerves.

RABIES IN MAN

Clinical picture

• Rabies in man is called hydrophobia.

• The disease begins with prodromal symptoms such as headache, malaise,

sore throat and slight fever lasting for 3-4 days.

• About 80% of patients complain of pain or tingling at the site of the bite. The
patient is intolerant to noise, bright light or a cold draught of air (sensory).
Aerophobia (fear of air) may be present.

• Examination : may show increased reflexes and muscle spasms (motor)

along with dilatation of the pupils and increased perspiration, salivation and
lachrimation (sympathetic). Mental changes include fear of death, anger,
irritability and depression. The duration of illness is 2 to 3 days, but may be
prolonged to 5-6 days. The patient may die abruptly during one of the
convulsions or may pass on to the stage of paralysis and coma.

• Diagnosis : A clinical diagnosis of hydrophobia can be made on the basis of

history of bite by a rabid animal and characteristic signs and symptoms.

• Treatment : There is no specific treatment for rabies. Case management

includes the following procedure :

(a) The patient should be isolated in a quiet room protected as far as possible from external stimuli
such as bright light, noise or cold draughts which may precipitate spasms or convulsions.

(b) Relieve anxiety and pain by liberal use of sedatives. Morphia in doses of 30-45 mg may be given
repeatedly.

(c) Ensure hydration and diuresis.

(e) Intensive therapy in the form of respiratory and cardiac support may be given.

PREVENTION OF HUMAN RABIES

POST-EXPOSURE PROPHYLAXIS

1. General consideration : The vast majority of persons requ1rmg anti-rabies treatment are those
who were bitten by a suspected rabid animal. The aim of post-exposure prophylaxis is to
neutralize the inoculated virus before it can enter the nervous system.

2. Local treatment of wound :

(a) Cleansing : Immediate flushing and washing the wound, scratches and the adjoining areas with
plenty of soap and water for at least 15 minutes

(b) Chemical treatment : After cleansing, should be inactivated by irrigation with virucidal agents
either alcohol (400-700 ml/litre), tincture or 0.01 % aqueous solution of iodine or povidone
iodine.

(c) Suturing : Bite wounds should not be immediately sutured to prevent additional trauma which
may help spread the virus into deeper tissues. If suturing is necessary, it should be done 24-48
hours later.

(d) Antibiotics and anti-tetanus measure: The application of antibiotics and antitetanus procedures
when indicated should follow the local treatment recommended above.

3. Immunization :

Since their development more than four decades ago, concentrated and purified· cell-culture vaccine
(CCV) and embryonated egg-based vaccine (EEV) have proved to be safe and effective in
preventing rabies.

MALARIA
• Malaria is a protozoa disease caused by infection with parasites of the genus
Plasmodium and transmitted to man by certain species of infected female
Anopheline mosquito.
Problem statement

The specific risk groups for malaria includes the following population:

1. Young children who have not yet developed protective immunity

2. Non-immune pregnant women

3. Semi-immune pregnant women in areas of high transmission

4. People with HIV/AIDS

5. International travellers from non-endemic areas because they lack immunity

India : Malaria continues to pose a major public health threat in India, particularly due to
Plasmodium falciparum which is prone to complications. In India about 21.98 per cent population
lives in malaria high transmission.

Epidemiological determinants

Agent factors

AGENT : Malaria in man is caused· by four distinct species of the malaria parasite - P. vivax, P.
falciparum, P. malariae and P. ovale. The largest focus of P. malariae in India is reported to be in
Tumkur and Hassan districts in Karnataka.

Life history : The malaria parasite undergoes 2 cycles of development the human cycle (asexual
cycle) and the mosquito cycle (sexual cycle). Man is the intermediate host and mosquito the
definitive host.

Host factors

(a) AGE : Malaria affects all ages. Newborn infants have considerable resistance to infection with P.
falciparum.

(b) SEX: Males are more frequently exposed to the risk of acquiring malaria than females because of
the outdoor life they lead.

(c) RACE : Individuals with AS haemoglobin (sickle- cell trait) have a milder illness with falciparum
infection than do those with normal (AA) haemoglobin
(d) PREGNANCY: Pregnancy increases the risk of malaria in women. Malaria during pregnancy may
cause intrauterine death of the foetus; it may also cause premature labour or abortion.

(e) IMMUNITY: The epidemic of malaria is influenced by the immune status of the population.
Immunity to malaria in humans is acquired only after repeated exposure over several years.

Environmental factor

(a) SEASON : Malaria is a seasonal disease. In most parts of India, the maximum prevalence is from
July to November.

(b) TEMPERATURE: Temperature affects the life cycle of the malaria parasite. The optimum
temperature for the development of the malaria parasite in the insect vector is between 20 deg.
to 30 deg.C .

(c) HUMIDITY: A relative humidity of 60 per cent is considered necessary for mosquitoes to live their
normal span of life.

(d) RAINFALL : Rain increases the atmospheric humidity which is necessary for the survival of
mosquitoes.

Mode of transmission

(a) VECTOR TRANSMISSION: Malaria is transmitted by the bite of certain species of infected, female,
anopheline mosquitoes

(b) DIRECT TRANSMISSION: Malaria may be induced accidentally by hypodermic intramuscular and
intravenous injections of blood or plasma, e.g., blood transfusion, malaria in drug addicts.

(c) CONGENITAL MALARIA: Congenital infection of the newborn from an infected mother may also
occur, but it is comparatively rare.

Incubation period

• The duration is 12 (9-14) days for falciparum malaria , 14 (8-17) days for
vivax malaria , 28 (18-40) days for quartan malaria and 17 (16-18) days for
ovale malaria.
Clinical features

The typical attack comprises three distinct stages, i.e., the cold stage, the hot stage and the
sweating stage.

COLD STAGE : The onset is with lassitude, headache, nausea and chilly sensation followed in an hour
or so by rigors. The temperature rises rapidly to 39-41°C. Headache is often severe and
commonly there is vomiting. In early part of this stage, skin feels cold; later it becomes hot. This
stage lasts for 1/4-1 hour.

HOT STAGE : The patient feels burning hot and casts off his clothes. The skin is hot and dry to touch.
This stage lasts for 2 to 6 hours.

SWEATING STAGE : Fever comes down with profuse sweating. The temperature drops rapidly to
normal and skin is cool and moist. This stage lasts for 2-4 hours.

Chemoprophylaxis

Chemoprophylaxis against malaria has, with the development of drug resistance, become unreliable.

(1) Dosing schedules for the children should be based on body weight.

(2) Antimalarials that have to be taken daily (e.g. Doxycycline) should be started the day before
arrival in the risk area.

(3) Weekly chloroquine should be started 1 week before arrival.

(4) Weekly mefloquine should preferably be started 2-3 weeks before departure.

(5) All prophylactic drugs should be continued for 4 weeks after the last possible exposure to
infection.

ACTIVE INTERVENTION MEASURES

• Neither chemotherapy nor chemoprophylaxis will be able to reduce

significantly the malaria prevalence or transmission. It can be obtained only
when proper anti-mosquito measures.
1. STRATIFICATION OF THE PROBLEM : Stratification of the problem has become an essential
feature for the planning and development of a sound control strategy to maximize the utilization
of available resources.

2. VECTOR CONTROL STRATEGIES : Vector control is still one of the primary weapons to control
malaria in endemic areas.

(a) Anti-adult measures:

(i) Residual spraying

(ii) Space application : It involves the application of pesticides in the form of fog or mist using special
equipment.

(iii)Individual protection : Use of repellents, protective clothing, bed-nets·, mosquito coils, screening
of houses etc.

(b) Anti-larval measures:

(i) Larvicides

(ii) Source reduction

Malaria vaccines

• Vaccination against malaria is a burning issue today. Over the past decades,
there has been significant progress in malaria vaccine development, yet
many valid candidate vaccines have been slow to enter clinical trial and an
effective vaccine is thought to be still 10 years away.

DENGUE
• Dengue viruses are arboviruses capable of infecting humans and causing disease. These
infections may be asymptomatic or may lead to

(a) classical dengue fever

(b) dengue haemorrhagic fever without shock

(c) dengue haemorrhagic fever with shock

Problem Statement

• In India, the risk of dengue has shown an increase in recent years due to rapid urbanization,
lifestyle changes and deficient water management including improper water storage
practices in urban, peri-urban and rural areas, leading to proliferation of mosquito breeding
sites.

• Dengue is endemic in 31 states/UTs. During 2013, about 74,168 cases were reported with
168 deaths.

Epidemiological determinants

Agent factors

(a) AGENT : The dengue virus form a distinct complex within the genus flavivirus based on antigenic
and biological characteristics. There are four virus serotypes which are designated as DENV-1,
DENV-2, DENV-3 and DENV-4.

(b) VECTOR : Aedes aegypti and Aedes Albopictus are the two most important vectors of dengue.

Transmission of disease

• The Aedes mosquito becomes infective by feeding on a patient from the day before onset to
the 5th day (viraemia stage) of illness. After an extrinsic incubation period of 8 to 10 days,
the mosquito becomes infective, and is able to transmit the infection. Once the mosquito
becomes infective, it remains so for life. The genital tract of the mosquito gets infected and
transovarian transmission of dengue virus occurs whe·n virus enters fully developed eggs at
the time of oviposition.

Environmental factors

• The population of Aedes aegypti fluctuates with rainfall and water storage. Its life span is
influenced by temperature and humidity, survives best between 16°C-30°C and a relative
humidity of 60-80 per cent.
Clinical manifestations

1. Undifferentiated fever : Infants, children and adults who have been infected with denuge virus,
especially for the first time (Le. primary dengue infection), may develop a simple fever.
Maculopapular rashes may accompany the fever.

2. Classical dengue fever : The illness is characterized by an incubation period of 3 to 10 days

(commonly 5-6 days). The onset is sudden, with chills and high fever, intense headache, muscle
and joint pains, which prevent all movement. Within 24 hours retroorbital pain, particularly on
eye movements or eye pressure and photophobia develops. The skin eruptions appear in 80 per
cent of cases during the remission or during second febrile phase, which lasts for 1-2 days.

3. Dengue haemorrhagic fever : Dengue haemorrhagic fever (DHF) is a severe form of dengue fever.
The course of dengue illness can be divided into three phases-febrile phase, critical phase and
recovery phase.

a. Febrile phase : Incubation period of four to six days, the illness commonly begins abruptly with
high fever accompanied by facial flushing and headache. Anorexia, vomiting, epigastric
discomfort, tenderness are common. During the first few days maculopapular rash usually
rubelliform type.

b. Critical phase : When the temperature drops to 37.5-38°C or less, and remains below this level,
usually on days 3-7 of illness, an increase in capillary permeability in parallel with increasing
haematocrit levels may occur. This marks the beginning of the critical phase. The period of
clinically significant plasma leakage usually lasts 24-48 hours. Progressive leukopenia followed by
a rapid decrease in platelet count usually precedes plasma leakage.

c. Recovery phase : If the patient survives the 24-48 hour critical phase, a gradual reabsorption of
extravascular compartment fluid takes place in the following 48-72 hours.

4. Severe dengue : Severe dengue is defined by one or more of the following :

(i) plasma leakage that may lead to shock with or without respiratory distress

(ii) severe bleeding

(iii) severe organ impairment

Laboratory diagnosis

(1) clinical management (2) epidemiological surveillance (3) research (4) vaccine trials.

• The following laboratory tests are available to diagnose dengue fever and DHF :

1. Virus isolation

2. Viral nucleic acid detection : Dengue viral genome, which consists of RNA, can be detected by
reverse transcriptase polymerase chain reaction (RT -PCR) assay and real time RT-PCR.

3. Immunological response and serological tests : a. Haemagglutination inhibition assay (HIA); b.

Complement Fixation (CF) c. Neutralization test (NT) d. Indirect lgG- ELISA

5. Rapid diagnostic test (RDT)

MANAGEMENT

1. Management of dengue fever :

(a) Encourage intake of oral rehydration solution (ORS), fruit juice and other fluids to replace losses
from fever and vomiting.

(b) Give paracetamol for high fever

(c) Instruct the care-givers that the patient should be brought to hospital immediately if any of the
following occur; no clinical improvement, persistent vomiting, cold and clammy extremities,
lethargy or irritability/ restlessness, bleeding (e.g. black stools or coffee-ground vomiting), not
passing urine for more than 4-6 hours.

2. Management of DHF (Febrile Phase) :

• The management of febrile phase is similar to that of DF. Paracetamol is recommended to

keep the temperature below 39°C.

3. Management of DHF Grade I and II :

• Any person who has dengue fever with thrombocytopenia and haemoconcentration and
presents with abdominal pain, black tarry stools, epistaxis, bleeding from the gums and
infection etc needs to be hospitalized.

4. Management of DHF Grade III and IV :

• The patient requires regular and sustained monitoring. If the patient has already received about
1000 ml of intravenous fluid, it should he changed to colloidal solution preferably Dextran
40/haemaccele or if haematocrit is decreasing, fresh whole blood transfusion 10 ml/kg/hour
should be given.

CONTROL MEASURES

1. Mosquito control : The vectors of DF and DHF (e.g., A. aegypti) breed in and around houses and, in
principle can be controlled by individual and community action, using antiadult and antilarval
measures.

2. Vaccines : There is no satisfactory vaccine and no immediate prospect of preventing the disease
by immunization.

3. Other measures : Isolation of the patient under bed-nets during the first few days; individual
protection against mosquitoes. The personal prophylactic measures are wearing of full sleeves
shirts and full pants; use of mosquito repellent creams, liquids, coils, mats etc.; use of bed-nets
for sleeping infants and young children during day time to prevent mosquito bite.

CHOLERA
➢ Cholera is an acute diarrhoeal disease caused by V. Cholerae 01 (classical or El Tor). It is
characterized by the sudden onset of profuse, effortless, watery diarrhoea followed by vomiting,
rapid dehydration, muscular cramps and suppression of urine.

Problem Statement

• Since the introduction of Cholera El Tor biotype in 1964, the geographic distribution of cholera in
India has considerably changed. West Bengal has lost its reputation as the "home" of cholera.
Many of the States which never had cholera or were free from it for a long time, got infected and
became endemic foci of El Tor infection.

Epidemiological determinants

Agent factors
(a) AGENT : The organism that causes cholera is labelled as V. cholerae 0 Group 1 or Vibrio cholerae
01 and 0139. The term "epidemic strain" has also been used for these vibrios.

(b) RESISTANCE : V. cholerae are killed within 30 minutes by heating at 56 deg.C or within a few
seconds by boiling. They remain in ice for 4-6 weeks or longer. Drying and sunshine will kill them
in a few hours. They are easily destroyed by coal tar disinfectants such as cresol.

(c) TOXIN PRODUCTION : The vibrios multiply in the lumen of the small intestine and produce an
exotoxin (enterotoxin). This toxin produces diarrhoea through its effect on the adenylate cyclase-
cyclic AMP system of mucosa! cells of the small intestine.

(d) RESERVOIR OF INFECTION : The human being is the only known reservoir of cholera infection. He
may be a case or carrier.

(e) INFECTIVE MATERIAL : The immediate sources of infection are the stools and vomit of cases and
carriers. Large numbers of vibrios (about 107-109 vibrios per ml of fluid) are present in the
watery stools of cholera patients; and an average patient excretes 10-20 litres of fluid.

(f) PERIOD OF COMMUNICABILITY : A case of cholera is infectious for a period of 7-10 days.

Host factors

(a) AGE AND SEX : Cholera affects all ages and both sexes. In endemic areas, attack rate is highest in
children.

(b) GASTRIC ACIDITY : An effective barrier. The vibrio is destroyed in an acidity of pH 5 or lower.

(c) IMMUNITY: An attack of cholera is followed by immunity to re-infection, but the duration and
degree of immunity are not known. In experimental animals specific lgA antibodies occur in the
lumen of the intestine. Vaccination gives only temporary, partial immunity for 3-6 months.

Environmental factors :

• Vibrio transmission is readily possible in a community with poor environmental sanitation. The
environmental factors of importance include contaminated water and food.

Mode of transmission

• Transmission occurs from man to man via (a) FAECALLY CONTAMINATED WATER (b)
CONTAMINATED FOOD AND DRINKS (c) DIRECT CONTACT
Incubation period : From a few hours up to 5 days, but commonly 1-2 days.

Clinical features

(a) STAGE OF EVACUATION : The onset is abrupt with profuse, painless, watery diarrhoea followed
by vomiting. The patient may pass as many as 40 stools in a day. The stools may have a "rice
water" appearance.

(b) STAGE OF COLLAPSE : The patient soon passes into a stage of collapse because of dehydration.
The classical signs are : sunken eyes, hollow cheeks, scaphoid abdomen, sub-normal
temperature, washerman's hands and feet, absent pulse, unrecordable blood pressure, loss of
skin elasticity, shallow and quick respirations.

(c) STAGE OF RECOVERY : If death does not occur, the patient begins to show signs of clinical
improvement. The blood pressure begins to rise, the temperature returns to normal, and urine
secretion is re-established. If anuria persists, the patient may die of renal failure.

CONTROL OF CHOLERA

1. Verification of the diagnosis : For the specific diagnosis of cholera, it is important to identify V.
cholerae 01 in the stools of the patient. Once the presence of cholera has been proved, it is not
necessary to culture stools of all cases or contacts.

2. Early case-finding : Early detection of cases also permits the detection of infected household
contacts and helps the epidemiologist in investigating the means of spread for deciding on
specific intervention.

3. Establishment of treatment centres : The mildly dehydrated patients should be treated at home
with oral rehydration fluid. Severely dehydrated patients, requiring intravenous fluids, should be
transferred to the nearest treatment centre or hospital

4. Rehydration therapy : The rehydration may be oral or intravenous.

5. Adjuncts to therapy Antibiotics should be given as soon as vomiting has stopped, which is usually
after 3 to 4 hours of oral rehydration.

6. Sanitation measures : (a) WATER CONTROL : The ultimate aim should be provision of piped water
supply on a permanent basis and elimination of alternative unsafe water sources.
(b) EXCRETA DISPOSAL : Provision of simple, cheap and effective excreta disposal system (sanitary
latrines} is a basic need of all human settlements.

(c) FOOD SANITATION : Health education must stress the importance of eating cooked hot food and
of proper individual food handling techniques. Cooking utensils should be cleaned and dried after
use.

(d) DISINFECTION : The most effective disinfectant for general use is a coal tar disinfectant with a
Rideal-Walker (RW) coefficient of 10 or more such as cresol.

7. Vaccination : ORAL VACCINE : Two types of oral cholera vaccines are available

(a) Dukoral (WC-rBS) : For children aged 2-5 years 1 booster dose is recommended every 6 months,
and if the interval between primary immunization and the booster is > 6 months, primary
immunization must be repeated. Dukoral is not licensed for children aged <2 years.

(b) Sancho! and mORCVAX : According to the manufacturer, vaccine should be administered orally in
2 liquid doses 14 days apart for individuals aged 1 year. A booster dose is recommended after 2
years.

• The live attenuated single-dose vaccine {CVD103-HgR} is no longer produced.

TYPHOID
➢ Typhoid fever is the result of systemic infection mainly by S. typhi found only in man. The disease
is clinically characterized by a typical continuous fever for 3 to 4 weeks relative bradycardia with
involvement of lymphoid tissue. The term "enteric fever" includes both typhoid and paratyphoid
fevers.

Problem statement

• Typhoid fever is endemic in India. Reported data for the year 2013 shows 1.53 million cases and
361 deaths. Maximum cases were reported from Bihar (261,791 cases with 2 deaths) followed by
Andhra Pradesh (233,212 cases with 5 deaths).
Epidemiological determinants

Agent factors

(a) AGENT : S. typhi is the major cause of enteric fever. S. para A and S. para Bare relatively
infrequent.

(b) RESERVOIR OF INFECTION : Man is the only known reservoir of infection. Convalescent carriers
excrete the bacilli for 6 to 8 weeks, after which their numbers diminish rapidly. The famous case
of "Typhoid Mary" who gave rise to more than 1300 cases in her life time is a good example of a
chronic carrier.

(c) SOURCE OF INFECTION : The primary sources of infection are faeces and urine of cases or
carriers; the secondary sources contaminated water, food, fingers and flies.

Host factors

(a) Age : Typhoid fever may occur at any age. Highest incidence of this disease occurs in the 5-19
years of age group.

(b) Sex : More cases are reported among males than females, probably as a result of increased
exposure to infection.

(c) Immunity : All ages are susceptible to infection. Antibody may be stimulated by the infection or
by immunization. Natural typhoid fever does not always confer solid immunity; second attacks
may occur when challenged with a large oral dose.

Environmental and social factors

• Enteric fevers are observed all through the year. The peak incidence is reported during July -
September. This period coincides with the rainy season and an increase in fly population. Outside
the human body, the bacilli are found in water, ice, food, milk and soil for varying periods of time.

Incubation period : Usually 10-14 days. But it may be as short as 3 days or as long as three weeks.
Modes of transmission

• Typhoid fever is transmitted via the faecal-oral route or urine-oral routes. This may take place
directly through soiled hands contaminated with faeces or urine of cases or carriers, or indirectly
by the ingestion of contaminated water, milk and/or food, or through flies.

Clinical features

• The onset is usually insidious but in children may be abrupt, with chills and high fever. During the
prodromal stage, there is malaise, headache, cough and sore throat, often with abdominal pain
and constipation.
• The fever ascends in a step-ladder fashion. After about 7-10 days, the patient looks toxic,
appearing exhausted and often prostrated. There may be marked constipation, especially in early
stage or "pea soup" diarrhoea. If there are no complications the patient's condition improves
over 7-10 days. However, relapse may occur for up to 2 weeks after termination of therapy.

CONTROL OF TYPHOID FEVER

1. Control of reservoir : The usual methods of control of reservoir are their identification, isolation,
treatment and disinfection.

(i) Early diagnosis : This is of vital importance as the early symptoms are non-specific.

(ii) Notification: This should be done where such notification is mandatory.

(iii)Isolation . Since typhoid fever is infectious and has a prolonged course, the cases are better
transferred to a hospital for proper treatment, as well as to prevent the spread of infection.

(iv)Treatment : The fluoroquinolones are widely regarded as the drug of choice for the treatment of
typhoid fever.

(v) Disinfection: Stools and urine are the sole sources of infection. They should be received in closed
containers and disinfected with 5 per cent cresol for at least 2 hours. All soiled clothes and linen
should be soaked in a solution of 2 per cent chlorine and steam-sterilized.
2. Control of sanitation : Protection and purification of drinking water supplies, improvement of
basic sanitation, and promotion of food hygiene are essential measures to interrupt transmission
of typhoid fever

3. Immunization : It can be given at any age upwards of two years. It is recommended to : (i) those
living in endemic areas (ii) household contacts (iii) groups at risk of infection such as school
children and hospital staff (iv) travellers proceeding to endemic areas.

ANTI-TYPHOID VACCINES : It is composed of purified Vi capsular polysaccharide from the Ty2 S.

Typhi strain and elicits a T-cell independent IgG response that is not boosted by additional doses.
The vaccine is administered subcutaneously or intramuscularly.

FOOD POISONING
➢ Food poisoning is an acute gastroenteritis caused by ingestion of food or drink contaminated with
either living bacteria or their toxins or inorganic chemical substances and poisons derived from
plants and animals.

Types
(a) Non-bacterial : Caused by chemicals such as arsenic, certain plant and sea foods. In recent years,
there has been a growing concern about contamination of food by chemicals, e.g., fertilizers,
pesticides, cadmium, mercury etc.
(b) Bacterial : Caused by the ingestion of foods contaminated by living bacteria or their toxins.
Bacterial food poisoning may be of the following types :

1. Salmonella food poisoning

(a) AGENT : S. typhimurium, S. cholera-suis and S. enteritidis, besides many others.
(b) SOURCE : Salmonellosis is primarily a disease of animals. Man gets the infection from farm
animals and poultry - through contaminated meat, milk and milk products, sausages, custards,
egg and egg products
(c) INCUBATION PERIOD : 12 to 24 hours commonly
(d) MECHANISM OF FOOD POISONING : The causative organisms, on ingestion, multiply in the
intestine and give rise to acute enteritis and colitis. The onset is generally sudden with chills,
fever, nausea, vomiting, and a profuse watery diarrhoea which usually lasts 2-3 days.

2. Staphylococcal food poisoning

(a) AGENT : Enterotoxins of certain strains of coagulase- positive Staphylococcus aureus.
(b) SOURCE: Staphylococci are ubiquitous in nature, and are found on the skin and in the nose and
throat of men and animals. They are a common agent of boils and pyogenic infections of man and
animals.
(c) INCUBATION PERIOD : 1-8 hours
(d) MECHANISM OF FOOD POISONING : Food poisoning results from ingestion of toxins preformed
in the food in which bacteria have grown ("intradietetic" toxins).

3. Botulism
(a) AGENT : Exotoxin of Clostridium botulinum generally Type A, B or E.
(b) SOURCE : The organism is widely distributed in soil, dust and the intestinal tract of animals and
enters food as spores. Botulism derives its name from the Latin word for sausage (botulus).
(c) INCUBATION PERIOD : 18 to 36 hours
(d) MECHANISM OF FOOD POISONING : The toxin is preformed in food ("intradietetic") under
suitable anaerobic conditions. It acts on the parasympathetic nervous system. The prominent
symptoms are dysphagia, diplopia, ptosis, dysarthria, blurring of vision, muscle weakness and
even quadriplegia. Botulism occurring in infants is called "infant botulism".

4. Cl. perfringens food poisoning

(a) AGENT : Clostridium (Cl.) perfringens (welchii).
(b) SOURCE : The organism has been found in faeces of humans and animals, and in soil, water and
air.
(c) INCUBATION PERIOD : 6 to 24 hours, with a peak from 10 to 14 hours.
(d) MECHANISM OF FOOD POISONING : The spores are able to survive cooking, and if the cooked
meat and poultry are not cooled enough, they will germinate.
(e) CLINICAL SYMPTOMS : The most common symptoms are diarrhoea, abdominal cramps and little
or no fever, occurring 8 to 24 hours after consumption of the food. Nausea and vomiting are rare.

5. B. cereus food poisoning

• Bacillus cereus is an aerobic, spore-bearing, motile, gram positive rod. It is ubiquitous in soil, and
in raw, dried and processed foods. The spores can survive cooking and germinate and multiply
rapidly when the food is held at favourable temperatures. Recent work has shown that B. cereus
produces at least 2 distinct enterotoxins, causing 2 distinct forms of food poisoning. One, the
emetic form with a short incubation period (1-6 hours) characterized by predominantly upper
gastro-intestinal tract symptoms.
INVESTIGATION OF FOOD POISONING

(a) Secure complete list of people involved and their history

(b) Laboratory investigations : The object is not only to incriminate the causative agent from stool,
vomit or remnants of food by inoculating into appropriate media, but also to determine the total
number of bacteria and the relative numbers of each kind involved.
(c) Animal experiments : It may be necessary to feed rhesus monkeys with the remnants of food.
(d) Blood for antibodies.
(e) Data analysis : The data should be analyzed according to the descriptive methods of time, place
and person distribution.

PREVENTION AND CONTROL

(a) FOOD SANITATION :
• The food animals must be free from infection.
• Personal hygiene among individuals engaged in the handling, preparation and cooking of food is
needed.
• Those suffering from infected wounds, boils, diarrhoea, dysentery, throat infection, etc should be
excluded from food handling.
• The handling of ready-to-eat foods with bare hands should be reduced to a minimum. Time
between preparation and consumption of food should be kept short.
• Sanitization of all work surfaces, utensils and equipments must be ensured.Normal handlers
should be educated in matters of clean habits and personal hygiene, such as frequent and
thorough hand washing.
(b) REFRIGERATION :
• In the prevention of bacterial food poisoning, emphasis must be placed on proper temperature
control. Food should not be left in warm pantries; a few germs can multiply to millions by the
next morning. "Cook and eat the same day" is a golden rule.

Differences between smallpox and chickenpox

SMALL POX CHICKEN POX
1. Incubation :
About 12 days (range: 7-17 days) About 15 days (range 7-21 days)
2. Prodromal symptoms:
Severe Usually mild
3. Distribution of rash :
(a) centrifugal (a) centripetal

(b) palms and soles frequently (b) seldom affected involved

(c) axilla usually free (c) axilla affected

(d) rash predominant on extensor surfaces and (d) rash mostly on flexor extensor surfaces and

bony prominences surfaces. bony prominences.

4. Characteristics of the rash:
(a) deep-seated
(b) vesicles multilocular and umbilicated
(c) only one stage of rash may be seen at one
time
(d) No area of inflammation is seen around the
vesicles
5. Evolution of rash :
(a) evolution of rash is slow, deliberate and
majestic, passing through definite stages of
macule, papule, vesicle and pustule.
(b) scabs begin to form 10-14 days after the rash
(a) superficial
(b) unilocular; dew-drop like appearance
(c) rash pleomorphic, i.e., different stages of the
rash evident at one given time, because rash
appears in successive crops
(d) an area of inflammation is seen around the
vesicles
(a) evolution of rash very rapid
(b) scabs begin to form 4-7 days after the rash
appears

appears
Fever: Fever subsides with the appearance of
rash, but may iise again in the pustular stage Temperature rises with each fresh crop of rash.
(secondary rise of fever).

CHICKENPOX
➢ Chickenpox or varicella is an acute, highly infectious disease caused by varicella-zoster (V-Z) virus.
It is characterized by vesicular rash that may be accompanied by fever and malaise.
Problem Statement

• In India, during the year 2013, about 28,090 cases of Chickenpox were reported with 61 deaths.
The case fatality rate was about 0.21 per cent. Kerala reported the highest number of cases
(12,168) and West Bengal reported the maximum number of deaths (68) due to chickenpox.

Epidemiological determinants

Agent factors

(a) AGENT : The causative agent of chickenpox, V-Z Virus is also called “Human (alpha) herpes

virus3”. Primary

(b) SOURCE OF INFECTION : Usually a case of chickenpox. The virus occurs in the oropharypgeal
secretions and lesions of skin and mucosa.

(c) INFECTIVITY : The period of communicability of patients with varicella is estimated to range from

1 to 2 days before the appearance of rash, and 4 to 5 days thereafter.

(d) SECONDARY ATTACK RATE: The secondary attack rate in household contacts approaches 90%.

Host factors

(a) AGE : Chickenpox occurs primarily among children under 10 years of age.

(b) IMMUNITY : One attack gives durable immunity; second attacks are rare.

(c) PREGNANCY : Infection during pregnancy presents a risk for the foetus leading to congenital

Varicella Syndrome. It occurs in 0.4-2.0 per cent of children born to mothers who become
infected with VZV during the first 20 weeks of gestation.

Transmission

• Chickenpox is transmitted from person to person by Droplet infection and by droplet nuclei. Most
patients are infected by “face-to-face” (personal) contact. The portal of entry of the virus is the
upper respiratory tract or the Conjunctiva. The virus can cross the placental barrier and infect the
foetus, a condition known as congenital varicella.

Incubation period

• Usually 14 to 16 days, although extremes as wide as 10 to 21 days have been reported.

Clinical features

1. PRE-ERUPTIVE STAGE : Onset is sudden with mild or moderate fever, pain in the back, shivering

and malaise. This stage is very brief, lasting about 24 hours.

2. ERUPTIVE STAGE : In children the rash is often the first sign. It comes on the day the fever starts.

The distinctive features of the rash are :

a. Distribution : The rash is symmetrical. It first appears on the trunk where it is abundant, and then
comes on the Face, arms and legs where it is less abundant. Mucosal surfaces and Axilla may be
affected.

b. Rapid evolution : The rash advances quickly through the stages of macule, papule, vesicle and
scab.

c. Pleomorphism : All stages of the rash (papules, vesicles and crusts) may be seen simultaneously at
one time, in the same area. This is due to the rash appearing in successive crops for 4 to 5 days in
the same area.

d. Fever : The fever does not run high but shows exacerbations with each fresh crop of eruption.

Control

• The usual control measures are notifications, isolation of cases for about 6 days after onset of
rash and disinfection of articles soiled by nose and throat discharges.

Prevention

1. VARICELLA-ZOSTER IMMUNOGLOBULIN (VZIG)

• Varicella-Zoster Immunoglobulin (VZIG) given within 72 hours of exposure has been

recommended for prevention of chickenpox in exposed susceptible individuals particularly in
Immunosuppressed persons. VZIG is given by intramuscular injection in a dose of 12.5 Units/kg
body weight up to a maximum of 625 units, with a repeat dose in 3 weeks.

2. VACCINE

• A live attenuated varicella virus vaccine is safe and currently recommended for children between
12-18 months of age who have not had chickenpox.
• Monovalent vaccine can be administered following one or two dose schedule (0.5 ml) each by
subcutaneous injection. A 2 dose schedule is recommended for all persons aged 2-13 years. The
duration of immunity is not known but is probably 10 years.

MEALES (RUBEOLA)
➢ An acute highly infectious disease of childhood caused by a specific virus of the group
myxoviruses. It is clinically characterized by fever and catarrhal symptoms of the upper
respiratory tract (coryza, cough), followed by a typical rash.

Problem statement

In India, measles is a major cause of morbidity and a significant contributor to childhood mortality.
prior to the Immunization programme, cyclical increase in the incidence of measles were
recorded every third year. With the increase in immunization coverage levels, the intervals
between cyclical peaks has increased and the intensity of the peak minimized.

Epidemiological determinants

Agent factors

(a) AGENT : Measles is caused by an RNA Paramyxovirus.

(b) SOURCE OF INFECTION: The only source of infection is a case of measles. Carriers are not known
to occur.

(c) INFECTIVE MATERIAL : Secretions of the nose, throat and respiratory tract of a case of measles
during the prodromal period and the early stages of the rash.

(d) COMMUNICABILITY : The period of communicability is approximately 4 days before and 4 days
after the appearance of the rash.

Host factors

(a) AGE : Affects virtually everyone in infancy or childhood between 6 months and 3 years of age in

(b) SEX : Incidence equal.

(c) IMMUNITY : No age is immune if there was no previous immunity. One attack of measles
generally confers life-long immunity.
(d) NUTRITION : Measles tends to be very severe in the malnourished child, carrying a mortality upto
400 times higher than in well-nourished children having measles.

Environmental factors

• In tropical zones, most cases of measles occur during the dry season. In temperate climates,
measles is a winter disease. Epidemics of measles are common in India during winter and early
Spring (January to April).

Transmission

• Transmission occurs directly from person to person mainly by droplet infection and droplet
nuclei, from 4 days before onset of rash until 4 days thereafter. The portal of entry is the
respiratory tract. Infection through conjunctiva is also considered likely to cause infection.

Incubation period

• Incubation period is commonly 10 days from exposure to onset of fever, and 14 days to
appearance of rash.

Clinical features
1. PRODROMAL STAGE

It begins 10 days after infection, and lasts until day 14. It Is characterized by fever, coryza with
sneezing and nasal discharge, cough, redness of the eyes, lacrimation and often photophobia.
There may be vomiting or diarrhoea. A day or two before the appearance of the rash Koplik’ s
spots like Table salt crystals appear on the buccal mucosa opposite the first and second lower
molars.

2. ERUPTIVE PHASE

This phase is characterized by a typical, dusky-red, macular or maculo-papular rash which begins
behind the Ears and spreads rapidly in a few hours over the face and Neck, and extends down the
body taking 2 to 3 days to progress to the lower extremities.

3. POST -MEASLES STAGE

The child will have lost weight and will remain weak for a number of days. There may be failure to
recover and a gradual deterioration into chronic illness due to increased susceptibility to other
bacterial and viral infections.
Prevention of measles

a. Achieving an immunization rate of over 95 per cent

b. On-going immunization against measles through successive generations of children.

1. Measles vaccination : Measles is best prevented by active immunization.

A. VACCINE : Only live attenuated vaccines are recommended for use; they are both safe and
effective, and may be used interchangeably within immunization Programmes. Each dose of 0.5
ml contains 21000 viral infective units of the vaccine strain; this is also true when it is presented
as an MCV combination. Measles vaccine may also contain Sorbitol and hydrolysed gelatin as
stabilizers, as well as a small amount of neomycin, but it does not contain Thiomersal.

B. AGE : Immunization later than 9 months means that a significant proportion of children will
contract measles in the interval between wearing off natural protection and the introduction of
the Vaccine. The most effective compromise is immunization as close to the age of 9 months.

C. ADMINISTRATION : The reconstituted vaccine is enerally injected subcutaneously, but it is also

effective when administered intramuscularly.

D. IMMUNE RESPONSES: Measles vaccine induces both Humoral and cellular immune responses
comparable to those following natural infection, although antibody titres are usually lower

E. REACTIONS : When injected into the body, the attenuated virus multiplies and induces a mild
“measles” illness (fever and rash) 5 to I0 days after immunization, but in reduced frequency and
severity.

F. CONTACTS : Susceptible contacts over the age of 9-12 months may be protected against measles
with Measles vaccine, provided that this is given within 3 days of exposure.

G. CONTRAINDICATIONS : Should be avoided if the patient has a high fever or other signs of serious
disease.

H. ADVERSE EFFECTS OF VACCINE : Toxic shock Syndrome (TSS) occurs when measles vaccine is
contaminated or the same vial is used for more than one session on the same day or next day.
The vaccine should not be used after 4 hours of opening the vial.

B. Immunoglobulin : Measles may be prevented by administration of Immunoglobulin (human) early

in the incubation period. The dose recommended by WHO is 0.25 ml per kg of body weight. It
should be given within 3-4 days of exposure.
RUBELLA
➢ Rubella or german measles is an acute childhood infection. Usually mild, of short duration
(approximately 3 days) and accompanied by low-grade fever, lymphadenopathy and a
maculopapular rash.

Problem Statement

• Rubella was considered a mild and benign disease until 1941 when Norman Gregg, an
ophthalmologist reported an Epidemic of congenital cataracts associated with other Congenital
defects in children born to mothers who had rubella during their pregnancies.

Epidemiological determinants

Agent factors

(a) AGENT : Rubella is caused by an RNA virus of the Togavirus family.

(b) SOURCE OF INFECTION : There is no known carrier state for postnatally acquired rubella.

(c) PERIOD OF COMMUNICABILITY: Rubella is much less communicable than measles, probably

because of the absence of coughing in rubella. It probably extends from a week before symptoms
to about a week after rash appears.

Host factors

(a) AGE : Mainly a disease of childhood particularly in the age group 3 to 10 years.

(b) IMMUNITY : One attack results in Life-long immunity; second attacks are rare.

Environmental factors

• Disease usually occurs in a seasonal pattern i.e. in Temperate zones during the late winter and
spring, with Epidemics every 4-9 years.

Transmission

• The virus is transmitted directly from person to person by Droplets from nose and throat, and
droplet nuclei (aerosols). The portal of entry is via the respiratory route. The virus can cross the
 placenta (vertical Transmission} and infect the foetus in utero, leading to Congenital rubella in
the newborn.

Incubation period : 2 to 3 weeks; average 18 days.

Clinical features

(a) PRODROMAL : The prodromal symptoms (coryza, sore throat, low-grade fever) herald the onset
of viraemia. They are generally mild and insignificant, and less frequent in children.

(b) LYMPHADENOPATHY: In Susceptible individuals, the enlargement of the postauricular and

posterior cervical lymph nodes appears as early as 7 days before the appearance of the rash.

(c) RASH: The rash is often the first indication of the disease in children. It appears first on the face,
usually within 24 hours of the onset of prodromal symptoms. It is a minute, discrete, pinkish,
macular rash and not confluent as the rash of measles. Conjunctivitis may occur.

Prevention

• RUBELLA VACCINES : Since the isolation of the virus in 1962, several live attenuated vaccines have
been developed. In 1979 the RA 27/3 vaccine, produced in human diploid Fibro -blast has
replaced all the other vaccines. This is because RA 27/3 vaccine induces higher antibody titres
and produces an immune response more closely paralleling natural infection than the other
vaccines. RA 27/3 vaccine is administered in a single dose of 0.5 ml subcutaneously.

DIPHTHERIA
➢ Diphtheria is an acute infectious disease caused by toxigenic strains of Corynebacterium
diphtheriae. The bacilli multiply locally, usually in the throat, and elaborate a powerful exotoxin
which is responsible for :

a. The formation of a greyish or yellowish membrane (“false membrane”) commonly over the tonsils,
Pharynx or larynx (or at the site of implantation)

b. Marked congestion, oedema or local tissue destruction

c. Enlargement of the regional lymph nodes

d. Signs and symptoms of toxaemia.

Problem statement

• Diphtheria is an endemic disease. The available retrospective data indicate a declining trend of
diphtheria in the country. It is due to increasing coverage of child population by immunization.
The reported incidence of the disease in the country during 1987 was about 12,952, whereas
during the year 2013, 4,090 cases and 64 deaths were reported.

Epidemiological determinants

Agent factors

(a) AGENT : The causative agent, C.diphtheriae is a Gram-positive, non-motile organism. It has non
invasive power, but produces a powerful exotoxin. Four types of Diphtheria bacilli are
differentiated gravis, mitis, belfanti and intermedius, all pathogenic to man.

(b) SOURCE OF INFECTION : The source of infection may be a case or carrier: (i) CASE : Cases range
from subclinical to frank clinical cases. (ii) CARRIER : The nasal carriers are particularly dangerous
as source of infection because of frequent shedding of the organism into the environment, than
do throat carriers.

(c) INFECTIVE MATERIAL : Nasopharyngeal secretions, discharges from skin· lesions, contaminated
fomites and possibly infected dust.

(d) PERIOD OF INFECTIVITY : Unless treated, the period of infectivity may vary from 14 to

28 days from the onset of the disease, but carriers may remain infective for much longer periods.

Host factors

(a) AGE : Diphtheria particularly affects children aged 1 to 5.

(b) SEX : Both sexes are affected.

(c) IMMUNITY : Infants born of immune mothers are relatively immune during the first few weeks or
months of life. Before artificial immunization, large proportion of population in developing
countries were acquiring active immunity through inapparent infection which resulted in
widespread production of antitoxin in the population.

Environmental factors

• Cases of diphtheria occur in all seasons, although winter months favour its spread.
Mode of transmission

• The disease is spread mainly by droplet infection. It can also be transmitted directly to
susceptible persons from infected cutaneous lesions. The portal of entry is respiratory route and
non-respiratory route (cuts, wounds, ulcers).

Incubation period

• 2 to 6 days, occasionally longer.

Clinical features

• Respiratory tract forms of diphtheria consist of Pharyngotonsillar, laryngotracheal, nasal, and

combinations. Thereoff patients with pharyngotonsillar diphtheria usually have a sore throat,
difficulty in swallowing, and low grade fever at presentation. Examination of the throat may show
only mild erythema, localized exudate, or a pseudomembrane.
• In the early stage the pseudo-membrane may be whitish and may wipe off easily. The membrane
may extend to become thick, Blue-white to grey-black, and adherent. Attempts to remove the
membrane result in bleeding.
• Laryngotracheal diphtheria most often is preceded by Pharyngotonsillar disease, usually is
associated with fever, Hoarseness and croupy cough at presentation.
• Nasal diphtheria, the mildest form of respiratory. Diphtheria, usually is localized to the septum or
turbinates of one side of the nose. Occasionally a membrane may extend into the pharynx.

CONTROL OF DIPHTHERIA

1. CASES AND CARRIERS

(a) Early detection : An active search for cases and carriers should start immediately amongst family
and school contacts. Carriers can be detected only by culture method. Swabs should be taken
from both the nose and throat and examined by culture methods for diphtheria bacilli.

(b) Isolation : All cases, suspected cases and carriers should be promptly isolated, preferably in a
Hospital, for at least 14 days or until proved free of infection.

(c) Treatment : (i) CASES : When diphtheria is suspected, Diphtheria antitoxin should be given
without delay, IM or IV, in doses ranging from 20,000 to 100,000 units or more.
(ii) CARRIERS : The carriers should be treated with 10 days course of oral erythromycin, which is the
most effective drug for the treatment of carriers.

2. CONTACTS

(a) where primary immunization or booster dose was received within the previous 2 years, no
further action would be needed

(b) where primary course or booster dose of diphtheria toxoid was received more than 2 years
before, only a booster dose of diphtheria toxoid need be given

(c) non-immunized close contact should receive prophylactic penicillin or Erythromycin.

3. COMMUNITY

• The only effective control is by active immunization with Diphtheria toxoid of all infants as early
in life as possible, as scheduled, with subsequent booster doses every 10 years thereafter. The
aim should be to immunize before the infant loses his maternally derived immunity

DIPHTHERIA IMMUNIZATION

These may be grouped as below :

A. Combined or mixed vaccines

▪ DPT (diphtheria-pertussis-tetanus vaccine)

▪ DTPw (diphtheria, tetanus, whole-cell pertussis)
▪ DTPa (diphtheria, tetanus, acellular pertussis)
▪ DT (diphtheria-tetanus toxoid)
▪ dT (diphtheria-tetanus, adult type)

B. Single vaccines

▪ FT (formal-toxoid)
▪ APT (alum-precipitated toxoid)
▪ PTAP (purified toxoid aluminium phosphate)
▪ PTAH (purified toxoid aluminium hydroxide)
▪ TAF (toxoid-antitoxin flocculus)

C. Antisera

▪ Diphtheria antitoxin
TETANUS
• An acute disease induced by the exotoxin of Clostridium tetani and clinically characterized
by muscular rigidity which persists throughout illness punctuated by painful paroxysmal
spasms of the voluntary muscles, especially the masseters (trismus or "lock-jaw"), the facial
muscles (risus sardonicus), the muscles of the back and neck (opisthotonos), and those of
the lower limbs and abdomen.

Problem statement

• Tetanus is an important endemic infection in India. Behaviours such as hand-washing,

delivery practices, traditional birth customs and interest in immunization, are all important
factors affecting the disease incidence.
• Medically under-served areas and livestock raising regions are two environments particularly
associated with behaviour conductive to neonatal tetanus.
• Since 1983 in India, the nationwide EPI has recommended the provision of 2 doses of
tetanus toxoid to all pregnant women during each pregnancy (or one booster dose if <3
years have passed since the previous pregnancy) to prevent neonatal and maternal tetanus.

• More recently, under the National Rural Health Mission launched in 2005, the Government
of India has provided training to health workers. The mission also actively encourages
institutional deliveries through interventions such as the 'Janani Suraksha Yojana".

Epidemiological determinants

Agent factors

(a) AGENT : Cl. tetani is a gram-positive, anaerobic, spore-bearing organism. The spores are terminal
and give the organism a drum-stick appearance. They germinate under anaerobic conditions and
produce a potent exotoxin ( "tetanospasmin"). The spores are best destroyed by steam unde r
pressure at 120 deg. C for 20 minutes.

(b) RESERVOIR OF INFECTION : The natural habitat of the organism is soil and dust. The bacilli are
found in the intestine of many herbivorous animals, e.g., cattle, horses, goats and sheep and are
excreted in their faeces. The spores survive for years in nature.
(c) EXOTOXIN : Tetanus bacilli produce a soluble exotoxin. It has an astounding lethal toxicity,
exceeded only by botulinum toxin. The lethal dose for a 70 kg man is about 0.1 mg. The toxin acts on
4 areas of the nervous system : (a) the motor end plates in skeletal system (b) the spinal cord (c) the
brain, and (d) the sympathetic system.

(d) PERIOD OF COMMUNICABILITY : Not transmitted from person to person.

Host factors

(a) AGE : Commonly, tetanus is a disease of the active age (5 to 40 years). Tetanus occurring in the
new-born is known as "neonatal tetanus".

(b) SEX : Although a higher incidence is found in males, females are more exposed to the risk of
tetanus, especially during delivery or abortion leading to "puerperal tetanus".

(c) OCCUPATION : Agricultural workers are at special risk because of their contact with soil.

(d) IMMUNITY : No age is immune unless protected by previous immunization. The immunity
resulting from 2 injections of tetanus toxoid is highly effective and lasts for several years.

Environmental and social factors

• Tetanus is a positive environmental hazard. Its occurrence depends upon man's physical and
ecological surroundings - the soil, agriculture, animal husbandry - and not on the presence or
absence of infection in the population. The environmental factors are compounded by social
factors such as unhygienic customs and habits (e.g:, application of dust or animal dung to
wounds); unhygienic delivery practices (e.g., using unsterilized instruments for cutting the
umbilical cord); ignorance of infection and lack of primary health care services.

Mode of transmission

• Infection is acquired by contamination of wounds with tetanus spores. The range of injuries
and accidents which may lead to tetanus comprise a trivial pin prick, skin abrasion, puncture
wounds, burns, human bites, animal bites and stings, unsterile surgery, intra-uterine death,
bowel surgery, dental extractions, injections, unsterile division of umbilical cord, compound
fractures, otitis media, chronic skin ulcers, eye infections, and gangrenous limbs.
Incubation period

• The incubation period is usually 6 to 10 days. However, it may be as short as one day or as
long as several months.

Types

(a) TRAUMATIC : Trauma is a major and important cause of tetanus. Sometimes tetanus may result
from most trivial or even unnoticed wounds.

(b) PUERPERAL : Tetanus follows abortion more frequently than a normal labour. A post-abortal
uterus is a favourable site for the germination of tetanus spores.

(c) OTOGENIC: Ear may be a rare portal of entry. Foreign bodies such as infected pencils, matches,
and beads may introduce the infection. Otogenic tetanus is a paediatric problem, but cases, may
occur in adults also.

(d) IDIOPATHIC : In these cases there is no definite history of sustaining an injury. Some consider it to
be the result of microscopic trauma. Others hold the view that it is due to the absorption of tetanus
toxin from the intestinal tract. A third view is that the tetanus spores may be inhaled and may start
the infection.

(e) TETANUS NEONATORUM : The common cause is infection of the umbilical stump after birth, the
first symptom being seen about the 7th day. Therefore tetanus is known as "8th day disease" in
Punjab.

PREVENTION

1. Active immunization : Tetanus is best prevented by active immunization with tetanus toxoid. The
aim should be to vaccinate the entire community and ensure a protective level of antitoxin
approximately 0.01 IU/ml serum throughout life.

a. Combined vaccine - DPT

b. Monovalent vaccines

i) Plain or fluid (formal) toxoid

ii) Tetanus vaccine, adsorbed (PTAP, APT)

a. COMBINED VACCINE

According to the National Immunization Schedule, the primary course of immunization consists of 3
doses of DPT, at intervals of 4-8 weeks, starting at 6 weeks of age, followed by a booster at 18
months of age, and a second booster (Only DT)at 5-6 years of age and a third booster (Only TT) after
10 years of age.

b. MONOVALENT VACCINES

A primary course of immunization consists of two doses of tetanus toxoid adsorbed (each dose 0.5
ml, injected into the arm) given at intervals of 1-2 months. The first booster dose (the third in order)
should be given a year after the initial two doses.

2. Passive immunization : Temporary protection against tetanus can be provided by an injection of

human tetanus hyperimmunoglobulin (TIG) or ATS.

(i) HUMAN TETANUS HYPERIMMUNOGLOBULIN : It is the best prophylactic to use. The dose for all
ages is 250 JU. It gives a longer passive protection upto 30 days or more compared with 7-10 days
for horse ATS.

(ii) ATS (EQUINE) : If human antitoxin is not available, equine antitoxin (anti-tetanus serum or ATS)
should be used. The standard dose is 1500 IU, injected subcutaneously after sensitivity testing. ATS
gives passive protection for about 7-10 days.

3. Active and .passive immunization : Simultaneous active and passive immunization is widely
carried out in non-immune persons. The patient is given 1500 units of ATS or 250 units of Human lg
in one arm, and 0.5 ml of adsorbed tetanus toxoid (PTAP or APT) into the other arm or gluteal
region.

4. Antibiotics : Active immunization with tetanus toxoid is the ideal method of tetanus prophylaxis,
but it is of no immediate avail to a person who is non-immune and has sustained injury.

Prevention of neonatal tetanus

• Over the last decade, most programmes in developing countries have concentrated on
training the traditional birth attendants, providing home delivery kits and educating
pregnant women about the "three cleans" - clean hands, clean delivery surface and clean
cord care i.e., clean blade for cutting the cord, clean tie for the cord and no application on
the cord stump.
 • In unimmunized pregnant women, two doses of tetanus toxoid should be given, the first as
early as possible during pregnancy and the second at least a month later and at least 3
weeks before delivery. According to the National Immunization Schedule, these doses may
be given between 16-36 weeks of pregnancy, allowing an interval of 1-2 months between
the 2 doses.

Prevention of tetanus after injury

• All wounds must be thoroughly cleaned soon after injury - removal of foreign bodies, soil,
dust, necrotic tissue. This procedure will abolish anaerobic conditions which favour
germination of tetanus spores
• When ATS is given, adrenaline solution 1 in 1000 for intramuscular injection in the dosage of
0.5 to 1 ml and hydrocortisone 100 mg for intravenous injection must be kept available in
case of a generalized anaphylactoid reaction.
• A test dose of ATS (0.1 ml in a tuberculin syringe) should be given subcutaneously {not
intradermally) and the patient observed carefully (not casually) at least for half an hour for
any evidence of general reaction (not only local reaction), e.g., alteration in pulse, fall in
blood pressure, dyspnoea and distress.

TUBERCULOSIS
• Tuberculosis is a specific infectious disease caused by M. tuberculosis. The disease primarily
affects lungs and causes pulmonary tuberculosis.

• It can also affect intestine, meninges, bones and joints, lymph glands, skin and other tissues
of the body. Pulmonary tuberculosis, the most important form of tuberculosis which affects
man, will be considered here.

Problem statement

• India is the highest TB burden country in the world in terms of absolute number of incident
cases that occur each year.
• It accounts for one-fourth of the estimated global incident TB cases in 2013. Tuberculosis
mortality has reduced from 38 per lac population in 1990 to 19 in 2013.
• In absolute numbers, mortality due to TB has reduced from 3.3 lacs to 2.4 lacs annually.
Among the new TB cases, 5 per cent of patients were in paediatric age-group (0-14 years).
Epidemiological determinants

Agent factors

(a) AGENT : M. tuberculosis is a facultative intracellular parasite, i.e. it is readily ingested by

phagocytes and is resistant to intracellular killing.

(b) SOURCE OF INFECTION : There are two sources of infection - human and bovine.

(i) Human source: The most common source of infection is the human case whose sputum is positive
for tubercle bacilli. Such sources can discharge the bacilli in their sputum for years.

(ii) Bovine source: The bovine source of infection is usually infected milk.

(c) COMMUNICABILITY : Effective anti-microbial treatment reduces infectivity by 90 percent within

48 hours.

Host factors

(a) AGE : Tuberculosis affects all ages. Developing countries show a sharp rise in infection rates from
childhood to adolescence

(b) SEX : More prevalent in males than in females

(c) HEREDITY : Tuberculosis is not a hereditary disease

(d) NUTRITION : Malnutrition is widely believed to predispose to tuberculosis

(e) IMMUNITY : Man has no inherited immunity against tuberculosis. It is acquired as a result of
natural infection or BCG vaccination. Past infection with atypical mycobacteria is also credited with
certain amount of naturally acquired immunity

SOCIAL FACTORS

• The social factors include many non-medical factors such as poor quality of life, poor
housing, and overcrowding, population explosion, undernutrition, smoking, alcohol abuse,
lack of education, large families, early marriages, lack of awareness of causes of illness, etc.
MODE OF TRANSMISSION

• Tuberculosis is transmitted mainly by droplet infection and droplet nuclei generated by

sputum-positive patients with pulmonary tuberculosis.
• To transmit infection, the particles must be fresh enough to carry a viable organism. The
frequency and vigour of cough and the ventilation of the environment influence
transmission of infection.

INCUBATION PERIOD

• The time from receipt of infection to the development of a positive tuberculin test ranges
from 3 to 6 weeks. Thus the incubation period may be weeks, months or years.

CONTROL OF TUBERCULOSIS

A. THE CASE : The first step in a tuberculosis control programme is early detection of sputum-
positive cases.

B. TARGET GROUP : Patients have one or more of the symptoms referable to chest, such as
persistent cough and fever.The chest symptoms often develop early, that is before the disease has
gone on to an advanced stage.

C. CASE-FINDING TOOLS : (i) Sputum examination : It enables us to discover the epidemiologically

most important cases of pulmonary tuberculosis, i.e., those excreting tubercle bacilli in their sputum.
This is the group which contributes most of the new cases to the "pool of infection" every year.

D.Collection of sputum samples : Secretions build up in the airways overnight. So an early morning
sputum sample is more likely to contain TB bacilli than one taken later in the day. It may be difficult
for an out-patient to provide two early morning sputum samples. Therefore in practice an out-
patient usually provides sputum samples as follows:

Ziehl-Neelsen acid-fast stain : This simple stain detects acid fast bacilli. The procedure is as follows:

1. Fix the smear on the slide by passing the slide with the smear up about three times slowly through
a flame

2. Cover with carbol fuchsin, steam gently for 5 minutes over direct flame (or for 20 minutes over a
water bath)
3. Wash with deionized water

4. Decolourize in 3.0 percent acid-alcohol (95 per cent ethanol and 3.0 per cent hydrochloric acid)
until only a faint pink colour remains

5. Wash with water

6. Counter stain for 1 minute with Loeffler's methylene blue

7. Wash with deionized water and let it dry

RNTCP
• National Tuberculosis Programme (NTP) has been in operation since 1962. However, the
treatment success rates were unacceptably low and the death and default rates remained
high.
• Spread of multidrug resistant TB was threatening to further worsen the situation.
• In 1992 Government of India along with WHO and SIDA reviewed the TB situation in the
country and came up with following conclusions :

a. NTP, though technically sound, suffered from managerial weaknesses

b. Inadequate funding

c. Over-reliance on X-ray for diagnosis Frequent interrupted supplies of drugs

d. Low rates of treatment completion

OBJECTIVES

1. Achievement of at least 85 per cent cure rate of infectious cases of tuberculosis; through DOTS
involving peripheral health functionaries.

2. Augmentation of case finding activities through quality sputum microscopy to detect at least 70
per cent of estimated cases.

• DOTS strategy adopted by Revised National TB Control Programme initially had the following
five main components:

a. Political will and administrative commitment

b. Diagnosis by quality assured sputum smear microscopy

c. Adequate supply of quality assured short course chemotherapy drugs

d. Directly observed treatment

e. Systematic monitoring and accountability

• In 2006, STOP TB strategy was announced by WHO and adopted by RNTCP. The components
are as follows :

a. Pursuing quality DOTS expansion and enhancement

b. Addressing TB/HIV and MDR-TB

c. Contributing to health system strengthening

d. Engaging all care providers

e. Empowering patients and communities

f. Enabling and promoting research (diagnosis, treatment, vaccine)

RNTCP endorsed TB diagnostics

1. Smear microscopy for acid fast bacilli

a. Sputum smear stained with Zeihl-Neelsen staining

b. Fluoresence stains and examined under direct or indirect microscopy with or without LED

2. Culture

a. Solid (Lowenstein Jansen) media

b. Liquid media (Middle Brook) using manual semi- automatic or automatic machines, e.g., Bactec,
MGIT etc

3. Rapid diagnostic molecular test

a. Conventional PCR based Line Probe Assay for MTB complex

b. Real-time PCR based Nucleic Acid Amplification Test NAAT for MTB complex, e.g. GeneXpert.

Initiation of treatment
 • Under the RNTCP active case finding is not pursued. Case finding is passive. Patients
presenting themselves with symptoms suspicious of tuberculosis are screened through 2
sputum smear examinations.
• Sputum microscopic examination is done in designated RNTCP microscopy centres. The
senior TB laboratory supervisor rechecks all the positive slides and 10 per cent of the
negative slides of these five microscopy centres.
• Thus the error in diagnosing a patient is minimized. It is essential to examine 2 sputum
specimens of each patient before a conclusive diagnosis can be made.
• All patients are provided short-course chemotherapy free of charge. During the intensive
phase of chemotherapy all the drugs are administered under direct supervision called Direct
Observed Therapy Short-term (DOTS).
• DOTS is a community based tuberculosis treatment and care strategy which combines the
benefits of supervised treatment, and the benefits of community based care and support.

WHOOPING COUGH (PERTUSSIS)

• An acute infectious disease, usually of young children, caused by B. pertussis. It is clinically
characterized by an insidious onset with mild fever and an irritating cough, gradually
becoming paroxysmal with the characteristic “whoop” (loud crowing inspiration) often with
cyanosis and vomiting.
• The Chinese call it a “Hundred Day Cough”.

Problem statement

• In India, there is marked decline of the disease after launch of universal immunization
programme. During the Year 1987; the reported incidence was about 1.63 lakh cases, whereas
during 2013 only 36,661 cases were reported showing a decline of about 77 per cent.

Epidemiological determinants

Agent factors

(a) AGENT : The causative agent in a large proportion of cases is B. pertussis. In a small percentage of
cases (less than 5%) B. parapertussis is probably responsible.
(b) SOURCE OF INFECTION : B. pertussis infects only man. The source of infection is a case of
Pertussis. More often, the source may be mild, missed and unrecognized cases. There is no
evidence that infection is ever subclinical.

(c) INFECTIVE MATERIAL: The bacilli occurs abundantly in the nasopharyngeal and bronchial
secretions, which are infective.

(d) INFECTIVE PERIOD : Whooping Cough is most infectious during catarrhal stage. The infective
period may be considered to extend from a week after exposure to about 3 weeks after the onset
of the paroxysmal stage.

Host factors

(a) AGE : Whooping cough is primarily a disease of infants and pre -school children. The highest
incidence is found below the age of 5 years. The median age of infection, i.e. the age when half
the children are likely to develop whooping cough is between 20 -30 months in developing
countries.

(b) SEX : Incidence and fatality are observed to be more among female than male children

(c) IMMUNITY : Recovery from whooping cough or adequate immunization is followed by immunity.
Second attacks may occur in persons with declining immunity, but these are usually mild.

Environmental factors

• Pertussis occurs throughout the year, but the disease shows a seasonal trend with more cases
occurring during winter and spring months, due to overcrowding.

Mode of transmission

• Whooping cough is spread mainly by droplet infection and direct contact. Each time the patient
coughs, sneezes or talks, the bacilli are sprayed into the air. The role of fomites in the spread of
infection appears to be very small, unless they are freshly contaminated.

Incubation period

• Usually 7 to 14 days, but not more than 3 weeks.

Clinical course
(a) catarrhal stage, lasting for about 10 days. It is characterized by its insidious onset, lacrimation,
sneezing and coryza, anorexia and malaise, and a hacking night cough that becomes diurnal

(b) paroxysmal stage, lasting for 2-4 weeks. It is characterized by bursts of rapid, consecutive coughs
followed by a deep, high-pitched inspiration (whoop). It is usually followed by vomiting

(c) convalescent stage, lasting for 1-2 weeks. The illness generally lasts 6 to 8 weeks.

• The chief complications of pertussis are bronchitis; bronchopneumonia.and bronchiectasis.

Control of Whooping Cough

1. CASES AND CONTACTS

(i) Cases :

• Early diagnosis is possible only by bacteriological examination of nose and throat secretions
which may be obtained by naso-pharyngeal swabs.

• The chances of isolating the organism are < 60 per cent if the material is obtained within 10-14
days from the onset of illness.
• Although several antibiotics are effective against B. pertussis, erythromycin is probably the drug
of choice. A dose of 30-50 mg/kg of body weight in 4 divided doses for 10 days has been
recommended. Possible alternatives are ampicillin, septran or tetracycline.

(ii) Contacts :

• Those known to have been in contact with whooping cough may be given prophylactic antibiotic
(erythromycin or ampicillin) treatment for 10 days. The best protection that can be given to an
infant is to administer a booster dose of DPT/DT to his siblings before he is born.

2. ACTIVE IMMUNIZATION

• The vaccine is usually administered in the national childhood immunization programme as

combined DPT, DTWP or DTaP vaccine. In India, the national policy is to immunize against
diphtheria, whooping cough and tetanus simultaneously, by administering 3 doses (each dose
about 0.5 ml) of DPT vaccine intramuscularly, at one month interval, starting at the age of 6
weeks. A booster dose is given at 18-24 months.
▪ CONTRAINDICATIONS : The contraindications to pertussis vaccination are anaphylactic reaction,
encephalopathy, a personal or strong family history of epilepsy, convulsions or similar CNS
 disorders: any febrile upset until fully recovered: or a reaction to one of the previously given
triple vaccine injections.

3. PASSIVE IMMUNIZATION

• The control of pertussis by immunization is still an unsolved problem. Even if the level of
immunization reaches 100 per cent, it is possible that the disease would not be entirely
eliminated because whooping cough vaccines have never been claimed to be more than 90 per
cent effective.

LEPROSY
• Leprosy (Hansen's disease) is a chronic infectious disease caused by M. Leprae. It affects
mainly the peripheral nerves. It also affects the skin, muscles, eyes, bones, testes and
internal organs.
• The disease manifests itself in two forms namely the lepromatous leprosy and tuberculoid
leprosy. Leprosy is clinically characterized by one or more of the following cardinal features :

a. hypopigmented patches

b. partial or total loss of cutaneous sensation in the affected areas

c. presence of thickened nerves

d. presence of acid-fast bacilli in the skin or nasal smears.

• The signs of advanced disease are striking : presence of nodules or lumps especially in the
skin of the face and ears, plantar ulcers, loss of fingers or toes, nasal depression, foot- drop,
claw toes and other deformities.

Problem Statement
• Leprosy is widely prevalent in India. Although the disease is present throughout the country,
the distribution is uneven.
• After introduction of MDT in the country, the recorded leprosy case load has come down
from 57.6 cases per 10,000 population.

Epidemiological determinants
Agent factors
(a) AGENT :

Leprosy is caused by M. leprae. They are acid-fast and occur in the human host both intracellularly
and extracellularly. They occur characteristically in clumps or bundles (called globi).
(b) SOURCE OF INFECTION : The role of individuals with tuberculoid forms of the disease as sources
of infection is not clear. The current view is that all patients with "active leprosy" must be
considered infectious.

(c) PORTAL OF EXIT : It is widely accepted that the nose is a major portal of exit. Lepromatous cases
harbour millions of M. leprae in their nasal mucosa which are discharged when they sneeze or blow
the nose.

(d) INFECTIVITY : Leprosy is a highly infectious disease but of low pathogenicity. Local application of
rifampicin (drops or spray) might destroy all the bacilli within 8 days.

Host factors
(a) AGE : Leprosy is not particularly a disease of children as was once believed. Infection can take
place at any time depending upon the opportunities for exposure. In endemic areas, the disease is
acquired commonly during childhood.

(b) SEX : Both the incidence and prevalence of leprosy appear to be higher in males than in females
in most regions of the world.

(c) MIGRATION : In India leprosy was considered to be mostly a rural problem.

(d) INACTIVATION OF DISEASE : Where leprosy treatment facilities exist, inactivation or cure due to
specific treatment is an important mode of elimination of cases from the prevalence pool.

(e) IMMUNITY : It is a well-established fact that only a few persons exposed to infection develop the
disease.

Environmental factors
(a) the presence of infectious cases in that environment

(b) overcrowding and lack of ventilation within households

Mode of transmission

(a) DROPLET INFECTION : Leprosy may be transmitted via aerosols containing M. leprae. The
possibility of this route of transmission is based on

(a) the inability of the organisms to be found on the skin

(b) large number of organisms in the nasal discharge

(c) bacilli in the nasal secretions

(b) CONTACT TRANSMISSION : Leprosy is transmitted from person-to-person by close contact

between an infectious patient and a healthy but susceptible person. This contact may be direct or
indirect (e.g. contact with soil and fomites such as contaminated clothes and linen).

(C) OTHER ROUTES : Bacilli may also be transmitted by insect vectors or by tattooing needles.
Incubation period

• Leprosy has a long incubation period an average of 3 to 5 years or more for lepromatous
cases.

Classification

Indian classification Madrid classification

Indeterminate type Indeterminate

Tuberculoid type Tuberculoid : flat; raised

Borderline type Borderline

Lepromatous type Lepromatous

Pure neuritic type

Diagnosis
1. Clinical examination

a. Interrogation

(i) collection of biodata

(ii) family history of leprosy

(iii) history of contact with leprosy cases

(iv) presenting complaint or symptom

b. Physical examination

(i) inspection of the body surface (skin) in good natural light

(ii) Palpation of the peripheral and cutaneous nerves for the presence of thickening or tenderness.

(iii) Testing for loss of sensation for heat, cold, pain and light touch in the skin patches.

2. Bacteriological examination

(i) Skin smears : Material from the skin is obtained from an active lesion, and also from one of the
ear lobe by the "slit and scrape" method.

(ii) Nasal smears or blows : Nasal smears can be best prepared from early morning mucus material.
The patient blows his nose into a clean dry sheet of cellophane or plastic.
(iii) Nasal scrapings : After going in 4.5 cm the blade is rotated towards the septum and scraped a
few times and withdrawn. A small ball of cotton is introduced into the nostril to absorb any blood
that may ooze out.

Leprosy control
I. Estimation of the problem : The first step in a leprosy control programme is to define the size of
the problem or disease load in the community by means of epidemiological surveys.

II. Early case detection : The aim of case detection is to identify and to register all cases of leprosy as
soon as possible after they become evident.

(a) CONTACT SURVEY : In areas where the prevalence of leprosy is generally low, (less than 1 case
per 1000 population).

(b) GROUP SURVEYS : When the prevalence is about 1 per 1000 or higher.

(c) MASS SURVEYS : Total population surveys for examination of each and every individual, family by
family by house-to-house visits are recommended only in hyperendemic areas.

III. Multidrug therapy : In the absence of primary prevention by a leprosy vaccine, the leprosy
control is based on effective chemotherapy (secondary prevention). Chemotherapy recommended
multiple drug therapy for both multibacillary and paucibacillary leprosy.

Drugs :

(a) Rifampicin (RMP) is the only drug that is highly bactericidal against M. leprae. A single dose of
1500 mg or 3-4 consecutive daily doses of 600 mg appear to kill 99 % of viable organisms.

(b) Dapsone (DDS) has been in use all over the world for the control of leprosy for more than 30
years. It is cheap and effective in the dosage employed (1-2 mg/kg of body weight).

(c) Clofazimine (CLF) was originally synthesized for the treatment of tuberculosis, but was
subsequently found to have far greater value in leprosy.

(d) Ethionamide and protionamide : These are bactericidal drugs killing 98 % of viable bacilli in 4 to 5
days.

(e) Quinolones : Oral ofloxacin is 98 % bioavailable with elimination half-life of about 5 to 8 hours.

(f) Minocycline : The standard dose is 100 mg daily. The side-effects include discoloration of teeth in
infants and children, occasional pigmentation of the skin and mucous membrane.

(g) Clarithromycin : Daily administration of 500 mg killed 99 % of viable M. Leprae within 28 days and
99.9 % by 56 days.
NATIONAL LEPROSY ERADICATION
PROGRAMME
• NLCP has been in operation since 1955 as a centrally aided programme to achieve control of
leprosy through early detection of cases and DDS (dapsone) monotherapy on an ambulatory
basis.
• In 1980 the Government of India declared its resolve to eradicate leprosy by the year 2000
and constituted a working Group recommended a revised strategy based on multi-drug
chemotherapy aimed at leprosy eradication through reduction in the quantum of infection
in the population, reduction in the sources of infection and breaking the chain of
transmission of disease.
• In 1983 the control programme was redesignated National Leprosy "Eradication"
Programme with the goal of eradicating the disease by the turn of the century. The aim was
to reduce case load to 1 or less than 1 per 10,000 population.
• The components of the programme are as follows :

(1) Decentralized integrated leprosy services through general health care system

(2) Capacity building of all general health services functionaries

(3) Intensified information, education and communication

(4) Prevention of disability and medical rehabilitation

(5) Intensified monitoring and supervision.

Major initiatives taken are as follows :

(1) More focus has now been given to new case detection

(2) Treatment completion rate has been taken as an important indicator

(3) More emphasis is being given on providing disability prevention and medical rehabilitation
(DPMR) services to leprosy affected persons.

(4) ASHAs have been involved in bringing out suspected leprosy cases from their villages for
diagnosis and treatment at PHC.

(5) There are 612 self settled colonies in the country where more than 50,000 leprosy affected
persons reside.

(6) Intensive IEC campaign with a theme "Towards Leprosy Free India" has been carried out towards
further reduction of leprosy burden in the community.
Urban leprosy control programme
The urban leprosy control programme was initiated in 2005 to address the complex problem of
larger population size, migration, poor health infrastructure and increasing leprosy cases in urban
areas.

POLIOMYELITIS
• Poliomyelitis is an acute viral infection caused by an RNA virus. It is primarily an infection of the
human alimentary tract but the virus may infect the central nervous system in a very small
percentage (about 1 per cent) of cases resulting in varying degrees of paralysis, and possibly
death.

Problem statement

• In the pre-vaccination era, poliomyelitis was found in all countries of the world. The extensive use
of polio vaccines since 1954 eliminated the disease in developed countries. In 1988, the World
Health Assembly resolved to eradicate poliomyelitis globally.

Epidemiological determinants

Agent factors

(a) AGENT : The causative agent is the poliovirus which has three serotypes 1, 2 and 3. Most
outbreaks of paralytic polio are due to type-I virus. Poliovirus can survive for long periods in the
external environment.

(b) RESERVOIR OF INFECTION : Man is the only known reservoir of infection. Most infections are
subclinical. It is the mild and subclinical infections that play a dominant role in the spread of
infection; they constitute the submerged portion of the iceberg.

(c) INFECTIOUS MATERIAL : The virus is found in the faeces and oropharyngeal secretions of an
infected person.

(d) PERIOD OF COMMUNICABILITY : The cases are most infectious 7 to 10 days before and after
onset of symptoms. In the faeces, the virus is excreted commonly for 2 to 3 weeks, sometimes as
long as 3 to 4 months.
Host factors

(a) AGE : The disease occurs in all age groups, but children are usually more susceptible than adults
because of the acquired immunity of the adult population.

(b) SEX : Sex differences have been noted in the ratio of 3 males to one female.

(c) RISK FACTORS : Several provocative or risk factors have been found to precipitate an attack of
paralytic polio in individuals already infected with polio viruses. They include fatigue, trauma,
intramuscular injections, operative procedures such as tonsillectomy undertaken especially
during epidemics of polio and administration of immunizing agents particularly alum-containing
DPT.

(d) IMMUNITY : The maternal antibodies gradually disappear during the first 6 months of life. Type-2
virus appears to be the most effective antigen. Neutralizing antibody is widely recognized as an
important index of immunity to polio after infection.

Environmental factors

• Polio is more likely to occur during the rainy season. Approximately 60 per cent of cases recorded
in India were during June to September. The environmental sources of infection are
contaminated water, food and flies.

Mode of transmission

(a) FAECAL-ORAL ROUTE : The infection may spread direct through contaminated fingers where
hygiene is poor, or indirectly through contaminated water, milk, foods, flies and articles of daily
use.

(b) DROPLET INFECTION : This may occur in the acute phase of disease when the virus occurs in the
throat. Close personaI·contact with an infected person facilitates droplet spread.

Incubation period

• Usually 7 to 14 days (range 3 to 35 days).

Clinical spectrum

(a) INAPPARENT (SUBCLINICAL) INFECTION : This occurs approximately in 91-96 per cent of
poliovirus infections. There are no presenting symptoms.
(b) ABORTIVE POLIO OR MINOR ILLNESS : Occurs in approximately 4 to 8 per cent of the infections. It
causes only a mild or self-limiting illness due to viraemia. The patient recovers quickly.

(c) NON-PARALYTIC POLIO : The presenting features are stiffness and pain in the neck and back. The
disease lasts 2 to 10 days. Recovery is rapid.

(d) PARALYTIC POLIO : The virus invades CNS and causes varying degrees of paralysis. The
predominant sign is asymmetrical flaccid paralysis.

PREVENTION

1. Inactivated (Salk) polio vaccine

• IPV is usually made from selected WPV strains - namely, Mahoney (Salk type-1), MEF-1 (Salk type-
2) and Saukett (Salk type-3) that are grown in Vero cell culture or in human diploid cells. The final
vaccine mixture is formulated to contain at least 40 units of type-1, 8 units of type-2 and 32 units
of type-3 D-antigen (D-antigen, which is expressed only on intact poliovirus particles, is used to
adjust the concentration of the individual viruses included in the trivalent IPV).
• IPV is administered by intramuscular injection (preferred) or subcutaneous injection. The first 3
doses are given at intervals of 1-2 months and 4th dose 6-12 months after the third dose. First
dose is usually given when the infant is 6 weeks old.

Disadvantages : (i) immunity is not rapidly achieved, as more than one dose is required to induce
immunity (ii) injections are to be avoided during epidemic times as they are likely to precipitate
paralysis.

Advantages : Inactivated polio vaccine, because it does not contain living virus, is safe to administer
(i) to persons with immune deficiency diseases (ii) to persons undergoing corticosteroid and
radiation therapy (iii) to those over 50 years who are receiving vaccine for the first time

2. Oral (Sabin) polio vaccine (OPV)

• Oral polio vaccine (OPV) was described by Sabin in 1957. It contains live attenuated virus (types
1,2 and 3) grown in primary monkey kidney or human diploid cell cultures. The dose is 2 drops.
This is the most direct and effective way to deliver the correct drop size. Tilt the child's back, and
gently squeeze the cheeks or pinch the nose to make the mouth open. Let the drops fall from the
dropper onto the child's tongue.
PLAGUE
• Plague is primarily and basically a zoonoses, caused by Y pestis involving rodents and fleas.

Problem statement
• Plague is often seen as a problem of the past or an ancient disease that is unlikely to
reappear. But continued outbreaks throughout the world attest to its tenacious presence.
• Plague continues to be a threat because vast areas exist where wild rodents are infected,
particularly in endemic countries in Africa, Asia and the Americas. Plague is a major concern
in countries where it remains endemic given its inherent communicability, its rapid clinical
course and high mortality if left untreated.
• Absence of human plague may simply mean that there has been reduced human contact
with plague bacteria circulating in nature. Therefore, there is a need to continue to make
concerted effort to strengthen surveillance and improve control measures in order to
manage human plague in endemic countries.

Epidemiological determinants
Agent factors
(a) AGENT : The causative agent Y. pestis is a gram- negative, non-motile, cocco-bacillus that exhibits
bipolar staining with special stains (e.g. Wayson's stain).

(b) RESERVOIR OF INFECTION : Wild rodents (e.g., field mice, gerbils, skunks and other small
animals) are the natural reservoirs of plague.

(c) SOURCE OF INFECTION : Infected rodents and fleas and case of pneumonic plague.

Host factors
(a) AGE AND SEX : All ages and both sexes are susceptible.

(b)HUMAN ACTIVITIES : Man may come into contact with natural foci in the course of hunting,
grazing, cultivation, harvesting and construction activities.

(c) MOVEMENT OF PEOPLE : Plague is associated with movement of people and cargo by sea or
land. Rats and rat fleas are transported in this way.

(d) IMMUNITY : Man has no natural immunity. Immunity after recovery is relative.

Environmental factors

(a) SEASON : The disease tends to die out with the onset of hot weather. Researches indicated that
the curious phenomenon of "plague season" depended primarily on the field rodent factors from
May onwards.
(b) TEMPERATURE AND HUMIDITY : A mean temperature of 20 to 25 deg C and a relative humidity
of 60 % and above are considered favourable for the spread of plague.

(c) RAINFALL : Heavy rainfall especially in the flat fields tend to flood the rat burrows.

Vectors of plague

• The commonest and the most efficient vector of plague is the rat flea, X. cheopis.

Human plague
Mode of transmission

(a) the bite of an infected flea

(b) occasionally by direct contact with the tissues of the infected animal

(c) by droplet infection from cases of pneumonic plague. There are at least 5 basic types of
transmission cycles in plague.

1. Commensal rats---rat fleas---man. This is the basic cycle in epidemic bubonic plague.

2. Wild rodents---wild rodent fleas or direct contact---man. The disease is transmitted from rodent
to rodent via wild rodent fleas or contaminated soil.

3. Wild rodents, peridomestic rodents, commensal rodents---wild rodent fleas, peridomestic rodent
fleas, commensal rodent fleas---man

4. Man---human flea (Pulex trritans)---man

5. Man---man. This results when a primary case of bubonic plague develops secondary pneumonic
plague and infects contacts via the respiratory toute.

Incubation period
(a) bubonic plague : 2 to 7 days

(b) septicaemic plague : 2 to 7 days

(c) pneumonic plague : 1to3 days

Disease in man

There are three main clinical forms :

(a) Bubonic plague : The infected rat fleas usually bite on the lower extremities and inoculate the
bacilli. The bacilli are intercepted by the regional lymphatic glands where they proliferate. Typically
the patient develops sudden fever, chills, headache, prostration and painful lymphadenitis.
(b) Pneumonic plague : Primary pneumonic plague is rare; it generally follows as a complication of
bubonic- septicaemic plague. The plague bacilli are present in the sputum.

(c) Septicaemic plague : Primary septicaemic plague is rare except for accidental laboratory
infections.

Laboratory investigations

(a) Staining : It is important to prepare smears of the clinical material (e.g., bubo fluid, sputum)
stained with Giemsa's or Wayson's stain to demonstrate bipolar bacilli.

(b) Culture : Blood for culture should be collected from all patients.

Prevention and control

1. Control of cases

(a) EARLY DIAGNOSIS : During epidemic situations, diagnosis of plague can be made readily on
clinical grounds

(b) ISOLATION : All patients with pneumonic plague including suspected cases should be isolated.

(c) TREATMENT : Streptomycin (30 mg per kg of body weight daily) administered intramuscularly in
two divided doses for 7 to 10 days. Penicillin is rather ineffective.

2. Control of fleas

The most effective method to break the chain of transmission (rodent---flea---man) is the
destruction of rat fleas by the proper application of an effective insecticide. Generally the
organochlorine insecticides remain effective for 2 to 4 months. Before spraying is to be done, the
inhabitants of premises should be asked to remove all foodstuffs and eating and cooking vessels
from their houses.

3. Control of rodents

Continuous mass destruction of rodents is an important plague-preventive measure.

4. Vaccination

Immunization with plague vaccine is a valuable preventive measure. Vaccination should be only for
the prevention, not the control of human plague. The vaccine is given subcutaneously in two doses
of 0.5 and 1.0 ml at an interval of 7 to 14 days.

5. Chemoprophylaxis

The drug of choice is tetracycline. For adults, the dose is 500 mg 6-hourly for 5 days. A cheaper
alternative is sulfonamide, 2 to 3 gram daily for 5 to 7 days.
6. Surveillance

Surveillance should cover all aspects of rodent and human plague e.g. microbiology, serology,
entomology, mammalogy, epidemiology and ecology.

7. Health education

Education should aim at providing the public with the facts about plague and at enlisting their
cooperation.

YELLOW FEVER
• Yellow fever is a zoonotic disease caused by an arbovirus. It affects principally monkeys and
other vertebrates and is transmitted to man by certain culicine mosquitoes.

Problem statement
• 45 countries in Africa and Latin America, with a combined population of more than 900
million, are at risk of yellow fever. In Africa, an estimated 508 million people live in 32
countries at risk.
• The remaining are in 13 countries of Latin America, with Bolivia, Brazil, Colombia, Ecuador
and Peru at greatest risk. There are an estimated 200,000 cases and 30,000 deaths
worldwide each year.

Epidemiological determinants
Agent factors

(a) AGENT : The causative agent, Flavivirus fibricus formerly classified as a group B arbovirus is a
member of the togavirus family.

(b) RESERVOIR OF INFECTION : In forest areas, the reservoir of infection is mainly monkeys and
forest mosquitoes.

(c) PERIOD OF COMMUNICABILITY : (i) MAN : Blood of patients is infective during the first 3 to 4
days of illness. (ii) MOSQUITOES: After an "extrinsic incubation period" of 8 to 12 days, the mosquito
becomes infective.

Host factors
(a) AGE AND SEX : All ages and both sexes are susceptible to yellow fever in the absence of
immunity

(b) OCCUPATION : Persons whose occupation brings them in contact with forests (wood cutters,
hunters).

(c) IMMUNITY : One attack of yellow fever gives lifelong immunity; second attacks are unknown.
Infants born of immune mothers have antibodies up to 6 months of life.
Environmental factors
(a) CLIMATE : A temperature of 24 deg.C or over is required for the multiplication of the virus in the
mosquito.

(b) SOCIAL FACTORS : In Africa, urbanization is leading to the extension of yellow fever.

Modes of transmission
1. Sylvatic (or jungle) yellow fever : In tropical rainforests, yellow fever occurs in monkeys that are
infected by wild mosquitoes. The infected mosquitoes bite humans entering the forest.

2. Intermediate yellow fever : Semi-domestic mosquitoes (that breed in the wild and around
households) infect both monkeys and humans.

3. Urban yellow fever : Large epidemics occur when infected people introduce the virus into densely
populated areas with a high number of non-immune people and Aedes mosquitoes.

Incubation period

• 3 to 6 days

Treatment
There is no specific treatment for yellow fever, only supportive care to treat dehydration and fever.
Associated bacterial infections can be treated with antibiotics.

Control
Jungle yellow fever : Mosquito control is difficult and can be considered only in restricted areas.
Vaccination of humans with 170 vaccine is the only control measure.

Urban yellow fever :

(1) VACCINATION : Rapid immunization of the population at risk is the most effective control
strategy for yellow fever. For international use, the approved vaccine is the 17D vaccine.

(2) VECTOR CONTROL : The vector Aedes mosquito is peri-domestic in habits. It can be controlled by
vigorous anti-adult and anti-larval measures. Such protection may include the use of repellents,
mosquito nets, mosquito coils and fumigation mats.

(3) SURVEILLANCE : A programme of surveillance (clinical, serological, histopathological and

entomological) should be instituted in countries.
Q FEVER

• Q fever is a highly infectious zoonotic disease with world- wide distribution. It occurs mainly
in persons associated with sheep, goats, cattle or other domestic animals.

Agent factors

(a) AGENT : The causative agent is Coxiella burnetii. It is found in ticks which act as vectors as well as
reservoir.

(b) ANIMAL HOSTS : Cattle, sheep, goats, ticks and some wild animals are natural reservoirs.
Infected animals shed the disease agent in the faeces and urine and heavily contaminate the soil.
The placenta of infected cows and sheep contains the infectious agent which may create infectious
aerosols during parturition. Camels, horses, dogs and many other domestic animals have been
shown to be capable of acting as maintenance hosts.

Mode of transmission

• Q fever differs from other rickettsial infections in that there is no arthropod involved in its
transmission to man. Transmission results from :

(i) inhalation of infected dust from soil previously contaminated by urine or faeces of diseased
animals. The organism can also be transmitted through aerosols.

(ii) the organism can also gain entry into the body through abrasions, conjunctivae or ingestion of
contaminated foods such as meat, milk and milk products. In most countries, the respiratory route is
regarded as most important.

Incubation period

• Usually 2 to 3 weeks.

Clinical features

• The disease has an acute onset with fever, chills, general malaise and headache. The clinical
picture is one of influenza or non-bacterial pneumonia rather than a typhus fever.
 • There is no rash or local lesion. The infection can cause pneumonia, hepatitis, encephalitis
and rarely endocarditis. Inapparent infections also occur.

Control measures

(a) TREATMENT : Chronic Q fever requires prolonged treatment for 18 months or longer.
Doxycycline is the drug of choice.

(b) PREVENTIVE MEASURES : Pasteurization or boiling of milk to inactivate the causative agent;
providing sanitary cattle sheds; adequate disinfection and disposal of products. An inactivated
Coxiella vaccine has also been prepared to protect occupationally exposed workers. Several purified
vaccines are under development.

SEXUALLY TRANSMITTED DISEASES

• The sexually transmitted diseases (STD) are a group of communicable diseases that are
transmitted predominantly by sexual contact and caused by a wide range of bacterial, viral,
protozoa! and fungal agents and ectoparasites.
• During the past few decades, STDs have undergone a dramatic transformation. First, the
change in name from venereal diseases (V.D.) to sexually transmitted diseases (STD)
indicates this transformation. The list of pathogens which are sexually transmissible has
expanded from ·the 5 "classical" venereal diseases (syphilis, gonorrhoea, chancroid,
lymphogranuloma venereum and donovanosis) to include more than 20 agent.

Problem Statement

• Sexually transmitted diseases are becoming a major public health problem in India.

(a) Syphilis : During 2013, about 33,570 cases of syphilis (18,081 male and 15,489 female) were
reported in the country with 1 death.

(b) Gonorrhoea : During 2013, about 97,180 gonorrhoea cases (31,564 male and 65,616 female)
were reported in the country.

(c) Chancroid : Chancroid or soft sore is reported to be fairly widely prevalent in India.

(d) LGV : It is reported to be more prevalent in the southern States of Tamil Nadu, Andhra Pradesh,
Maharashtra and Karnataka than in the northern States.
(e) Donovanosis: Donovanosis or granuloma inguinale is endemic in Tamil Nadu, Andhra Pradesh,
Orissa, Karnataka and Maharashtra. A greater prevalence along the coastal areas has been reported.

(f) Other STDs : Information on the other STDs is not readily available, as there is no reporting
system for these diseases.

Epidemiological determinants

Agent factors : Over 20 pathogens have been found to be spread by sexual contact.

Host factors

(a) Age : The highest rates of incidence are observed in 20-24 year-olds, followed by the 25-29 and
15-19 years age groups.

(b) Sex : The overall morbidity rate is higher for men than for women, but the morbidity caused by
infection is generally much more severe in women, as for example, pelvic inflammatory disease.

(c) Marital status : The frequency of STD infection is higher among single, divorced and separated
persons than among married couples

(d) Socio-economic status : Individuals from the lowest socio- economic groups have the highest
morbidity rate.

Demographic factors

• Certain demographic factors will undoubtedly contribute to increase in STDs in the

developing countries. These include population explosion and marked increase in the
number of young people, the group at highest risk for STD in the population; rural to urban
migration; increasing educational opportunities for women delaying their marriage and
increasing STD risks.

Social factors

(a) Prostitution : The prostitute acts as a reservoir of infection. In Asia, most STDs are contracted
from prostitutes, whereas in many developed countries, the professional prostitute has largely been
replaced by the "good-time girl". The male component of prostitution - the prostituant is equally
important.
(b) Broken homes : Social studies indicate the promiscuous women are usually drawn from broken
homes, e.g., homes which are broken either due to death of one or both parents or their separation.
The atmosphere in such homes is unhappy, and children reared in such an atmosphere are likely to
go astray in search of other avenues of happiness.

(c) Sexual disharmony : Married people with strained relations, divorced and separated persons are
often victims of STDs.

(d) Easy money : In most of the developing world, prostitution is simply a reflection of poverty. It
provides an occupation for earning easy money.

(e) Emotional immaturity

(f) Social disruption : Caused by disasters, wars and civil unrest have always caused an increase in the
spread of STDs.

(g) Alcoholism : The effect of alcohol seems to be more indirect than direct. Alcohol may encourage
prostitution and conversely, prostitution may boost the sale of alcohol.

Clinical spectrum

1. GONOCOCCAL INFECTION: Gonococcal infection causes inflammation of the genital tract involving
the urethra in men and women, the cervix and rectum in women, and the rectum in men who have
sex with men. In men, complications include inflammation of the epididymis.

2. SYPHILIS : Syphilis causes ulceration of the uro-genital tract, mouth or rectum. Congenital syphilis
is an important cause of stillbirth. The antibiotics used to treat syphilis are penicillin, doxycycline and
erythromycin.

3. CHLAMYDIAL INFECTION : If symptoms occur they are similar to those caused by gonorrhoea. In
men it can cause urethritis with possible epididymitis. The antibiotics used are doxycycline or
azithromycin.

4. TRICHOMONIASIS : This parasitic infection leads to vaginitis and vaginal discharge in women.
Usually, there are no symptoms. In most men there are no symptoms but it may cause urethritis.

5. CHANCROID : After infection a small papule develops at the site of inoculation, normally within 2-
3 days. The lesion then erodes into a deep ulcer that is extremely painful.
6. LYMPHOGRANULOMA VENEREUM : It commonly presents with swelling of lymph nodes in the
groin. Although initially there is a small, painless ulcer of the genitalia 3-30 days after exposure.

7. DONOVANOSIS : Synonyms are granuloma inguinale, granuloma venereum. The first

manifestation, appearing after a 3-40 days incubation period, is usually a small papule which
ruptures to form a granulomatous lesion that is characteristically pain free and bleeds readily on
contact, often elevated above the level of the surrounding skin.

8. GENITAL HERPES : Classical genital herpes can be recognized by the presence of typical papular
lesions that progress to multiple blisters and ulcers.

9. HUMAN PAPILLOMA VIRUS : Human papilloma virus (HPV) causes ano-genital warts, which vary
from the common soft, flesh-coloured protuberances which may become exuberant (cauliflower
like) to papular flat warts on drier areas (eg. shaft of penis).

Control of STDs

• The aim of the control programme for STDs is the prevention of ill-health resulting from the
above conditions through various interventions.

1. INITIAL PLANNING

• The disease problem must be defined in terms of prevalence, psychosocial consequences

and other health effects - by geographic areas and population groups, with the aid of sero-
epidemiological surveys and population surveys.

• Rational planning requires establishment of priorities. This will depend upon health problem
considerations (e.g., magnitude, consequences) and feasibility of control (e.g., availability of
adequate resources, social and political commitment).
• Priorities must be converted into discrete, achievable and measurable objectives. That is, to
reduce the magnitude of the problem, in a given population and a stated time.
• A variety of intervention strategies are available. Planners must define the mixture of
strategies that appears to be most appropriate to the setting.

2. INTERVENTION STRATEGIES

(a) SCREENING : Screening is the testing of apparently healthy volunteers from the general
population for the early detection of disease. High priority is given to screening of special groups, viz.
pregnant women, blood donors, industrial workers, army, police, refugees, prostitutes, convicts,
restaurant and hotel staff etc.

(b) CONTACT TRACING : Contact tracing is the term used for the technique by which the sexual
partners of diagnosed patients are identified, located, investigated, and treated. The key to success
in contact tracing is the patient himself who must disclose all sex contacts voluntarily.

(c) CLUSTER TESTING : Here the patients are asked to name other persons of either sex who move in
the same socio-sexual environment.

(d) Personal prophylaxis (i) Contraceptives : Mechanical barriers (e.g., condoms and the diaphragms)
can be recommended for personal prophylaxis against STDs. These barrier methods, especially when
used with spermicides, will minimize the risk of acquiring STD infections. The exposed parts should
be washed with soap and water as soon after contact as possible.

(ii) Vaccines : The development of a vaccine for hepatitis B has raised hopes that vaccines will be
found for other STDs.

3. SUPPORT COMPONENTS

a. STD clinic : The starting point for the control of STDs is the establishment of STD clinics where all
consultation, investigations and treatment, contact tracing and all other relevant services are
available. An ideal service is one that is free, easily accessible to patients and available for long hours
each day.

b. Laboratory services : Adequate laboratory facilities and trained staff are essential for proper
patient management. It provides a basis for correct aetiological diagnosis and treatment decisions;
for contact tracing; surveillance of morbidity and detection of antimicrobial resistance.

c. Primary health : This will imply inclusion of primary health care workers (e.g., village health guides,
multipurpose workers) in the STD "health team".

d. Information system : The basis of an effective control programme of any communicable disease is
the existence of an information system.

e. Legislation : The Immoral Traffic (Prevention) Act, 1986 (which replaced the earlier Suppression of
the Immoral Traffic Act, 1956) covers all persons, whether male or female, who are exploited
sexually for commercial purposes.
f. Social welfare measures : It implies there should be "social therapy" which would prevent or
control the conditions leading to promiscuity and STDs.

4. MONITORING AND EVALUATION

A critical aspect of effective management is the monitoring of disease trends and evaluating
programme activities. Evaluation will show if the activities have been performed in a satisfactory
way.

CHD
• Coronary heart disease (syn : ischaemic heart disease) has been defined as impairment of
heart function due to inadequate blood flow to the heart compared to its needs, caused by
obstructive changes in the coronary circulation to the heart.
• CHD may manifest itself in many presentations :

a. angina pectoris

b. myocardial infarction

c. irregularities of the heart

d. cardiac failure

e. sudden death

Epidemicity

• The reasons for the changing trends in CHD are not precisely known. The WHO has
completed a project known as MONICA "(multinational monitoring of trends and
determinants in cardiovascular diseases)" to elucidate this issue.
• In India Coronary heart disease is assuming serious dimension in developing countries. It is
expected to be the single most important cause of death in India by the year 2015.
• There is a considerable increase in prevalence of CHD in urban areas in India during the last
decade. Although there is increase in prevalence of CHD in rural areas also, but it is not that
steep because life-style changes have affected people in urban areas more than in rural
areas.
 • In urban areas the pooled estimate was 6.1 per cent for males and 6.7 percent for females.
In rural areas the estimate was 2.1 per cent for males and 2.7 percent for females.

Risk factors

• The aetiology of CHD is multifactorial. Apart from the obvious ones such as increasing age
and male sex, studies have identified several important "risk" factors (i.e., factors that make
the occurrence of the disease more probable).

1. Smoking

• Some people commit suicide by drowning, but many by smoking.

• A uniquely human habit, smoking has been identified as a major CHD risk factor with several
possible mechanisms carbon monoxide induced atherogenesis, nicotine stimulation of
adrenergic drive raising both blood pressure and myocardial oxygen demand, lipid
metabolism with fall in "protective" high-density lipoproteins, etc.

• Cigarettes seem to be particularly important in causing sudden death from CHD especially in
men under 50 years of age.

2. Hypertension

• The blood pressure is the single most useful test for identifying individuals at a high risk of
developing CHD.
• Hypertension accelerates the atherosclerotic process, especially if hyperlipidaemia is also
present and contributes importantly to CHD. The risk role of "mild" hypertension is generally
accepted.

3. Serum cholesterol

• It is nearly three decades since it became clear that elevation of serum cholesterol was one
of the factors which carried an increased risk for the development of myocardial infarction.
• Today, there is a vast body of evidence showing a triangular relationship between habitual
diet, blood cholesterol-lipoprotein levels and CHD, and that these relationships are judged to
be causal.
• When we look at the various types of. lipoproteins, it is the level of low-density lipoprotein
(LOL) cholesterol that is most directly associated with CHD.
4. Other risk factors

(i) Diabetes : The risk of CHO is 2-3 times higher in diabetics than in non-diabetics.

(ii) Genetic factors : A family history of CHO is known to increase the risk of premature death.

(iii) Physical activity : Sedentary life-style is associated with a greater risk of the development of early
CHD.

(iv) Hormones : It has been hypothesized that hyperestrogenemia may be the common underlying
factor that leads both to atherosclerosis and its complications such as CHD, stroke and peripheral
vascular disease.

(v) Alcohol : High alcohol intake, defined as 75 g or more per day is an independent risk factor for
CHD, hypertension and all cardiovascular diseases.

(vi) Miscellaneous : The possible role of dietary fibre, sucrose and soft water have been debated.
Dyspnoea on exertion and low vital capacity have also been cited as possible risk factors.

PREVENTION OF CHD

A. Population strategy

• CHD is primarily a mass disease. The strategy should therefore be based on mass approach
focusing mainly on the control of underlying causes (risk factors) in whole populations, not
merely in individuals.

1. Dietary changes : Dietary modification is the principal preventive strategy in the prevention of
CHO. Reduction of fat intake to 20-30 per cent of total energy intake consumption, reduction of
dietary cholesterol to below 100 mg per 1000 kcal per day, incr ease in complex carbohydrate
consumption (i.e., vegetables, fruits, whole grains and legumes), avoidance of alcohol consumption,
reduction of salt intake to 5 g daily or less.

2. Smoking : The goal should be to achieve a smoke-free society, and several countries are
progressing towards this goal.

3. Blood pressure : It has been estimated that even a small reduction in the average blood pressure
of the whole population by a mere 2 or 3 mm Hg would produce a large reduction in the incidence of
cardiovascular complications. This involves a multifactorial approach based on a "prudent diet"
(reduced salt intake and avoidance of a high alcohol intake), regular physical activity and weight
control.

4. Physical activity : Regular physical activity should be a part of normal daily life.

B. High risk strategy

(i) Identifying risk : Simple tests such as blood pressure and serum cholesterol measurement it is
possible to identify individuals at special risk. Individuals at special risk also include those who
smoke, those with a strong family history of CHD, diabetes and obesity and young women using oral
contraceptives.

(ii) Specific advice : Having identified those at high risk, the next step will be to bring them under
preventive care and motivate them to take positive action against all the identified risk factors, e.g.,
an elevated blood pressure should be treated; the patient should be helped to break the smoking
habit permanently nicotine chewing gum can be tried to wean patients from smoking.

C. Secondary prevention

• The aim of secondary prevention is to prevent the recurrence and progression of CHO.
Secondary prevention is a rapidly expanding field with much research in progress (e.g., drug
trials, coronary surgery, use of pace makers).
• The most promising results to date have come from beta-blockers which appear to reduce
the risk of CHD mortality in patients who have already suffered at least one infarct in the
order of 25 percent. For example, cessation of smoking is the most effective single means of
intervention currently available in the management of patients after a heart attack.

DIABETES MELLITUS
• Diabetes is now seen as a heterogeneous group of diseases, characterized by a state of
chronic hyperglycemia, resulting from a diversity of aetiologies, environmental and genetic,
acting jointly.

• The underlying cause of diabetes is the defective production or action of insulin, a hormone
that controls glucose, fat and amino acid metabolism.
• Characteristically, diabetes is a long-term disease with variable clinical manifestations and
progression.
Classification

1. Diabetes mellitus (DM)

i) Type 1 or Insulin-dependent diabetes mellitus
ii) Type 2 or Non-insulin dependent diabetes mellitus
iii) Malnutrition-related diabetes mellitus (MRDM)
iv) Other types (secondary to pancreatic, hormonal, drug-induced, genetic and other abnormalities)
2. Impaired glucose tolerance (IGT)
3. Gestational diabetes mellitus (GDM)

Problem statement

• Diabetes is an "iceberg" disease. The population in India has an increased susceptibility to

diabetes mellitus.
• This propensity was demonstrated by multiple surveys of migrant Indians residing in Fiji,
Singapore, South Africa, U.K. and USA.
• The rates of diabetes in migrants from the Indian subcontinent have consistently shown to
exceed those of the local population. During the year 2004, there were an estimated 37.7
million cases of diabetes in the country, of these 21.4 million were in urban areas and 16.3
million in rural areas.

Epidemiological determinants

AGENT FACTORS

(a) pancreatic disorders - inflammatory, neoplastic and other disorders such as cystic fibrosis

(b) defects in the formation of insulin, e.g., synthesis of an abnormal, biologically less active insulin
molecule

(c) destruction of beta cells (e.g. viral infections and chemical agents)

(d) decreased insulin sensitivity, due to decreased numbers of adipocyte and monocyte insulin
receptors

(e) genetic defects (e.g. mutation of insulin gene)

(f) auto- immunity

HOST FACTORS

(a) AGE : Although diabetes may occur at any age, surveys indicate that prevalence rises steeply with
age. Type 2 diabetes usually comes to light in the middle years of life and thereafter begins to rise in
frequency.

(b) SEX : In some countries (e.g. UK) the overall male-female ratio is about equal.

(c) GENETIC FACTORS: The genetic nature of diabetes is undisputed.

(d) GENETIC MARKERS :Type 1 diabetes is associated with HLA-B8 and B15, and more powerfully
with HLA-DR3 and DR4. The highest risk of type 1 diabetes is carried by individuals with both DR3
and DR4. On the other hand type 2 diabetes is not HLA-associated.

(e) OBESITY: Obesity particularly central adiposity has long been accepted as a risk factor for type 2
diabetes.

(f) MATERNAL DIABETES : Offsprings of diabetic pregnancies including gestational diabetes are often
large and heavy at birth, tend to develop obesity in childhood and are at high risk of developing type
2 diabetes at an early age.

ENVIRONMENTAL RISK FACTORS

(a) SEDENTARY LIFESTYLE : Sedentary life style appears to be an important risk factor for the
development of type 2 diabetes.

(b) DIET : A high saturated fat intake has been associated with a higher risk of impaired glucose
tolerance, and higher fasting glucose and insulin levels.

(c) DIETARY FIBRE : High intakes of dietary fibre have been shown to result in reduced blood glucose
and insulin levels in people with type 2 diabetes and impaired glucose tolerance.

(d) MALNUTRITION : Damage to beta cells may well explain the associated impaired carbohydrate
tolerance in kwashiorkor.

(e) ALCOHOL

(f) VIRAL INFECTIONS: Among the viruses that have been implicated are rubella, mumps, and human
coxsackie virus B4.
(g) STRESS : Surgery, trauma, and stress of situations, internal or external, may "bring out" the
disease.

SCREENING FOR DIABETES

1. Urine examination

Urine test for glucose, 2 hours after a meal, is commonly used in medical practice for detecting cases
of diabetes. All those with glycosuria are considered diabetic unless otherwise proved by a standard
oral glucose tolerance test.

2. Blood sugar testing

Because of the inadequacies of urine examination, "standard oral glucose test" remains the
cornerstone of diagnosis of diabetes.

PREVENTION

1. Primary prevention

A. POPULATION STRATEGY

• The development of prevention programmes for type 2 diabetes based on elimination of

environmental risk factors is possible.
• The preventive measures comprise maintenance of normal body weight . through adoption
of healthy nutritional habits and physical exercise.
• The nutritional habits include an adequate protein intake, a high intake of dietary fibre and
avoidance of sweet foods.

B. HIGH-RISK STRATEGY

• There is no special high-risk strategy for type 1 diabetes. Since NIDDM appears to be linked
with sedentary life- style, over-nutrition and obesity, correction of these may reduce the risk
of diabetes and its complications.
• Since alcohol can indirectly increase the risk of diabetes, it should be avoided.

2. Secondary prevention

(a) diet alone - small balanced meals more frequently

(b) diet and oral antidiabetic drugs

(c) diet and insulin.

Glycosylated haemoglobin : There should be an estimation of glycated {glycosylated) haemoglobin

at half-yearly intervals. This test provides a long-term index of glucose control.

3. Tertiary prevention

• Diabetes is major cause of disability through its complications, e.g., blindness, kidney failure,
coronary thrombosis, gangrene of the lower extremities, etc.

• The main objective at the tertiary level is to organize specialized clinics (Diabetic clinics) and
units capable of providing diagnostic and management skills of a high order.

HYPERTENSION
• Hypertension is a chronic condition of concern due to its role in the causation of coronary
heart disease, stroke and other vascular complications. It is one of the major risk factors for
cardiovascular mortality, which accounts for 20-50 per cent of all deaths.

• Sir George Peckering first fomulated a concept that blood pressure in a population is
distributed continuously as a bell-shaped curve with no real separation between
normotension and hypertension

Classification

• Hypertension is classified as "essential" when the causes are generally unknown. Essential
hypertension is the most prevalent form of hypertension accounting for 90 per cent of all
cases of hypertension.

• Hypertension is classified as "secondary" when some other disease process or abnormality is

involved in its causation.

Prevalence in India

• A community based survey was carried out by ICMR in the states of Andhra Pradesh, Kerala,
Madhya Pradesh, Maharashtra, Uttarakhand, Tamil Nadu and Mizoram. According to the
 survey report, the prevalence of hypertension was varying from 17 to 21 per cent in all the
states with marginal rural-urban differences.

Risk factors

1. Non-modifiable risk factors

(a) AGE : Blood pressure rises with age in both sexes and the rise is greater in those with higher
initial blood pressure. These communities are for the most part primitive societies with calorie
and often salt intakes at subsistence level.

(b) SEX : Early in life there is little evidence of a difference in blood pressure between the sexes.
However, at adolescence, men display a higher average level.

(c) GENETIC FACTORS : The evidence is based on twin and family studies. Twin studies have
confirmed the importance of genetic factors in hypertension. The blood pressure values of
monozygotic twins are usually more strongly correlated than those of zygotic twins.

(d) ETHNICITY : Population studies have consistently revealed higher blood pressure levels in black
communities than other ethnic groups.

2. Modifiable risk factors

(a) OBESITY

(b) SALT INTAKE : There is an increasing body of evidence to the effect that a high salt intake (i.e., 7-8
g per day} increases blood pressure proportionately.

(c) SATURATED FAT : Saturated fat raises blood pressure as well as serum cholesterol

(d) DIETARY FIBRE : Several studies indicate that the risk of CHD and hypertension is inversely related
to the consumption of dietary fibre.

(e) ALCOHOL

(f) PHYSICAL ACTIVITY : Physical activity by reducing body weight may have an indirect effect on
blood pressure.

(h) ENVIRONMENTAL STRESS

(i) OTHER FACTORS : The commonest present cause of secondary hypertension is oral contraception,
because of the oestrogen component in combined preparations. Other factors such as noise,
vibration, temperature and humidity require further investigation.

PREVENTION

1. PRIMARY PREVENTION

• Primary prevention has been defined as "all measures to reduce the incidence of disease in a
population by reducing the risk of onset". The earlier the prevention starts the more likely it
is to be effective.

a. POPULATION STRATEGY : The concept of population approach is based on the fact that even a
small reduction in the average blood pressure of a population would produce a large reduction in
the incidence of cardiovascular complications such as stroke and CHD

(1) NUTRITIO N : (i) reduction of salt intake to an average of not more than 5 g per day (ii) moderate
fat intake (iii) the avoidance of a high alcohol intake (iv) restriction of energy intake appropriate
to body needs.

(2) WEIGHT REDUCTION : The prevention and correction of over weight/obesity {Body Mass Index
greater than 25)

(3) EXERCISE PROMOTION : The evidence that regular physical activity leads to a fall in body weight,
blood lipids and blood.

(4) BEHAVIOURAL CHANGES : Reduction of stress and smoking, modification of personal life-style,
yoga and transcendental meditation could be profitable.

(5) HEALTH EDUCATION

b. HIGH-RISK STRATEGY

• The aim of this approach is "to prevent the attainment of levels of blood pressure at which
the institution of treatment would be considered"
2. SECONDARY PREVENTION

• The goal of secondary prevention is to detect and control high blood pressure in affected
individuals. Modern anti- hypertensive drug therapy can effectively reduce high blood
pressure

(i) EARLY CASE DETECTION : This is because high blood pressure rarely causes symptoms until
organic damage has already occurred, and our aim should be to control it before this happens.

(ii) TREATMENT : The aim of treatment should be to obtain a blood pressure below 140/90, and
ideally a blood pressure of 120/80. Control of hypertension has been shown to reduce the
incidence of stroke and other complications. Care of hypertensives should also involve attention
to other risk factors such as smoking and elevated blood cholesterol levels.

CANCER
• Cancer may be regarded as a group of diseases characterized by an

(i) abnormal growth of cells

(ii) ability to invade adjacent tissues and even distant organs

(iii)the eventual death of the affected patient if the tumour has progressed beyond that stage when
it can be successfully removed.

• The major categories of cancer are :

(a) Carcinomas, which arise from epithelial cells lining the internal surfaces of the various organs
(e.g. mouth, oesophagus, intestines, uterus) and from the skin epithelium

(b) Sarcomas, which arise from mesodermal cells constituting the various connective tissues

(c) Lymphomas, myeloma and leukaemias arising from the cells of bone marrow and immune
systems.

• The term "primary tumour" is used to denote cancer in the organ of origin, while "secondary
tumour" denotes cancer that has spread to regional lymph nodes and distant organs.
Problem statement

• In India, the National Cancer Registry Programme of the ICMR provides data on incidence,
mortality and distribution of cancer from 25 population-based registries and 5 hospital
based registries.

• It gives an incidence rate of 92.4 per lac population. Same year about 6.83 lac persons died
of cancer, (3.57 lac males and 3.26 lac females), a mortality rate of 69. 7 per lac population

Time trends

• Few decades ago, cancer was the sixth leading cause of death in industrialized countries;
today, it is the second leading cause of death. There are a number of reasons for this
increase, the three main ones being a longer life expectancy, more accurate diagnosis and
the rise in cigarette smoking, especially among males.

Cancer patterns

There are wide variations in the distribution of cancer throughout the world. That cancer of the
stomach is very common in Japan, and has a low incidence in United States. The cervical cancer is
high in Columbia and has a low incidence in Japan. In the South-East Asia, the great majority are
cancers of the oral cavity and uterine cervix.

1. ENVIRONMENTAL FACTORS

(a) TOBACCO: Tobacco in various forms of its usage (e.g., smoking, chewing) is the major
environmental cause of cancers of the lung, larynx, mouth, pharynx, oesophagus, bladder,
pancreas and probably kidney.

(b) ALCOHOL : Excessive intake of alcoholic beverages is associated with oesophageal and liver
cancer.

(c) DIETARY FACTORS : Dietary factors are also related to cancer. Smoked fish is related to stomach
cancer, dietary fibre to intestinal cancer, beef consumption to bowel cancer and a high fat diet to
breast cancer.

(d) OCCUPATIONAL EXPOSURES : These include exposure to benzene, arsenic, cadmium, chromium,
vinyl chloride, asbestos, polycyclic hydrocarbons, etc.
(e) VIRUSES: An intensive search for a viral origin of human cancers revealed that hepatitis B and C
virus is causally related to hepatocellular carcinoma.

(f) PARASITES : Parasitic infections may also increase the risk of cancer, as for example,
schistosomiasis in Middle East producing carcinoma of the bladder.

(g) OTHERS : There are numerous other environmental factors such as sunlight, radiation, air and
water pollution, medications (e.g., oestrogen) and pesticides which are related to cancer.

2. GENETIC FACTORS

• Genetic influences have long been suspected. For example, retinoblastoma occurs in
children of the same parent.

• Mongols are more likely to develop ·cancer (leukaemia) than normal children. However,
genetic factors are less conspicuous and more difficult to identify.

Cancer control

1. PRIMARY PREVENTION

(a) CONTROL OF TOBACCO AND ALCOHOL CONSUMPTION

(b) PERSONAL HYGIENE

(c) RADIATION

(d) OCCUPATIONAL

(e) IMMUNIZATION: In the case of primary liver cancer, immunization against hepatitis B virus and
for prevention of cancer cervix immunization against HPV presents an exciting prospect.

(f)FOODS, DRUGS AND COSMETICS

2. SECONDARY PREVENTION

(i) CANCER REGISTRATION : It provides a base for assessing the magnitude of the problem and for
planning the necessary services. Cancer registries are basically of two types : hospital-based and
population based.

(a) HOSPITAL- BASED REGISTRIES

(b) POPULATION-BASED REGISTRIES

(ii) EARLY DETECTION OF CASES : Cancer screening is the main weapon for early detection of cancer
at a pre-invasive (in situ) or pre.-malignant stage. Effective screening programmes have been
developed for cervical· cancer, breast cancer and oral cancer.

(iii) TREATMENT : Treatment facilities should be available to all cancer patients. Certain forms of
cancer are amenable to surgical removal, while some others respond favourably to radiation or
chemotherapy or both. For those who are beyond the curable stage, the goal must be to provide
pain relief. A largely neglected problem in cancer care is the management of pain.

OBESITY
• Obesity may be defined as an abnormal growth of the adipose tissue due to an enlargement
of fat cell size (hypertrophic obesity) or an increase in fat cell number (hyperplastic obesity)
or a combination of both. Obesity is often expressed in terms of body mass index (BMI).
• The distribution of fat induced by the weight gain affects the risk associated with obesity as
a result of "abdominal fat distribution" or "android obesity" from those with the less serious
"gynoid" fat distribution in which fat distributed around the body.

Prevalence
• Obesity is perhaps the most prevalent form of malnutrition affecting children as well as
adults.
• Overweight and obesity are the fifth leading risk of global deaths.
• Worldwide, obesity has more than doubled since 1980. In 2008 more than 1.4 billion adults
20 years and older were overweight. Of these over 200 million men and nearly 300 million
women were obese.

Epidemiological determinants
(a) AGE : Obesity can occur at any age, and generally increases with age. Hyperplastic obesity in
adults is extremely difficult to treat.

(b) SEX : Women generally have higher rate of obesity than men.

(c) GENETIC FACTORS : Twin studies have shown a close correlation between the weights of identical
twins even when they are reared in dissimilar environments.

(d) PHYSICAL INACTNITY : There is convincing evidence that regular physical activity is protective
against unhealthy weight gain. Sedentary lifestyle particularly sedentary occupation and inactive
recreation related to overweight and obesity.

(e) SOCIO-ECONOMIC STATUS : There is a clear inverse relationship between socio-economic status
and obesity.
(f) EATING HABITS : Eating habits (e.g., eating in between meals, preference to sweets, refined foods
and fats) are established very early in life.

(g) PSYCHOSOCIAL FACTORS : Psychosocial factors (e.g., emotional disturbances) are deeply
involved in the aetiology of obesity.

(h) FAMILIAL TENDENCY : Obesity frequently runs in families (obese parents frequently having obese
children), but this is not necessarily explained solely by the influence of genes.

• Body mass index (BMI) is a simple index of weight for height that is commonly used to
classify underweight, overweight and obesity in adults. It is defined as the weight in
kilograms divided by the square of the height in metres (kg/m2). For example, an adult who
weighs 70 kg and whose height is 1. 75 m will have a BMI of 22.9
o BMI = 70 (kg)/l. 75 2 (m2) = 22.9

CLASSIFICATION BMI

Underweight < 18.50

Normal range 18.50-24.99

Overweight ≥25.00

Pre-obese 25.00-29.99

Obese class I 30.00-34.99

Obese class II 35.00-39.99

Obese class III ≥40.00

Prevention and control

Prevention of obesity should begin in early childhood. Obesity is harder to treat in adults than it is in
children.

(a) DIETARY CHANGES : The following dietary principles apply both to prevention and treatment : the
proportion of energy-dense foods such as simple carbohydrates and fats should be reduced; the
fibre content in the diet should be increased.

(b) INCREASED PHYSICAL ACTIVITY : Regular physical exercise is the key to an increased energy
expenditure.

(c) OTHERS: Appetite suppressing drugs have been tried in the control of obesity.

TAENIASIS
• A group of cestode infections which are important zoonotic diseases. Two parasites of
importance in taeniasis are Taenia saginata and T. solium. Commom name is Tapeworm.
Problem statement
(a) T. SAGINATA : This parasite is virtually global in distribution wherever beef is eaten. There is a
moderate prevalence in Europe, in most of the Indian subcontinent, Southern Asia, and in Japan.
Australia, Canada and USA are generally regarded as low endemic areas.

(b) T. SOLIUM : T. solium infection is endemic in many countries of Latin America, Africa and Asia as
well as in some parts of Europe and the USSR.

Mode of transmission
(a) through the ingestion of infective cysticerci in undercooked beef

(b) through ingestion of food, water or vegetables contaminated with eggs

(c) reinfection by the transport of eggs from the bowel to the stomach by retroperistalsis

Incubation period
• For the adult tapeworm, from 8 to 14 weeks.

Clinical illness
• They do not lead to clinical ill health, except occasional abdominal discomfort, anorexia and
chronic indigestion. Straying of proglottids may sporadically cause appendicitis or
cholangitis.

Control measures
(a) treatment of infected persons

(b) meat inspection

(c) health education

(d) adequate sewage treatment and disposal

Treatment
• Praziquantel and niclosamide have replaced former taenicides. They are safe and effective in
more than 90 % of patients.
• Praziquantel is given in a single dose of 10 mg/kg body wt. With a single dose of 4 tablets (2
grams) of niclosamide cure rates are over 90 %. This drug is given in the morning-empty
stomach. The tablets must be chewed thoroughly and swallowed with water.
OCCUPATIONAL HAZARDS
1. Physical hazards

(a) HEAT AND COLD :

• The common physical hazard in most industries is heat. The direct effects of heat exposure
are burns, heat exhaustion, heat stroke and heat cramps.
• The indirect effects are decreased efficiency, increased fatigue and enhanced accident rates.
Many industries have local "hot spots" ovens and furnaces, which radiate heat.
• Radiant heat is the main problem in foundry, glass and steel industries, while heat
stagnation is the principal problem in jute and cotton textile industry.
• Physical work under such conditions is very stressful and impairs the health and efficiency of
the workers. For gainful work involving sustained and repeated effort, a reasonable
temperature must be maintained in each work room.

• The work of Rao (1952, 1953) and Mookerjee et al. (1953) indicate that a corrected effective
temperature of 69 to 80 deg. F (20°C to 27°C) is the comfort zone in this country and
temperatures above 80 deg. F (27°C) cause discomfort.
• Important hazards associated with cold work are chilblains, erythrocyanosis, immersion foot,
and frostbite as a result of cutaneous vasoconstriction.

(b) LIGHT :

• The workers may be exposed to the risk of poor illumination or excessive brightness. The
acute effects of poor illumination are eye strain, headache, eye pain, lachrymation,
congestion around the cornea and eye fatigue.
• The chronic effects on health include "miner's nystagmus". Exposure to excessive brightness
or "glare" is associated with discomfort, annoyance and visual fatigue.

• Intense direct glare may also result in blurring of vision and lead to accidents. There should
be sufficient and suitable lighting, natural or artificial, wherever persons are working.

(c) NOISE :

(i) Auditory effects which consist of temporary or permanent hearing loss.

(ii) Non-auditory effects which consist of nervousness, fatigue, interference with communication by
speech, decreased efficiency and annoyance.
(d) VIBRATION :

• Vibration, especially in the frequency range 10 to 500 Hz, may be encountered in work with
pneumatic tools such as drills and hammers.

• Vibration usually affects the hands and arms. After some months or years of exposure, the
fine blood vessels of the fingers may become increasingly sensitive to spasm (white fingers).

(e) ULTRAVIOLET RADIATION :

• Occupational exposure to ultraviolet radiation occurs mainly in arc welding. Such radiation
mainly affects the eyes, causing intense conjunctivitis and keratitis (welder's flash).
• Symptoms are redness of the eyes and pain, these usually disappear in a few days with no
permanent effect on the vision or on the deeper structures of the eye.

(f) IONIZING RADIATION :

• Ionizing radiation is finding increasing application in medicine and industry, e.g. X-rays and
radio-active isotopes. Important radio-isotopes are cobalt 60 and phosphorus 32.
• Certain tissues such as bonemarrow are more sensitive than others and from a genetic
standpoint, there are special hazards when the gonads are exposed.
• The radiation hazards comprise genetic changes, malformation, cancer, leukaemia,
depilation, ulceration, sterility and in extreme cases death.

2. Chemical hazards

(a) LOCAL ACTION :

• Some chemicals cause dermatitis, eczema, ulcers and even cancer by primary irritant action;
some cause dermatitis by an allergic action.
• Some chemicals, particularly the aromatic nitro and amino compounds such as TNT and
aniline are absorbed through the skin and cause systemic effects. Occupational dermatitis is
a big problem in industry.

(b) INHALATION :

(i) DUSTS :
 • Dusts are finely divided solid particles with size ranging from 0.1 to 150 microns. They are
released into the atmosphere during crushing, grinding, abrading, loading and unloading
operations.
• Dusts are produced in a number of industries mines, foundry, quarry, pottery, textile, wood
or stone working industries.

• Dust particles larger than 10 microns settle down from the air rapidly, while the smaller ones
remain suspended indefinitely.

• Particles smaller than 5 microns are directly inhaled into the lungs arid are retained there.
This fraction of the dust is called "respirable dust".

(ii) GASES :

• Gases are sometimes classified as simple gases (e.g., oxygen, hydrogen), asphyxiating gases
(e.g. carbon monoxide, cyanide gas, sulphur dioxide, chlorine) and anaesthetic gases (e.g.,
chloroform, ether, trichlorethylene). Carbon monoxide hazard is frequently reported in coal-
gas manufacturing plants and steel industry.

(iii) METALS AND THEIR COMPOUNDS :

• A large number of metals, and their compounds are used throughout the industry. The chief
mode of entry of some of them is by inhalation as dust or fumes.
• The ill-effects depend upon the duration of exposure and the dose or concentration of
exposure. Unlike the pneumoconiosis, most chemical intoxications respond favourably to
cessation, exposure and medical treatment.

(c) INGESTION :

• Usually these substances are swallowed in minute amounts through contaminated hands,
food or cigarettes.
• Much of the ingested material is excreted through faeces and only a small proportion may
reach the general blood circulation.

3. Biological hazards

• The occupational diseases in this category are brucellosis, leptospirosis, anthrax, hydatidosis,
psittacosis, tetanus, encephalitis, fungal infections, schistosomiasis and a host of others.
• Persons working among animal products (e.g., hair, wool, hides) and agricultural workers are
specially exposed to biological hazards.
4. Mechanical hazards

• The mechanical hazards in industry centre round machinery, protruding and moving parts
and the like. About 10 percent of accidents in industry are said to be due to mechanical
causes.

5. Psychosocial hazards

• Frustration, lack of job satisfaction, insecurity, poor human relationships, emotional tension
are some of the psychosocial factors which may undermine both physical and mental health
of the workers.
• The capacity to adapt to different working environments is influenced by many factors such
as education, cultural background, family life, social habits, and what the worker expects
from employment.

• The health effects can be classified in two main categories: (a) Psychological and behavioural
changes : including hostility, aggressiveness, anxiety, depression, tardiness, alcoholism, drug
abuse, sickness, absenteeism (b) Psychosomatic ill health : including fatigue, headache; pain
in the shoulders, neck and back; propensity to peptic ulcer, hypertension, heart disease and
rapid aging.

OCCUPATIONAL DISEASES
• Occupational diseases are usually defined as diseases arising out of or in the course of
employment.

I. Diseases due to physical agents

(1) Heat : Heat hyperpyrexia, heat exhaustion, heat syncope, heat cramps, burns and local effects
such as prickly heat

(2) Cold : Trench foot, frost bite, chilblains

(3) Light : Occupational cataract, miner's nystagmus

(4) Pressure: Caisson disease, air embolism, blast (explosion)

(5) Noise : Occupational deafness

(6) Radiation : Cancer, leukaemia, aplastic anaemia, pancytopenia

(7) Mechanical : Injuries, accidents factors

(8) Electricity : Burns.

II. Diseases due to chemical agents

(1) Gases: CO 2 CO, HCN, CS2, NH3, N2, H2S, HCI, SO 2

(2) Dusts (Pneumoconiosis)

(i) Inorganic dusts :

(a) Coal dust---Anthracosis

(b) Silica ---Silicosis

(c) Asbestos---Asbestosis, cancer lung

(d) Iron---Siderosis

(ii) Organic (vegetable) dusts

(a) Cane fibre---Bagassosis

(b) Cotton dust--- Byssinosis

(c) Tobacco--- Tobacossis

(d) Hay or grain dust--- Farmers' lung

(3) Metals and their compounds : Toxic hazards from lead, mercury, cadmium, manganese,
beryllium, arsenic, chromium etc.

(4) Chemicals : Acids, alkalies, pesticides

(5) Solvents : Carbon bisulphide, benzene, trichloroethylene, chloroform, etc.

III. Diseases due to biological agents : Brucellosis, leptospirosis, anthrax, actinomycosis, hydatidosis,
psittacosis, tetanus, encephalitis, fungal infections, etc.

IV. Occupational cancers : Cancer of skin, lungs, bladder.

V. Occupational dermatosis : Dermatitis, eczema.

VI. Diseases of psychological origin : Industrial neurosis, hypertension, peptic ulcer, etc.

PNEUMOCONIOSIS
• Dust within the size range of 0.5 to 3 micron, is a health hazard producing, after a variable
period of exposure, a lung disease known as pneumoconiosis.
 • The hazardous effects of dusts on the lungs depend upon a number of factors such as (a)
chemical composition (b) fineness (c) concentration of dust in the air (d) period of exposure
and (e) health status of the person exposed.
• The important dust diseases are silicosis, anthracosis, byssinosis, bagassosis, asbestosis and
farmer's lung.

1. Silicosis

• Among the occupational diseases, silicosis is the major cause of permanent disability and
mortality. It is caused by inhalation of dust containing free silica or silicon dioxide (Si02).
• It was first reported in India from the Kolar Gold Mines (Mysore) in 1947. Ever since, its
occurrence has been uncovered in various other industries, e.g., mining industry (coal, mica,
gold, silver, lead, zinc, manganese and other metals), pottery and ceramic industry, sand
blasting, metal grinding, building and construction work, rock mining, iron and steel industry
and several others.
• The incidence of silicosis depends upon the chemical composition of the dust, size of the
particles, duration of exposure and individual susceptibility.

• The higher the concentration of free silica in the dust, the greater the hazard. Particles
between 0.5 to 3 micron are the most dangerous because they reach the interior of the
lungs with ease.
• The longer the duration of exposure, the greater the risk of developing silicosis. It is found
that the incubation period may vary from a few months up to 6 years of exposure.
• The particles are ingested by the phagocytes which accumulate and block the lymph
channels. Pathologically, silicosis is characterized by a dense "nodular" fibrosis, the nodules
ranging from 3 to 4 mm in diameter. Clinically the onset of the disease is insidious.

• Some of the early manifestations are irritant cough, dyspnea· on exertion and pain in the
chest. With more advanced disease, impairment of total lung capacity (TLC) is commonly
present. An X-ray of the chest shows "snow-storm" appearance in the lung fields.
• There is no effective treatment for silicosis. Fibrotic changes that have already taken place
cannot be reversed. The only way that silicosis can be controlled (if not altogether
eliminated) is by (a) rigorous dust control measures, e.g., substitution, complete enclosure,
isolation, hydroblasting, good house-keeping, personal protective measures (b) regular
physical examination of workers.
2. Anthracosis

• Previously it was thought that pulmonary "anthracosis" was inert.

• Studies indicate that there are two general phases in coal miners pneumoconiosis (a) the
first phase is labelled simple pneumoconiosis which is associated with little ventilatory
impairment. This phase may require about 12 years of work exposure for its de velopment
and (b) the second phase is characterised by progressiue massiue fibrosis (PMF); this causes
severe respiratory disability and frequently results in premature death.

• Coal-miners' pneumoconiosis has been declared a notifiable disease in the Indian Mines Act
of 1952, and also compensatable in the Workmen's Compensation (Amendment) Act of
1959.

3. Byssinosis

• Byssinosis is due to inhalation of cotton fibre dust over long periods of time. The symptoms
are chronic cough and progressive dyspnoea, ending in chronic bronchitis and emphysema.

4. Bagassosis

• Bagassosis is the name given to an occupational disease of the lung caused by inhalation of
bagasse or sugarcane dust.
• The sugarcane fibre which earlier went to waste, is now utilized in the manufacturing of
paper, cardboard and rayon.

• Bagassosis has been shown to be due to a thermophilic actinomycete for which the name
Thermoactinomyces sacchari was suggested.
• The symptoms consist of breathlessness, cough, haemoptysis and slight fever. Initially there
is acute diffuse bronchiolitis. Skiagram may show mottling in lungs or shadow.

Prevention

(a) DUST CONTROL

(b) PERSONAL PROTECTION : (masks or respirators with mechanical filters or with oxygen or air
supply)

(c) MEDICAL CONTROL : Initial medical examination and periodical medical check-ups of the workers
5. Asbestosis

• Asbestos is the commercial name given to certain types of fibrous materials. They are
silicates of varying composition; the silica is combined with such bases as magnesium, iron,
calcium, sodium and aluminium.
• Asbestos is of two types - serpentine or chrysolite variety and the amphibole type. Ninety
percent of the world's production of asbestos is of the serpentine variety, which is hydrated
magnesium silicate, the amphibole type contains little magnesium.

• The amphibole type occurs in different varieties, e.g., crocidolite (blue}, amosite (brown),
and anthrophyllite (white). Asbestos enters the body by inhalation, and fine dust may be
deposited in the alveoli. The fibres are insoluble.
• The dust deposited in the lungs causes pulmonary fibrosis leading to respiratory insufficiency
and death, carcinoma of the bronchus, mesothelioma of the pleura or peritoneum, and
cancer of the gastro-intestinal tract.

• The disease does not usually appear until after 5 to 10 year s of exposure. Clinically the
disease is characterized by dyspnoea which is frequently out of proportion to the clinical
signs in the lungs.
• In advanced cases, there may be dubbing of fingers, cardiac distress and cyanosis. The
sputum shows "asbestos bodies" which are asbestos fibres coated with fibrin. An X-ray of
the chest shows a ground-glass appearance in the lower two- thirds of the lung fields

Prevention

(a) use of safer types of asbestos (chrysolite and amosite)

(b) substitution of other insulants: glass fibre, mineral wool, calcium silicate, plastic foams, etc.

(c) rigorous dust control

(d) periodic examination of workers; biological monitoring (clinical, X-ray, lung function)

6. Farmer's lung

• Farmer's lung is due to the inhalation of mouldy hay or grain dust. In grain dust or hay with a
moisture content of over 30 per cent bacteria and fungi grow rapidly, causing a rise of
temperature to 40 to 50 deg. C.
 • This heat encourages the growth of thermophilic actinomycetes, of which Micropolyspora
faeni is the main cause of farmer's lung.
• The acute illness is characterized by general and respiratory symptoms and physical signs.
Repeated attacks cause pulmonary fibrosis and inevitable pulmonary damage and cor -
pulmonale.

ESI Act (The Employees State Insurance Act)

• The ESI Act passed in 1948 is an important measure of social security and health insurance in
this country.
• It provides for certain cash and medical benefits to industrial employees in case of sickness,
maternity and employment injury.

SCOPE

• The ESI Act covered all power-using factories other than seasonal factories wherein 10 or
more persons were employed (excluding mines, railways and defence establishments).

a) Small factories employing 10 or more persons

b) Shops

c) Hotels and restaurants

d) Cinemas and theatres

e) Road-motor transport establishments

f) Newspaper establishments

g) The scheme has been extended to private medical and educational institutions employing 20 or
more persons in some states.

ADMINISTRATION

• The administration of the ESI Scheme under the Act is entrusted to an autonomous body
called the ES! Corporation.
• The Union Minister for Labour is the Chairman and the Secretary to Govt. of India Ministry of
Labour is the Vice-Chairman of this corporation.
 • The chief executive officer of the Corporation is the Director General who is assisted by four
Principal Officers - (1) Insurance Commissioner (2) Medical Commissioner (3) Financial
Commissioner (4) Actuary.
• The head office in New Delhi, the corporation has 23 regional offices and 26 sub-regional
offices at 2 divisional offices and 624 branch offices, 197 cash offices and 406 inspection
offices all over the country for the administration of the scheme.

• ESI gives coverage to about 185 lakh family units of about 165 lakh employees including
about 26.79 lakh females.There are 406 inspection offices throughout the country to inspect
factories and for checking insurability of employees and correct payment of contributions.

FINANCE

• The scheme is run by contributions by employees and employers and grants from Central
and State Governments. The employer contributes 4.75 per cent of total wage bill; the
employee contributes 1.75 percent of wages

BENEFITS TO EMPLOYEES

(1) Medical benefit

(2) Sickness benefit

(3) Maternity benefit

(4) Disablement benefit

(5) Dependant's benefit

(6) Funeral expenses

(7) Rehabilitation allowance

1. Medical benefit consists of "full medical care" including hospitalization, free of cost, to the insured
persons in case of sickness, employment injury and maternity. The services comprise : out-patient
care, supply of drugs and dressings, specialist services in all branches of medicine, pathological and
radiological investigations, domiciliary services, antenatal, natal and postnatal services,
immunization services, family planning services, emergency services, in-patient treatment.
2. Sickness benefit It consists of periodical cash payment to an insured person in case of sickness, if
his sickness is duly certified by an Insurance Medical Officer or Insurance Medical Practitioner. The
benefit is payable for a maximum period of 91 days, in any continuous period of 365 days.

EXTENDED SICKNESS BENEFIT: In addition to 91 days of sickness benefit, insured persons suffering
from certain long-term diseases are entitled to Extended Sickness Benefit.

3. The benefit is payable in cash to an insured woman for confinement/miscarriage or sickness

ansmg out of pregnancy/confinement or premature birth of child or miscarriage. For confinement,
the duration of benefit is 12 weeks (84 days), for miscarriage 6 weeks and for sickness arising out of
confinement etc. 30 days.

4. The Act provides for cash payment, besides free medical treatment, in the event of temporary or
permanent disablement as a result of employment injury as well as occupational diseases. In case of
total permanent disablement, the insured person is given life pension worked out on the basis of
loss of earning capacity determined by a medical board.

5. In case of death, as a result of employment injury, the dependants of an insured person are
eligible for periodical payments. An eligible son or daughter is entitled to dependant's benefit up to
the age of 18; the benefit is withdrawn if the daughter marries earlier.

6. Funeral benefit is a cash payment payable on the death of an insured person towards the
expenses on his funeral, the amount not exceeding Rs. 10,000.

7. On monthly payment of Rs 10, the insured person and his family members continue to get medical
treatment after permanent disablement, or retirement.

Benefits to employers

(1) Exemption from the applicability of Workmen's Compensation Act 1923

(2) Exemption from Maternity Benefit Act 1961

(3) Exemption from payment of Medical allowance to employees and their dependants or arranging
for their medical care

(4) Rebate under the Income Tax Act on contribution deposited in the ESI Account

(5) Healthy work-force

PURIFICATION OF WATER
• Purification of water is of great importance in community medicine. It may
be considered under two headings :

1. Purification of water on a large scale

2. Purification of water on a small scale

1. PURIFICATION OF WATER ON A LARGE SCALE

• The purpose of water treatment is to produce water that is safe and

wholesome. Ground water (e.g. wells and springs) may need no treatment,
other than disinfection.

• Surface water (e.g. river water) which tends to be turbid and polluted,
requires extensive treatment.. The components of a typical water
purification system comprise one or more of the following measures :

I. Storage

II. Filtration

III. Disinfection

(I) Storage Water is drawn out from the source and impounded in natural or artificial reservoirs

(a) Physical : By mere storage, the quality of water improves. About 90 per cent of the suspended
impurities settle down in 24 hours by gravity. The water becomes clearer. This allows penetration
of light, and reduces the work of the filters

(b) Chemical : Certain chemical changes also take place during storage. The aerobic bacteria oxidize
the organic matter present in the water with the aid of dissolved oxygen. As a result, the content
of free ammonia is reduced and a rise in nitrates occurs.

(c) Biological : A tremendous drop takes place in bacterial count during storage. The pathogenic
organisms gradually die out. It is found that when river water is stored the total bacterial count
drops by as much as 90 per cent in the first 5-7 days. The optimum period of storage of river
water is considered to be about 10-14 days.
(II) Filtration : Filtration is the second stage in the purification of water, and quite an important stage
because 98-99 per cent of the bacteria are removed by filtration.

• Two types of filters : "biological" or "slow sand" filters and the "rapid sand"
or "mechanical" filters.

SLOW SAND OR BIOLOGICAL FILTERS

(1) Supernatant water

• The supernatant water above the sand bed, whose depth varies from 1 to
1.5 metre, serves two important purposes :

• It provides a constant head of water so as· to overcome the resistance of

the filter bed and thereby promote the downward flow of water through
the sand bed

• Secondly, it provides waiting period of some hours (3 to 12 hours,

depending upon the filtration velocity) for the raw water to undergo partial
purification by sedimentation , oxidation and particle agglomeration.

(2) Sand bed

• The most important part of the filter is the sand bed. The sand should be
clean and free from clay and organic matter. The sand bed is supported by a
layer of graded gravel 30-40 cm deep which also prevents the fine grains
being carried into the drainage pipes.

• Vital layer : When the filter is newly laid, it acts merely as a mechanical
strainer, and cannot truly be considered as "biological".

(3) Under-drainage system

• At the bottom of the filter bed is the under-drainage system. It consists of

porous or perforated pipes which serve the dual purpose of providing an
outlet for filtered water, and supporting the filter medium above.

• Filter box : The first 3 elements (e.g. supernatant water, sand bed and
under-drainage system) are contained in the filter box.
(4) Filter control

• The filter is equipped with certain valves and devices which are incorporated
in the outlet-pipe system. The purpose of these devices is to maintain a
constant rate of filtration.

Advantages of a slow sand filter are :

(1) simple to construct and operate

(2) the cost of construction is cheaper than that of rapid sand filters

(3) the physical, chemical and bacteriological quality of filtered water is very high.

RAPID SAND OR MECHANICAL FILTERS

• Rapid sand filters are of two types, the gravity type (e.g. Paterson's filter)
and the pressure type (e.g. Candy's filter).

(1) Coagulation : The raw water is first treated with a chemical coagulant such as alum, the dose of
which varies from 5 to 40 mg or more per litre, depending upon the turbidity and colour,
temperature and the pH value of the water.

(2) Rapid mixing : The treated water is then subjected to violent agitation in a "mixing chamber" for
a few minutes. This allows a quick and thorough dissemination of alum throughout the bulk of
the water, which is very necessary.

(3) Flocculation : The next phase involves a slow and gentle stirring of the treated water in a
"flocculation chamber" for about 30 minutes.

(4) Sedimentation : The coagulated water is now led info sedimentation tanks where it is detained
for periods varying from 2-6 hours when the flocculent precipitate together with impurities and
bacteria settle down in the tank.

(5) Filtration : The partly clarified water is now subjected to rapid sand filtration. Filter beds : The
gravel supports the sand bed and permits the filtered water to move freely towards the under-
drains.
Filtration

As filtration proceeds, the "alum-floe" not removed by sedimentation is held back on the sand bed.
It forms a slimy layer comparable to the zoogleal layer in the· slow sand filters. It adsorbs bacteria
from the water and effects purification. When the "loss of head" approaches 7-8 feet, filtration is
stopped and the filters are subjected to a washing process known as "backwashing".

Backwashing

Rapid sand filters need frequent washing daily or weekly, depending upon the loss of head. Washing
is accomplished by reversing the flow of water through the sand bed, which is called
"backwashing".

Advantages of a rapid sand filter are :

(1) rapid sand filter can deal with raw water directly.

(2) the filter beds occupy less space

(3) filtration is rapid, 40-50 times that of a slow sand filter

(4) the washing of the filter is easy

(5) there is more flexibility in operation

2. PURIFICATION OF WATER ON A SMALL SCALE

(1) Household purification of water

(a) BOILING

• Boiling is a satisfactory method of purifying water for household purposes.

To be effective, the water must be brought to a "rolling boil" for 10 to 20
minutes. It kills all bacteria, spores, cysts and ova and yields sterilized water.
Boiling also removes temporary hardness by driving off carbon dioxide and
precipitating the calcium carbonate.
(b) CHEMICAL DISINFECTION

(1) Bleaching powder : The amount of bleaching powder required to disinfect certain quantities of
water. The principle in chlorination is to ensure a "free" residual chlorine of 0.5 mg/litre at the
end of one hour contact.

(2) Chlorine solution : Chlorine solution may be prepared from bleaching powder. If 4 kg of bleaching
powder with 25 per cent available chlorine is mixed with 20 litres of water, it will give a 5 per cent
solution of chlorine

(3) High test hypochlorite: Solutions prepared from HTH are used for water disinfection.

(4) Chlorine tablets : Under various trade names (viz., halazone tablets) are available in the market.
They are quite good for disinfecting small quantities of water, but they are costly.

(5) Iodine : Iodine may be used for emergency disinfection of water. Two drops of 2 per cent ethanol
solution of iodine will suffice for one litre of clear water. A contact time of 20 to 30 minutes is
needed for effective disinfection.

(6) Potassium permanganate : It is not a satisfactory agent for disinfecting water. It may kill cholera
vibrios, but is of little use against other disease organisms

(c) FILTRATION

• Water can be purified on a small scale by filtering through ceramic filters

such as Pasteur Chamberland filter, Berkefeld filter and "Katadyn" filter.
Filter candles of the fine type usually remove bacteriae found in drinking
water, but not the filter-passing viruses.

(d) ULTRAVIOLET IRRADIATION

• Germicidal property of UV rays have been recognized for many years. UV

irradiation is effective against most microorganisms known to contaminate
water supplies like bacteria, yeast, viruses, fungi, algae, protozoa etc.

• The advantages are that the exposure is for short period, no foreign matter
introduced and no taste and odour produced.

• The disadvantages are that no residual effect is available and there is a lack
of a rapid field test for assessing the treatment efficiency.
(e) MULTI-STAGE REVERSE OSMOSIS PURIFICATION OF WATER

Multistage reverse osmosis purification process is used to make water both chemically and
microbiologically potable by reducing the total dissolved solids, hardness, heavy metals and
disease causing bacteria, virus, protozoa and cysts.

(2) Disinfection of wells

• Wells are the main source of water supply in the rural areas. The need often
arises to disinfect them, sometimes on a mass scale, during epidemics of
cholera and gastroenteritis. The most effective and cheapest method of
disinfecting wells is by bleaching powder.

STEPS IN WELL DISINFECTION

(1) Find the volume of water in a well

(2) Find the amount of bleaching powder required for disinfection Estimate t

(3) Dissolve bleaching powder in water

(4) Delivery of chlorine solution into the well

(5) Contact period

(6) Orthotolidine arsenite test

DISINFECTION
For a chemical or an agent to be potentially useful as a disinfectant in water supplies, it has to satisfy
the following criteria :

(a) it should be capable of destroying the pathogenic organisms present, within the contact time
available and not unduly influenced by the range of physical and chemical properties of water
encountered particularly temperature, pH and mineral constituents

(b) should not leave products of reaction which render the water toxic or impart colour or otherwise
make it unpotable
(c) have ready and dependable availability at reasonable cost permitting convenient, safe and
accurate application to water

(d) possess the property of leaving residual concentration to deal with small possible
recontamination

(e) be amenable to detection by practical, rapid and simple analytical techniques in the small
concentration ranges to permit the control of the efficiency of the disinfection process. In water
works practice, the term disinfection is synonymous with chlorination

CHLORINATION
• Chlorine kills pathogenic bacteria, but is has no effect on spores and certain viruses (e.g.,
polio, viral hepatitis) except in high doses.

• Chlorine has several important secondary properties of value in water treatment : it oxidizes
iron, manganese and hydrogen sulphide, it destroys some taste and odour, it controls algae
and slime organisms and aids coagulation.
• Action of chlorine : When chlorine is added to water, there is formation of hydrochloric and
hypochlorous acids. The hydrochloric acid is neutralized by the alkalinity of the water.
• Chlorine acts best as a disinfectant when the pH of water is around 7 because of the
predominance of hypochlorous acid. When the pH value exceeds 8.5 it is unreliable as a
disinfectant.
• It is fortunate that most waters have a pH value between 6-7.5.

PRINCIPLES OF CHLORINATION :

(1) First of all, the water to be chlorinated should be clear and free from turbidity. Turbidity impedes
efficient chlorination

(2) Secondly, the "chlorine demand" of the water should be estimated.

• The sum of the chlorine demand of the specific water plus the free residual chlorine of 0.5
mg/L constitutes the correct dose of chlorine to be applied.
METHOD OF CHLORINATION

• For disinfecting large bodies of water, chlorine is applied either as (1) chlorine gas (2)
chloramine or (3) perchloron.
• Chlorine gas is the first choice, because it is cheap, quick in action, efficient and easy to
apply. Since chlorine gas is an irritant to the eyes and poisonous, a special equipment known
as "chlorinating equipment" is required to apply chlorine gas to water supplies.
• Paterson's chloronome is one such device for measuring, regulating and administering
gaseous chlorine to water supplies.
• In some water treatment plants, they use chloramine instead of chlorine gas. Chloramines
are loose compounds of chlorine and ammonia.
• They have a less tendency to produce chlorinous tastes and give a more persistent type of
residual chlorine.

• Perchloron or high test hypochlorite (H.T.H.) is a calcium compound which carries 60-70 per
cent of available chlorine.

BREAK POINT CHLORINATION

• The addition of chlorine to ammonia in water produces chloramines which do not have the
same efficiency as free chlorine.
• If the chlorine dose in the water is increased, a reduction in the residual chlorine occurs, due
to the destruction of chloramine by the added chlorine.
• The end products do not represent any residual chlorine. This fall in residual chlorine will
continue with further increase in chlorine dose and after a stage, the residual chlorine
begins to increase in proportion to the added dose of chlorine.

SUPER CHLORINATION

• Superchlorination followed by dechlorination comprises the addition of large doses of

chlorine to the water, and removal of excess of chlorine after disinfection, this method is
applicable to heavily polluted waters whose quality fluctuates greatly.

ORTHOTOLIDINE (OT) TEST

• Orthotolidine test enables both free and combined chlorine in water to be determined with
speed and accuracy. The reagent consists of analytical grade Orthotolidine, dissolved in 10
percent solution of hydrochloric acid. When this reagent is added to water containing
 chlorine, it turns yellow and the intensity of the colour varies with the concentration of the
gas. The yellow colour is produced by both free and combined chlorine residuals.
• The test is carried out by adding 0.1 ml of the reagent to 1 ml of water. The yellow colour
produced is matched against suitable standards or colour discs.
• It is essential to take the reading within 10 seconds after the addition of the reagent to
estimate free chlorine in water.

• The colour that is produced after a lapse, say 15-20 minutes, is due to the action of both free
and combined chlorine.

ORTHOTOLIDINE-ARSENITE (OTA) TEST

• This is a modification of the OT test to determine the free and combined chlorine residuals
separately.

• Further, the errors caused by the presence of interfering substances such as nitrites, iron
and manganese all of which produce a yellow colour with Orthotolidine, are overcome by
the OTA test .

HARDNESS OF WATER
Hardness may be defined as the soap destroying power of water. The hardness in water is caused
mainly by four dissolved compounds. These are

(1) Calcium bicarbonate

(2) Magnesium bicarbonate

(3) Calcium sulphate

(4) Magnesium sulphate.

• The presence of any one of these compounds produces hardness. Chlorides and nitrates of
calcium and magnesium can also cause hardness but they occur generally in small amounts.
• Hardness is classified as carbonate and non-carbonate. The carbonate hardness which was
formerly designated as temporary hardness is due to the presence of calcium and
magnesium bicarbonates.
• The non-carbonate hardness formerly designated as permanent hardness, is due to calcium
and magnesium sulphates, chlorides and nitrates.
• Hardness in water is expressed in terms of milli- equivalents per litre (mEq/L).
• Drinking water should be moderately hard. Softening of water is recommended when the
hardness exceeds 3 mEq/L (150 mg per litre).
CLASSIFICATION LEVEL OF HARDNESS (mEg/L)

(a) Soft water Less than 50 mg/L

(b) Moderately hard 1-3 (50-150 mg/L)

(c) Hard water 3-6 (150-300 mg/L)

(d) Very hard water Over 6 (>300 mg/L)

Disadvantages
(1) Hardness in water consumes more soap and detergents

(2) When hard water is heated the carbonates are precipitated and bring about furring or scaling of
boilers. This leads to great fuel consumption, loss of efficiency and may sometimes cause boiler
explosions

(3) Hard water adversely affects cooking, food cooked in soft water retains its natural colour and
appearance

(4) fabrics washed with soap in hard water do not have a long life

(5) there are many industrial processes in which hard water is unsuited and gives rise to economic
losses

(6) hardness shortens the life of pipes and fixtures

Treatment
1. Temporary hardness (a) Boiling (b) Addition of lime (c} Addition of sodium carbonate (d) Permutit
process

2. Permanent hardness (a) Addition of sodium carbonate (b) Base exchange process

EXCRETA DISPOSAL
• Human excreta is a source of infection. It is an important cause of environmental pollution.
The HEALTH HAZARDS of improper excreta disposal are :

(1) soil pollution

(2) water pollution

(3) contamination of foods

(4) propagation of flies

 • The resulting diseases are typhoid and paratyphoid fever, dysenteries, diarrhoeas, cholera,
hookworm disease,. ascariasis, viral hepatitis and similar other intestinal infections and
parasitic infestations.

Problem Statement

• In many areas of the world, including India, excreta disposal is a problem of grave
importance. Nearly 70 per cent of India's population live in rural areas and the majority of
them "go to the fields" for defecation and thereby pollute the environment with human
excrement.
• Hookworm disease is also known to be highly prevalent about 45 million people are
estimated to be infested with hookworms. The solution to the problem is only through
hygienic disposal of human excreta..

• The human excreta of a sick person or a carrier of disease is the main focus of infection. It
contains the disease agent which is transmitted to a new host through various channels like
water, fingers, flies, soil and food.

Sanitation barrier

Community medicine aims at breaking the disease cycle at vulnerable points. The disease cycle may
be broken at various levels : segregation of faeces, protection of water supplies, protection of foods,
personal hygiene and control of flies.

Methods of excreta disposal

I. Unsewered areas

1. SERVICE TYPE LATRINES (CONSERVANCY SYSTEM) : Nightsoil is collected from pail or bucket type
of latrines by human agency, and later disposed of by burying or composting.

2. NON-SERVICE TYPE (SANITARY LATRINES)

(a) Bore hole latrine

(b) Dug well or pit latrine

(c) Water-seal type of latrines (i) P.R.A.I. type (ii) R.C.A. type (iii) Sulabh Shauchalaya

(d) Septic tank

(e) Aqua privy.

3. LATRINES SUITABLE FOR CAMPS AND TEMPORARY USE

(a) Shallow trench latrine

(b) Deep trench latrine

(c) Pit latrine

(d) Bore hole latrine

II. Sewered areas

1. WATER-CARRIAGE SYSTEM AND SEWAGE TREATMENT

(a) Primary treatment Screening Removal of grit Plain sedimentation

(b) Secondary treatment Trickling filters Activated sludge process

(c) Other methods (i) Sea outfall (ii) River outfall (iii) Sewage farming (iv) Oxidation ponds.

I. Excreta disposal in unsewered areas

1. SERVICE TYPE (CONSERVANCY SYSTEM)

• The collection and removal of nightsoil from bucket or pail latrines by human agency is
called the service type or conservancy system, and the latrines are called service latrines.
The nightsoil is transported in "nightsoil carts" to the place of final disposal, where it is
disposed off by

(i) composting

(ii) burial in shallow trenches.

• The emptying operation of the buckets is not always satisfactory. It is also difficult to recruit
adequate staff needed for the collection of nightsoil. If the sweepers go on strike, the entire
machinery collapses with dire consequences to public health.

2. NON-SERVICE TYPE OF LATRINES (SANITARY LATRINES)

(1) Excreta should not contaminate the ground or surface water

(2) Excreta should not pollute the soil

(3) Excreta should not be accessible to flies, rodents, animals (pigs, dogs, cattle, etc.) and other
vehicles of transmission

(4) Excreta should not create a nuisance due to odour or unsightly appearance

(a) BORE HOLE LATRINE

• The bore hole latrine is the forerunner of the non-service type of latrines in this country. It
was first introduced by the Rockefeller foundation during 1930 in campaigns of hookworm
control.
• The latrine consists of a circular hole 30 to 40 cm (12-16 in) in diameter, dug vertically into
the ground to a depth of 4 to 8 m (13-26 ft), most commonly 6 m (20 ft).
• A special equipment known as auger is required to dig a bore hole. In loose and sandy soils,
the hole is lined with bamboo matting or earthen-ware rings to prevent caving in of the soil.

Merits : There is no need for the services of a sweeper for daily removal of nightsoil. The pit is dark
and unsuitable for fly breeding. If located 15 m (50 ft) away from a source of water supply, there
should be no danger of water pollution.

Demerits : The bore hole fills up rapidly because of its small capacity. A special equipment, the
auger, is required for its construction which may not be readily available. In many places, the subsoil
water is high and the soil loose, with the result it may be difficult to dig a hole deeper than 3 m.

(b) DUG WELL LATRINE

• Dug well latrine or pit latrine was first introduced in Singur, West Bengal. It is an
improvement over the bore hole latrine.
• A circular pit about 75 cm (30 in) in diameter and 3 to 3.5 m (10-12 ft) deep is dug into the
ground for the reception of the nightsoil.
• In sandy soil, the depth of the pit may be reduced to 1.5 to 2 m ( 6-7 ft). The pit may be lined
with pottery rings, and as many rings as necessary to prevent caving in of the soil may be
used.

Advantages : It is easy to construct and no special equipment such as an auger is needed to dig the
pit. The pit has a longer life than the bore hole because of greater cubic capacity. Will last for about
5 years for a family of 4 to 5 persons. When the pit is filled up, a new pit is constructed.
(c) WATER SEAL LATRINE

A further improvement in the designing of sanitary latrines for rural families is the hand-flushed
"water seal" type of latrine.

The water seal performs two important functions : (1) it prevents access by flies (2) it prevents
escape of odours and foul gases and thereby eliminates the nuisance from smell. Once the latrine is
flushed, nightsoil is no longer visible.

Several designs of water seal latrines have been tested in the field, and two types have gained
recognition for wide use. These are : (1) the P.R.A.I. type, evolved by the Planning, Research and
Action Institute, Lucknow (Uttar Pradesh) and (2) the RCA type, designed by the Research-cum-
Action Projects in Environmental Sanitation of the Ministry of Health, Government of India.

RCA LATRINE

(1) LOCATION : It may be stated, that latrines of any kind should not be located within 15 m (50 ft)
from a source of water supply, and should be at a lower elevation to prevent the possibility of
bacterial contamination of the water supply.

(2) SQUATTING PLATE : It should be made of an impervious material so that it can be washed and
kept clean and dry. If kept dry, it will not facilitate the survival of hookworm larvae. There is a slope
1/2 inch towards the pan. A circular squatting plate of 90 cm (3 ft.) diameter and of 5 cm (2 in)
uniform thickness, has also been found satisfactory.

(3) PAN : The pan receives the nightsoil, urine and wash water. The length of the pan is 42.5 cm (17
in). The width of the front portion of the pan has a minimum of 12.5 cm (5 in) and the width at its
widest portion is 20 cm (8 in).

(4) TRAP : The trap is a bent pipe about 7.5 cm (3 in) in diameter and is connected with the pan. It
holds water and provides the necessary 'water seal'.

(5) CONNECTING PIPE : When the pit is dug, away from the squat plate, the trap is connected to the
pit by a short length of connecting pipe 7.5 cm (3 in) in diameter and at least 1 m (3 ft) in length with
a bend at the end. An advantage with the indirect type is that when the pit fills up, a second pit can
be put into operation by merely changing the direction of the connecting pipe.

(6) DUG WELL : The dug well or pit is usually 75 cm (30 in) in diameter, and 3 to 3.5 m (10-12 ft) deep
and is covered. When the pit fills up, a second pit is dug nearby and the direction of the connecting
pipe is changed into the second pit. When the second pit fills up, the first one may be emptied and
reused.

(7) MAINTENANCE : The life of a latrine will depend upon several factors such as care in usage and
maintenance. The latrine should be used only for the purpose intended and not for disposal of
refuse or other debris.

SULABH SHAUCHALAYA

• The "Sulabh Shauchalaya" model, the invention of a Patna-based firm, is a low cost pour-
flush, water-seal type of latrine, which is now being used in many parts of India. Basically it is
an improved version of the standard handflush latrine (e.g., RCA type).
• It consists of a specially designed pan and a water-seal trap. It is connected to a pit 3 feet
square and as deep. Excreta undergoes bacterial decomposition and is converted to manure
(compost). The method requires very little water.

(d) SEPTIC TANK

The septic tank is water-tight masonry tank into which household sewage is admitted for treatment.
It is a satisfactory means of disposing excreta and liquid wastes from individual dwellings, small
groups of houses and institutions which have adequate water supplies but do not have access to a
public sewerage system.

The main design features of a septic tank are as follows

(1) Capacity : A capacity of 20-30 gallons or 21/ 2-5 c.ft. per person is recommended for household
septic tanks. The minimum capacity of a septic tank should be at least 500 gallons.

(2) Length : The length is usually twice the breadth.

(3) Depth : The depth of a septic tank is from 1.5 to 2 m (5-7 ft).

(4) Liquid depth : The recommended liquid depth is only 1.2 m (4 ft).

(5) Air space: There should be a minimum air space of 30 cm (12 in) between the level of liquid in the
tank and the undersurface of the cover.

(6) Bottom : In some septic tanks, the bottom is sloping towards the inlet end.

(7) Inlet and outlet : There is an inlet and outlet pipe, which are submerged.
(8) Cover : The septic tank is covered by a concrete slab of suitable thickness and provided with a
manhole.

(9) Retention Period : Septic tanks are designed in this country to allow a retention period of 24
hours.

WORKING OF A SEPTIC TANK

• The solids settle down in the tank, to form "sludge", while the lighter solids including grease
and fat rise to the surface to form "scum". The solids are attacked by the anaerobic bacteria
and fungi and are broken down into simpler chemical compounds. This is the first stage of
purification, called anaerobic digestion.
• The sludge is much reduced in volume as a result of anaerobic digestion, and is rendered
stable and inoffensive. A portion of the solids is transferred into liquids and gases (principally
methane) which rises to the surface in the form of bubbles. The liquid which passes out of
the outlet pipe from time to time is called the "effluent".
• The effluent is allowed to percolate into the sub-soil. It is dispersed by means of perforated
or open-jointed pipes laid in trenches 90 cm (3 ft) deep and the trenches are then covered
with soil.
• The effluent percolates into the surrounding soil. There are millions of aerobic bacteria in
the upper layers of the soil, which attack the organic matter present in the effluent. As a
result, the organic matter is oxidized into stable end- products, i.e., nitrates, carbon dioxide
and water. This stage of purification is called aerobic oxidation.

OPERATION AND MAINTENANCE

(1) The use of soap water and disinfectants such as phenol should be avoided as they are injurious to
the bacterial flora in the septic tank.

(2) The contents of the septic tank should be bailed out at least once a year. This operation is called
"desludging".

(3) Newly built septic tanks are first filled with water up to the outlet level and then seeded with ripe
sludge drawn from another septic tank, to provide the right type of bacteria to carry out the
decomposition process.
(e) AQUA PRIVY

• The aqua privy functions like a septic tank.The privy consists of a water-tight chamber filled
with water. A short length of a drop pipe from the latrine floor dips into the water. The
shape of the tank may be circular or rectangular.

• The size of the tank depends upon the number of users. A capacity of one cubic metre (35
cu.ft) is recommended for a small family, allowing 6 years or more for cleansing purposes.
Aqua privies are designed for public use also.
• Night soil undergoes purification by anaerobic digestion. Since there is evolution of gases, a
vent should be provided for the escape of gases into the atmosphere, the vent should be
open above the roof of dwellings.
• The effluent is far from innocuous. It contains finely divided faecal matter in suspension and
may carry parasitic and infective agents.
• It should be treated in the same manner as the effluent from a septic tank by sub-soil
irrigation or absorption. The digested sludge which accumulates in the tank should be
removed at intervals.

3. LATRINES SUITABLE FOR CAMPS AND TEMPORARY USE

(a) SHALLOW TRENCH LATRINE

• This is simply a trench dug with ordinary tools. The trench is 30 cm (1 ft) wide and
90-150 cm (3-5 ft) deep necessary for 100 people. The earth from the trench should
be piled up at the side.
• People should be instructed to cover faeces with earth each time they use the
latrine. However, these instructions may not be carried out, and it will be necessary
to post sweepers in attendance to do this work.

(b) DEEP TRENCH LATRINE

• This type of latrine is intended for camps of longer duration, from a few weeks to a
few months. The trench is 1.8 to 2.5 m (6-8 ft.) deep and 75-90 cm (30-35 in.) wide.
• Depending upon the local customs, a seat or a squatting plate is provided. A
superstructure is built for privacy and protection.
II. Sewered areas

1. WATER CARRIAGE SYSTEM

• The water carriage system or sewerage system implies collecting and transporting of
human excreta and waste water from residential, commercial and industrial areas,
by a net-work of underground pipes, called sewers to the place of ultimate disposal.
• It is the method of choice for collecting and transporting sewage from cities and
towns where population density is high.
• There are two types in water carriage system the combined sewer system and the
separate sewer system.
• In the combined system, the sewers carry both the sewage and surface water. In the
separate system, surface water is not admitted into sewers. A water carriage system
consists of the following elements:

1. Household sanitary fittings where sewers exist, every house is expected to be connected
to the nearest sewer. The usual household sanitary fittings are : (i) water closet (ii) urinal (iii)
wash basin.

WATER CLOSETS may be broadly divided into two types : Indian squatting type and the
Western commode type. It is recommended that for efficient performance : (a) the water
seal area should not be more than 7.5 cm. (b) there should not be any sharp corners in the
trap design. (c) the volume of water in trap should be as little as possible, preferably not
exceeding 1. 75 litres to maintain a minimum of 50 mm deep water seal. (d) the interior of
the bowl should be vertical at least 50 to 75 mm just above the surface of water seal. The
water closets are provided with a 'flushing rim'.

2. House drain : The house drain empties the sewage into the main sewer or public drain.

3. Public sewer : The trunk sewers collect sewage from several houses and transport to the
main outfall or place of final disposal.

4. Sewer appurtenances : These are (a) manholes and (b) traps which are installed in the
sewerage system.
MANHOLES are openings built into the sewerage system. They are placed (a) whenever
there is a change in the direction of sewers, (b) at the meeting point of two or more sewers
(c) at distances of 100 metres in long straight runs.

TRAPS are placed in three situations : (a) under the basin of water closets, (b) where the
house drain joins the public drain (intercepting trap), and (c) where surface waste water
enters the drains.

SOLID WASTES(REFUSE)
• The term "solid wastes" includes garbage (food wastes) rubbish (paper, plastics, wood,
metal, throw-away containers, glass), demolition products (bricks, masonry, pipes), sewage
treatment residue (sludge and solids from the coarse screening of domestic sewage), dead
animals, manure and other discarded material. Solid waste, if allowed to accumulate, is a
health hazard because:

a. it decomposes and favours fly breeding

b. it attracts rodents and vermin

c. the pathogens which may be present in the solid waste may be conveyed back to man's food
through flies and dust

d. there is a possibility of water and soil pollution

e. heaps of refuse present an unsightly appearance and nuisance from bad odours

Sources of refuse

(1) Refuse that is collected by the street cleansing service or scavenging is called street refuse. It
consists of leaves, straw, paper, animal droppings and litter of all kinds.

(2) Refuse that is collected from markets is called market refuse. It contains a large proportion of
putrid vegetable and animal matter.

(3) Refuse that is collected from stables is called stable litter. It contains mainly animal droppings
and left-over animal feeds.
(4) Industrial refuse comprises a wide variety of wastes ranging from completely inert materials such
as calcium carbonate to highly toxic and explosive compounds.

(5) The domestic refuse consists of ash, rubbish and garbage.

Storage

• The first consideration should be given to the proper storage of refuse, while awaiting
collection. The galvanized steel dust bin with dose fitting cover is a suitable receptacle for
storing refuse.

• A recent innovation in the western countries is the "paper sack." Refuse is stored in the
paper sack, and the sack itself is removed with the contents for disposal and a new sack is
substituted.
• Public bins cater for a larger number of people. They are usually without cover in India
because people do not like to touch them.

Collection

• The method of collection depends upon the funds available. House-to-house collection is by
far the best method of collecting refuse.

• Only at some places in the urban areas this kind of facility is available. In majority of places in
India, there is no house-to-house collection system. Refuse is dispersed all along the street,
and some is thrown out in front and around the house.
• As a result, an army of sweepers is required for sweeping the streets in addition to the gang
for collecting the refuse from public bins. The refuse is then transported in refuse collection
vehicles to the place of ultimate disposal.
• The Environmental Hygiene Committee (1949) recommended that municipalities and other
local bodies should arrange for collection of refuse not only from the public bins but also
from individual houses.

• The latest arrival in the western countries is the "Dustless Refuse Collector" which has a
totally enclosed body.
Methods of disposal

(a) Dumping

• Refuse is dumped in low lying areas partly as a method of reclamation of land but mainly as
an easy method of disposal of dry refuse. The drawbacks of open dumping are :

(1) the refuse is exposed to flies and rodents

(2) it is a source of nuisance from the smell and unsightly appearance

(3) the loose refuse is dispersed by the action of the wind

(4) drainage from dumps contributes to the pollution of surface and ground water

(b) Controlled tipping

• Controlled tipping or sanitary landfill is the most satisfactory method of refuse disposal
where suitable land is available. Three methods are used in this operation :

(1) The trench method: Where level ground is available, the trench method is usually chosen. The
refuse is compacted and covered with excavated earth where compacted refuse is placed in the fill
to a depth of 2m.

(2) The ramp method : This method is well suited where the terrain is moderately sloping. Some
excavation is done to secure the covering material.

(3) The area method : This method is used for filling land depressions, disused quarries and clay pits.
The refuse is deposited, packed and consolidated in uniform layers up to 2 to 2.5m deep. Such
sealing prevents infestation by flies and rodents and suppresses the nuisance of smell and dust.
Normally it takes 4 to 6 months for complete decomposition of organic matter into an innocuous
mass. The bulldozer achieves the tasks of spreading trimming and spreading top soil.

(c) Incineration

• Refuse can be disposed of hygienically by burning or incineration. It is the method of choice

where suitable land is not available.
• Hospital refuse which is particularly dangerous is best disposed of by incineration.
Incineration is not a popular method in India because the refuse contains a fair proportion of
fine ash which makes the burning difficult. A preliminary separation of dust or ash is needed.
(d) Composting

• Composting is a method of combined disposal of refuse and nightsoil or sludge. It is a

process of nature whereby organic matter breaks down under bacterial action resulting in
the formation of relatively stable humus-like material, called the compost which has
considerable manurial value for the soil.
• The principal by-products are carbon dioxide, water and heat. The heat produced during
composting about 60 deg C or higher, over a period of several days, destroys eggs and larvae
of flies, weed seeds and pathogenic agents. The following methods of composting are now
used :

(1) BANGALORE METHOD (Hot fermentation process)

• It has been recommended as a satisfactory method of disposal of town wastes and nightsoil.
Trenches are dug 90 cm (3 ft) deep, 1.5 to 2.5 m (5-8 ft) broad and 4.5 to 10 m (15-30 ft)
long, depending upon the amount of refuse and nightsoil to be disposed of depths greater
than 90 cm (3 ft.) are not recommended because of slow decomposition.
• The composting procedure is as follows : First a layer of refuse about 15 cm (6 in) thick is
spread at the bottom of the trench. Over this, nightsoil is added corresponding to a
thickness of 5 cm (2 in).

• Then alternate layers of refuse and nightsoil are added in the proportion of 15 cm (6 in) and
5 cm (2 in) respectively, till the heap rises to 30 cm (1 ft) above the ground level. The top
layer should be of refuse, at least 25 cm (9 in) thickness. Then the heap is covered with
excavated earth.

• Within 7 days as a result of bacterial action considerable heat (over 60 deg C) is generated in
the compost mass.

• This intense heat which persists over 2 or 3 weeks, serves to decompose the refuse and
nightsoil and to destroy all pathogenic and parasitic organisms.
• At the end of 4 to 6 months, decomposition is complete and the resulting manure is a well
decomposed, odourless, innocuous material of high manurial value ready for application to
the land.
(2) MECHANICAL COMPOSTING

• Another method of composting known as 'Mechanical composting' is becoming popular. In

this, compost is literally manufactured on a large scale by processing raw materials and
turning out a finished product.
• The refuse is first cleared of salvageable materials such as rags, bones, metal, glass and
items which are likely to interfere with the grinding operation.
• It is then pulverised in a pulverising equipment in order to reduce the size of articles to less
than 2 inches.
• The pulverised refuse is then mixed with sewage, sludge or nightsoil in a rotating machine
and incubated.
• The factors which are controlled in the operation are a certain carbon-nitrogen ratio,
temperature, moisture, pH and aeration.
• The entire process of composting is complete in 4 to 6 weeks.

(e) Manure pits

• In rural areas in India, there is no system for collection and disposal of refuse. Refuse is
thrown around the houses indiscriminately resulting in gross pollution of the soil.
• The problem of refuse disposal in rural areas can be solved by digging 'manure pits' by the
individual householders.
• The garbage, cattle dung, straw, and leaves should be dumped into the manure pits and
covered with earth after each day's dumping.

• Two such pits will be needed, when one is closed, the other will be in use. In 5 to 6 month's
time, the refuse is converted into manure which can be returned to the field.

(f) Burial

• This method is suitable for small camps. A trench 1.5 m wide and 2 m deep is excavated, and
at the end of each day the refuse is covered with 20 to 30 cm of earth.
• When the level in the trench is 40 cm from ground level, the trench is filled with earth and
compacted, and a new trench is dug out.
• The contents may be taken out after 4 to 6 months and used on the fields. If the trench is 1
m in length for every 200 persons, it will be filled in about one week.
Public education

• People have very little interest in cleanliness outside their homes. Many municipalities and
corporations usually look for the cheapest solution, especially in regard to refuse disposal.
• Police enforcement of the laws may also be needed at times.

Economics and finance

• In the highly industrialized countries up to 20 percent of municipal budgets are spent on the
collection and disposal of solid wastes, and even more will be required if the job is to be
done adequately.

Sewage
Sewage is waste water from a community, containing solid and liquid excreta, derived from houses,
street and yard washings, factories and industries. It resembles dirty water with an unpleasant smell.

The term "sullage" is applied to waste water which does not contain human excreta, e.g., waste
water from kitchens and bathrooms. The amount of sewage that flows in the sewers depends upon:
(a) Habits of the people (b) Time of day : The average amount of sewage which flows through the
sewerage system in 24 hours is called the "dry weather flow."

Health aspects

a. creation of nuisance, unsightliness and unpleasant odours

b. breeding of flies and mosquitoes

c. pollution of soil and water supplies

d. contamination of food

e. increase in the incidence of disease, especially enteric and helminthic diseases.

Composition

Sewage contains 99.9 % of water. The solids which comprise barely 0.1% are partly organic and
partly inorganic; they are partly in suspension and partly in solution.
The offensive nature of the sewage is mainly due to the organic matter which it contains. The
organic matter decomposes according to the laws of nature during which process it gives off
offensive odours. The average adult person excretes daily some 100 grams of faeces.

Aim of sewage purification

Raw sewage or inadequately treated sewage should not be discharged into rivers, sea or other
sources of water supply. This is because, the oxygen in the water supply is used up by the numerous
aerobic bacteria found in the sewage.

The aim of sewage treatment is to "stabilize" the organic matter so that it can be disposed off safely;
and, to convert the sewage water into an effluent of an acceptable standard of purity which can be
disposed off into land, rivers or sea.

A standard test which is an indicator of the organic content of the sewage is biochemical oxygen
demand (BOD).

The "strength" of the sewage is expressed in terms of (a) BIOCHEMICAL OXYGEN DEMAND (BOD) :
BOD values range from about 1 mg per litre for natural waters to about 300 mg per litre for
untreated domestic sewage. If the BOD is 300 mg/L and above, sewage is said to be "strong"; if it is
100 mg/L, it is said to be "weak"

(b) CHEMICAL OXYGEN DEMAND (COD): If wastes contain toxic substances, this test may be the only
practical method for determining the organic load.

(c) SUSPENDED SOLIDS : The suspended solids are yet another indicator of the "strength" of sewage.
The amount of suspended solids in domestic sewage may vary from 100 to 500 p.p.m. (mg/L).

Decomposition of organic matter

(1) Aerobic process : The process requires a continuous supply of free dissolved oxygen. The organic
matter is broken down into simpler compounds namely CO 2 , water, ammonia, nitrites, nitrates and
sulphates by the action of bacterial organisms including fungi and protozoa.

(2) Anaerobic process : The end-products of decomposition are methane, ammonia, CO 2 and H2 In
anaerobic decomposition, the reactions are slower and the mechanism of decomposition extremely
complex.

MODERN SEWAGE TREATMENT

Modern sewage treatment plants are based on biological principles of sewage purification, where
the purification is brought about by the action of anaerobic and aerobic bacteria.

a. PRIMARY TREATMENT

1. Screening : Sewage arriving at a disposal work is first passed through a metal screen which
intercepts large floating objects such as pieces of wood, rags, masses of garbage and dead animals.
Their removal is necessary to prevent clogging of the treatment plant. The screenings are removed
from time to time either manually or mechanically, and disposed off by trenching or burial.

2. Grit chamber : Sewage is then passed through a long narrow chamber called the grit chamber or
detritus chamber. The function of the grit chamber is to allow the settlement of heavier solids such
as sand and gravel, while permitting the organic matter to pass through. The grit which collects at
the bottom of the chamber is removed periodically or continuously, and disposed off by plain
dumping or trenching.

3. Primary sedimentation :

• Sewage is now admitted into a huge tank called the primary sedimentation tank. It is a very
large tank, holding from 1/ 4 to 1/3 the dry weather flow.
• Sewage is made to flow very slowly across the tank at a velocity of 1-2 feet per minute. The
sewage spends about 6-8 hours in the tank.
• The organic matter which settles down is called sludge and is removed by mechanically
operated devices, without disturbing the operation in the tank.
• A certain amount of fat and grease rise to the surface to form scum which is removed from
time to time and disposed of.
• When the sewage contains organic trade wastes, it is treated with chemicals such as lime,
aluminium sulphate and ferrous sulphate.

b. SECONDARY TREATMENT

(a) TRICKLING FILTER METHOD :

• The effluent from the primary sedimentation tank is sprinkled uniformly on the surface of
the bed by a revolving device.
• The device consists of hollow pipes each of which have a row of holes. The pipes keep
rotating, sprinkling the effluent in a thin film on the surface of the filter.
 • Over the surface and down through the filter, a very complex biological growth consisting of
algae, fungi, protozoa and bacteria of many kinds occurs. This is known as the "zoogleal
layer".
• The trickling filters are very efficient in purifying sewage. They do not need rest pauses,
because wind blows freely through the beds supplying. the oxygen needed by the zoogleal
flora.

• The dead matter sloughs off, breaks away and is washed down the filter. It is a light green,
flocculent material and is called "humus". The oxidized sewage is now led into the secondary
sedimentation tanks or humus tanks.

(b) ACTIVATED SLUDGE PROCESS :

• The "heart" of the activated sludge process is the aeration tank. The effluent from the
primary sedimentation tank is mixed with sludge drawn from the final settling tank (also
known as activated sludge or return sludge; this sludge is a rich culture of aerobic bacteria).
• The proportion of activated sludge to the incoming effluent is of the order of 20 to 30 per
cent.
• During the process of aeration, the organic matter of the sewage gets oxidized into carbon
dioxide, nitrates and water with the help of the aerobic bacteria in the activated sludge.

Secondary sedimentation

• The oxidized sewage from the trickling filter or aeration chamber is led into the secondary
sedimentation tank where it is detained for 2-3 hours.
• The sludge that collects in the secondary sedimentation tank is called 'aerated sludge' or
activated sludge, because it is fully aerated.
• It differs from the sludge in the primary sedimentation tank in that it is practically
inoffensive and is rich in bacteriae, nitrogen and phosphates. It is a valuable manure, if
dehydrated. Part of the activated sludge is pumped back into the "aeration tanks".

Sludge digestion

• One of greatest problems associated with sewage treatment is the treatment and disposal of
the resulting sludge. One million gallons of sewage produces 15-20 tons of sludge.
• The sludge is a thick, black mass containing 95 percent of water, and it has a revolting odour.
There are a number of methods of sludge disposal :
(a) Digestion : Modern sewage treatment plants employ digestion of sludge as the method of
treatment. Sludge digestion is carried out in special tanks known as "sludge digestion tanks".
Methane gas, which is a by-product of sludge digestion, can be used for heating and lighting
purposes.

(b) Sea disposal: Sea coast towns and cities can dispose of sludge by pumping it into the sea.

(c) Land : Sludge can be disposed of by composting with town refuse.

Disposal of effluent

(a) Disposal by dilution : Disposal into water courses such as rivers and streams is called 'disposal by
dilution'. The effluent is diluted in the body of water and the impurities are oxidized by the dissolved
oxygen in water.

• The diluting capacity of the river or the receiving body of water and its dissolved oxygen
contents, are important considerations before discharging the effluent into a river or any
body of water.
• Consequently, the effluent may contain substances toxic to man, or substances that can kill
fish, damage agriculture or interfere with the normal functioning of a stream.

(b) Disposal on land : If suitable land is available the effluent can be used for irrigation purposes
(e.g., the Okhla Sewage Treatment Plant in Delhi).

OTHER METHODS OF SEWAGE DISPOSAL.

(a) Sea outfall

(b) River outfall

(c) Land treatment

(d) Oxidation ponds

(e) Oxidation ditches.

(a) Sea coast towns and cities may dispose of their sewage by discharging it into the sea. Purification
takes place by dilution in the large body of sea water, and the solids get slowly oxidized.

(b) Raw sewage should never be discharged into rivers. The present day practice is to purify the
sewage before it is discharged into rivers.
(c)) If sufficient and suitable land (porous soil) is available, sewage may be applied to the land after
grit removal, screening and a short period of settlement. This type of treatment is practised in some
Indian towns and cities and is known as Sewage Farming or Broad Irrigation.

(d) A cheap method of sewage treatment is the oxidation pond which has been referred to by many
different names - waste stabilization pond, redox pond, sewage lagoons, etc. The term "waste
stabilization pond" is more appropriate. The term 'waste' includes both sewage and industrial
wastes.

(e) Other methods recommended are (1) oxidation ditches and (2) aerated lagoons. These methods
make use of mechanical rotors for extended aeration. For treatment of the wastes of a population
between 5,000 to 20,000 an oxidation ditch requires an area of one acre as compared to 22 acres for
an oxidation pond and 2.5 acres for an aerated lagoon.

AIR POLLUTION
• The term "air pollution" signifies the presence in the ambient (surrounding) atmosphere of
substances (e.g., gases, mixtures of gases and particulated matter) generated by the
activities of man in concentrations that interfere with human health, safety or comfort, or
injurious to vegetation and animals and other environmental media.

• The direct effect of air pollutants on plants, animals and soil can influence the structure and
function of ecosystems, including self regulation ability, thereby affecting the quality of life.
In the past, air pollution meant smoke pollution.
• Primary air pollutants are those that are emitted into the atmosphere from a source such as
a factory chimney or exhaust pipe, or through suspension of contaminated dusts by the
wind.
• Secondary air pollutants are those formed within the atmosphere itself. They arise from
chemical reactions of primary pollutants, possibly involving the natural components of the
atmosphere, especially oxygen and water. The most familiar example is ozone.
• Gaseous air pollutants are those present as gases or vapours, i.e. as individual small
molecules capable of passing through filters, provided they do not adsorb to or chemically
react with the filter medium.

• Particulate air pollutants comprise material in solid or liquid phase suspended in the
atmosphere. Such particles can be either primary or secondary and cover a wide range of
sizes.
Sources

(a) AUTOMOBILES : They emit hydrocarbons, carbon monoxide, lead, nitrogen oxides and
particulate matter. In strong sunlight, certain of these hydrocarbons and oxides of nitrogen may be
converted in the atmosphere into "photochemical" pollutants of oxidizing nature.

(b) INDUSTRIES : Combustion of fuel to generate heat and power produces smoke, sulphur dioxide,
nitrogen oxides and fly ash.

(c) DOMESTIC SOURCES : Domestic combustion of coal, wood· or oil is a major source of smoke,
dust, sulphur dioxide and nitrogen oxides.

(d) Tobacco : The most direct and important source of air pollution affecting the health of many
people is tobacco smoke.

(e) MISCELLANEOUS : These comprise burning refuse, incinerators, pesticide spraying, natural
sources (e.g., wind borne dust, fungi, molds, bacteria) and nuclear energy programmes.

Air pollutants

• The important ones are carbon monoxide, carbon dioxide, hydrogen sulphide, sulphur
dioxide, sulphur trioxide, nitrogen oxides, fluorine compounds, organic compounds (e.g.,
hydrocarbons, aldehydes, ketones, organic acids), metallic contaminants (e.g., arsenic, zinc,
iron resulting from smelting operation), radio-active compounds, photochemical oxidants
(e.g., ozone).

Indoor air pollution

• The indoor environment represents an important microenvironment in which people spend

a large part of their time each day.
• As a result, indoor air pollution, originating from both outdoor and indoor sources, is likely
to contribute more to population exposure than the outdoor environment.
• The major sources of indoor air pollution worldwide include combustion of solid fuels
indoors, tobacco smoking, outdoor air pollutants, emissions from construction materials and
furnishings, and improper maintenance of ventilation and air conditioning systems.
• 4.3 million people die every year prematurely from illness attributable to the household air
pollution caused by inefficient use of solid fuels.
Monitoring of air pollution

(a) Sulphur dioxide : This gas is a major contaminant in many urban and industrial areas. Its
concentration is estimated in all air pollution surveys.

(b) Smoke or soiling index : A known volume of air is filtered through a white filter paper under
specified conditions and the stain is measured by photoelectric meter.

(c) Grit and dust measurement : Deposit gauges collect grit, dust and other solids. These are
analyzed monthly.

(d) Coefficient of haze : A factor used, particularly in the USA in assessing the amount of smoke or
other aerosol in air.

(e) Air pollution index : It is an arbitrary index which takes into account one or more pollutants as a
measure of the severity of pollution.

Effects of air pollution

(a) Health aspects : The health effects of air pollution are both immediate and delayed. The
immediate effects are borne by the respiratory system, the resulting state is acute bronchitis. If the
air pollution is intense, it may result even in immediate death by suffocation. Lead poisons many
systems in the body and is particularly dangerous to children developing brain and nervous system.

(b) Social and economic aspects : These comprise destruction of plant and animal life, corrosion of
metals, damage to buildings, cost of cleaning and maintenance and repairs and aesthetic nuisance.

Prevention

(a) Containment : That is, prevention of escape of toxic substances into the ambient air.
Containment can be achieved by a variety of engineering methods such as enclosure, ventilation and
air deaning.

(b) Replacement : That is, replacing a technological process causing air pollution, by a new process
that does not. Increased use of electricity, solar power generation, natural gas, and central heating
in place of coal have greatly helped in smoke reduction.
(c) Dilution : Dilution is valid so long as it is within the self- cleaning capacity of the environment. For
example, some air pollutants are readily removed by vegetation. The establishment of "green belts"
between industrial and residential areas is an attempt at dilution.

(d) Legislation: Air pollution is controlled in many countries by suitable legislation, e.g., Clean Air
Acts. Legislation covers such matters as height of chimneys, powers to local authorities to carry out
investigations, research and education concerning air pollution, creation of smokeless zones and
enforcement of standard for ambient air quality.

Disinfection of air

(1) MECHANICAL VENTILATION : This reduces vitiated air and bacterial density.

(2) ULTRAVIOLET RADIATION : Since direct exposure to ultraviolet rays is a danger to the eyes and
skin, the ultraviolet lamps are shaded and located in the upper portion of the rooms near the inlet of
air.

(3) CHEMICAL MISTS : Triethylene glucol vapours have been found to be effective air bactericides,
particularly against droplet nuclei and dust.

(4) DUST CONTROL : Application of oil to floors of hospital wards reduces the bacterial content of the
air.

VENTILATION
The modern concept of ventilation implies not only the replacement of vitiated air by a supply of
fresh outdoor air but also control of the quality of incoming air with regard to its temperature,
humidity and purity with a view to provide a thermal environment that is comfortable and free from
risk of infection.

Standards of ventilation

The fixing of standards of ventilation is a matter of much difficulty. Most of the standards of
ventilation have been based on the efficiency of ventilation in removing body odour.

(1) Cubic space : Different workers have advocated standards for the minimal fresh air supply
ranging from 300 to 3,000 c.ft per hour per person.
(2) Air change : Air change is more important than the cubic space requirement. It is recommended
that in the living rooms there should be 2 or 3 air changes in one hour, in work rooms and
assemblies 4 to 6 air changes.

(3) Floor space: Floor space per person is even more important than cubic space. Heights in excess of
10 to 12 feet are ineffective from the point of view of ventilation, as the products of respiration tend
to accumulate in the lower levels.

Types of ventilation

1. NATURAL VENTILATION

Natural ventilation is the simplest system of ventilating small dwellings, schools and offices. In this
method, reliance is placed on certain forces which operate in nature. These are:

(1) THE WIND : The wind is an active force in ventilation. When it blows through a room it is called
perflation. When there is an obstruction it bypasses and exerts a suction action at its tail end is
called aspiration.

(2) DIFFUSION : Air passes through the smallest openings or spaces by diffusion.

(3) INEQUALITY OF TEMPERATURE: Air flows from high density to low density, it rises when slightly
heated and escapes from openings provided high up in the room. The outside air which is cooler and
more dense will enter the room through inlets placed low.

2. MECHANICAL VENTILATION

(1) Exhaust ventilation : In this system, air is extracted or exhausted to the outside by exhaust fans
usually driven by electricity. Exhaust ventilation is generally provided in large halls and auditoria for
removal of vitiated air.

(2) Plenum ventilation : In this system, fresh air is blown into the room by centrifugal fans so as to
create a positive pressure and displace the vitiated air.

(3) Balanced ventilation : This is a combination of the exhaust and plenum systems of ventilation.

(4) Air conditioning : Air conditioning is defined as the simultaneous control of all or at least the first
three of those factors affecting both the physical and chemical conditions of the atmosphere within
any confined space or room.
COMFORT ZONES
• Comfort zones may be defined as the range of ETs over which the majority of adults feel
comfortable.
• There is no unanimous decision on a single zone of comfort for all people because comfort is
quite a complex subjective experience which depends not only on physical, physiological
factors, but also on psychological factors which are difficult to determine.
• Considering only the environmental factors, comfortable thermal conditions are those under
which a person can maintain normal balance between production and loss of heat, at
normal body temperature and without sweating. Comfort zones evaluated in India are as
below :

Corrected effective temperature deg C

1. Pleasant and cool 20
2. Comfortable and cool 20-25
3. Comfortable 25-27
4. Hot and uncomfortable 27-28
5. Extremely hot 28 +
6. Intolerably hot 30 +
Predicted four-hour sweat rate (P4SR)
1. Comfort zone 1-3 litres
2. Just tolerable 3-4.5 litres
3. Intolerable 4.5 + litres

INCINERATION
• Incineration is a high temperature dry oxidation process, that reduces organic and
combustible waste to inorganic incombustible matter and results in a very significant
reduction of waste-volume and weight.
• The process is usually selected to treat wastes that cannot be recycled, reused or disposed
off in a land fill site. Characteristics of the waste suitable for incineration are :

(a) low heating volume - above 2,000 kcal/kg for single-chamber incinerators, and above 3,500
kcal/kg for pryolytic double-chamber incinerators
(b) content of combustible matter above 60 per cent

(c) content of non-combustible solids below 5 per cent

(d) content of non-combustible fines below 20 percent

(e) moisture content below 30 per cent

• Waste types not to be incinerated are :

(a) pressurized gas containers

(b) large amount of reactive chemical wastes

(c) silver salts and photographic or radiographic wastes

(d) Halogenated plastics such as PVC

(e) waste with high mercury or cadmium content, such as broken thermometers, used batteries, and
lead-lined wooden panels

(f) sealed ampules or ampules containing heavy metals

TYPES OF INCINERATORS

(a) Double-chamber pyrolytic incinerators which may be especially designed to burn infectious
health-care waste

(b) Single-chamber furnaces with static grate, which should be used only if pyrolytic incinerators are
not affordable

(c) Rotary kilns operating at high temperatures, capable of causing decomposition of genotoxic
substances and heat-resistant chemicals

FERTILITY
• By fertility is meant the actual bearing of children. A woman's reproductive period is roughly
from 15 to 45 years -a period of 30 years. A woman married at 15 and living till 45 with her
husband is exposed to the risk of pregnancy for 30 years.
• Fertility depends upon several factors. The higher fertility in India is attributed to universality
of marriage, lower age at marriage, low level of literacy, poor level of living, limited use of
contraceptives and· traditional ways of life.
Other Factors
1. Age at marriage

• The age at which a female marries and enters the reproductive period of life has a great
impact on her fertility. Females who marry before the age of 18 gave birth to a larger
number of children than those who married after 18.
• If marriages were postponed from the age of 16 to 20-21, the number of births would
decrease by 20-30 %.

2. Duration of married life

• Indicate that 10-25 per cent of all births occur within 1-5 years of married life, 50-55 per cent
of all births within 5-15 years of married life. Births after 25 years of married life are very
few.

3. Spacing of children

• Have shown that when all births are postponed by one year, in each age group there was a
decline in total fertility.

4. Education

• There is an inverse association between fertility and educational status. Education provides
knowledge, increased exposure to information and media, builds skill for gainful
employment, increases female participation in family decision making.

5. Economic status

• The total number of children born declines with an increase in per capita expenditure of the
household.

6. Caste and religion

• Muslims have a higher fertility than Hindus.

7. Nutrition

• All well-fed societies have low fertility, and poorly-fed societies high fertility. The effect of
nutrition on fertility is largely indirect.

8. Family planning

• In a number of developing countries, family planning has been a key factor in declining
fertility.
Fertility-related statistics
1. Birth Rate

Birth Rate = Number of live births during the year x 1000

Estimated mid-year population

2. General Fertility Rate (GFR)

GFR = Number of live births in an area during the year x 1000

Mid-year female population age 15-44 (or 49) in the same area in same year

3. General Marital Fertility Rate (GMFR)

GMFR = Number of live births in a year x 1000

Mid-year married female population in the age-group 15-49 years

4. Age-specific Fertility Rate (ASFR)

ASFR = Number of live births in a particular age group x 1000

Mid-year female population of the same age-group

5. Age-specific Marital Fertility Rate (ASMFR)

ASMFR = Number of live births in a particular age group x 1000

Mid-year married female population of the same age group

6. Child-woman Ratio

• It is the number of children 0-4 years of age per 1000 women of child-bearing age usually
defined as 15-44 or 49 years of age.

7. Pregnancy Rate

• It is the ratio of number of pregnancies in a year to married women in the ages 15-44 (or 49)
years.

8. Abortion Rate

• The annual number of all types of abortions, usually per 1000 women of child-bearing age
(usually defined as age 15-44).

9. Abortion Ratio

• This is calculated by dividing the number of abortions performed during a particular time
period by the number of live births over the same period.
10. Marriage Rate

Marriage rate = Rate Number of marriages in the year x 1000

Mid-year population

FAMILY PLANNING
• A way of thinking and living that is adopted voluntarily, upon the basis of knowledge,
attitudes and responsible decisions by individuals and couples, in order to promote the
health and welfare of the family group and thus contribute effectively to the social
development of a country.

Objectives

• avoid unwanted births

• to bring about wanted births

• to regulate the intervals between pregnancies

• to control the time at which births occur in relation to the ages of the parent

• to determine the number of children in the family.

Scope of family planning services

• the proper spacing and limitation of births

• advice on sterility

• education for parenthood

• sex education

• screening for pathological conditions related to the reproductive system (e.g., cervical cancer)

• genetic counselling

• premarital consultation and examination

• carrying out pregnancy tests

• marriage counselling

• the preparation of couples for the arrival of their first child

• providing services for unmarried mothers

• teaching home economics and nutrition

• providing adoption services

Health aspects

WOMEN'S HEALTH : Pregnancy can mean serious problems for many women. It may damage the
mother's health or even endanger her life. The risk increases as the mother grows older and after
she has had 3 or 4 children. The health impact of family planning occurs primarily through :

• the avoidance of unwanted pregnancies

• limiting the number of births and proper spacing

• timing the births, particularly the first and last, in relation to the age of the mother.

FOETAL HEALTH : A number of congenital anomalies (e.g., Down's syndrome) are associated with
advancing maternal age. Such congenital anomalies can be avoided by timing the births in
relation to the mother's age.

CHILD HEALTH : Issues relating to family planning are highly relevant to paediatrics.

• Child mortality : It is well known that child mortality increases when pregnancies occur in rapid
succession. A birth interval of 2 to 3 years is considered desirable to reduce child mortality.

• Child growth, development and nutrition : Birth spacing and family size are important factors in
child growth and development. Family planning, in other words, is effective prevention against
malnutrition.

• Infectious diseases : Children living in large-sized families have an increase in infection, especially
infectious gastroenteritis, respiratory and skin infections.
Eligible couples :

• An "eligible couple" refers to a currently married couple wherein the wife is in the
reproductive age, which is generally assumed to lie between the ages of 15 and 45. There
will be at least 150 to 180 such couples per 1000 population in India.

• These couples are in need of family planning services. About 20 per cent of eligible couples
are found in the age group 15-24 years. On an average 2.5 million couples are joining the
reproductive group every year.
• The "Eligible Couple Register" is a basic document for organizing family planning work. It is
regularly updated by each functionary of the family planning programme for the area falling
within his jurisdiction.

Target couples :

• In order to pin-point the couples who are a priority group within the broad definition of
"eligible couples", the term "target couple" was coined. Hitherto, the term target couple was
applied to couples who have had 2-3 living children, and family planning was largely directed
to such couples.

• The definition of a target couple has been gradually enlarged to include families with one
child or even newly married couples (34) with a view to develop acceptance of the idea of
family planning from the earliest possible stage.
• In effect, the term target couple has lost its original meaning. The term eligible couple is now
more widely used and has come to stay.

CONTRACEPTIVE METHODS
• Contraceptive methods are preventive methods to help women avoid unwanted pregnancies.
Contraceptive is safe, effective, acceptable, inexpensive, reversible, simple to administer,
independent of coitus, long-lasting enough to obviate frequent administration and requiring little
or no medical supervision.

• The contraceptive methods may be broadly grouped into two classes spacing methods and
terminal methods, as shown below :

A. Spacing methods

a. Barrier methods
b. Physical methods

c. Chemical methods

d. Combined methods

2. Intra-uterine devices

3. Hormonal methods

4. Post-conceptional methods

5. Miscellaneous.

B. Terminal methods

1. Male sterilization

2. Female sterilization

BARRIER METHODS

• A variety of barrier or "occlusive" methods, suitable for both men and women are available. The
aim of these methods is to prevent live sperm from meeting the ovum.

PHYSICAL METHODS

• Condom : Condom is the most widely known and used barrier device by the males around the
world. In India, it is better known by its trade name NIRODH, a Sanskrit word, meaning
prevention. Condom prevents the semen from being deposited in vagina.

ADVANTAGES : (a) they are easily available (b) safe and inexpensive (c) easy to use (d) no side
effects (e) light, compact and disposable (f) provides protection not only against pregnancy but
also against STD.

DISADVANTAGES : It may slip off or tear during coitus due to incorrect use.

• Female condom : The female condom is a pouch made of polyurethane, which lines the vagina.
An internal ring in the close end of the pouch covers the cervix and an external ring remains
outside the vagina
• Diaphragm : The diaphragm is a vaginal barrier. Also known as "Dutch cap' . The diaphragm is a
shallow cup made of synthetic rubber or plastic material. It ranges in diameter from 5-10 cm (2-4
inches).

ADVANTAGES : The primary advantage of the diaphragm is the almost total absence of risks and
medical contraindications.

DISADVANTAGES : Initially a physician or other trained person will be needed to demonstrate the
technique of inserting the diaphragm into the vagina and to ensure a proper fit.

• Vaginal sponge : Another barrier is the sponge soaked in vinegar or olive oil. It is a small
polyurethane foam sponge saturated with the spermicide.

CHEMICAL METHODS

a) Foams : foam tablets, foam aerosols b) Creams, jellies and pastes squeezed from a tube c)
Suppositories inserted manually d) Soluble films - C-film inserted manually.

INTRA-UTERINE DEVICES

• There are two basic types of IUD : non-medicated and medicated. Both are usually made of
polyethylene or other polymers.

1. Non-medicated or inert IUDs - first generation IUDs.

2. Copper IUDs - second

3. Hormone-releasing IUDs - third generation IUDs

4. Earlier devices : Copper- 7 , Copper T -200

5. Newer devices : (i) Cu-T-220 C (ii) Cu-T-380 A or Ag - Nova T - Multiload devices (i) ML-Cu-250 (ii)
ML-Cu-375

Advantages : (a) simplicity i.e. no complex procedures are involved in insertion, no hospitalization is
require (b) insertion takes only a few minutes (c) once inserted IUD stays in place as long as
required
Contraindications :

1. ABSOLUTE : (a) suspected pregnancy (b) pelvic inflammatory disease (c) vaginal bleeding of
undiagnosed aetiology (d) cancer of the cervix, uterus or adnexia and other pelvic tumours (e)
previous ectopic pregnancy

2. RELATIVE : (a) anaemia (b) menorrhagia (c) history of PID

HORMONAL CONTRACEPTIVES

Gonadal steroids :

1. Oral pills

2. Combined pill

3. Progestogen only pill (POP)

4. Post-coital pill

5. Once-a-month (long-acting) pill

6. Male pill

ORAL PILLS

• Combined pill The combined pill is one of the major spacing methods of contraception. The
"original pill" contained 100-200 mcg of a synthetic oestrogen and 10 mg of a progestogen. The
pill is given orally for 21 consecutive days beginning on the 5th day of the menstrual cycle .

• India has made available 2 types of low-dose oral pills under the brand names of MALA-N and
MALA-D.

Progestogen-only pill (POP) : This pill is commonly referred to as "minipill" or "micropill". It contains
only progestogen, which is given in small doses throughout the cycle.

Post-coital contraception : Post-coital (or "morning after") recommended within 72 hours of

intercourse.

Once-a-month (long-acting) pill : Experiments with once-a-month oral pill in which quinestrol, a
long-acting oestrogen is given in combination with a short-acting progestogen, have been
disappointing
Male pill : (a) preventing spermatogenesis (b) interfering with sperm storage and maturation (c)
preventing sperm transport in the vas, and {d) affecting constituents of the seminal fluid.

POST-CONCEPTIONAL METHODS (Termination of pregnancy)

1. Menstrual regulation : A relatively simple method of birth control is "menstrual regulation". It

consists of aspiration of the uterine contents 6 to 14 days of a missed period.

2. Menstrual induction : This is based on disturbing the normal progesterone- prostaglandin balance
by intrauterine application of 1-5 mg solution (or 2.5-5 mg pellet) of prostaglandin F2.

3. Oral abortifacient Mifepristone : RU 486 in combination with misoprostol is 95 % successful in

terminating pregnancies of upto 9 week's duration with minimum complications.

4. ABORTION : Abortion is theoretically defined as termination of pregnancy before the foetus

becomes viable (capable of living independently). This has been fixed administratively at 28 weeks:
when the foetus weighs approximately 1000 g.

MISCELLANEOUS

1. Abstinence : The only method of birth control which is completely effective is complete sexual
abstinence.

2. Coitus interruptus : This is the oldest method of voluntary fertility control. The male withdraws
before ejaculation, and thereby tries to prevent deposition of semen into the vagina.

3. Safe period (rhythm method) : This is also known as the "calendar method" , based on the fact
that ovulation occurs from 12 to 16 days before the onset of menstruation .

Male sterilization :

• Male sterilization or vasectomy being a comparatively· simple operation can be performed even
in primary health centres by trained doctors under local anaesthesia. In vasectomy, it is
customary to remove a piece of vas at least 1 cm after clamping. The ends are ligated and then
folded back on themselves and sutured into position, so that the cut ends face away from each
other.
Female sterilization :

• Female sterilization can be done as an interval procedure, postpartum or at the time of abortion.
Two procedures have become most common, namely : laparoscopy and minilaparotomy.

• Laparoscopy : This is a technique of female sterilization through abdominal approach with a

specialized instrument called "laparoscope". The abdomen is inflated with gas (carbon dioxide,
nitrous oxide or air) and the instrument is introduce d into the abdominal cavity to visualize the
tubes. Once the tubes are accessible, the Fallope rings (or clips) are applied to occlude the tubes.
• Minilap operation : Minilaparotomy is a modification of abdominal tubectomy. It is a much
simpler procedure requiring a smaller abdominal incision of only 2.5 to 3 cm conducted under
local anaesthesia.

RCH
• Reproductive and child health approach has been defined as people have the ability to
reproduce and regulate their fertility, women are able to go through pregnancy and child
birth safely, the outcome of pregnancies is successful in terms of maternal and infant
survival and well being, and couples are able to have sexual relations, free of fear of
pregnancy and of contracting disease.

Interventions in all districts

• Child Survival interventions i.e. immunization, Vitamin A (to prevent blindness), oral
rehydration therapy and prevention of deaths due to pneumonia.
• Safe Motherhood interventions e.g. antenatal check up, immunization for tetanus, safe
delivery, anaemia control programme.
• Implementation of Target Free Approach.
• High quality training at all levels.
• IEC activities
• RTl/STD Clinics at District Hospitals (where not available)
• Facility for safe abortions at PHCs by providing equipment, contractual doctors etc.

Interventions in selected States

• Emergency obstetric care at selected FRUs by providing drugs.

• Essential obstetric care by providing drugs and PHN/ Staff Nurse at PHCs.
 • Additional ANM at sub-centres in the weak districts for ensuring MCH care.
• Improved delivery services and emergency care by providing equipment kits, IUD insertions
and ANM kits at sub-centres.
• Facility of referral transport for pregnant women during emergency to the nearest referral
centre through Panchayat in weak districts.

RCH - Phase I

(a) Essential obstetric care : Essential obstetric care intends to provide the basic maternity services
to all pregnant women through

(1) early registration of pregnancy (within 12-16 weeks)

(2) provision of minimum three antenatal check ups by ANM or medical officer

(3) provision of safe delivery at home or in an institution

(b) Emergency obstetric care : Complications associated with pregnancy are not always predictable
hence, emergency obstetric care is an important intervention to prevent maternal morbidity and
mortality.

(c) 24-Hour delivery services at PHCs/CHCs

(d) Medical Termination of Pregnancy : MTP is a reproductive health measure that enables a woman
to opt out of an unwanted or unintended pregnancy in certain specified circumstances without
endangering her life, through MTP Act 1971.

(e) Control of reproductive tract infections (RTI) and sexually transmitted diseases (STD)

(f) Immunization : The Universal Immunization Programme (UIP) became a part of CSSM programme
in 1992 and RCH programme in 1997.

(g) Essential newborn care The primary goal of essential newborn care is to reduce perinatal and
neonatal mortality.

(h) Diarrhoeal disease control and Acute respiratory disease control

RCH - PHASE II

RCH-phase II began from 1st April, 2005. The major strategies under the second phase of RCH are :
• Essential obstetric care

a. Institutional delivery

b. Skilled attendance at delivery

• Emergency obstetric care

a. Operationalizing First Referral Units

b. Operationalizing PHCs and CHCs for round the clock delivery services

• The Government of India has given some broad guidelines and strategies for achieving the
reduction in maternal mortality rate and infant mortality rate. The initiatives which have
been planned are :

Essential obstetric care

a. Institutional delivery : To promote institutional delivery it was envisaged that fifty % of the PHCs
and all the CHCs would be made operational as 24-hour delivery centres.

b. Skilled attendance at delivery : The WHO has also emphasized that skilled attendance at every
birth is essential to reduce the maternal mortality in any country.

c. The policy decisions : ANMs / LHVs / SNs have now been permitted to use drugs in specific
emergency situations to reduce maternal mortality.

Emergency obstetric care

1. 24 hour delivery services including normal and assisted deliveries

2. Emergency obstetric care including surgical interventions like caesarean sections

3. New-born care

4. Emergency care of sick children

5. Full range of family planning services including laproscopic services

6. Safe abortion services

7. Treatment of STl/RTI

8. Blood storage facility

New initiatives

1. Training of MBBS doctors in life saving anaesthetic skills for emergency obstetric care : Provision
of adequate and timely emergency obstetric care (EmOC) has been recognized as the most
important intervention for saving lives of pregnant women who may develop complications during
pregnancy or childbirth.

The training of MBBS doctors will be undertaken for only such numbers who are required for the
functioning of FRUs and CHCs and shall be limited to the requirement of tackling emergency
obstetric situations only.

2. Setting up of blood storage centres at FRUs according to government of India guidelines.

MCH (Maternal and child health)

• The term "maternal and child health" refers to the promotive, preventive, curative and
rehabilitative health care for mothers and children.
• The specific objectives of MCH are

(a) reduction of maternal, perinatal, infant and childhood mortality and morbidity

(b) promotion of reproductive health

(c) promotion of the physical and psychological development of the child and adolescent within the
family.

• The ultimate objective of MCH services is lifelong health is Pregenancy detection. The simple
way to confirm pregnancy in the first trimester is to conduct a urine examination using a
pregnancy test kit.

• The kit detects pregnancy on the basis of presence of human chorionic gonadotrophin
hormone in the urine. The test is performed soon after a missed period and is simple to
perform.
• The· pregnancy test should be offered to any women who is in reproductive age group and
comes with a history of amenorrhoea or symptoms of pregnancy.
• The Government of India has made "Nischay" pregnancy test kit available across the
country. Other test kits are also available in the market. The kit is provided to ASHA or other
link workers and the women should be advised appropriately on the result of the test.
ANTENATAL CARE

• Antenatal care is the care of the woman during pregnancy. The primary aim of antenatal
care is to achieve at the end of a pregnancy a healthy mother and a healthy baby. Ideally this
care should begin soon after conception and continue throughout pregnancy.
• The objectives of antenatal care are :

(1) To promote, protect and maintain the health of the mother during pregnancy.

(2) To detect "high-risk" cases and give them special attention.

(3) To foresee complications and prevent them.

(4) To remove anxiety and dread associated with delivery.

(5) To reduce maternal and infant mortality and morbidity.

(6) To teach the mother elements of child care, nutrition, personal hygiene, and environmental
sanitation.

(7) To sensitize the mother to the need for family planning, including advice to cases seeking medical
termination of pregnancy

(8) To attend to the under-fives accompanying the mother.

The above objectives are achieved by the following programme of health care services :

(1) Antenatal visits

• Ideally the mother should attend the antenatal clinic once a month during the first 7
months; twice a month, during the next month; and thereafter, once a week, if everything is
normal. In these cases, a minimum of 4 visits covering the entire period of pregnancy should
be the target, as shown below : The suggested schedule is as follows :

1st visit - within 12 weeks, preferably as soon as the pregnancy is suspected, for registration of
pregnancy and first antenatal check-up

2nd visit between 14 and 26 weeks

3rd visit - between 28 and 34 weeks

4th visit - between 36 weeks and term. It is advisable for the woman to visit medical officer at the
PHC for an antenatal check-up during the period of 28-34 weeks (3 rd visit ).

• Early pregnancy detection is important for the following reasons :

1. It facilitates proper planning and allows for adequate care to be provided during pregnancy for
both the mother and the foetus.

2. Record the date of last menstrual period and calculate the expected date of delivery.

3. The health status of the mother can be assessed and any medical illness that she might be
suffering from can be detected.

4. It helps in timely detection of complications at an early stage and helps to manage them
appropriately by referral as and where required.

5. It also helps to confirm if the pregnancy is wanted and if not, then refer the women at the earliest
to a 24 hours PHC or FRU that provides safe abortion services.

6. Early detection of pregnancy and provision of care from the initial stage facilitates a good
interpersonal relationship between the care giver and the pregnant woman.

PREVENTIVE SERVICES FOR MOTHERS (ANTENATAL CHECK-UP)

I. History-taking

(1) Confirm the pregnancy (first visit only)

(2) Identify whether there were complications during any previous pregnancy/confinement that may
have a bearing on the present one

(3) Identify any current medical/ surgical or obstetric conditions that may complicate the present
pregnancy

(4) Record the date of 1st day of last menstrual period and calculate the expected date of delivery by
adding 9 months and 7 days to the 1st day of last menstrual period

(5) Record symptoms indicating complications, e.g. fever, persisting vomiting, abnormal vaginal
discharge or bleeding, palpitation, easy fatigability, breathlessness at rest or on mild exertion,
generalized swelling in the body, severe headache and blurring of vision, burning in passing urine,
decreased or absent foetal movements etc;
(6) History of any current systemic illness, e.g., hypertension, diabetes, heart disease, tuberculosis,
renal disease, epilepsy, asthma, jaundice, malaria, reproductive tract infection, STD, HIV/AIDS etc.

(7) History of drug allergies and habit forming drugs.

II. Physical examination

1. Pallor : Presence of pallor indicates anaemia. Pallor should be co-related with haemoglobin
estimation.

2. Pulse : The normal pulse rate is 60 to 90 beats per minute. If the pulse rate is persistently low or
high, with or without other symptoms, the woman needs medical attention.

3. Respiratory rate : It is important to check the respiratory rate, especially if the woman complaints
of breathlessness. Normal respiratory rate is 18-20 breaths per minute.

4. Oedema : Oedema (swelling), which appears in the evening and disappears in the morning after a
full night's sleep, could be a normal manifestation of pregnancy. Any oedema of the face, hands,
abdominal wall and vulva is abnormal. Woman.

5. Blood pressure: Measure the woman's blood pressure at every visit. This is important to rule out
hypertensive disorders of pregnancy. Hypertension is diagnosed when two consecutive readings
taken four hours or more apart show 140/90 mmHg or more.

6. Weight : A pregnant woman's weight should be taken at each visit. Normally, a woman should
gain 9-11 kg during her pregnancy. Ideally after the first trimester, a pregnant woman gains around 2
kg every month.

7. Breast examination : Observe the size and shape of the nipples for the presence of inverted or flat
nipples.

III. Abdominal examination

1. Measurement of fundal height : (a) 12 weeks - Uterine fundus just palpable per abdomen

(b) 20 weeks - Fundus flat at the lower border of umbilicus

(c) 36 weeks - Fundus felt at the level of xiphisternum

2. Foetal heart sounds : The foetal heart sounds can be heard after 6th month. The rate varies
between 120 to 140 per minute.
3. Foetal movements : Foetal movements can be felt by the examiner after 18-22nd week by gently
palpating the abdomen.

4. Foetal parts : These can be felt about the 22nd week. After the 28th week, it is possible to
distinguish the head, back and limbs.

IV. Assessment of gestation age

• The most accurate "gold standard" for assessment is routine early ultrasound assessment
together with foetal measurements ideally in the first trimester. Gestational age assessment
based on the date of last menstrual period (LMP) was previously the most widespread
method used. Many countries now use "best obstetric estimate", combining ultrasound and
LMP as an approach to estimate gestational age.

V. Laboratory investigations

a. At the sub-centre : Pregnancy detection test - Haemoglobin examination - Urine test for presence
of albumin and sugar - Rapid malaria test

b. At the PHC/CHC/FRU: - Blood group, including Rh factor - VDRL/RPR - HIV testing - Rapid malaria
test (if unavailable at SC) - Blood sugar testing - HBsAg for hepatitis B infection.

(2) Prenatal advice

(i) DIET: Reproduction costs energy. A pregnancy in total duration consumes about 60,000 kcal, over
and above normal metabolic requirements. Lactation demands about 550 kcal a day. On an average,
a normal healthy woman gains about 9-11 kg of weight during pregnancy. A balanced and adequate
diet is therefore, of utmost importance during pregnancy and lactation to meet the increased needs
of the mother, and to prevent "nutritional stress".

(ii) PERSONAL HYGIENE : The need to bathe every day and to wear clean clothes should be
explained. The hair should also be kept clean and tidy.

• 8 hours sleep, and at least 2 hours rest after mid-day meals should be advised.
• Constipation should be avoided by regular intake of green leafy vegetables, fruits and extra
fluids.
• Light household work is advised, but manual physical labour during late pregnancy may
adversely affect the foetus.
 • Smoking should be cut down to a minimum. The perinatal mortality amongst babies whose
mothers smoked during pregnancy is between 10-40 per cent higher than in non-smokers.
• Heavy drinking has been associated with a fetal syndrome (FAS) which includes intrauterine
growth retardation and developmental delay.
• Sexual Intersourse should be restricted especially during the last trimester.
• Certain drugs taken by the mother during pregnancy may affect the foetus adversely and
cause foetal malformations.
• Exposure to radiation is a positive danger to the developing foetus. The most common
source of radiation is abdominal X-ray during pregnancy.
• WARNING SIGNS : (a) swelling of the feet (b) fits (c) headache (d) blurring of the vision (e)
bleeding or discharge per vagina
• CHILD CARE : Mother-craft education consists of nutrition education, advice on hygiene and
childrearing, cooking demonstrations, family planning education, family budgeting, etc.

(3) Specific health protection

(i) ANAEMIA : The major aetiological factors being iron and folic acid deficiencies. The Government
of India has initiated a programme in which 100 mg of elemental iron and 500 mcg of folic acid are
being distributed daily for 100 days to pregnant women through antenatal clinics, primary health
centres and their subcentres.

(ii) OTHER NUTRITIONAL DEFICIENCIES : The mother should be protected against other nutritional
deficiencies that may occur, particularly protein, vitamin and mineral especially vit A and iodine
deficiency.

(iii) TOXEMIAS OF PREGNANCY : The presence of albumine in urine and an increase in blood pressure
indicates toxemias of pregnancy.

(iv) TETANUS : If the mother was not immunized earlier, 2 doses of adsorbed tetanus toxoid should
be given the first dose at 16-20 weeks and the second dose at 20-24 weeks of pregnancy.

(v) SYPHILIS : Pregnancies in women with primary and secondary syphilis often end in spontaneous
abortion, stillbirth, perinatal death, or the birth of a child with congenital syphilis.

(vi) GERMAN MEASLES : When rubella was contracted in the first 16 weeks of pregnancy, foetal
death or death during the first year of life occurred in the offspring of 17 per cent of the
pregnancies.
(vii) Rh STATUS : The foetal red cells may enter the maternal circulation in a number of different
circumstances, during labour, caesarean section, therapeutic abortion, external cephalic version, and
apparently spontaneously in the late pregnancy.

(viii) HIV INFECTION·: HIV may pass from an infected mother to her foetus, through the placenta or
to her infant during delivery or by breast-feeding. About one-third of the children of HIV-positive
mothers get infected through this route.

(ix) HEPATITIS B INFECTION : Spread of infection from HBV carrier mothers to their babies appears to
be a factor for the high prevalence of HBV infection in some regions.

(x) PRENATAL GENETIC SCREENING : Prenatal genetic screening includes screening for chromosomal
abnormalities associated with serious birth defects, screening for direct evidence of congenital
structural anomalies, and screening for haemoglobinopathies and other inherited conditions

(4) Mental preparation

Mental preparation is as important as physical or material preparation. Sufficient time and

opportunity must be given to the expectant mothers to have a free and frank talk on all aspects of
pregnancy and delivery. The "mothercraft" classes at the MCH Centres help a great deal in achieving
this objective.

(5) Family planning

• Educational and motivational efforts must be initiated during the antenatal period. If the
mother has had 2 or more children, she should be motivated for puerperal sterilization.

(6) Paediatric component

• It is suggested that a paediatrician should be in attendance at all antenatal clinics to pay

attention to the under-fives accompanying the mothers.

MCH problems
• MCH problems cover a broad spectrum. At one extreme, the most advanced countries are
concerned with problems such as perinatal problems, congenital malformations, genetic and
certain behavioural problems.
• At the other extreme, in developing countries, the primary concern is reduction of maternal
and child mortality and morbidity, spacing of pregnancies, limitation of family size,
prevention of communicable diseases, improvement of nutrition and promoting acceptance
of health practices.
1. Malnutrition

• Malnutrition is like an iceberg, most people in the developing countries live under the
burden of malnutrition.
• Pregnant women, nursing mothers and children are particularly vulnerable to the effects of
malnutrition.
• The adverse effects of maternal malnutrition have been well documented-maternal
depletion, low birth weight, anaemia, toxemias of pregnancy, postpartum haemorrhage, all
leading to high mortality and morbidity.
• The effects of malnutrition are also frequently more serious during the formative years of
life. Previously it was thought that malnutrition was largely concentrated in school age
children, and in toddlers.
• Now it is realized that the intrauterine period of life is a very important period from the
nutritional standpoint.
• Measures to improve the nutritional status of mothers and children may be broadly divided
into direct and indirect nutrition interventions.
• Direct interventions cover a wide range of activities, viz. supplementary feeding
programmes, distribution of iron and folic acid tablets, fortification and enrichment of foods,
nutrition education, etc.
• Indirect nutrition interventions have still wider ramifications because they are not
specifically related to nutrition. These include measures such as control of communicable
diseases through immunization, improvement of environmental sanitation, provision of
clean drinking water, family planning, food hygiene, education and primary health care.

2. Infection

• Maternal infections may cause a variety of adverse effects such as foetal growth retardation,
low birth weight, embryopathy, abortion and puerperal sepsis.
• Many women are infected with HIV, hepatitis B, cytomegalo viruses, herpes simplex virus or
toxoplasma during pregnancy. Furthermore, as many as 25% of the women in rural areas
suffer at least one bout of urinary infection.
• As far as the baby is concerned, infection may begin with labour and delivery and increase as
the child grows older.
• Children may be ill with debilitating diarrhoeal, respiratory and skin infections for as much as
a third of their first year of life.
• Prevention and treatment of infections in mother and children is a major and important part
of normal MCH care activity. It is now widely recognized that children in developing areas
need to be immunized against six infections tuberculosis, diphtheria, whooping cough,
tetanus, measles and polio.

3. Uncontrolled reproduction

• The health hazards for the mother and the child resulting from unregulated fertility have
been well recognized - increased prevalence of low birth weight babies, severe anaemia,
abortion, antepartum haemorrhage and a high maternal and perinatal mortality, which have
shown a sharp rise after the 4th pregnancy.
• Because family planning has a striking impact on the health of the mother and the child, a
number of countries have integrated family planning in the MCH care activities.
 • The introduction of new types of· IUD; easier and safer techniques of pregnancy termination
and female sterilization; oral pills and long-acting injectable medroxy- progesterone acetate
(MPA) have contributed a good deal in the utilization of family planning services.

INDICATORS OF MCH CARE

• Maternal and child health status is assessed through measurements of mortality, morbidity
and, growth and development. The commonly used mortality indicators of MCH care are :

1. Maternal mortality ratio

2. Mortality in infancy and childhood

a. Perinatal mortality rate

b. Neonatal mortality rate

c. Post-neonatal mortality rate

d. Infant mortality rate e. 1-4 year mortality rate

f. Under-5 mortality rate g. Child survival rate

Maternal mortality ratio

• According to WHO, a maternal death is defined as "the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of the duration and site of
pregnancy, from any cause related to or aggravated by the pregnancy or its management
but not from accidental or incidental causes".
• Maternal mortality ratio measures women dying from "puerperal causes" and is defined as

Total no. of female deaths due to complications of pregnancy, childbirth or within 42 days of delivery
from "puerperal causes" in an area during a given year x 1000 (or 100,000)

Total no. of live births in the same area and year

• Late maternal death : Complications of pregnancy or childbirth can also lead to death
beyond the six-weeks postpartum period.
• The International Classification of Diseases (ICD) has recommended that maternal deaths
may be disaggregated into two groups :

(1) Direct obstetric deaths : those resulting from obstetric complications of the pregnant state
(pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a
chain of events resulting from any of the above.

(2) Indirect obstetric deaths: those resulting from previous existing disease or disease that
developed during pregnancy and which was not due to direct obstetric causes, but which was
aggravated by physiological effects of pregnancy.
The maternal mortality rate, the direct obstetric rate and the indirect obstetric rate are fine
measures of the quality of maternity services.

Causes

• Maternal deaths mostly occur from the third trimester to the first week after birth (with the
exception of deaths due to complications of abortion).
• Studies show that mortality risks for mothers are particularly elevated within the first two
days after birth.
• Most maternal deaths are related to obstetric complications including postpartum
haemorrhage, infections, eclampsia and prolonged or obstructed labour and complications
of abortion.
• About 80 % of maternal deaths are due to direct causes i.e. obstetric complications of
pregnancy, labour and puerperium to interventions or incorrect treatment, is obstetric
haemorrhage, generally occurring postpartum which can lead to death very rapidly in the
absence of prompt life-saving care.
• Puerperal infections, often the consequence of poor hygiene during delivery, or untreated
reproductive tract infections account for about 15% of maternal mortality.
• Hypertensive disorders of pregnancy, particularly eclampsia (convulsions) result in about
13% of all maternal deaths.

Social correlates
A number of social factors influence maternal mortality. The important ones are :

(a) Women's age : The optimal child-bearing years are between the ages of 20 and 30 years

(b) Birth interval : Short birth intervals are associated with an increased risk of maternal mortality

(c) Parity: High parity contributes to high maternal mortality

Preventive and social measures

High maternal mortality reflects not only in inadequacy of health care services for mothers, but also
a low standard of living and socio-economic status of the community.

1. Early registration of pregnancy

2. At least four antenatal check-ups

3. Dietary supplementation including correction of anaemia

4. Prevention of infection and haemorrhage during puerperium

5. Prevention of complications, e.g. eclampsia, malpresentations, ruptured uterus

6. Treatment of medical conditions, e.g. hypertension, diabetes, tuberculosis, etc. Anti-malaria and
tetanus prophylaxis

7. Anti-malaria & tetanus prophylaxis

8. Clean delivery practice

9. In India, a large number of maternal deaths could be prevented with the help of trained local dais
and female health workers

10. Institutional deliveries for women with bad obstetric history and risk factors

11. Promotion of family planning - to control the number of children to not more than two and
spacing of births

12. Identification of every maternal death, and searching for its cause

13. Safe abortion services

FEEDING OF INFANTS
(1) Breast-feeding

• Under any circumstances, breast milk is the ideal food for the infant. No other food is
required by the baby until 6 months after birth. Under normal conditions, Indian mothers
secrete 450 to 600 ml of milk daily with 1.1 gm protein per 100 ml. The energy value of
human milk is 70 kcals per 100 ml.
• A child who is breast-fed has greater chances of survival than a child artificially fed.
Prolonged breast feeding does protect the infant from early malnutrition and some
infections. A breast-fed baby is likely to have an IQ of around 8 points higher than a non-
breast fed baby.

Advantages of breast-feeding

(a) it is safe, clean, hygienic, cheap and available to the infant at correct temperature

(b) it fully meets the nutritional requirements of the infant in the first few months of life

(c) it contains antimicrobial factors such as macrophages, lymphocytes, secretory IgA, anti-
streptococcal factor, lysozyme and lactoferrin which provide considerable protection not only
against diarrhoeal diseases and necrotizing enterocolitis

(d) it is easily digested and utilized by both the normal and premature babies

(e) it promotes "bonding" between the mother and infant

(f) sucking is good for the baby - it helps in the development of jaws and teeth
(g) it protects babies from the tendency to obesity

(h) it prevents malnutrition and reduces infant mortality

(i) it helps parents to space their children by prolonging the period of infertility

(2) Artificial feeding

The main indications for artificial feeding are failure of breast milk, prolonged illness or death of the
mother. It is crucial for the baby to be fed "breast-milk substitutes" - e.g., dried whole milk powder,
fresh milk from a cow or other animal, or commercial formulae.

Principles of Artificial Feeding

a. Infants require an average of 100 kcal of energy per kg of body weight per day, i.e., about 150 ml
of milk per kg of body weight each day.

b. The estimated protein requirement is about 2 g/kg of body weight during the first 6 months; it
declines to about 1.5 g/kg by the end of one year.

c. The carbohydrate requirement is about 10 g/kg of body weight daily.

d. After 4 months of age, undiluted boiled and cooled milk should be given

e. Infants need feeding at frequent intervals about 6-8 times a day; older babies 5 times a day

f. During illness (e.g., fevers) the calorie need is increased, and it should be met.

(a) DRIED MILK : The safest milk is undoubtedly dried whole milk, which is scientifically prepared for
infant feeding. It is free from bacteria; there is little danger from flies; it does not become sour and is
simple to reconstitute. It is usually fortified with vitamins. But it is expensive and, therefore, beyond
the reach of many Indian families.

(b) COW'S MILK : A cheaper alternative which is well within the reach of many Indian families is
cow's milk, which in fact is widely used for infant feeding. Most health workers give very conflicting
advice on the use of cow's milk for infant feeding. Most authorities in India and abroad including the
World Health Organization have persistently recommended dilution of cow's milk during the first 2
months in order to reduce the solute load on neonatal kidneys.
Milk
• Milk is the best and most complete of all foods. It is secreted by the animals to serve as the
sole and wholesome food for their suckling young ones.
• It is a fine blend of all the nutrients necessary for growth and development of the young
ones. Thus milk is a good source of proteins, fats, sugars, vitamins and minerals.

• Milk is consumed in a variety of forms - as whole milk, butter, ghee, cheese, dried and
condensed milk, khoa, ice cream, etc. Milk from which fat has been removed, is known as
"skimmed milk". It is devoid of fat and fat soluble vitamins, but a good source of milk protein
(35 %) and calcium.

(i) Proteins :

• The chief protein of milk is casein; it occurs in combination with calcium as calcium
caseinogenate. The other proteins are lactalbumin and lactoglobulin.
• Animal milks contain nearly three times as much protein as human milk. Milk proteins
contain all the essential amino acids. Human milk proteins contain greater amounts of
tryptophan and sulphur-containing amino-acids (especially cystein) than the animal milk
proteins.

(ii) Fat :

• The fat content of milk varies from 3.4 per cent in human milk to 8.8 per cent in buffalo milk.
Human milk contains a higher percentage of linoleic. acid and oleic acid than animal milks.
Milk fat is a good source of retinal and vitamin D.

(iii) Sugar :

• The carbohydrate in all milks is lactose or milk sugar. It is found nowhere else in nature. It is
less sweet than cane sugar and is readily fermented by lactic acid bacilli. Human milk
contains more sugar than animal milks.

(iv) Minerals :

Milk contains almost all known minerals needed by the body such as calcium, phosphorus, sodium,
potassium, magnesium, cobalt, copper, iodine, etc. Milk is particularly rich in calcium; it is however a
poor source of iron.
(v) Vitamins :

• Milk is a good source of all vitamins except vitamin C.

Toned milk : The term "toned" is an Indian coinage. It is a blend of natural milk and "made-up" milk.
It contains 1 part of water, 1 part of natural milk and 1/8 part of skim milk powder. The mixture is
stirred, pasteurized and supplied in bottles. Toned milk has a composition nearly equivalent to cow's
milk. It is cheaper and yet a wholesome product

PASTEURIZATION OF MILK
• Pasteurization may be defined as the heating of milk to such temperatures and for such periods
of time as are required to destroy any pathogens that may be present while causing minimal
changes in the composition, flavour and nutritive value. There are three methods of
pasteurization:

1. Holder (Vat) method : In this process, milk is kept at 63-66°C for at least 30 minutes, and then

quickly cooled to 5°C.

2. HTST method (High Temperature and Short Time): Milk is rapidly heated to a temperature of

nearly 72°C, is held at that temperature for not less than 15 seconds, and is then rapidly cooled to
4°C.

3. UHT Method (ultra-high temperature): Milk is rapidly heated usually in 2 stages (the second stage

usually being under pressure) to 125°C for a few seconds only. It is then rapidly cooled and
bottled as quickly as possible.

Tests of pasteurized milk

• Phosphatase test : This test is widely used to check the efficiency of pasteurization. The test is
based on the fact that raw milk contains an enzyme called phosphatase which is destroyed on
heating. At 60°C for 30 minutes.

• Standard plate count : The bacteriological quality of pasteurized milk is determined by the
standard plate count.

• Coliform count : Coliform organisms are usually completely destroyed by pasteurization.

BALANCED DIET
• A balanced diet is defined as one which contains a variety of foods in such quantities and
proportions that the need for energy, amino acids, vitamins, minerals, fats, carbohydrate
and other nutrients is adequately met for maintaining health, vitality and general well-being.
• The following principles should be borne in mind : The daily requirement of protein(10-15%)
daily, fat requirement (15-30 %) daily should be met. Carbohydrates rich in natural fibre
should constitute the remaining food energy.

Dietary goals

(a) dietary fat should be limited to approximately 15-30 per cent of total daily intake

(b) saturated fats should contribute no more than 10 per cent of the total energy intake;
unsaturated vegetable oils should be substituted for the remaining fat requirement

(c) excessive consumption of refined carbohydrate should be avoided; some amount of

carbohydrate rich in natural fibre should be taken

(d) sources rich in energy such as fats and alcohol should be restricted

(e) salt intake should be reduced to an average of not more than 5g per day

NUTRITIONAL HEALTH PROBLEMS

1. Low birth weight

• Low birth weight (i.e. birth weight less than 2500 g) is a major public health problem in many
developing countries.
• About 28 per cent of babies born in India are LBW as compared to 4 percent in some
developed countries.

• In countries where the proportion of LBW is high, the majority are suffering from foetal
growth retardation. In countries where the proportion of LBW infants is low, most of them
are preterm.
• Among the other causes of LBW are hard physical labour during pregnancy and illnesses
especially infections.
 • Short maternal stature, very young age, high parity, smoking, close birth intervals are all
associated factors.
• All these factors are interrelated. Since the problem is multifactorial, there is no universal
solution. Interventions have to be cause-specific.
• The proportion of infants born with LBW was selected as one of the nutritional indicators for
monitoring progress towards Health for All by the year 2000.

2. PROTEIN ENERGY MALNUTRITION

• Protein energy malnutrition (PEM) is identified as a major health and nutrition problem in India.
It occurs particularly in weaklings and children in the first years of life.

• The current concept of PEM is

kwashiorkor and marasmus - are two different clinical picture.

• The incidence of PEM in India in pre-school age children is 1-2 per cent.PEM is primarily due to

• an inadequate intake of food (food gap) both in quantity and quality

• infections, notably diarrhoea, respiratory infections, measles and intestinal worms.

• The first indicator of PEM is under-weight for age.

Classification of PEM:

• PEM is a spectrum of conditions ranging from growth failure to overt marasmus or kwashiorkor,
hence classification has to be based on arbitrary cut-off-points.

• Gomez' classification : Gomez classification is based on weight retardation.

Weight for age (%) = weight of the child ×100

weight of a normal child of same age

• Waterlow's classification : When a child's age is known, measurement of weight enables almost
instant monitoring of growth : measurements of height assess the effect of nutritional status on
long-term growth.
 Arm circumference: Arm circumference yields a relatively reliable estimation of the body's
muscle mass, the reduction of which is one of the most striking mechanisms by which the body
adjusts to inadequate energy intakes.

• An arm circumference exceeding 13.5 cm is a sign of a satisfactory nutritional status, between

12.5 and 13.5 cm it indicates mild-moderate malnutrition and below 12.5 cm severe malnutrition.

3. Xerophthalmia

• Xerophthalmia (dry eye) refers to all the ocular manifestations of vitamin A deficiency in
man. It is the most widespread and serious nutritional disorder leading to blindness
particularly in South-East Asia.
• Xerophthalmia is most common in children aged 1-3 years, and is often related to weaning.
The younger the child, the more severe the disease.
• It is often associated with PEM. Mortality is often high in this age group. The victims belong
to the poorest families.
• In some countries, "epidemics" of xerophthalmia have occurred in association with food
donation programmes involving skimmed milk, which is totally devoid of vitamin A.
• The States badly affected are the southern and eastern States of India notably Andhra; Tamil
Nadu, Karnataka, Bihar and West Bengal. These are predominantly rice -eating States and
rice is devoid of carotene. The North Indian States have relatively few cases of
xerophthalmia.

Prevention

(a) Short-term action : A short-term preventive approach that has already demonstrated its efficacy
is the administration of large doses of vitamin A orally, in recommended doses to vulnerable groups,
on a periodic basis. This can be organized quickly and with a minimum of infrastructure.

(b) Medium-term action : An approach widely used to promote regular and adequate intake of
vitamin A is fortification of certain foods with vitamin A. Addition of vitamin A to dalda in India is a
typical example. Many other foods have also been considered for vitamin A fortification viz. sugar,
salt, tea, margarine and dried skimmed milk.
• (c) Long-term action : These are measures aimed at reduction or elimination of factors
contributing to ocular disease, e.g., persuading people in general, and mothers in particular, to
consume generously dark green leafy vegetables or other vitamin A rich foods.

4. NUTRITIONAL ANAEMIA

• Nutritional anaemia is a disease syndrome caused by malnutrition in its widest sense.

• It has been defined by WHO as "a condition in which the haemoglobin content of blood is
lower than normal as a result of a deficiency of one or more essential nutrients.

Problem Statement

• Iron deficiency anaemia is the most widespread micronutrient deficiency affecting all age
groups irrespective of gender, cast, creed and religion.
• In India, this silent emergency is rampant among women belonging to reproductive age
group (15-49 years), children (6-35 months) and low socio-economic strata of the
population.
• Overall, 72.7 per cent of children up to the age 3 years in urban areas and 81.2 per cent in
rural areas are anaemic.
• While analyzing the data for states with anaemia level of 70% among children, it was found
that, except for Punjab, all other states had more than 50% prevalence of anaemia among
pregnant women.
• As per District Level Health Survey (DLHS) (2002-04), prevalence of anaemia in adolescent
girls is very high (72.6%) in India, with prevalence of severe anaemia among them much
higher (21.1 %) than that in preschool children {2.1%).

Detrimental effects

(a) Pregnancy : In India, 19 percent of maternal deaths were found to be due to anaemia. Conditions
such as abortions, premature births, postpartum haemorrhage and low birth weight were especially
associated with low haemoglobin levels in pregnancy.

(b) Infection : Anaemia can be caused or aggravated by parasitic diseases, e.g., malaria, intestinal
parasites.
(c) Work capacity : Anaemia (even when mild) causes a significant impairment of maximal work
capacity. The more severe the anaemia, the greater the reduction in work performance, and thereby
productivity.

Interventions

(1) Iron and folic acid supplementation

• In order to prevent nutritional anaemia among mothers and children, the Government of
India sponsored a National Nutritional Anaemia Prophylaxis Programme during the Fourth
Five Year Plan.
• The beneficiaries are "at risk" groups viz pregnant women, lactating mothers and children
under 12 years.

Eligibility criteria : These are determined by the haemoglobin levels of the patients. If the
haemoglobin is between 10 and 12, daily supplement with iron and folic acid tablets is advised; if it
is less than 10 g, the patient is referred to the nearest primary health centre.

Dosage : (a) MOTHERS : One tablet of iron and folic acid containing 100 mg of elemental iron (300
mg of ferrous sulphate) and 0.5 mg of folic acid should be given daily. The daily administration
should be continued until 2 to 3 months after haemoglobin level has returned to normal.

(b) CHILDREN : If anaemia is suspected, a screening test for anaemia may be done on infants at 6
months, and 1 and 2 years of age. One tablet of iron and folic acid containing 20 mg of elemental
iron (60 mg of ferrous sulphate) and 0.1 mg of folic acid should be given daily for 100 days. For
children 6-60 months, ferrous sulphate and folic acid is to be provided in a liquid formulation.

(2) Iron fortification

• When consumed over a period of 12-18 months, iron fortified salt was found to reduce
prevalence of anaemia significantly.
• Fortification of salt with iron has been accepted by the Government of India as a public
health approach to reduce prevalence of anaemia.

(3) Other strategies

• There are other strategies such as changing dietary habits, control of parasites and nutrition
education.
 • These are longterm measures applicable to situations where the prevalence and severity of
anaemia are lower.

5. IDD

• Iodine deficiency is yet another major nutrition problem in India. Previously, iodine
deficiency was equated with goitre. In recent years, it has become increasingly clear that
iodine deficiency leads to a much wider spectrum of disorders commencing with the
intrauterine life and extending through childhood to adult life with serious health and social
implications.
• Iodine deficiency is a health problem of considerable magnitude in India and the
neighbouring countries of Bangladesh, Bhutan, Myanmar, Indonesia, Nepal, Sri Lanka and
Thailand. More people are affected and levels of severity are higher in South-East Asia than
anywhere else in the world. It has always been thought in India that goitre and cretinism
were only found to a significant extent in the "Himalaya goitre belt" which is the world's
biggest goitre belt.
• The magnitude of the problem in India is far greater than what had been estimated in 1960s,
when it was estimated that about 9 million persons were affected by goitre.

Goitre control

1. Iodized salt : In India the level of iodization is fixed under the Prevention of Food Adulteration
(PFA) Act and is not less than 30 ppm at the production point, and not less than 15 ppm of iodine at
the consumer level. Another method which has demonstrated its efficacy for controlling goitre is
intramuscular injection of iodized oil (mostly poppy-seed oil). The advantage of the injection
procedure is that an average dose of 1 ml will provide protection for about 4 years.

2. Iodine monitoring : (a) iodine excretion determination (b) determination of iodine in water, soil
and food as part of epidemiological studies (c) determination of iodine in salt for quality control

3. Manpower training : It is vital for the success of control that health workers and others engaged in
the programme be fully trained in all aspects of goitre control including legal enforcement and public
education.

4. Mass communication : It should be fully used in goitre control work.

5. Hazards of iodization : A mild increase in incidence of thyrotoxicosis has now been described
following iodized salt programmes. An increase in lymphocytic thyroiditis (Hashimoto's disease) has
also been claimed.

6. Endemic fluorosis

• In many parts of the world where drinking water contains excessive amounts of fluorine (3-5
mg/L), endemic fluorosis has been observed.
• Endemic fluorosis has been reported to be an important health problem in certain parts of
the country, e.g., Andhra Pradesh (Nellore, Nalgonda and Prakasam districts), Punjab,
Haryana, Karnataka, Kerala and Tamil Nadu.
• The toxic manifestation of fluorosis comprise the following:

(a) Dental fluorosis : It is characterized by "mottling" of dental enamel, which has been reported at
levels above 1.5 mg/L intake. The teeth lose their shiny appearance and chalk- white patches
develop on them. This is the early sign of dental fluorosis. Later the white patches become yellow
and sometimes brown or black.

(b) Skeletal fluorosis : This is associated with lifetime daily intake of 3.0 to 6.0 mg/L or more (102).
There is heavy fluoride deposition in the skeleton. When a concentration of 10 mg/L is exceeded,
crippling fluorosis can ensue. It leads to permanent disability.

(c) Genu valgum : A new form of fluorosis characterized by genu valgum and osteoporosis of the
lower limbs has been reported in some districts of Andhra Pradesh and Tamil Nadu. The syndrome
was observed among people whose staple was sorghum (jowar).

Intervention

(a) Changing the water source : One solution to the problem is to find a new source of drinking water
with a lower fluoride content (0.5 to 0.8 mg/L.

(b) Chemical treatment : If the above is not possible, the water can be chemically defluoridated in a
water treatment plant, even though such treatment is moderately expensive.

(c) Other measures : The use of fluoride toothpaste in areas of endemic fluorosis is not
recommended for children upto 6 years of age.
7. LATHYRISM

• Lathyrism is a paralyzing disease of humans and animals. In the humans it is referred to as

neurolathyrism because it affects the nervous system and in animals as osteolathyrism
(odoratism) because the pathological changes occur in the bones resulting in skeletal deformities.

• Neurolathyrism is a crippling disease of the nervous system characterized by gradually developing

spastic paralysis of lower limbs, occurring mostly in adults consuming the pulse, Lathyrus sativus
in large quantities.

• Neurolathyrism is prevalent in parts of Madhya Pradesh, Uttar Pradesh, Bihar and Orissa. It has
also been reported in Maharashtra, West Bengal, Rajasthan, Assam and Gujarat where the pulse
is grown.

• Lathyrus sativus is commonly known as "Khesari dhal". It is known by local names such as Teora
dhal, Lak dhal, Batra, Gharas, Matra etc.

• The seeds of lathyrus have a characteristic triangular shape and grey colour. The toxin present in
lathyrus seeds has been identified as Beta oxalyl amino alanine (BOM).

• It has been isolated in crystalline form and is water soluble; this property has been made use of in
removing the toxin from the pulse by soaking it in hot water and rejecting the soak water.

• The disease affects mainly young men between the age of 15 to 45 years.Symptoms are
weakness, fatigue, paralysis of the legs, atrophy of leg muscles, and skeletal deformities.
The possible interventions are:

• Vitamin C prophylaxis : The daily administration of 500-1000 mg of ascorbic acid for a week.

• Banning the crop: This is an extreme step not feasible for immediate implementation.

• Removal of toxin : Steeping method: Since the toxins are water soluble, they can be removed by
soaking the pulse in hot water.

• Parboiling : Simple soaking in lime water overnight followed by boiling is credited to destroy the
toxin.

• Education : The public must be educated on the dangers of consuming this pulse and the need for
removing its toxin before consumption.
VITAMIN A
• Vitamin A covers both a pre-formed vitamin, retinal, and a pro-vitamin, beta carotene, some
of which is converted to retinal in the intestinal mucosa.
• In 1960, the term "retinal" was introduced for vitamin A1 alcohol (which is available in
crystalline form), but most workers prefer the older term vitamin A and the international
unit.
• The international unit (IU) of vitamin A is equivalent to 0.3 microgram of retinal (or 0.55
microgram of retinal palmitate).

Functions

(a) It is indispensable for normal vision. It contributes to the production of retinal pigments which
are needed for vision in dim light

(b) It is necessary for maintaining the integrity and the normal functioning of glandular and epithelial
tissue which lines intestinal, respiratory and urinary tracts as well as the skin and eyes

(c) It supports growth especially skeletal growth

(d) It is anti-infective; there is increased susceptibility to infection and lowered immune response in
vitamin A deficiency

(e) It may protect against some epithelial cancers such as bronchial cancers

Sources

(a) ANIMAL FOODS: Foods rich in retinal are liver, eggs, butter, cheese, whole milk, fish and meat.
Fish liver oils are the richest natural sources of retinal

(b) PLANT FOODS: The cheapest source of vitamin A is green leafy vegetables such as spinach and
amaranth which are found in great abundance in nature throughout the year. The darker the green
leaves, the higher its carotene content. Vitamin A also occurs in most green and yellow fruits and
vegetables (e.g., papaya, mango, pumpkin) and in some roots (e.g., carrots).

(c) FORTIFIED FOODS : Foods fortified with vitamin A (e.g., vanaspati, margarine, milk) can be an
important source.
Deficiency

(a) Nightblindness : Lack of vitamin A, first causes nightblindness or inability to see in dim light.
Nightblindness is due to impairment in dark adaptation.

(b) Conjunctival Xerosis : This is the first clinical sign of vitamin A deficiency. The conjuctiva becomes
dry and non-wettable. It has been well described as "emerging like sand banks at receding tide"
when the child ceases to cry.

(c) Bitot's spots : Bitot's spots are triangular, pearly-white or yellowish, foamy spots on the bulbar
conjunctiva on either side of the cornea.

(d) Corneal xerosis : This stage is particularly serious. The cornea appears dull, dry and non-wettable
and eventually opaque.

(e) Keratomalacia : Keratomalacia or liquefaction of the cornea is a grave medical emergency. The
cornea (a part or the whole) may become soft and may burst open.

Treatment

• Vitamin A deficiency should be treated urgently. Nearly all of the early stages of
xerophthalmia can be reversed by administration of a massive dose (200,000 IU or 110 mg of
retinol palmitate) orally on two successive days.

Prevention

(a) improvement of people's diet so as to ensure a regular and adequate intake of foods rich in
vitamin A

(b) reducing the frequency and severity of contributory factors, e.g., PEM, respiratory tract

Toxicity

• An excess intake of retinol causes nausea, vomiting, anorexia and sleep disorders followed
by skin desquamation and then an enlarged liver and papillar oedema. High intakes of
carotene may colour plasma and skin, but do not appear to be dangerous.

VITAMINS B GROUP
1. Thiamine
• Thiamine (vitamin B1) is a water-soluble vitamin. It is essential for the utilization of
carbohydrates.
• In thiamine deficiency, there is accumulation of pyruvic and lactic acids in the tissues and
body fluids.

Sources

• Important sources are : whole grain cereals wheat gram, yeast, pulses, oilseeds and nuts,
especially groundnut'. Meat, fish, eggs, vegetables and fruits contain smaller amounts.
• Milk is an important source of thiamine for infants, provided the thiamine status of their
mothers is satisfactory.
• The main source of thiamine in the diet of Indian people is cereals (rice and wheat) which
contribute from 60-85 per cent of the total supply.
• Thiamine is readily lost from rice during the process of milling. Being a water-soluble
vitamin, further losses take place during washing and cooking of rice.
• This is the basis for advising people to eschew highly polished rice and eat parboiled or
under-milled rice.Much of thiamine in fruits and vegetables is generally lost during
prolonged storage.

Deficiency

• The two principal deficiency diseases are beriberi and Wernick's encephalopathy. Beriberi
may occur in three main forms :

(a) the dry form characterized by nerve involvement (peripheral neuritis)

(b) the wet form characterized by heart involvement (cardiac beriberi)

(c) infantile beriberi seen in infants between 2 and 4 months of age.

• Wernick's encephalopathy (seen often in alcoholics) is characterized by ophthalmoplegia,

polyneuritis, ataxia and mental deterioration.

Prevention

• Beriberi can be eliminated by educating people to eat well-balanced, mixed diets containing
thiamine-rich foods (e.g., parboiled and undermilled rice) and to stop all alcohol.
• Direct supplementation of high-risk groups (e.g. lactating mothers) is another approach.

2. Riboflavin
• Riboflavin (Vitamin B2) is a member of the B-group vitamins. It has a fundamental role in
cellular oxidation. It plays an important role in maintaining the integrity of mucocutaneous
structure.
Sources

• Its richest natural sources are milk, eggs, liver, kidney and green leafy vegetables. Meat and
fish contain small amounts.

Deficiency

• Riboflavin deficiency is angular stomatitis which occurs frequently in malnourished children.

Other clinical signs include cheilosis, glossitis, nasolabial dyssebacia, increased susceptibility
to cataract.

Requirement

• Daily requirement is 0.6 mg per 1000 kcal of energy intake.

3. Niacin

• Niacin or nicotinic acid (Vitamin B3) is essential for the metabolism of carbohydrate, fat and
protein. It is also essential for the normal functioning of the skin, intestinal and nervous systems.

Sources :

• Foods rich in niacin and/or tryptophan are liver, kidney meat, poultry, fish, legumes and
groundnut. Milk is a poor source of niacin but its proteins are rich in tryptophan which is
converted in the body into niacin (about 60 mg of tryptophan is required to result in 1 mg of
niacin).

Deficiency :

• Niacin deficiency results in pellagra. The disease is characterized by three D's - diarrhoea,
dermatitis and dementia. Glossitis and Stomatitis usually occur.

• It is prevalent in some parts of Western Asia and Southern Africa where people subsist on maize
and little else. Excess of leucine appears to interfere in the conversion of tryptophan to niacin.

Prevention :

• Pellagra is a preventable disease. A good mixed diet containing milk and/or meat is universally
regarded as an essential part of prevention and treatment. Avoidance of total dependence on
maize or sorghum is an important preventive measure. Pellagra is a disease of poverty.
4. Pyridoxine
• Pyridoxine (vitamin B3) exists in three forms : pyridoxine, pyridoxal and pyridoxamine. It
plays an important role in the metabolism of amino-acids, fats and carbohydrate.
• It is widely distributed in foods, e.g., milk, liver, meat, egg yolk, fish, whole grain cereals,
legumes and vegetables.
• Pyridoxine deficiency is associated with peripheral neuritis. Riboflavin deficiency impairs the
optimal utilization of pyridoxine.
• Adults may need 2 mg/day, during pregnancy and lactation 2.5 mg/day.

5. Pantothenic acid
• There is a long standing evidence for a relation between pantothenic acid (vitamin B3) and
adrenal cortical function. Specific role for pantothenic acid in the biosynthesis of
corticosteroids.
• Human blood normally contains 18 to 35 mg of pantothenic acid per 100 ml mostly present
in the cells as coenzyme A. The daily requirement is set at 10 mg.

6. Folate
• Alternative name is folacin and the usual pharmaceutical preparation is folic acid. Folk acid
occurs in food in two forms : free folates and bound folates.
• In man, free folate is rapidly absorbed primarily from the proximal part of small intestine.
• Folic acid plays a role in the synthesis of the nucleic acids (which constitute the
chromosomes). It is also needed for the normal development of blood cells in the marrow.

Sources

• The name comes from the latin folia (leaf) but foods such as liver, meat, dairy products,
eggs, milk, fruits and cereals are as good dietary sources as leafy vegetables.
• Overcooking destroys much of folk acid and thus contributes to folate deficiency in man.
Folate deficiency has been reported in babies given milk foods subjected to heat
sterilization.

Deficiency

• Folate deficiency may occur simply from a poor diet. It is commonly found in pregnancy and
lactation.
• It results in megaloblastic anaemia, glossitis, cheilosis and gastrointestinal disturbances such
as diarrhoea, distension and flatulence.
• Severe folate deficiency may cause infertility or even sterility.

Requirement
Healthy adults 200 mg

Pregnancy 500 mg
Lactation 300 mg

Children 80-120 mg

7. Vitamin B12
• Vitamin B12 is complex organo-metallic compound with a cobalt atom. Vitamin B12
cooperates with folate in the synthesis of DNA, so deficiency of either leads to
megaloblastosis.
• The physiological mechanism for its absorption requires intrinsic factor from the stomach,
and the complex is absorbed only at a special site in the terminal ileum.

Sources

• Good sources are liver, kidney, meat, fish, eggs, milk and cheese. Vitamin B12 is not found in
foods of vegetable origin.

Deficiency

• Vitamin B12 deficiency is associated with megaloblastic anaemia (pernicious anaemia),

demyelinating neurological lesions in the spinal cord and infertility (in animal species) which
is rarely seen in India.

Requirement

Normal adult 1mg

Pregnancy 1.2 mg

Lactation 1.5 mg

Infant & Children 0.2 mg

VITAMIN D
• The nutritionally important forms of Vitamin D in man are Calciferol (Vitamin D2) and
Cholecalciferol (Vitamin D3).
• Calciferol may be derived by irradiation of the plant sterol, ergosterol. Cholecalciferol is the
naturally occurring (preformed) vitamin D which is found in animal fats and fish liver oils.
• It is also derived from exposure to UV rays of the sunlight which convert the cholesterol in
the skin to vitamin D.
Vitamin D : Kidney hormone

• It has been proposed that vitamin D should be regarded as a kidney hormone because it
does not meet the classic definition of a vitamin, that is, a substance which must be
obtained by dietary means because of a lack of capacity in the human body to synthesize it.
• In fact, vitamin D3 is not a dietary requirement at all in conditions of adequate sunlight. It
can be synthesized in the body in adequate amounts by simple exposure to sunlight even for
5 minutes per day.

Functions

Intestine Promotes intestinal absorption of calcium and

phosphorus
Bone Stimulates normal mineralization, enhances
bone reabsorption,affects collagen maturation.

Kidney Increases tubular reabsorption of phosphate,

Variable effect on reabsorption of calcium

Other Permits normal growth.

Sources

(a) Sunlight : Vitamin D is synthesized by the body by the action of UV rays of sunlight on 7 -
dehydrocholesterol, which is stored in large abundance in the skin. Exposure to UV rays is critical;
these can be filtered off by air pollution. Dark-skinned races such as Negros, also suffer from this
disadvantage because black skin can filter off up to 95 per cent of UV rays.

(b) Foods : Vitamin D occurs only in foods of animal origin. Liver, egg yolk, butter and cheese, and
some species of fish contain useful amounts. Human milk has been shown to contain considerable
amounts of water-soluble vitamin D sulphate.
DEFICIENCY

(1) Rickets : Observed in young children between the age of six months and two years. There is
reduced calcification of growing bones. The disease is characterized by growth failure, bone
deformity, muscular hypotonia, tetany and convulsions due to hypocalcaemia.

(2) Osteomalacia : Occurs mainly in women, especially during pregnancy and lactation when
requirements of vitamin D are increased.

Prevention

(a) Educating parents to expose their children regularly to sunshine

(b) Periodic dosing (prophylaxis) of young children with vitamin D

(c) Vitamin D fortification of foods, especially milk.

Daily requirements

• Under minimal exposure to sunlight, particularly in certain urban groups, like 1 -2 year old
children, a specific recommendation of a daily supplement of 400 IU (10 mcg) is suggested.

VITAMIN K
• Vitamin K occurs in at least two major forms - vitamin K and vitamin K2. Vitamin K1 is found
mainly in fresh green vegetables particularly dark green ones and in some fruits.
• Cow's milk is a richer source (60 mcg/L) of vitamin K than human milk (15 mcg/L). Vitamin K2
is synthesized by the intestinal bacteria, which usually provides an adequate supply in man.
• Long-term administration of antibiotic doses for more than a week may temporarily
suppress the normal intestinal flora (a source of vitamin) and may cause a deficiency of
vitamin K.
• Vitamin K is stored in the liver. The role of vitamin K is to stimulate the production or the
release of certain coagulation factors.

• In vitamin K deficiency, the prothrombin content of blood is markedly decreased and the
blood clotting time is considerably prolonged.
 • The vitamin K requirement of man is met by a combination of dietary intake and microbial
synthesis in the gut. The daily requirement for man appears to be about 0.03 mg/kg for the
adult.
• Newborn infants tend to be deficient in vitamin K due to minimal stores of prothrombin at
birth and lack of an established intestinal flora.

• Soon after birth, all infants or those at increased risk should receive a single intramuscular
dose of a vitamin K preparation (0.1-0.2 mg of menadione sodium bisulphite or 0.5 mg of
vitamin K1) by way of prophylaxis.

PROTEINS
• Proteins are complex organic nitrogenous compounds. They are composed of carbon,
hydrogen, oxygen, nitrogen and sulphur in varying amounts.
• Proteins constitute about 20 % of the body weight in an adult.

Essential amino acids

• Proteins are made up of smaller units, called amino acids. Some 20 amino acids are stated to
be needed by the human body of which 9 are called "essential" because the body cannot
synthesize them in amounts corresponding to its needs.
• They are : leucine, isoleucine, lysine, methionine, phenylalanine, threonine, valine,
tryptophan and histidine.
• Non-essential amino acids include arginine, asparaginic acid, serine, glutamic acid, praline
and glycine. Both essential and non-essential amino acids are needed for synthesis of tissue
proteins.
• Some of the essential amino acids have important biological functions, e.g., formation of
niacin from tryptophan; the action of methionine. There is evidence that cystine and
tyrosine are essential for premature babies.
• A protein is said to be "biologically complete" if it contains all the EAA in amounts
corresponding to human needs.

Functions
(a) body building

(b) repair and maintenance of body tissues

(c) maintenance of osmotic pressure

(d) synthesis of certain substances like antibodies, plasma proteins, haemoglobin, enzymes,
hormones and coagulation factors. Proteins can also supply energy (4 kcal per one gram) when the
calorie intake is inadequate.
Sources
(a) ANIMAL SOURCES: Proteins of animal origin are found in milk, meat, eggs, cheese, fish and fowl.

(b) VEGETABLE SOURCES : Vegetable proteins are found in pulses (legumes), cereals, beans, nuts, oil-
seed cakes, etc. They are poor in EAA.

Supplementary action

• Man derives protein not from a single source, but from a variety of food sources, animal and
vegetable.
• Cereal proteins are deficient in lysine and threonine and pulse proteins in methionine. These
are known as "limiting" amino acids.
• When two or more of vegetarian foods are eaten together (as for example, rice-dhal
combination in India) their proteins supplement one another and provide a protein
comparable to animal protein. This is known as supplementary action of proteins.

Protein metabolism

(a) since proteins are not stored in the human body in the way that energy is stored in adipose
tissue, they have to be replaced every day.

(b) the body proteins are constantly being broken down into their constituent amino acids and then
reused for protein synthesis.

(c) it is not only the amount of protein that is maintained constant, but also the pattern of specific
protein in body.

Evaluation

• The net protein utilization (NPU) is the "proportion of ingested protein that is retained in the
body under specified conditions for the maintenance and/or growth of the tissues".

Assessment

• The creatinine height index, serum albumin and transferrin, total body nitrogen. Serum
albumin concentration should be more than 3.5 g/dl, a level of 3.5 g/dl is considered mild
degree of malnutrition; a level of 3.0 g/dl severe malnutrition.

Requirements

• 1.0 g protein/kg body weight for an Indian adult.

FOOD ADULERATION
• Adulteration of foods is an age-old problem. It consists of a large number of practices, e.g.
mixing, substitution, concealing the quality, putting up decomposed foods for sale,
misbranding or giving false labels and addition of toxicants.
• Adulteration results in two disadvantages for the consumer : first he is paying more money
for a foodstuff of lower quality and secondly some forms of adulteration are injurious to
health even resulting in death as for example, adulteration of mustard oil with argemone oil
causing epidemic dropsy.
• It may vary from one part of the country to another and from time to time.

FOOD MATERIALS COMMON ADULTERATIONS

Cereals such as rice, wheat Mud, grits, Soapstone bits

Dals Coal tar dyes, khesari dal

Haldi powder Lead chromate powder

Dhania powder Starch, cow dung or horse dung powder

Black pepper Dried seeds of papaya

Chilli powder Saw dust, brick powder

Tea dust/leaves Black gram husk, tamarind seeds powder, saw dust,
used tea dust

Coffee powder Date husk, tamarind husk, chicory

Asafoetida (Hing) Sand, grit, resins, gums

Mustard seeds Seeds of prickly poppy- Argemone

Edible oils Minerals oils, argemone oils

Butter Starch, animal fat

Ice-cream Cellulose, starch, Non permitted colours

Sweetmeats Non permitted colours

Fresh green peas Green dye

Milk Extraction of fat, addition of starch and fat

Ghee Vanaspati
 Prevention of Food Adulteration Act, 1954
• Enacted by the Indian Parliament in 1954, with the objective of ensuring pure and
wholesome food to the consumers and to protect them from fraudulent and deceptive trade
practices.
• The Prevention of Food Adulteration (PFA) Act was amended in 1964, 1976 and lately in
1986.
• A minimum imprisonment of 6 months with a minimum fine of Rs.1,000 under the Act for
cases of proven adulteration.
• The cases of adulteration which may render the food injurious to cause death or such harm
(within the meaning of section 320 of I.P.C.) the punishment may go upto life imprisonment
and a fine which shall not be less than Rs.5,000.
• A chain of food laboratories and four regional appellate Central Food Laboratories (Kolkata,
Mysore, Ghaziabad and Pune) whose report is considered to be final have been established.
• The general public, traders, and Food Inspectors are all responsible for perpetuating this evil
the public because of lack of awareness of the dangers of adulteration and their general
disinterest; the traders, for their greed for money.

GROWTH AND DEVELOPMENT

• A phenomenon peculiar to the paediatric age group is growth and development. The term
growth refers to increase in the physical size of the body, and development to increase in
skills and functions.

• Growth and development include not only physical aspect, but also intellectual, emotional
and social aspects. Normal growth and development take place only if there is optimal
nutrition, if there is freedom from recurrent episodes of infections, and if there is freedom
from adverse genetic and environmental influences.

Determinants of growth and development

(a) GENETIC INHERITANCE : Genetic factors influence growth and deveiopment, especially height and
weight, mental and social development and personality.

(b) NUTRITION : Nutrition influences growth and development before as well as after birth. In fact,
retardation of growth rate is an indication of malnutrition. When the diet is improved the child
begins to grow in height and weight.

(c) AGE: Growth rate is maximum during foetal life, during the first year of life and then again at
puberty. At other periods, growth is slower.
(d) SEX: At about the age of 10 to 11 years, female children show a sudden increase in height and
weight. In male children, the growth spurt occurs a little later, i.e. between 12 and 13 years.

(e) PHYSICAL SURROUNDINGS : Sunshine, good housing, lighting and ventilation have their effects on
growth and development.

(f) PSYCHOLOGICAL FACTORS: Love, tender care and proper child-parent relationship do affect the
social, emotional and intellectual development of children.

(g) INFECTIONS AND PARASITOSIS: Certain infections of the mother during pregnancy (e.g., rubella,
syphilis) affect the intrauterine growth of the foetus.

(h) ECONOMIC FACTORS : The standard of living of the family is an important factor. Children from
well-to-do families have better height and weight.

Normal growth

• A normal child may be defined as one whose characteristics fall within the range of
measurements accepted as normal for the majority of children in the same (or reference)
age group. Conventionally, these limits the limits of normal variation are assumed to include
two standard deviations above and below the mean (i.e. between the 3rd and the 97th
centiles).
• For example, we measure growth in terms of kilograms and centimetres. But very great
difficulties are encountered in connection with psychomotor, emotional and social
development; most measurement techniques are based on observations such as "milestones
of development."

Methods of assessment

• In children, the parameters of growth generally used are : weight, height (or length in
infants), and head and chest circumferences.

(i) The first method is based on mean (or median) values.

(ii) The second method is by means of percentile or (centiles).

(iii) Thirdly, it is also possible to assess the growth of a child by such indices as weight for length, and
weight for height. These are age-independent indices.
 • The assessment of growth may be longitudinal or cross- sectional. Longitudinal assessment
of provides valuable data about a child's progress. Cross-sectional comparisons involve large
number of children of the same age.

Average weight and height increase during the first 5 years :

AGE INCREMENTS
Weight increments per week
0-3 months 200g
4-6 months 150 g
7-9 months 100g
10 - 12 months 50- 75 g
Weight increments per year
1-2 years 2.5kg
3-5 years 2.0kg
Length increments per year
1st year 25cm
2nd year 12cm
3rd year 9cm
4th year 7cm
5th year 6cm

SCHOOL HEALTH SERVICE

• School health is an important branch of community health. According to modern concepts,
school health service is an economical and powerful means of raising community health, and
more important, in future generations.

• The school health service is a personal health service. It has developed during the past 70
years from the narrower concept of medical examination of children to the present- day
broader concept of comprehensive care of the health and well-being of children throughout
the school years.

Health Problems of School Child

(1) malnutrition
(2) infectious diseases

(3) intestinal parasites

(4) diseases of skin, eye and ear

(5) dental caries.

OBJECTIVES OF SCHOOL HEALTH SERVICE

1. the promotion of positive health

2. the prevention of diseases

3. early diagnosis, treatment and follow-up of" defects

4. awakening health consciousness in children

5. the provision of healthful environment.

Aspects of School Health Service

The tasks of a school health service are manifold, and vary according to local priorities. Where
resources are plentiful, special school health services may be developed. Some aspects of a school
health service are as follows : 1. Health appraisal of school children and school personnel 2.
Remedial measures and follow-up 3. Prevention of communicable diseases 4. Healthful school
environment 5. Nutritional services 6. First-aid and emergency care 7. Mental health 8. Dental health
9. Eye health 10. Health education 11. Education of handicapped children 12. Proper maintenance
and use of school health records.

1. Health appraisal

(a) Periodic Medical Examination

(b) School Personnel

(c) Daily Morning Inspection : (1) unusually flushed face (2) any rash or spots (3) symptoms of acute
cold (4) coughing and sneezing (5) sore throat (6) rigid neck (7) nausea and vomiting (8) red or
watery eyes (9) headache (10) chills or fever (11) listlessness or sleepiness (12) disinclination to play
(13) diarrhoea (14) pains in the body (15) skin conditions like scabies and ringworm (16) pediculosis
2. Remedial measures and follow-up

Medical examinations are not an end in themselves; they should be followed by appropriate
treatment and follow-up.

3. Prevention of communicable diseases

• A well planned immunization programme should be drawn up against the common

communicable diseases. When the child leaves school, the health record should accompany
him.

4. Healthful school environment

• The school should normally be centrally situated with proper approach roads and at a fair
distance from busy places and roads, cinema houses, factories, railway tracks and market
places.

• The site should be on suitable high land, and not subject to inundation or dampness and can
be properly drained.
• Nursery and secondary schools, as far as possible, be single storied. Exterior walls should
have a minimum thickness of 10 inches and should be heat resistant.
• Verandhas should be attached to classrooms. No classroom should accommodate more than
40 students. The windows should be broad with the bottom sill, at a height of 2'-6" from the
floor level.
• Inside colour of the classroom should be white and should be periodically white-washed.
Furniture should suit the age group of students. Desks should be of "minus" type.
• There should be an independent source of safe and potable water supply, which should be
continuous, and distributed from the taps.

• Vendors other than those approved by the school authorities should not be allowed inside
school premises; there should be a separate room provided for mid-day meals.
• Privies and urinals should be provided one urinal for 60 students and one latrine for 100
students.

5. Nutritional services

• The diet should contain all the nutrients in proper proportion, adequate for the maintenance
of optimum health. Studies in India have shown that nutritional disorders are widely
prevalent among school children, particularly deficiencies relating to proteins; vitamins A, C,
thiamine and riboflavin, calcium and iron.
6. First-aid and emergency care

(a) accidents leading to minor or serious injuries

(b) medical emergencies such as gastroenteritis, colic, epileptic fits, fainting, etc

7. Mental health

• Juvenile delinquency, maladjustment and drug addiction are becoming problems among
school children. The school is the most strategic place for shaping the child's behaviour and
promoting mental health.

8. Dental And Eye health services

• A school health programme should have provision for dental examination, at least once a
year. Schools should be responsible for the early detection of refractive errors, treatment of
squint and amblyopia, and detection and treatment of eye infections such as trachoma.

10. Health education

• The need for hygiene of skin, hair, teeth and clothing should be impressed upon them.
Attention to posture is also important.
• Encouraging young people to take part in health activities and keep their environment clean
is an important function of school health services.

11. Education of handicapped children

• The ultimate goal is to assist the handicapped child and his family so that the child will be
able to reach his maximum potential, to lead as normal a life as possible, to become as
independent as possible.

CHILD TRAFFICKING
• Trafficking of children takes many different forms. Some children are forcibly abducted,
others are tricked and still others opt to let themselves be trafficked by promise of earnings,
but not suspecting the level of exploitation they will suffer at the other end of the recruiting
chain.
 • Trafficking always involves journey, whether within the country or across the international
border. The relocation takes children away from their families, communities and support
net-work, leaving them isolated and utterly vulnerable to exploitation.
• Children in unconditional worst forms of child labour and exploitation
• Though the trafficking of children is a shadowy practice, some dominant regional patterns
are identifiable. In West and Central Africa, children are "placed" in a marginal position
within other families. This practice is being used to exploit children both within and outside
home.
• Children are also trafficked into plantations and mines, and in those countries affected by
conflict, they are directly abducted by militias.
• In East Asia and Pacific, most trafficking is into child prostitution, though some children are
also recruited for industrial and agricultural work.
• In South Asia, trafficking forms most of immense child labour problem in the sub- continent,
often related to debt bondage. In addition, significant number of children are trafficked for
other purposes, including into prostitution, carpet and garment factories, construction
projects and begging.

• In Europe, children are mainly trafficked from east to west, reflecting the demand for cheap
labour and child prostitution in richer countries of the continent. Children are also used as
unskilled labour and in the entertainment sector.

Key elements of a protective environment

a. Strengthening the capacity of families and communities to care for and protect children.

b. Government commitment to child protection by providing budgetary support and social welfare
policies targeted at the most excluded and invisible children.

c. Prosecution of perpetrators of crimes against children, and avoidance of criminalizing child

victims.

d. An open discussion by civil society and the media of attitudes, prejudices, beliefs and practices
that facilitate or lead to abuses.

UJJAWALA : "Ujjawala", a comprehensive scheme to combat trafficking was launched in India by

the Ministry of Women and Child Development on 4th December, 2007 and is being implemented
mainly through NGOs.
(1) Formation of community vigilance groups, adolescents groups, awareness creation

(2) Safe withdrawal of victims from the place of exploitation

(3) Rehabilitation of victims by providing them safe shelter, basic amenities, medical care, legal aid,
vocational training and employment

(4) Re-integration of victims into society

(5) Provide support to cross-border victims for their safe repatriation to the country of origin

JUVENILE DELINQUENCY
• The Children Act, 1960 in India defines delinquent as "a child who has committed an
offence". Juvenile means a boy who has not attained the age of 16 years and a girl who has
not attained the age of 18 years.
• In a broad sense, delinquency is not merely "juvenile crime". It embraces all deviations from
normal youthful behaviour and includes the incorrigible, ungovernable, habitually
disobedient and those who desert their homes and mix with immoral people, those with
behaviour problems and indulge in antisocial practices.

INCIDENCE

• In the United States it is reported that 2 per cent of children between 7 and 17 years attend
juvenile courts. The highest incidence is found in children aged 15 and above. The incidence
among boys is 4 to 5 times more than among girls.

CAUSES

(1) Biological causes: Certain biological causes such as hereditary defects, feeble -mindedness,
physical defects and glandular imbalance may be at the bottom of juvenile delinquency. Recent
studies indicate that chromosome anomaly might be associated with a tendency for delinquency and
crime. A survey of criminal patients in Scotland and elsewhere demonstrated such a link - some of
the patients showing an extra Y chromosome.

(2) Social causes : Among the social causes may be mentioned broken homes, e.g., death of parents,
separation of parents, step mothers and disturbed home conditions, e.g., poverty, alcoholism,
parental neglect, ignorance about child care, too many children, etc.
PREVENTIVE MEASURES

• A well adjusted family can stem the tide of delinquency.

• The school comes next to home in the community in ordering the behaviour of children.
There should be a healthy teacher-pupil relationship.

• These comprise recreation facilities, parent-counselling, child guidance, educational facilities

and adequate general health services.

Children in difficult circumstances : Some children have been categorized as children in difficult
circumstances and these categorizations include: -

a. Homeless children (pavement dwellers, displaced/evicted, etc.)

b. Orphaned or abandoned children whose parents cannot or are not able to take care of them

c. Children separated from parents Migrant and refugee children

d. Children in prostitution

Mid-day meal programme

• The mid-day meal programme (MDMP) is also known as School Lunch Programme.

Objectives

(a) the meal should be a supplement and not a substitute to the home diet

(b) the meal should supply at least one-third of the total energy requirement, and half of the protein
need

(c) the cost of the meal sbould be reasonably low

(d) the meal should be such that it can be prepared easily in schools; no complicated cooking process
should be involved

(e) as far as possible, locally available foods should be used; this will reduce the cost of the meal, and

(f) the menu should be frequently changed to avoid monotony

 • School feeding should not be considered as an end in itself. The important goals to be
accomplished are : reorientation of eating habits; incorporating nutrition education into the
curriculum; encouraging the use of local commodities; improving school attendance as well
as educational performance of the pupils.

• The mid-day meal programme became part of the Minimum Needs Programme in the Fifth
Five Year Plan.

Mid-day meal scheme

• Its objective being universalization of primary education by increasing enrolment, retention
and attendance and simultaneously impacting on nutrition of students in primary classes.
• The programme originally covered children of primary stage (classes I to V) in government,
local body and government aided schools to cover children studying in Education Guarantee
Scheme and Alternative and Innovative Education Centres also.
• To achieve the objective, a cooked mid-day meal with minimum 300 Calories and 8 to 12
grams of protein content will be provided to all the children in class I to V. Some
suggesstions for preparation of nutritious and economical mid-day meals are as under :

a. Foodgrains must be stored in a place away from moisture, in air tight containers/bins to avoid
infestation. Use whole wheat or broken wheat (dalia) for preparing mid-day meals. Rice should
preferably be parboiled or unpolished.

b. 'Single Dish Meals' using broken wheat or rice and incorporating some amount of a pulse or
soyabeans, a seasonal vegetable/green leafy vegetable, and some amount of edible oil will save both
time and fuel besides being nutritious.

c. Cereal pulse combination is necessary to have good quality protein. The cereal pulse ratio could
range from 3:1 to 5:1. Sprouted pulses have more nutrients and should be incorporated in single
dish meals.

d. Leafy vegetables when added to any preparation should be thoroughly washed before cutting.

e. Soaking of rice, dal, bengal gram etc. reduces cooking time. Wash the grains thoroughly and soak
in just sufficient amount of water required for cooking. Rice water if left after cooking should be
mixed with dal if these are cooked separately and should never be thrown away.
f. Fermentation improves nutritive value. Preparation of idli, dosa, dhokla etc. may be encouraged.
Cooking must be done with the lid on to avoid loss of nutrients.

g. Over cooking should be avoided. Reheating of oil used for frying is harmful and should be avoided.
Leafy tops of carrots, radish, turnips etc. should not be thrown but utilized in preparing mid -day
meals. Only 'iodized salt" should be used for cooking mid-day meals.

HOUSING
• Housing, in the modern concept includes not only the physical structure providing shelter
but also the immediate surroundings and the related community services and facilities.
• A WHO Expert use the term "residential environment" which is defined as the physical
structure that man uses and the environs of the structure including all necessary services,
facilities, equipment and devices needed or desired for the physical and mental health and
the social well-being of the family.

• Social goals of housing Goals are statements about desirable or projected conditions. The
generally accepted goals of housing are :

(1) Shelter : House should provide a sanitary shelter which is a basic need

(2) Family life : House should provide adequate space for family life and related activities, viz
preparation and storage of food, meeting, sleeping, individual activities and other basic activities.

(3) Access to community facilities : Such as health services, schools, shopping areas, places of
worship etc.

(4) Economic stability : Housing is a form of investment of personal savings. It provides for economic
stability and well being of the family.

Criteria for healthful housing

1. Healthful housing provides physical protection and shelter

2. provides adequately for cooking, eating, washing, and excretory functions

3. is designed, constructed, maintained and used in a manner such as to prevent the spread of
communicable diseases

4. provides for protection from hazards of exposure to noise and pollution

5. is free from unsafe physical arrangements due to construction or maintenance and from toxic or
harmful materials

6. encourages personal and community development, promotes social relationships, reflects a

regard for ecological principles, and by these means promotes mental health ·

Housing standards

SITE : The site should be elevated from its surroundings, should have an independent access to a
street, it should be away from mosquitoes and flies, it should be away from nuisances such as dust,
smoke, smell, excessive noise and traffic, should be in pleasing surroundings.

SET BACK : For proper lighting and ventilation, there should be an open space all round the house is
called set back.

FLOOR : The floor must be smooth and free from cracks and crevices to prevent the breeding of
insects and harbourage of dust, should be damp-proof, height should be 2 to 3 feet.

WALLS : The walls should be reasonably strong, should have a low heat capacity.

ROOF : The height of the roof should not be less than 10 feet (3 m) in the absence of air-conditioning
for comfort. The roof should have a low heat transmittance coefficient.

ROOMS : The number of living rooms should not be less than two, at least one of which can be
closed for security.

WINDOWS : The windows should be placed at a height of not more than 3 feet (1 m) above the
ground in living rooms.

KITCHEN : The kitchen must be protected against dust and smoke, adequately lighted provided with
arrangements for storing food, fuel and provisions, provided with water supply, provided with a sink
for washing utensils and fitted with arrangements for proper drainage.

PRIVY : A sanitary privy is a must in every house belonging exclusively to it and readily accessible.

GARBAGE AND REFUSE : These should be removed from the dwelling at least daily and disposed off
in a sanitary manner.
OVERCROWDING

• Overcrowding refers to the situation in which more people are living within a single dwelling
than there is space for so that movement is restricted, privacy secluded, hygiene impossible,
rest and sleep difficult.
• The risks of infectious diseases spread rapidly under conditions of overcrowding. The effects
on psychosocial health are not so clear-cut, viz. irritability, frustration, lack of sleep, anxiety,
violence and mental disorders.

• Children are said to be more affected. Overcrowding is a health problem in human dwellings.
If may promote the spread of respiratory infections such as tuberculosis, influenza and
diphtheria.
• High morbidity and mortality rates are observed where housing conditions are substandard.
The accepted standards with respect to overcrowding are as below :

(1) PERSONS PER ROOM : The degree of overcrowding can best be expressed as the number of
persons per room.

1 room 2 persons
2 rooms 3 persons
3 rooms 5 persons
4 rooms 7 persons
5 or more rooms 10 persons (additional 2 for each further room)
(2) FLOOR SPACE

110 sq ft. (11 sq m.) or more 2 persons

90-100 sq ft. (9-10 sq m.) 1 ½ persons
70-90 sq ft. (7-9 sq m.) 1 person
50-70 sq ft. (5-7 sq m.) ½ person
Under 50 sq ft (5 sq m.) Nil

Indicators of housing

(1) Physical : These are based on floor space, cubic space, room height, persons per room, rooms per
dwelling, environmental quality (e.g., air, light, water, noise, sewage disposal, etc).

(2) Economic indicators : .These are cost of the building, rental levels, taxes, expenditure on housing,
etc.
(3) Social indicators : The following were proposed at an inter-regional seminar on the Social Aspects
of Housing, organized by the UN in 1975.

(a) Indicators related to prevention of illness :

(1) Frequency of illness due to inadequate sewage and garbage collection

(2) Frequency of illness associated with contaminated water source

(3) Frequency of insect borne diseases

(4) Frequency of illness due to overcrowding, accidents

(b) Indicators related to comfort :

(1) Thermal comfort

(2) Acoustic comfort

(3) Visual comfort

(4) Spatial comfort

MOSQUITO
• Mosquitoes constitute the most important single family of insects from the standpoint of
human health.
• The four important groups of mosquitoes in India which are related to disease transmission
are the Anopheles, Culex, Aedes and Mansonia.
• The body of a mosquito consists of three parts : head, thorax and abdomen

(a) HEAD : The head is semi-globular in outline, bears a pair of large compound eyes and a long
needle-like structure, called the proboscis with which the mosquito bites, a pair of palpi, a pair of
antennae or feelers. The antennae are bushy in the male, and not quite so in the female.

(b) THORAX: The thorax is large and rounded in appearance and bears a pair of wings dorsally, three
pairs of legs ventrally. The buzzing noise which the mosquitoes produce is due to the beating of their
wings, and not to "singing".

(c) ABDOMEN : The abdomen is long and narrow and is composed of 10 segments, the last two of
which are modified to form the external genitalia.
Life Cycle

(1) EGG : Eggs are laid on the surface of water, 100-250 at a time. The Anopheles lays her eggs singly
(boat-shaped), Culex in small clusters or rafts, Aedes lays her eggs singly (cigar- shaped), Mansonia in
star-shaped clusters. Under favourable conditions, the egg stage of mosquitoes lasts for 1 -2 days.
The period that elapses from the moment a blood meal is taken until the eggs are laid is called the
gonotrophic cycle. It is about 48 hours in hot and humid tropical areas.

(2) LARVA : It feeds on algae, bacteria and vegetable matter and passes through four stages of
growth called "instars" with moulting between each stage. The larval stage occupies 5-7 days.

(3) PUPA : The pupa is comma-shaped in appearance, with a large rounded cephalothorax and a
narrow abdomen. Two small respiratory tubes or trumpets project from the upper surface of the
thorax. The pupal stage lasts for 1-2 days.

(4) ADULT : When the development is complete, the pupal skin splits along the back and the adult
mosquito. Under favourable conditions of temperature and food supply the life cycle from the egg to
adult is complete in 7-10 days. Normally the adult mosquito lives for about 2 weeks.

Habits of mosquitoes

(1) FEEDING HABITS : The males never bite : they subsist on plant juices. The females on the contrary
are haematophagous. They require a blood meal, once in 2-3 days for the development of eggs.

(2) TIME OF BITING : In general mosquitoes bite in the evening or in the early part of the night,

(3) RESTING HABITS : Mosquitoes obscure themselves during the day in dark and cool corners. Some
rest indoors (endophilia), and some outdoors (exophilia).

(4) BREEDING HABITS : In general, the Anophelines prefer clean water for breeding; the Culex prefer
dirty and polluted water, Aedes prefer artificial collections of water, Mansonia breed in water
containing certain types of aquatic vegetation.

(5) HIBERNATION : Mosquitoes are known to hibernate in the adult stage when the environmental
conditions are not favourable.

(6) DISPERSAL : Mosquitoes do not generally fly far from the place where they breed unless swept by
currents of wind. The range of flight varies with the species, and may range upto 11 kms.

(7) LIFE SPAN : The normal life span of mosquitoes varies from 8 to 34 days.
Mosquito-borne diseases

TYPES DISEASE
Anopheles Malaria
Filaria (not in India)
Culex Bancroffian Filariasis
Japanese Encephalitis
West Nile Fever
Viral Arthritis
Aedes Yellow fever
Dengue
Dengue haemorrhagic fever
Chikangunya fever
Chikangunya haemorrhagic fever
Rift valley fever
Filaria (not in India)
Mansonia Malayan (Brugian) Filariasis
Chikangunya fever

MOSQUITO CONTROL MEASURES

2 ANTI-ADULT MEASURES (a) Residual sprays (b) Space sprays (c) Genetic control.

3 PROTECTION AGAINST MOSQUITO BITES (a) Mosquito net (b) Screening (c) Repellents.

1. ANTI-LARVAL MEASURES

(a) Environmental control

• The most important step in reducing the numbers of mosquitoes is to eliminate their
breeding places.
• This is known as "source reduction", and comprises minor engineering methods such as
filling, levelling, drainage of breeding places and water management (such as intermittent
irrigation).
• These are proven methods of larval control. Source reduction also implies rendering the
water unsuitable for mosquito breeding, as for example, changing the salinity of water.
(b) Chemical control

(i) Mineral oils : The oils most widely used are the diesel oil, fuel oil, kerosene and various fractions
of crude oils. Special oils (e.g., Mosquito Larvicidal oil) are also available. The usual application rate
for oils is 40 to 90 litres per hectare

(ii) Paris green : Paris green or copper acetoarsenite is an emerald green, micro-crystalline powder
practically insoluble in water. Paris green is a stomach poison and to be effective it must be ingested
by the larvae. Paris green is prepared by mixing 2 kg of paris green and 98 kg of a diluent such as
soapstone powder or slaked lime in a "rotary mixer".

(iii) Synthetic insecticides : Fenthion, Chlorpyrifos, and Abate are the most effective larvicides (10).
These organophosphorous compounds hydrolyze quickly in water.

(c) Biological control

• A wide range of small fish feed readily on mosquito larvae. The best known are the
Gambusia affinis and Lebister reticulatus (sometimes known as Barbados Millions).

2. ANTI-ADULT MEASURES

(a) Residual sprays

• DDT is the insecticide of choice and dosages of 1-2 grams of pure DDT per sq.metre are
applied 1-3 times a year to walls and other surfaces where mosquitoes rest.

(b) Space sprays

Space sprays are those where the insecticidal formulation is sprayed into the atmosphere in the
form of a mist or fog to kill insects. The common space sprays are Pyrethrum extract and Residual
Insecticides

(c) Genetic control

• In recent years, control of mosquitoes by genetic methods such as sterile male technique,
cytoplasmic incompatibility, chromosomal translocations, sex distortion, and gene
replacement have been explored. Their use is still in the "Research Phase".
3. PROTECTION AGAINST MOSQUITO BITES

(a) Mosquito net

• The mosquito net offers protection against mosquito bites during sleep. The material of the
net should be white, to allow easy detection of mosquitoes.
• The size of the openings in the net is of utmost importance - the size should not exceed
0.0475 inch in any diameter. The number of holes in one square inch is usually 150.

(b) Screening

• Screening of buildings with copper or bronze gauze having 16 meshes to the inch is
recommended. The aperture should not be larger than 0.0475 inch.

(c) Repellents

• Diethyltoluamide (deet) has been found to be an outstanding all-purpose repellent. It has

been found to remain active against C. fatigans for 18-20 hours.

SAND FLIES
• Sandflies are small insects, light or dark-brown in colour. They are smaller than mosquitoes,
measuring 1.5 to 2.5 mm in length with their bodies and wings densely clothed with hair.
• The important ones are : Phlebotomus argentipes, P papatasii, P sergenti, and Sergentomyia
punjabensis.

General characters

(1) HEAD: The head bears a pair of long, slender and hairy antennae, palpi and a proboscis. Only the
females bite, the males live on vegetable juices.

(2) THORAX : The thorax bears a pair of wings and three pairs of legs. The wings are upright,
lanceolate in shape and densely hairy.

(3) ABDOMEN : The abdomen has 10 segments and is covered with hair. In the female, the tip of the
abdomen is rounded and in male there are claspers.

• Sandflies may be distinguished from mosquitoes by the following characteristics :

(1) Size : Sandflies are smaller than mosquitoes

(2) Wings : The wings of the sandfly are up-right and lanceolate in shape

(3) Legs : The legs of the sandfly are longer compared with the size of the body

(4) Hairs : Sandfly is a hairy insect

(5) Hopping: Sandflies hop about and do not fly by choice

Life history

(1) EGG : The eggs are comparatively large, and torpedo-shaped with longitudinal wavy lines on the
outside. The eggs hatch within 7 days.

(2) LARVA : The larvae are hairy maggots with a distinct head, thorax and abdomen. The larva feeds
on decaying organic matter and becomes a pupa in about 2 weeks.

(3) PUPA: The pupal stage lasts for about 1 week.

(4) ADULT : The average life of a sandfly is about 2 weeks.

Habits

• Sandflies are troublesome noctural pests. Their bite is irritating and painful, while their
presence is scarcely observed.
• They infest dwellings during night, and take shelter during day in holes and crevices in walls,
holes in trees, dark rooms, stables and store rooms.
• The females alone bite as they require a blood meal every third or fourth day for oviposition.
Sandflies are generally confined to within 50 yards of their breeding places.

Diseases transmitted

SPECIES DISEASES CARRIED

Phlebotomus argentipes Kala-azar
Phlebotomus papatasii Sandfly fever
Oriental sore
Phlebotomus sergenti Oriental sore
S. punjabensis Sandfly fever

Control
(1) INSECTICIDES : A single application of 1 to 2 g/m2 of DDT or 0.25 g/m2 of lindane has been found
effective in reducing sandflies. DDT residue may remain effective for a period of 1 to 2 years, and
lindane only for a period of 3 months.

(2) SANITATION : Sanitation measures such as removal of shrubs and vegetation within 50 yards of
human dwellings, filling up cracks and crevices in walls and floors, and location of cattle sheds and
poultry houses.

HOUSEFLIES
• Houseflies are the commonest and most familiar of all insects which live close to man. They
occur in abundance all the year round in India. The majority of house -frequenting flies in
India are non-biting.
• The most important of these are : Musca domestica, M. vicinia, M. nebulo and M. sorbens.

General characters

• The common housefly (M. domestica) is mouse-grey in colour. The body is divided into head,
thorax and abdomen.

(1) HEAD : The head bears a pair of antennae, a pair of large compound eyes and a retractile
proboscis, which is adapted for sucking liquid foods.

(2) THORAX : The thorax is marked with 2 to 4 dark longitudinal stripes, which is characteristic of the
genus, musca. The thorax bears a pair of wings and three pairs of legs. The legs and the body are
covered with numerous short and stiff hairs, called the tenent hairs which secrete a sticky substance.

(3) ABDOMEN : The abdomen is segmented and shows light and dark markings.

Life history

(1) EGG : The female lays from about 120 to 150 eggs at one sitting in moist decaying organic matter
such as human and animal excreta, manure heaps, garbage and. vegetable refuse. The eggs hatch in
8 to 24 hours during summer. In India they may hatch within 3 hours.

(2) LARVA : The larvae or maggots measure 1 to 2 mm in length at birth. They are white, segmented
and footless with a narrow anterior end, and a broad posterior end. The full grown larva may
measure up to 12 mm in length. The larval period lasts from 2 to 7 days, but this stage may be
prolonged in cold weather.

(3) PUPA : The pupa are dark- brown and barrel shaped and measure about quarter of an inch. The
pupal stage in the tropics occupies 3 to 6 days.

(4) ADULT : The complete life cycle from egg to adult may take 5 to 6 days during summer in India,
but at other times it may take 8 to 20 days.

Habits

(1) BREEDING HABITS : (a) fresh horse manure (b) human excreta (c) manure of other animals (d)
garbage (e) decaying fruits and vegetables (f) rubbish dumps containing organic matter and (g)
ground where liquid wastes are spilled.

(2) FEEDING HABITS : The housefly does not bite. It is attracted to food by its sense of smell. It
cannot eat solid foods; it vomits on solid food to make a solution of it and sucks in a liquid state.

(3) RESTLESSNESS : The fly is a restless insect and moves back and forth between food and filth. This
helps in the spread of infection mechanically.

(4) VOMIT DROP: The fly vomits frequently. The "vomit drop" is often a culture of disease agents.

(5) DEFECATION : The housefly has the habit of defecating constantly all the day. Thus it deposits
countless bacteria on exposed food.

Transmission of disease

(1) MECHANICAL TRANSMISSION : They transport microorganisms on their feet and hairy legs.
Pathogenic organisms, ova and cysts have been recovered from the bodies of the common housefly.
Houseflies are therefore called "porters of infection".

(2) VOMIT DROP : The regurgitated stomach contents or "vomit drop" is a rich bacterial culture.

(3) DEFECATION : By its habit of constant defecation, the housefly spreads these diseases.

CONTROL MEASURES

1. Environmental control

(a) storing garbage, kitchen wastes and other refuse in bins with tight lids, pending disposal
(b) efficient collection, removal and disposal of refuse by incineration, composting or sanitary landfill

(c) provision of sanitary latrines, e.g., pit privies, septic tanks, water-seal latrines and sanitary system

(d) stopping open air defecation

(e) sanitary disposal of animal excreta

(f) stepping up general sanitation

2. Insecticidal control

(1) RESIDUAL SPRAYS : Susceptible flies may be killed by DDT (5%), methoxychlor (5%), lindane
(0.5%), or chlordane (2.5%) sprayed at about 5 litres per 100 square metres of surface; for flies
resistant to these, diazinon (2%) dimethoate (2.5%), fenthion (2.5%), malathion (5%), or ronnel (5%)
may be used.

(2) BAITS : Baits may be solid or liquid. Poisoned baits containing 1 or 2 per cent diazinon, malathion,
dichlorvos, ronnel and dimethoate have been tried with success. Liquid baits containing 0.1 to 0.2
per cent of the same insecticides and 10 per cent sugar water have given good results.

(3) CORDS AND RIBBONS : Cords and strips impregnated with diazinon, fenthion, or dimethoate have
been tried with success. The period of effectiveness ranges from 1 to 6 months.

(4) SPACE SPRAYS : Space sprays containing pyrethrin and DDT or HCH are available commercially.
They produce only a temporary effect on adult fly populations; consequently, repeated applications
are necessary.

(5) LARVICIDES: Insecticides such as 0.5% diazinon, 2% dichlorovos, 2% dimethoate or 1 % ronnel

applied at the rate of 28-56 litres per 100 sq. metres have been used for the treatment of fly
breeding places.

3. Fly papers

• These papers can be easily made by mixing 2 lbs of resin and one pint of castor oil which
should be heated together until the mixture resembles molasses. The adhesive mixture can
also be applied to strips of wire and hung up in places where flies abound.
4. Protection against flies

• Screening of houses, hospitals, food markets, restaurants and all other similar
establishments will give considerable relief from houseflies.

5. Health education

It is difficult to achieve fly control without the willing co-operation of the people. A "fly
consciousness" should be created among the people, through health education. Fly control
campaigns require organized individual and community effort which is the basis of a successful
public health programme.

CYCLOPS
• Cyclops or water flea is a crustacean present in most collections of fresh water. It is a tiny
arthropod, not more than 1 mm in length and just visible to the trained eye.
• It has a pear-shaped semi-transparent body, a forked tail, 2 pairs of antennae, 5 pairs of legs
and a small pigmented eye. It swims in water with characteristic jerky movements. The
average life of a cyclops is about 3 months.

• Cyclops is the intermediate host of Dracunculiasis or guinea-worm disease. Man acquires

infestation by drinking water containing infected cyclops.
• Cyclops mediates also as one of the intermediate hosts of fish tape worm, Diphytlobothrium
latum infestation. The disease is rare in India.

Control

(1) PHYSICAL

(a) Straining: Straining of water through a piece of fine cloth is sufficient to remove cyclops

(b) Boiling: Cyclops is readily killed by heat at 60°C. The physical methods are useful for individual
prophylaxis

(2) CHEMICAL

(a) Chlorine: Chlorine destroys cyclops and larvae of guinea worm in a strength of 5 ppm. This high
concentration of chlorine gives an objectionable smell and taste to drinking water.
(b) Lime: Lime at a dosage of 4 gram per gallon of water is found to be very efficient for killing
cyclops.

(c) Abate: The organophosphorus insecticide, Abate (OMS - 786) has been found effective in killing
cyclops at a concentration of 1 mg/litre.

(3) BIOLOGICAL

Certain kinds of small fish, e.g., barbel fish and gambusia fish have been found to feed on cyclops.
The most satisfactory and permanent method of controlling cyclops in drinking water is to provide
piped water supply or tube wells.

INSECTICIDES
Insecticides are substances which are used to kill insects. The word pesticide is a general term that
includes insecticides, fungicides, rodenticides, herbicides, disinfectants, repellents, and other
chemicals used for the control of pests.

Insecticides are classified into three groups : contact poisons, stomach poisons and fumigants.

o CONTACT POISONS : are those which kill insects primarily by contact e.g. pyrethrum, DDT,
HCH, dieldrin.
o STOMACH POISONS : are those which when ingested cause the death of the insects e.g. paris
green, sodium fluoride.
o FUMIGANTS : are those which give off vapours which have a lethal effect on the insects e.g.
sulphur dioxide.
• Most of the present-day insecticides available for vector control may be classified
conveniently into 3 groups :
• Group I Organochlorine compounds : DDT, HCH, dieidrin, chlordane, methoxychlor, etc
• Group II Organophosphorous compounds : malathion, fenthion, chiorpyrifos, abate, etc
• Group llI : Carbamates - Propoxur, carbaryl

1. DDT (Dichloro-diphenyl-trichloroethane)

(a) PROPERTIES : DDT is a white amorphous powder with a mild, but not unpleasant smell. It is
insoluble in water but dissolves in most organic solvents.
(b) ACTION : DDT is primarily a contact poison. It acts on the nervous system of insects. It permeates
into the insect body through the cuticle, after dissolving in the waxy covering of the feet, and causes
paralysis of legs and wings, convulsions and finally death. The residual action of DDT may last as long
as 18 months depending upon the treated surface.

(c) APPLICATION : As a residual spray, DDT is applied at a dosage of 100-200 mg. per square foot
area. In recent years DDT has earned the reputation of being an "environmental pollutant".

2. HCH (BHC) Benzene hexachloride or hexachlorocyclo-hexane or gammexane or hexidol

(a) PROPERTIES : HCH is a white or chocolate coloured powder with a musty smell. It is irritating to
the eyes, nose and skin. Pure HCH containing 99 % of the gamma isomer is called lindane or gamma
HCH. HCH is slightly volatile.

(b) ACTION : HCH kills insects by direct contact but its residual action is of a shorter duration up to 3
months.

(c) APPLICATION : HCH is used like DDT. A dose of 25 to 50 mg of gamma HCH per sq. ft.

3. Malathion

The technical product is a yellow or clear- brown liquid with an unpleasant smell. Malathion is used
in doses of 100-200 mg. per sq. ft. every 3 months.

4. Abate

Abate (Temephos) is an organophosphorus compound. It is a brown viscous liquid, soluble in

petroleum solvents. Abate is less effective as adulticide.

5. Diazinon

Diazinon is a liquid product. Being volatile, it kills insects not only by direct contact but also by
fumigant action. At a dosage of 60 to 100 mg per sq. foot it has given satisfactory control of flies and
mosquitoes.

6. Fenthion

Fenthion or baytex is a brown liquid smelling slightly of garlic. It is practically insoluble in water. The
usual dosage for residual sprays is 100 mg/sq ft.
7. Dichlorovos

Dichlorovos or DDVP is highly volatile liquid insecticide which kills insects by fumigant action.

8. Propoxur

The new carbamate insecticide, propoxur has been recommended as a substitute for DDT in areas
where the anophelines have developed resistance to both DDT and dieldrin.

9. Pyrethrum

It is extracted from the flowers of Chrysanthemum cinerariafolium. It has been used extensively in
the past for killing adult mosquitoes, and other insects.

10. Synthetic pyrethroids

Synthetic pyrethroids are now being developed to replace natural pyrethrins.

11. Rotenone

Rotenone is obtained from the roots of a plant, Derris elliptica. The roots are dried and powdered
and then are blended to give a rotenone content between 4 to 5 % and used as insecticidal dust.

Toxicity of insecticides

1. Organo-chlorine compounds

• DDT and its chemical relations are all nerve poisons. They increase the nervous excitability,
and cause tremors and convulsions. Of the three commonly used compounds namely DDT,
HCH and dieldrin, DDT is the least toxic.
• The median lethal dose for the humans is about 250 mg per kg of body weight. Gamma-HCH
is about twice as toxic as DDT, and dieldrin is about 5 to 8 times as toxic as DDT.
• Treatment : Poisoning with chlorinated hydrocarbons is treated with barbiturates, specially
phenobarbitone. Stomach washouts are generally necessary, purgative may be useful but no
oils or fats should be given.

2. Organophosphorus compounds and carbamates

• These insecticides interfere with the mechanism of transmission of nerve impulses. They act
by inhibiting cholinesterase, the enzyme which catalyses the degradation of acetyl choline in
the synapse of striated muscle.
 • The effects of poisoning are headache, giddiness, apprehension, restlessness, cold sweating,
salivation, uncontrolled urination and defecation, unconsciousness and in extreme cases,
ataxia and paralysis of respiratory centre.
• Treatment : Atropine is the specific antidote for poisoning by organophosphorus
insecticides. It should be injected in doses of 1 to 2 mg intramuscularly and repeated if
necessary at 30 minutes interval.

RODENTS
• Rats and mice are part of man's environment. Often their numbers exceed human
population. A female rat can have 100 offsprings each year.
• By living in close proximity to man, they not only cause substantial economic loss by
damaging buildings, consuming and contaminating foodstuffs (36%) and other commodities,
but also act as sources or reservoirs of some important communicable diseases such as
plague and typhus fever. Rodents may be classified into two distinct groups :

(1) DOMESTIC RODENTS : The rodents of chief public health concern are those that live in close
association with man namely the black rat (Rattus rattus) and the Norway rat (R. norvegicus) and the
house mouse (Mus musculus).

(2) WILD RODENTS : The common wild rodents in India are Tatera indica, Bandicota bengalensis
varius (Gunomys kok), B.indica, Millardia meltada, M. gleadowi and Mus booduga. In India, Tatera
indica has been found to be the natural reservoir of plague.

Rodents and disease

(1) Bacterial : plague, tularaemia, salmonellosis

(2) Viral : Lassa fever, haemorrhagic fever, encephalitis

(3) Rickettsial : scrub typhus, murine typhus, rickettsial pox

(4) Parasitic : hymenolepis diminuata, leishmaniasis, amoebiasis, trichinosis, Chagas disease

(5) Others: rat bite fever, leptospirosis, histoplasmosis, ring worm

Mode of transmission

may be directly through rat bite (e.g. rat bite fever), some through contamination of food or water
(e.g., salmonellosis, leptospirosis) and some through rat fleas (e.g. plague and typhus).

Antirodent measures

1. Sanitation measures : Sound environmental sanitation is the most effective weapon in

deratization campaign. Rats require three things : food, water and shelter. If these are denied, rats
will naturally decrease in density. The environmental sanitation measures comprise :

(a) proper storage, collection and disposal of garbage

(b) proper storage of food-stuffs

(c) construction of rat-proof buildings, godowns and warehouses

(d) elimination of rat burrows by blocking them with concrete.

2. Trapping : Trapping of rats is a simple operation. But it causes temporary reduction in the number
of commensal rodents. The 'wonder trap' developed by the Haffkine Institute, Mumbai is credited to
trap as many as 25 rats at a time. The traps are usually baited with indigenous foods of the locality.

3. Rodenticides : Rodenticides are of two main types single -dose (acute) and multiple-dose
(cumulative). The multiple-dose (cumulative) poisons are : warfarin, diphacinone, coumafuryl and
pindone. As anticoagulants, they cause internal haemorrhage and slow death in 4 to 10 days.

(4) Fumigation : Fumigation is an effective method of destroying both rats and rat fleas. The
fumigants used in anti-rat campaigns are calcium cyanide, carbon disulphide, methyl bromide,
sulphur dioxide, etc.

(5) Chemosterilants : A chemosterilant is a chemical that can cause temporary or permanent sterility
in either sex or both sexes.

ZOONOSES
• Zoonotic diseases have been known since antiquity. Bubonic plague and rabies were known
since biblical times. The discovery of causative agents during the "golden era" of
microbiology called attention principally to diseases exclusively pathogenic to man.
 • Zoonotic diseases were overshadowed by diseases peculiar to man alone. Only as human
infections came under better control was attention drawn to zoonotic diseases. More than
150 zoonoses have been recognized.
• In recent years, several new zoonotic diseases have emerged e.g. KFD, Monkey Pox etc.,
Quite apart from the morbidity and mortality they cause, zoonoses are responsible for great
economic losses, particularly in animals, meat, milk and other foods and products of animal
origin.
• The developing countries suffer much more severe losses than do the industrialized
countries, partly because they have less well- developed public health and veterinary
services and partly because of their unfavourable climatic and environmental conditions.

• Zoonoses and human health are matters of particular concern in India - because nearly 80%
of India's population is rural and live in close contact with domestic animals, and often not
far from wild ones.
• Zoonoses have been defined as "Those diseases and infections [the agents of] which are
naturally transmitted between [other] vertebrate animals and man." G.S. Nelson has pointed
out that it is essential to discuss the direction of transmission, as it is of little value to know
that a particular organism is found in both man and animals.
• The zoonoses have been classified in terms of their reservoir hosts, whether these are men
or lower vertebrate animals. Thus, the term anthropo-zoonoses has been applied to
infections transmitted to man from lower vertebrate animals.
• The term zooanthroponoses is applied to infections transmitted from man to lower
vertebrate animals; however, these terms have also been used interchangeably for all
diseases found in both animals and man.

• A third term, amphixenoses, has been used for infections maintained in both man and lower
vertebrate animals that may be transmitted in either direction.
• A classification that is based upon the type of life cycle of the infecting organism and that
divides the zoonoses into four categories, each with important shared epidemiologic
features; has considerable teaching value. The four categories are :

(1) Direct zoonoses are transmitted from an infected vertebrate host to a susceptible vertebrate
host by direct contact, by contact with a fomite, or by a mechanical vector. The agent itself
undergoes little or no propagative changes and no essential developmental change during
transmission. Examples are rabies, trichinosis, and brucellosis.
(2) Cyclo-zoonoses require more than one vertebrate host species, but no invertebrate host, in order
to complete the developmental cycle of the agent. Examples are the human taeniases,
echinococcosis, and pentastomid infections.

(3) Meta-zoonoses are transmitted biologically by invertebrate vectors. In the invertebrate, the
agent multiplies or develops, or both, and there is always an extrinsic incubation (prepatent) period
before transmission to another vertebrate host is possible. Examples are numerous and include
arbovirus infections, plague, and schistosomiasis.

(4) Sapro-zoonoses have both a vertebrate host and a non-animal developmental site or reservoir.
Organic matter (including food), soil, and plants are considered to be non-animal. Examples include
the various forms of larva migrants and some of the mycoses.

LEPTOSPIROSIS
• Leptospirosis is essentially animal infection by several serotypes of Leptospira (Spirocheates) and
transmitted to man under certain environmental conditions

Problem statement

Leptospirosis is considered to be the most widespread of the disease transmissible from animal to
man . It has high prevalence in warm humid tropical countries.

Epidemiological determinants

Agent factors

(a) AGENT : Leptospira are thin and light motile spirocheates 0.1-0.2 µm wide and 5-15 µm long with

hooked ends

(b) SOURCE OF INFECTION: Leptospira are excreted in the urine of infected animals for a long time.

(c) ANIMAL RESERVOIRS : Leptospirosis affects wild and domestic animals worldwide especially

rodents such as rats, mice and voles. Most domestic animals including cattle, sheep, goats, water
buffalo, pigs and horses may be infected through grazing.
Host factors

(a) AGE : Children acquire the infection from dogs more frequently than do adults.

(b) OCCUPATION : Human infections are usually due to occupational exposure to the urine of
infected animals, e.g, agricultural and livestock farmers, workers in rice fields, sugarcane fields,
and underground sewers, abattoir workers, meat and animal handlers, veterinarians etc.

(c) IMMUNITY : A solid serovar specific immunity follows infection.

Mode of transmission

(a) DIRECT CONTACT : Leptospira can enter the body through skin abrasions or through intact
mucous membrane by direct contact with urine or tissue of infected animal.

(b) INDIRECT CONTACT : Through the contact of the broken skin with soil, water or vegetation
contaminated by urine of infected animals or through ingestion of food or water contaminated
with leptospirae.

(c) DROPLET INFECTION : Infection may also occur through inhalation as when milking infected cows
or goats by breathing air polluted with droplets of urine .

Incubation period : Usually 10 days with a range of 4 to 20 days.

Control

• ANTIBIOTICS : Penicillin is the drug of choice but other antibiotics (tetracycline or doxycycline) are
also effective. The dosage of penicillin is 6 million units daily intravenously.

• ENVIRONMENTAL MEASURES : This includes preventing exposure to potentially contaminated

water, reducing contamination by rodent control and protection of workers in hazardous
occupation. Measures should be taken to control rodents, proper disposal of wastes and health
education etc.

• Vaccination Immunization of farmers and pets prevent disease.

• Without census data, it is not possible to obtain quantified health, demographic and socio-
economic indicators.
PHC
• The concept of primary health centre is not new to India. The Bhore committee in 1946 gave
the concept of a primary health centre as a basic health unit, to provide, as close to the
people as possible, an integrated curative and preventive health care to the rural population
with emphasis on preventive and promotive aspects of health care.
• The Bhore Committee aimed at having a health centre to serve a population of 10,000 to
20,000 with 6 medical officers, 6 public health nurses and other supporting staff.
• The health planners in India have visualized the primary health centre and its sub-centres as
the proper Infrastructure to provide health services to the rural population.
• The Central Council of Health at its first meeting held in January 1953 had recommended the
establishment of primary health centres in community development blocks to provide
comprehensive health care to the rural population.

Functions

Indian Public Health Standards for PHCs

The objectives of IPHS for PHCs are :

a. To provide comprehensive primary health care to the community through the Primary Health
Centres

b. To achieve and maintain an acceptable standard of quality of care. iii. To make the services more
responsive and sensitive to the needs of the community

1. MEDICAL CARE

(a) OPD services : 4 hours in the morning and 2 hours in the afternoon/evening. Minimum OPD
attendance should be 40 patients per doctor per day

(b) 24 hours emergency services : appropriate management of injuries and accident, First-aid,
stabilization of the condition of patient before referral, dog bite/snake bite/ scorpion bite cases, and
other emergency conditions

(c) Referral services

(d) In-patient services (6 beds)

2. MATERNAL AND CHILD HEALTH CARE

Antenatal care : (a) Early registration of pregnancy and minimum 3 antenatal check-up

(b) Minimum laboratory investigations such as haemoglobin, urine albumin and sugar .and RPR test
for syphilis

(c) Nutrition and health counselling

(d) Supplementation of folic acid and iron tablets and tetanus toxoid immunization

Intranatal care : (a) 24 hours services for normal delivery

(b) Promotion of institutional delivery

(c) Conducting assisted deliveries including forceps and vacuum delivery whenever required

(d) Manual removal of placenta

Postnatal care : (a) A minimum of 2 post-partum home visits, first within 48 hours of delivery and
2nd within 7 days through sub-centre staff

(b) Initiation of breast-feeding within half-hour of delivery

(c) Education on nutrition, hygiene and contraception

(d) Provision of facilities under Janani Suraksha Yojana

New born care : (a) Essential new born care

(b) Facilities and care for neonatal resuscitation

(c) Management of neonatal hypothermia and jaundice

Care of the child : (a) Emergency care of sick child including Integrated Management of Neonatal
and Childhood Illness (IMNCI)

(b) Care of routine childhood illness

(c) Promotion of breast-feeding for 6 months

(d) Full immunization of all infants and children against vaccine preventable diseases
3. Medical termination of pregnancy

4. Health education for prevention and management of RTl/STI

5. Nutrition Services : Diagnosis ·and management of malnutrition, anaemia and vitamin A

deficiency and coordination with ICDS

6. School health services

7. Adolescent health care

8. Disease surveillance and control of epidemics

9. Collection and reporting of vital events

STAFFING PATTERN :

STAFF EXISTING RECOMMENDED

Medical Officer 1 3 (atleast 1 female)
AYUSH practitioner NIL 1 (AYUSH or any ISM system
prevalent locally)
Account Manager NIL 1
Pharmacist 1 2
Nurse-midwife (Staff) (Nurse) 1 5
Health workers (F) 1 1
Health Educator 1 1
Health Asstt. (Male & Female) 2 2
Clerks 2 2
Laboratory Technician 1 2
Driver 1 Optional/Vehicles may be out
sourced
Class IV 4 4
Total 15 24/25
INFANT MORTALITY RATE
• IMR is defined as the ratio of infant deaths registered in a given year to the total number of
live births registered in the same year, usually expressed as a rate per 1000 live births. It is
given by the formula:
• IMR = Number of deaths of children (<1 year of age) in a year x 1000

Number of live births in the same year

• Infant mortality is given a separate treatment by demographers because :

(a) infant mortality is the largest single age-category of mortality

(b) deaths at this age are due to a peculiar set of diseases and conditions to which the adult
population is less exposed or less vulnerable

(c) infant mortality is affected rather quickly and directly by specific health programmes and hence
may change more rapidly than the general death rate

Infant mortality in India

• The all-India rate masks variations that exist among sub-groups of the population. An
examination of state-wise IMR shows a vast regional variation, with Madhya Pradesh having
IMR of 56 and Kerala as low as 12 per thousand live births during the year 2012.
• Among the larger States Kerala, Maharashtra, Punjab, Tamil Nadu, West Bengal, Andhra
Pradesh, Haryana, Karnataka, Gujarat, Himachal Pradesh, and Jharkhand have achieved IMR
below the national average of 42.
• There is plenty of evidence to show that better control of infant mortality is related to a
wider spread of literacy (particularly female literacy) and primary health care

Medical causes of infant mortality

Neonatal Mortality Post Neonatal Mortality

1. Low birth weight 1. Diarrhoeal diseases and prematurity
2. Acute respiratory 2. Birth injury and difficult labour infections
3. Sepsis 3. Other communicable
4. Congenital anomalies diseases 4. Malnutrition
5. Haemolytic diseases of newborn 5. Congenital anomalies
6. Conditions of placenta and cord 6. Accidents
7. Diarrhoeal diseases
8. Acute respiratory infections
9. Tetanus

Factors affects

1. BIOLOGICAL FACTORS

(a) Birth weight : Babies of low birth weight (under 2.5 kg) and high birth weight {over 4 kg) are at
special risk. Virtually, all infants weighing less than 1000 g at birth succumb.

(b) Age of the mother : Infant mortality rates are greater when the mother is either very young
(below the age of 19 years) or relatively older (over 30 years).

(c) Birth order : The highest mortality is found among first born, and the lowest among those born
second. The risk of infant mortality escalates after the third birth.

(d) Birth spacing : Repeated pregnancies exert a great influence on infant mortality. They cause
malnutrition and anaemia in the mother, again predispose to low birth weight.

(e) Multiple births : Infants born in multiple births face a greater risk of death.

(f) Family size : The number of episodes of infectious diarrhoea, prevalence of malnutrition, and
severe respiratory infections have been found to increase with family size.

(g) High fertility : Fertility is one of the most important factors that influence infant mortality. High
fertility and high infant mortality go together.

(2) ECONOMIC FACTORS

• Statistics reveal that infant mortality rates are highest in the slums and lowest in the richer
residential localities.

(3) CULTURAL AND SOCIAL FACTORS

(a) Breast-feeding
(b) Religion and caste

(c) Early marriages

(d) Sex of the child In most parts of India, female infants receive far less attention than males.

(e) Quality of mothering

(f) Maternal education

(g) Quality of health care

(h) Broken families

(i) Illegitimacy

(j) Brutal habits and customs : These include depriving the baby of the first milk or colostrum,
frequent purgation, branding the skin, application of cow dung to the cut end of umbilical cord,
faulty feeding practices and early weaning.

(k) The indigenous dai : She is usually an illiterate person devoid of all knowledge of rules of hygiene.

(I) Bad environmental sanitation

Preventive and social measures

1. Prenatal nutrition

• The risk of death begins to appear even before birth, if the mother is malnourished.
Therefore, the very first need is to improve the state of maternal nutrition.
• There is mounting evidence that the addition of even a small amount of extra food by way of
supplementation to the mother's basic diet goes a long way in improving the birth weight of
babies.

2. Prevention of infection

• The major causes of sickness and death of children in India are infectious diseases, many of
which are preventable by immunization, as for example, neonatal tetanus.
3. Breast-feeding

• The most effective measure for lowering infant mortality is to promote breast-feeding,
which is a safeguard against gastrointestinal and respiratory infections and PEM.

4. Growth monitoring

• All infants should be weighed periodically (at least once a month) and their growth charts
maintained. These charts help to identify children at risk of malnutrition early.

5. Family planning

• Family limitation and spacing of births contribute substantially to lowering of infant

mortality rate.
• The risk of death is greatly enhanced if the last child was born less than 2 years ago, and if
the mother already has four or more children.

6. Sanitation

• For infants and young children, the risk of dying is very closely related to the environment in
which they live.

7. Provision of primary health care

(a) Local dai should collaborate and work together as a team

(b) Prenatal care must be improved

(c) "Special care baby units" must be provided for all babies weighing less than 2000 g

8. Socio-economic development

• This must include spread of education (especially female literacy), improvement of

nutritional standards, provision of safe water and basic sanitation, improvement of housing
conditions, the growth of agriculture and industry and the availability of commerce and
communication.

9. Education

• Educated women generally do not have early pregnancies, are able to space their
pregnancies, have better access to information related to personal hygiene and care of their
children.
 Role of Community Medicine in Homoeopathy
A. Primary Aspects
1. Promotion of health : The knowledge of community medicine intended to improve the general
health and well- being of a community. It includes-
a. Proper Nutrition

b. Individual and community hygiene

c. Lifestyle changes

d. Health education

2. Specific immunization : It refers to inducing immunity against any specific disease. It includes :

a. Protection against fatal diseases

b. Avoidance of allergens

c. Intake of proper nutrients to avoid deficiency diseases.

• In Homoeopathy, some medicines are used as prophylaxis eg. Belladonna in Scarlet fever,
Diphtherinum in diphtheria. In epidemic condition, Genus epidemicus can be selected.

3. Protection against occupational hazards : One should be aware of the harmful effects of his
workplace. Example- silicosis in miners, pneumoconiosis in coal workers.

4. Current status of community : Community medicine gives a knowledge of the current status of
disease condition prevailing in the country. It helps the physician to select a similimum
homoeopathic medicine. It keeps the physician updated with the indicators of the health.

B. Secondary Aspects :
1. Diagnosis of disease :

• In the condition of slight alteration and tissue changes, there is a need to make a proper
diagnosis.
• Community medicine serves with the widespread knowledge of the disease their causation
and their preventive measures.

2. Treatment :

• For the proper treatment of the disease, a physician requires proper knowledge of the
fundamental and exciting causes of the disease.
• Community medicine helps the physician in early diagnosis and proper treatment to avoid
complication. For the restoration of the health, the most similimum is given after proper
case taking.
3. Tertiary Aspects :
1. Management of disease :

• In the case of disability, gross deformities, and major tissue changes, there is needs to
manage the case.
• By the knowledge of community medicine physician can manage the case in the most
appropriate manner.

2. Rehabilitation :

• Rehabilitation means to restore to the original state. The knowledge of the progress of the
disease condition enables us to know various homoeopathic approaches.

DEMOGRAPHY
• Demography is the scientific study of human population. It focuses its attention on three
readily observable human phenomena :

(a) changes in population size (growth or decline)

(b) the composition of the population

(c) the distribution of population in space.

• It deals with five "demographic processes" namely fertility, mortality, marriage, migration
and social mobility.

Demographic cycle : There is a demographic cycle of 5 stages :

(1) FIRST STAGE (High stationary) : This stage is characterized by a high birth rate and a high death
rate which cancel each other and the population remains stationary.

(2) SECOND STAGE (Early expanding) : The death rate begins to decline while the birth rate remains
unchanged.

(3) THIRD STAGE (Late expanding) : The death rate declines still further, and the birth rate tends to
fall. The population continues to grow because births exceed deaths.

(4) FOURTH STAGE (Low stationary) : This stage is characterized by a low birth and low death rate
with the result that the population becomes stationary.

(5) FIFTH STAGE (Declining) : The population begins to decline because birth rate is lower than the
death rate.

FATS
• Fats are solid at 20 deg C, if they are liquid they are called "oils". Fats and oils are
concentrated sources of energy. They are classified as :
(a) Simple lipids e.g. triglycerides

(b) Compound lipids e.g. phospholipids

(c) Deriued lipids e.g. cholesterol

• The human body can synthesize triglycerides and cholesterol endogenously. Most of the
body fat (99%) in the adipose tissue (10 to 15 % of body weight) is in the form of
triglycerides.
• The accumulation of one kilogram of adipose tissue corresponds to 7, 700 kcal of energy.

Fatty acids
• Fatty acids are divided into saturated fatty acids such as Lauric, palmitic and stearic acids,
and unsaturated fatty acids which are further divided into monounsaturated (MUFA) (e.g.
oleic acid) and poly-unsaturated fatty acids (PUFA) (e.g. linoleic acid and cx-linolenic acid).
The poly-unsaturated fatty acids are mostly found in vegetable oils, and the saturated fatty
acids mainly in animal fats.
• The most important essential fatty acid (EFA) is linolelc acid. Linoleic acid is abundantly
found in vegetable oils.

Sources

(a) ANIMAL FATS : The major sources of animal fats are ghee, butter, milk, cheese, eggs, and fat of
meat and fish.

(b) VEGETABLE FATS : Some plants store fat in their seeds, e.g., groundnut, mustard, sesame,
coconut, etc.

(c) OTHER SOURCES : Small quantities of fat (invisible fat) are found in most other foods such as
cereals, pulses, nuts and vegetables.

Visible and invisible fats

• Visible fats are those that are separated from their natural source, e.g. ghee (butter) from
milk, cooking oils from oil-bearing seeds and nuts. It is easy to estimate their intake in the
daily diet.
• Invisible fats are those which are not visible to the naked eye. They are present in almost
every article of food, e.g., cereals, pulses, nuts, milk, eggs, etc.
• Animal foods like butter, ghee, whole milk cream, fatty cheese and fatty meats provide
cholesterol and high amount of saturated fatty acids, and are natural source of trans-fatty
acids.
• Egg has high cholesterol but are good source of linoleic acid, alpha-linolenic acid and
docosahexaenoic acid (DHA).

Functions

• Providing as much as 9 kcal for every gram.

 • Fats serve as vehicles for fat-soluble vitamins. Fats in the body support viscera such as heart,
kidney and intestine
• Fat beneath the skin provides insulation against cold. Without fat, food is limited in
palatability.
• The non-calorie roles of fats have been discovered. For example vegetable fats are rich
sources of essential fatty acids which are needed by the body for growth, for structural
integrity of the cell membrane and decreased platelet adhesiveness, reduce serum
cholesterol and low-density lipoproteins.

Hydrogenation

• When vegetable oils are hydrogenated under conditions of optimum temper ature and
pressure in the presence of a catalyst, the liquid oils are converted into semi-solid and solid
fat.
• The resulting hydrogenated fat is known as vanaspati or vegetable ghee, which is a popular
cooking medium in India.
• During the process of hydrogenation, unsaturated fatty acids are converted into saturated
acids and trans-fatty acids.
• Partial hydrogenation - the process used to increase shelf-life of poly-unsaturated fatty acids
(PUFAs) creates trans-fatty acids and intake of trans-fatty acids increases the risk of coronary
heart disease.
• It takes years for trans-fatty acids to be flushed from the body.

Refined oils
• Refining is usually done by treatment with steam, alkali, etc. Refining and deodourization of
raw oils remove the free fatty acids and rancid materials. It only improves the quality and
taste of oils. Refined oils are costly.

Fats and disease

(a) OBESITY : A diet, rich in fat, can pose a threat to human health by encouraging obesity.

(b) PHRENODERMA : Deficiency of essential fatty acids in the diet is associated with rough and dry
skin, a condition known as phrenoderma or "toad skin". It is characterized by horny papular
eruptions on the posterior and lateral aspects of limbs and on the back and buttocks.

(c) CORONARY HEART DISEASE : High fat intake has been identified as a major risk factor for CHD

(d) CANCER : In recent years, there has been some evidence that diets high in fat increase the risk of
colon cancer and breast cancer.

(e) OTHERS : The skin lesions of kwashiorkor and those induced by EFA deficiency are similar.

Choice of cooking oils

1. Correct combination of vegetable oils to be used

2. Limit use of butter/ghee

3. Avoid use of PHVO as medium for cooking/frying

4. Replacements for PHVO Frying

Requirements
• The minimum intakes of visible fat for Indian adults range between 20-40 g/day.

DOTS (Directly Observed Treatment)

DOTS is a strategy to ensure cure by providing the most effective medicine and confirming that it is
taken.

It is the only strategy which has been documented to be effective world-wide on a programme basis.

In DOTS, during the intensive phase of treatment a health worker or other trained person watches as
the patient swallows the drug in his presence.

During continuation phase, the patient is issued medicine for one week in a multiblister combipack,
of which the first dose is swallowed by the patient in the presence of health worker or trained
person.

The consumption of medicine in the continuation phase is also checked by return of empty
multiblister combipack, when the patient comes to collect medicine for the next week.

The drugs are provided in patient-wise boxes with sufficient shelf-life.

Category of treatment Type of patient Regimen

New cases Category 1 Red Box New sputum smear-positive 2(HRZE)3 + 4(HR)3

New sputum smear-negtive

New extra pulmonary

New others

Previously Treated Category 2 Sputum smear-positive relapse 2(HRZES)3 + 1(HRZE)3 +

Blue Box 5(HRE)3
Sputum smear-positive failure

Sputum smear-positive
treatment after default others

• H: lsoniazid (600 mg)

• R: Rifampicin (450 mg)
• Z: Pyrazinamide (1500 mg)
• E: Ethambutol (1200 mg)
• S: Streptomycin (750 mg)
 • Patients who weigh more than 60 kg receive additional Rifampicin 150 mg.
• Patients more than 50 years old receive streptomycin 500 mg.

NATIONAL RURAL HEALTH MISSION

• The government of India launched NRHM on 5th April, 2005 for a period of 7 years (2005-
2012) and recently extended upto year 2017.
• The mission seeks to improve rural health care delivery system by making necessary changes
in the basic health care delivery system the mission adopts a synergic approach by relating
health to determinants of good health viz. of nutrition, sanitation, hygiene and safe drinking
water. It also brings the Indian system of medicine (AYUSH) to the mainstream of health
care.
• The main aim of NRHM is to provide accessible, affordable, accountable, effective and
reliable primary health care, and bridging the gap in rural health care through creation of a
cadre of Accredited Social Health Activist (ASHA).

Plan of action to strengthen infrastructure

1. Creation of a cadre of Accredited Social Health Activist (ASHA)

2. Strengthening sub-centres by :

(a) Supply of essential drugs both allopathic and AYUSH to the sub-centre

(b) Provision of multipurpose worker (male)/additional ANMs wherever needed

(c) Strengthening sub-centres with untied funds of Rs. 10,000 per annum

3. Strengthening PHC :

(a) Adequate and regular supply of essential drugs and equipment to PHCs

(b) Provision of 24 hours service in PHCs by including an AYUSH practitioner

(c) Following standard treatment guidelines

4. Strengthening Community Health Centres for First Referral care by

(a) Operating all existing CHCs (30-50 beds) as 24 hours first referral units

(b) Codification of new "Indian Public Health Standards" by setting up norms for infrastructure, staff,
equipment, management etc.

(c) Promotion of "Rogi Kalyan Samiti" for hospital management

ASHA

• Selection of ASHA : ASHA must be the resident of the village - a woman (married /widow/
divorced) preferably in the age group of 25 to 45 years with formal education up to eighth
class. Her responsibilities will be as follows :

1. ASHA will take steps to create awareness and provide information to the community on
determinants of health such as nutrition, basic sanitation and hygienic practices, healthy living and
working conditions, information on existing health services, and the need for timely utilization of
health and family welfare services.

2. She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and
complementary feeding, immunization, contraception and prevention of common infections
including reproductive tract infection/sexually transmitted infection and care of the young child.

3. ASHA will mobilize the community and facilitate them in accessing health and health related
services available at the anganwadi/subcentre/primary health centres, such as immunization,
antenatal check-up, postnatal check-up, supplementary nutrition, sanitation and other services
being provided by the government.

4. She will work with the village health and sanitation committee of the gram panchayat to develop a
comprehensive village health plan.

5. She will arrange escort/accompany pregnant women and children requiring treatment/admission
to the nearest pre-identified health facifity i.e. primary health centre/community health centre/First
Referral Unit.

6. ASHA will provide primary medical care for minor ailments such as diarrhoea, fevers, and first-aid
for minor injuries.

7. She will also act as a depot holder for essential provisions being made available to every
habitation like oral rehydration therapy, iron folic acid tablet, chloroquine, disposable delivery kits,
oral pills and condoms etc. Contents of the kit include both AYUSH and allopathic formulations.

8. Her role as a provider can be enhanced subsequently. Training to her for providing newborn care
and management of a range of common ailments, particularly childhood illnesses.

9. She will inform about the births and deaths in her village and any unusual health
problems/disease outbreaks in the community to the sub-centre/primary health centre.

10. She will promote construction of household toilets under total sanitation campaign.

Anganwadi

Anganwadi worker will guide ASHA in performing following activities :

(a) Organizing Health Day once/twice a month. On health day, the women, adolescent girls and
children from the village will be mobilized for orientation on health related issues such as
importance of nutritious food, personal hygiene, care during pregnancy, importance of antenatal
check-up and institutional delivery, home remedies for minor ailment and importance of
immunization etc.
(b) AWWs and ANMs will act as resource persons for the training of ASHA.

(c) IEC activity through display of posters, folk dances etc on these days can be undertaken to
sensitize the beneficiaries on health related issues.

(d) Anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA.

(e) AWW will update the list of eligible couples and also the children less than one year of age in the
village with the help of ASHA

(f) ASHA will support the AWW in mobilizing pregnant and lactating women and infants for nutrition
supplement.

ORAL REHYDRATION THERAPY

• WHO it is now firmly established that oral rehydration treatment can be safely and
successfully used in treating acute diarrhoeas in all age groups and in all countries. The aim
of oral fluid therapy is to prevent dehydration and reduce mortality.
• Oral fluid therapy is based on the observation that glucose given orally enhances the
intestinal absorption of salt and water, and is capable of correcting the electrolyte and water
deficit.
• The composition of oral rehydration salt (ORS) recommended by WHO was sodium
bicarbonate based. Inclusion of trisodium citrate in place of sodium bicarbonate increases
intestinal absorption of sodium and water.
• Decreasing the sodium concentration of ORS solution improved the efficacy for children with
acute non-cholera diarrhoea.

Composition of reduced osmolarity ORS

REDUCED OSMOLARITY ORS Grams/Litre

Sodium chloride 2.6

Glucose, anhydrous 13.5

Potassium chloride 1.5

Trisodium citrate, dihydrate 2.9

Total weight 20.5

REDUCED OSMOLARITY ORS mmol/Litre

Sodium 75

Chloride 65
Glucose, anhydrous 75

Potassium 20

Citrate 10

Total osmolarity 245

• Mothers should be taught how to administer ORS solution to their children. For children
under age 2 years give a teaspoon every 1 to 2 minutes.
• After each loose stool give children under 2 years of age : 50-100 ml (a quarter to half a large
cup) of fluid, children aged 2 up to 10 years : 100-200 ml (a half to one large cup) and older
children and adults : as much fluid as they want.
• If the child vomits wait for 10 minutes then try again giving the solution slowly - a spoonful
every 2 to 3 minutes. If the child wants to drink more ORS solution than the estimated
amount and does not vomit there can be no harm in feeding him/her more.
• The ingredients required for the preparation of oral fluid are inexpensive and readily
available and the solution can be prepared with ordinary drinking water and needs no
sterilization.
• Packets of "oral rehydration mixture" are now freely available at all primary health centres,
sub-centres, hospitals and chemist shops. The contents of the packet are to be dissolved in
one litre of drinking water. The solution should be made fresh daily and used within 24
hours. It should not be boiled or otherwise sterilized.
• If the WHO mixture of salts is not available, a simple mixture consisting of table salt (one
level teaspoon) and sugar (6 level teaspoon) dissolved in one litre of drinking water may be
safely used until the proper mixture is obtained.
• The aim is to give as much nutrient rich food as the child will accept. Most children with
watery diarrhoea regain their appetite after dehydration is corrected, whereas those with
bloody diarrhoea often eat poorly until the illness resolves.