DEPARTMENT OF COMMUNITY MEDICINE

BANGALORE MEDICAL COLLEGE & RESEARCH INSTITUTE

Sl No. TOPIC PAGE NO.

1. EDWIN CHADWICK
2. JOHN SNOW
3. LOUIS PASTEUR
4. DR. ROBERT KOCH
5. JAMES LIND
6. EDWARD JENNER
7. AYUSH IN HEALTH CARE
8. HUMAN GENOME PROJECT
9. MANAGEMENT BY OBJECTIVES
10. OPERATIONAL RESEARCH
11. MEDICAL AUDIT
12. TELEMEDICINE
13. COMMUNITY BASED REHABILITATION
14. INDIAN RED CROSS SOCIETY
15. MALE CONTRACEPTION
16. GREAT SANITARY AWAKENING
17. GIS IN HEALTH
18. BERKSONIAN BIAS
19. IDEAL MALARIA VACCINE
20. LEPROSY VACCINE
21. HIV VACCINE
22. SURVIVAL ANALYSIS
23. RAINWATER HARVESTING
24. VERBAL AUTOPSY
25. STRATEGIES FOR FILARIASIS ELIMINATION
26. REGISTRATION OF VITAL EVENTS
27. SAMPLE REGISTRATION SYSTEM
28. HEALTH HAZARDS OF FOUNDRY WORKERS
29. GENE THERAPY
30. HARDY-WEINBERG LAW
31. LIFE TABLE
32. ROLE OF HOSPITALS IN PRIMARY HEALTH CARE
33. REMOTE SENSING IN VECTOR BORNE DISEASE
CONTROL
34. ANTIMICROBIAL RESISTANCE
35. EVOLUTION OF CONCEPT OF IUCD
36. MEDICAL OFFICER AS A MANAGER OF HEALTH TEAM
37. HOSPITAL ACQUIRED INFECTION
38. CYBER MEDICINE
39. CANCER REGISTRIES
40. META ANALYSIS
41. FRAMINGHAM HEART STUDY
42. NON-PARAMETRIC TESTS
43. ROGI KALYAN SAMITIS
44. MICROPLANNING
45. ROTARY INTERNATIONAL
46. SRIVASTAVA COMMITTEE
47. MUDALIAR COMMITTEE
48. KARTAR SINGH COMMITTEE
49. BAJAJ COMMITTEE
50. MUKERJI COMMITTEE
51. JUNGALAWALA COMMITTEE
52. CHADHA COMMITTEE
53. CENSUS 2011
54. CONFIDENCE INTERVALS
55. DESIGNING A RESEARCH STUDY TO TEST A NEW
ANTIMALARIAL DRUG
56. COST EFFECTIVENESS ANALYSIS
57. CHICKENPOX (VARICELLA) VACCINE
58. COMMUNITY CARE CENTRES
59. LINK ART CENTRES
60. INTEGRATED VECTOR MANAGEMENT
61. STIMULUS VARIATION IN CLASSROOM TEACHING
62. FEMALE FOETICIDE
63. PRENATAL DIAGNOSIS
64. SOCIAL DIAGNOSIS
65. IEC IN CANCER
66. TRIBAL HEALTH
67. SOCIAL MOBILIZATION
68. EMERGING INFECTIOUS DISEASES
69. WORLD HEALTH DAY 2010
70. WORLD HEALTH DAY 2009
71. WORLD HEALTH DAY 2008
72. WORLD HEALTH DAY 2007
73. WORLD HEALTH DAY 2006
74. WORLD HEALTH DAY 2005
75. BHORE COMMITTEE - RELEVANCE IN 21ST CENTUARY
76. COMMINITY OPHTHALMOLOGY
77. ESSENTIAL DRUGS
78. RATIONALE USE OF DRUGS
79. HEALTH FORECASTING
80.
81.
82.
83.
84.
85.
 Dr. Shashidhar S B

EDWIN CHADWICK
He was born in Manchester on 24th January, 1800. While studying in London to
become a lawyer Chadwick was appointed as one of the assistant commissioners. After the
influenza and typhoid epidemics in 1837 and 1838, Edwin Chadwick was asked by the
government to carry out a new enquiry into sanitation.
His report, The Sanitary Conditions of the Labouring Population was published in 1842.
In the report Chadwick argued that disease was directly related to living conditions and that
there was a desperate need for public health reform Over 7,000 copies of the report was
published and it helped to create awareness and need for government to take action in order
to protect the lives of people living in Britain's towns and cities. Sir Robert Peel and his
Conservative administration were unwilling to support Chadwick's recommendations.
However, it was only after the 1847 General Election, when a new Liberal government
came new legislation was introduced. In 1848 Parliament passed the first Public Health Act
that provided for the formation of a Central Board of Health. This new body had powers to
create local boards to oversee street cleansing, refuse collection, water supply and sewerage
systems.
Chadwick, who was appointed Sanitation Commissioner, had several ideas on how
public health could be improved. This included a constant supply of fresh clean water, water
closets in every house, and a system of carrying sewage to outlying farms, where it would
provide a cheap source of fertilizer. Attempts to introduce public health reforms were
resisted successfully by people with vested interests, for example, landlords and water
companies, in maintaining the present system.
However In 1854 though the govt was a supporter of public health reform, it came to the
conclusion that Chadwick was so unpopular it would be impossible to persuade the House of
Commons to renew the powers of the Board of Health while he remained in charge of the
organisation. In order to preserve the reforms that he had achieved, Chadwick agreed to
resign.
Although officially retired on a £1,000 a year pension, Chadwick continued to campaign for
changes in the law. This included the reform of sanitation, education and transportation.
Edwin Chadwick died on 6th July, 1890

JOHN SNOW (1813 -1858)

Snow was a British physician who is considered one of the founders of epidemiology for his
work identifying the source of a cholera outbreak in 1854.
John Snow was born into a labourer's family on 15 March 1813 in York and at 14 was
apprenticed to a surgeon. In 1836 he moved to London to start his formal medical education.
He became a member of the Royal College of Surgeons in 1838, graduated from the
University of London in 1844 and was admitted to the Royal College of Physicians in 1850.
At the time, it was assumed that cholera was airborne. However, Snow did not accept this
'miasma' (bad air) theory, arguing that in fact entered the body through the mouth. He
published his ideas in an essay 'On the Mode of Communication of Cholera' in 1849. A few

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years later, Snow was able to prove his theory in dramatic circumstances. In August 1854 a
cholera outbreak occurred in Soho. After careful investigation, including plotting cases of
cholera on a map of the area, Snow was able to identify a water pump in Broad (now
Broadwick) Street as the source of the disease. He had the handle of the pump removed, and
cases of cholera immediately began to diminish. However, Snow's 'germ' theory of disease
was not widely accepted until the 1860s.
Snow was also a pioneer in the field of anaesthetics. By testing the effects of controlled doses
of ether and chloroform on animals and on humans, he made those drugs safer and more
effective. In April 1853, he was responsible for giving chloroform to Queen Victoria at the
birth of her son Leopold, and performed the same task in April 1857 when her daughter
Beatrice was born.
Snow died of a stroke on 16 June 1858.

LOUIS PASTEUR
Louis Pasteur was born on December 27, 1822, in the town of Dole, in eastern France.Most
of his teachers thought he would just leave school and work in his father‘s tannery. However,
Louis had a great desire to increase his knowledge.
At 15 years of age, Louis went to Paris to complete his secondary schooling. He
completed Bachelor of Science degree in 1842.Teachers for Louis decided to attend the Ecole
Normale in Paris, which trained French colleges and universities. He passed the entrance
examination in 1842, but knew he could have achieved a higher standard. So he studied for
another year to improve his knowledge before entering the Ecole Normale.
This determination to accept nothing less than his best effort characterized his work
throughout his career. Louis studied chemistry at the Ecole Normale, receiving a Master of
Science degree in 1845.He was asked to go to Lille to set up an applied science faculty which
would train scientists to put their theoretical knowledge to work to solve the practical
scientific problems of industry and business. Pasteur longed to put to use the science he loved
to benefit ordinary people.
he focused his own research efforts on the process of fermentation—the process which is
used to produce alcohol from sugar, but which also causes milk to go sour. Most chemists
believed that the chemicals present merely reacted together and could not explain why the
process sometimes produced unexpected results. Pasteur proved that fermentation took place
only when small living things called microbes were present. If the right microbe was present,
the desired result was obtained. If the wrong microbe was present, the wrong substance was
produced, such as sour milk or bitter wine. Pasteur‘s findings helped established a new
branch of science—microbiology.
Contribution to science as a chemist
He was working with tartaric acid crystals. He could pick up the dextro and levo rotatory
crystals by seeing the morphology of the crystals. Later he was called to solve some of the
problems in fermentation industry and turned his attention to biological process of
fermentation.

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Pasteur‟s swan neck flask

Pasteur poured meat infusions into flasks and then drew the top of each flask into a long
curved neck that would admit air but not dust. He found that if the infusions were heated,
they remained sterile (free from any growth) until they were exposed to dust. He opened them
on a dusty road and resealed them and demonstrated the growth of microorganisms in all the
flasks. The unopened flasks were sterile.
Pasteur now had a good theoretical understanding of microbes. He sought to apply his
findings to the practical problem of stopping wine from spoiling. As many families depended
on the wine industry for their livelihoods, and the French economy was heavily dependent on
wine exports, this was a big problem.Pasteur heated the wine enough to kill most of the
microbes present without altering the flavor. Chilling prevented any microbes left from
multiplyingIf Louis Pasteur had chosen to patent this process, he would have become a rich
man. Instead, he chose to make his discovery freely available so that all could benefit from it.
His only reward was fame and recognition, with the new process becoming known as
‗pasteurization‘.
Undeterred by this opposition, Pasteur moved on to the next, and perhaps greatest, step—
diseases in humans. In 1882, he began studying rabies. Pasteur began his experiments using
animals. He followed the same procedures as before, but was hampered by the long delay of
several weeks between the animal‘s being bitten and the germs‘ reaching the brain. While
this delay made research time-consuming, it enabled a significant difference in treatment to
be possible.
Previous vaccination work had required that the vaccine be given prior to exposure to the
disease. However, the delay in the rabies germs reaching the brain enabled the rabies vaccine
to be given after the bite had occurred. Therefore only those who had been bitten by a rabid
animal needed to be treated. In 1885, a small boy who had been bitten by a rabid dog was
brought to Pasteur. Although he was not yet sure whether the treatment would work on
humans, Pasteur knew the boy would die without the vaccine. After several tense weeks of
treatment on the boy, it was clear that the rabies vaccine was a success.
In 1888, the Pasteur Institute was established in Paris to continue the fight against
diseases. Pasteur by then was almost 66 years old and in failing health. He served largely in
an advisory capacity while those whom he had trained took over responsibility for continuing
the research.
Louis Pasteur‘s personal life had been punctuated by sickness and tragedy. Three of his
five children died of childhood diseases. Also he had been brought up with a sister left
mentally retarded by a childhood disease.Rather than crushing his spirit, these tragedies
spurred him on in his efforts to spare others the heartbreak of losing their children to disease.
His own life was touched by a brain hemorrhage and several strokes which left him partially
paralysed.

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DR. ROBERT KOCH (1843 -1910)

Born On December 11, 1843 was a German physician. Koch came from a poor
mining family and it took him a lot of determination to get a university place where he first
studied mathematics and natural science and then studied medicine.
Pasteur was convinced that microbes caused diseases. He was never able to directly
link one microbe with a disease. Koch succeeded in doing this. Koch was a doctor and he had
a detailed knowledge of the human body – something that Pasteur, as a research scientist –
lacked.
In 1872, Koch became district medical officer for a rural area near Berlin. He started to
experiment with microbes in a small laboratory he had built for himself in his surgery. After
Casimir Davaine showed the direct transmission of the anthrax bacillus between cows, Koch
studied anthrax more closely. He invented methods to purify the bacillus from blood samples
and grow pure cultures He found that, while it could not survive outside a host for long,
anthrax built persisting endospores that could last a long time. These endospores, embedded
in soil, were the cause of unexplained "spontaneous" outbreaks of anthrax. He urged the
sterilization of surgical instruments using heat.
He improved the methods including staining (He modified Ziehl-Neelsen acid fast staining
procedure which was introduced by Ehrlich) and purification techniques, and bacterial
growth media, including agar plates (thanks to the advice of Angelina and Walther Hesse and
the Petri dish, named after its inventor, his assistant Julius Richard Petri. With these
techniques, he was able to discover the bacterium causing tuberculosis (Mycobacterium
tuberculosis) in 1882 (he announced the discovery on March 24).
In 1883, Koch worked with a French research team in Alexandria, Egypt, studying
cholera. Koch identified the vibrio bacterium that caused cholera, Koch was so devoted to
proving his ideas that he was willing to infect himself with cholera in order to try to get to the
bottom of the disease.The bacterium had been previously isolated by Italian anatomist Filippo
Pacini in 1854, but his work had been ignored . Koch was unaware of Pacini's work and made
an independent discovery, and his greater preeminence allowed the discovery to be widely
spread for the benefit of others. In 1965, however, the bacterium was formally renamed
Vibrio cholera Pacini 1854.
In 1885, he became professor of hygiene at the University of Berlin, then in 1891 he
was made Honorary Professor of the medical faculty and Director of the new Prussian
Institute for Infectious Diseases (eventually renamed as the Robert Koch Institute), a position
from which he resigned in 1904. He started traveling around the world, studying diseases in
South Africa, India, and Java
Probably as important as his work on tuberculosis, for which he was awarded a Nobel
Prize (1905), are Koch's postulates, which say that to establish that an organism is the cause
of a disease, it must be:
• Found in all cases of the disease examined
• Prepared and maintained in a pure culture
• Capable of producing the original infection, even after several generations in culture
• Retrievable from an inoculated animal and cultured again.
his pupils found the organisms responsible for diphtheria, typhoid, pneumonia,
gonorrhoea, cerebrospinal meningitis, leprosy, bubonic plague, tetanus, and syphilis, among
others, by using his methods. Koch died from a heart-attack aged 66 on may 27 in 1910.

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JAMES LIND
Lind was born on October 4, 1716, in Edinburgh, Scotland, to a prosperous merchant
.He attended grammar school in his youth, and then was apprenticed to the Edinburgh
physician George Langlands in1731. He became a surgeon's mate in the British navy in 1739,
and in 1747, was promoted to surgeon.
Lind performed one of his most important experiments on curing scurvy in 1747. Many
people knew that far more sailors on British warships died from scurvy than from battle. In
retrospect, if sailors did not get vitamin C in their food, especially from fruits like oranges,
lemons, or limes, then they developed the symptoms of scurvy: bleeding gums, loosened
teeth, stiff or swollen joints, and bleeding under the skin. Infections often resulted, and if
infections did not kill the sailors, then they soon died from convulsions or coma if they were
left untreated.
In 1754, Lind published A Treatise of the Scurvy. In 1757, Lind published a second book,
On the Most Effectual Means of Preserving the Health of Seamen, which also recommended
giving sailors citrus fruits on long voyages. In 1758, Lind was appointed the chief physician
of the Royal Naval Hospital at Gosport in the south of England.
His son, John, replaced him. Lind died in Gosport on July 13, 1794. In spite of Lind's
works, his advice about giving sailors citrus fruits to prevent scurvy was not taken seriously
by the British Navy until after his death. Some physicians of the time simply did not believe
that scurvy was caused by dietary problems. Others refused to believe that any disease as bad
as scurvy could be cured so easily with an orange a day. In the next year, 1795, the Royal
Navy adopted the practice of giving seamen citrus fruits and juices as part of their diets.
Scurvy promptly vanished from the Royal Navy

EDWARD JENNER
Edward Jenner was an English country doctor who pioneered vaccination. Jenner's discovery
in 1796 that inoculation with cowpox gave immunity to smallpox, was an immense medical
breakthrough and has saved countless lives.
Edward Jenner was born on May 17 1749 in the small village of Berkeley in Gloucestershire.
From an early age Jenner was a keen observer of nature and after nine years as a surgeon's
apprentice he went to St George's Hospital, London to study anatomy and surgery under the
prominent surgeon John Hunter. After completing his studies, he returned to Berkeley to set
up a medical practice where he stayed until his death in 1823.
Jenner worked in a rural community and most of his patients were farmers or worked on
farms with cattle. In the 18th century smallpox was a very common disease and was a major
cause of death. The main treatment was by a method which had brought success to a Dutch
physiologist Jan Ingenhaus and was brought to England in 1721 from Turkey by Lady Mary
Wortly Montague. This method involved inoculating healthy people with substances from the
pustules of those who had a mild case of the disease, but this often had fatal results.
In 1788 an epidemic of smallpox hit Gloucestershire and during this outbreak Jenner
observed that those of his patients who worked with cattle and had come in contact with the

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much milder disease called cowpox never came down with smallpox. Jenner needed a way of
showing that his theory actually worked.
Jenner was given the opportunity on the 14 May 1796, when a young milkmaid called Sarah
Nelmes came to see him with sores on her hands like blisters. Jenner identified that she had
caught cowpox from the cows she handled each day.
Jenner now had the opportunity to obtain the material try out his theories. He carefully
extracted some liquid from her sores and then took some liquid from the sores of a patient
with mild smallpox.
Jenner believed that if he could inject someone with cowpox, the germs from the cowpox
would make the body able to defend itself against the dangerous smallpox germs which he
would inject later.
Jenner approached a local farmer called Phipps and asked him if he could inoculate his son
James against smallpox. He explained to the farmer that if his theory was correct, James
would never contract smallpox. Surprisingly, the farmer agreed.
Jenner made two small cuts on James's left arm. He then poured the liquid from Sarah's
cowpox sores into the open wounds which he bandaged.
James went down with cowpox but was not very ill. Six weeks later when James had
recovered, Jenner vaccinated him again, this time with the smallpox virus.
This was an extremely dangerous experiment. If James lived Jenner would have found a way
of preventing smallpox. If James developed smallpox and died he would be a murderer.
To Jenner's relief James did not catch smallpox. His experiment had worked.
In 1798 after carrying out further successful tests, he published his findings: An Inquiry into
the Causes and Effects of the Variolae Vaccinae, a Disease Known by the Name of Cow
Pox. Jenner called his idea " vaccination" from the word vaccinia which is latin for cowpox.
Jenner also introduced the term virus.
Jenner found a great deal of scepticism to his ideas and was subject to much ridicule. A
cartoon was drawn, showing cows coming out of various parts of people's bodies after they
had been vaccinated with cowpox.
However, Jenner persevered and eventually, doctors found that vaccination did work and by
1800 most were using it. Jenner was awarded £30 000 by Parliament to enable him to
continue carrying out his tests. Deaths from smallpox plummeted and vaccination spread
through Europe and North America.
Jenner died in Berkeley on January 26, 1823 aged 74.

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AYUSH IN HEALTH CARE

AYUSH STANDS FOR
Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy.
AYUSH is synonymous with ISM & H, Allied sciences, Traditional health care, Indigenous
system of medicine, Alternative medicine
Background efforts to Integrate AYUSH
 Chopra committee 1960
 National Health Policy of 1983
 Separate department for AYUSH-march 1995
 the National Policy on ISM&H -2002
 National Rural Health Mission-2005
Envisaged integration of AYUSH with the modern system of medicine
Why mainstreaming/integration of AYUSH systems in National Health Care Delivery
System under “NRHM”.
 Practices are well accepted by the community, particularly, in rural areas.
 The medicines are easily available and prepared from locally available resources,
 economical and comparatively safe
 Deficiency and not agreeing to work in rural areas by allopathic doctors
 Cure for some diseases present in these system of medicine
 resurgence of interest in holistic systems of health care,
 No single system of health care has the capacity to solve all of society‘s health needs.
 Taking full advantage of local enterprise for solving local health problems
 The Ayurveda system is popular mostly in the States of Kerala, Himachal Pradesh
,Gujarat, Karnataka
 Unani system is particularly popular in Andhra Pradesh, Karnataka, Tamil Nadu,
Bihar,
 The Homeopathy is practiced all over the country but primarily popular in Uttar
Pradesh, Kerala, West Bengal,
AYUSH Interventions under NRHM
 Co-location of AYUSH dispensaries in 3528 PHCs in different States.
 Appointment of 452 AYUSH doctors and paramedics (pharmacists) on contractual
basis in the primary health care system.
 Inclusion of AYUSH modules in training of ASHA.
 Inclusion of Punarnavdi Mandoor in the ASHA Kit for management of anemia
during pregnancy.
 Inclusion of seven Ayurvedic and five Unani medicines in the RCH programme.
 Establishment of specialty clinics, specialized therapy centers, and AYUSH wings in
district hospitals

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Guidelines under NRHM regarding AYUSH

 Under the same roof of the Health Infrastructure, i.e., PHC, CHC, however, separate
space should be allocated exclusively for them in the same building.
 Appropriate Regulatory Authorities lays down the terms & conditions
 Provision of one Doctor of any of the AYUSH systems as per the local acceptability
assisted by a Pharmacist in PHC.
 Supply of appropriate medicines pertaining of AYUSH systems.
 The specific choice of AYUSH system decided by the State depending on the local
preference.
 The already existing AYUSH infrastructure should be mobilized.
 Cross referral between allopathic and AYUSH streams should be encouraged based
on the need for the same.
 AYUSH Doctors shall be involved in IEC, health promotion and also supervisory
activities.
Funds
 the Tenth Plan was Rs 775.00 crore, which was increased to Rs 1214.00 crore in 11th
five year plan
Ayurveda ( 'science of life')
 Origin : Vedas—the Atharvaveda , 1000 BC charak , sushrutha
 Principles : Panchamahabhutas
3 dhoshas- vata ( ether + air), pitta (fire), kapha (water +earth)
Yoga
 ORIGIN : Its founders were great Saints and Sages systematized by the great Indian
sage Patanjali in the Yoga Sutra
 PHILOSOPHY :Yoga is a science as well an art of healthy living physically,
mentally, morally and spiritually. Yoga aims at preventing the disease and promoting
health by reconditioning the psycho-physiological mechanism of the individual.
- Karma Yoga, the path of work, - Bhakti Yoga‘ the path of worship
-Jnana Yoga, the path of philosophy , - Raja Yoga, the path of psychic control,
NATUROPATHY
 Nature Cure does not believe in the specific cause of disease and its specific treatment
 takes into account the totality of factors responsible for diseases
 such as one‘s un-natural habits in living, thinking, working, sleeping, relaxation,
sexual indulgence etc,
 also considers the environmental factors involved which on the whole disturbs the
normal functioning of the body and lead it to a morbid, weak and toxic state
treatment
 it primarily stresses on correcting all the factors involved and allowing the body to
recover itself.

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 A Nature Cure physician helps in Nature‘s effort to overcome disease by applying

correct natural modalities and
 controlling the natural forces to work within safe limits.
 The five main modalities of treatment are air, water, heat, mud and space.
UNANI
 ORIGIN :Unani System of Medicines originated in Greece
In India ,was introduced by Arabs
 Arthritis, Leucoderma, Jaundice, Liver disorders, Nervous system disorders,
Bronchial Asthma –better than other system
 Temperament (Mizaj) of the patient, hereditary condition and effects, different
complaints, signs and symptoms of the body, external observation, examination of the
PULSE (Nubz), urine and stool etc
 Dieto therapy (Ilaj-bil-Ghiza),
 Climatic therapy (Ilaj-bil-Hawa),
 Regimental therapy (Ilaj-bit-Tadbir),
 Pharmacotherapy (Ilaj-bid-Dawa)
SIDDHA
Origin : one of the oldest systems of medicine in India
 attributed to the great Siddha Ayastiyar
 Siddha literature is in Tamil and
 it is practiced largely in Tamil speaking part of India and abroad
 The Siddha System is largely therapeutic in nature.
 use of metals and minerals is very much advocated.
 25 varieties of water-soluble inorganic compounds called ‗UPPU
 64 varieties of mineral drugs
 The Siddha system is capable of treating all types of disease other than emergency
cases
HOMOEOPATHY
 Origin :first defined by Samuel Hahnemann in the 18th century ‗Peruvian bark trial‘
 Law of Similars (like cures like)
 Law of the Infinitesimal Dose (The more diluted a remedy is, the more potent it is.)
 illness is specific to the individual
 ill person can be treated using a substance that can produce, in a healthy person,
symptoms similar to those of the illness.
 Homeopathy uses many animal, plant, mineral, and synthetic substances in its
remedies
Critique --Quackery ? Emergency situation

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HUMAN GENOME PROJECT

The Human Genome Project (HGP) refers to the international 13-year effort, formally
begun in October 1990 and completed in 2003, to discover all the estimated 20,000-25,000
human genes and make them accessible for further biological study.
Another project goal was to determine the complete sequence of the 3 billion DNA
subunits (bases in the human genome). As part of the HGP, parallel studies were carried out
on selected model organisms such as the bacterium E. coli and the mouse to help develop the
technology and interpret human gene function. The DOE Human Genome Program and the
NIH National Human Genome Research Institute (NHGRI) together sponsored the U.S.
Human Genome Project.
GOALS
 identify all the approximately 20,000-25,000 genes in human DNA,
 determine the sequences of the 3 billion chemical base pairs that make up human
DNA,
 store this information in databases,
 improve tools for data analysis,
 transfer related technologies to the private sector, and
 address the ethical, legal, and social issues (ELSI) that may arise from the project.
 To help achieve these goals, researchers also studied the genetic makeup of several
nonhuman organisms. These include the common human gut bacterium Escherichia
coli, the fruit fly, and the laboratory mouse.
BENEFITS
Molecular Medicine
• improve diagnosis of disease
• detect genetic predispositions to disease
• create drugs based on molecular information
• use gene therapy and control systems as drugs
• design ―custom drugs‖ (pharmacogenomics) based on individual genetic profiles
Microbial Genomics
• Rapidly detect and treat pathogens (disease-causing microbes) in clinical practice
• develop new energy sources (biofuels)
• monitor environments to detect pollutants
• protect citizenry from biological and chemical warfare
• clean up toxic waste safely and efficiently
DNA Identification (Forensics)
• identify potential suspects whose DNA may match evidence left at crime scenes
• exonerate persons wrongly accused of crimes
• identify crime and catastrophe victims
• establish paternity and other family relationships
• identify endangered and protected species as an aid to wildlife officials (could be used for
prosecuting poachers)
• detect bacteria and other organisms that may pollute air, water, soil, and food
• match organ donors with recipients in transplant programs

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• determine pedigree for seed or livestock breeds

• authenticate consumables such as caviar and wine
Risk Assessment
• evaluate the health risks faced by individuals who may be exposed to radiation (including
low levels in industrial areas) and to cancer-causing chemicals and toxins
Bioarchaeology, Anthropology, Evolution, and Human Migration
• study evolution through germline mutations in lineages
• study migration of different population groups based on maternal inheritance
• study mutations on the Y chromosome to trace lineage and migration of males
• compare breakpoints in the evolution of mutations with ages of populations and historical
events
Agriculture, Livestock Breeding, and Bioprocessing
• grow disease-, insect-, and drought-resistant crops
• breed healthier, more productive, disease-resistant farm animals
• grow more nutritious produce
• develop biopesticides
• incorporate edible vaccines incorporated into food products
• develop new environmental cleanup uses for plants like tobacco
Privacy and confidentiality of genetic information.
• Fairness in the use of genetic information by insurers, employers, courts, schools,
adoption agencies, and the military, among others.
• Psychological impact, stigmatization, and discrimination due to an individual‘s genetic
differences.
• Reproductive issues including adequate and informed consent and use of genetic
information in reproductive decision making.
• Clinical issues including the education of doctors and other health-service providers, people
identified with genetic conditions, and the general public about capabilities, limitations, and
social risks; and implementation of standards and quality-control measures.

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MANAGEMENT BY OBJECTIVES
― A System where in the superior and the subordinate managers of an organization
jointly define its common goals, define each individual‘s major areas of responsibility in
terms of the results expected of him and use these measures as guides for operating the unit
and assessing the contribution of each of its member‖
 Cascading of organizational goals and objectives
 Specific objectives for each member
 Participative decision making
 Explicit time period
 Performance evaluation and provide feed back

Benefits of MBO
 Improvement in Managing
 Clarification of organizational roles and Structures
 Encouragement of personal commitment to the goals
 Development of effective controls through more effective planning ensuring more
effective controls

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Drawbacks & Dysfunctional Effects of MBO

 Overemphasis on Short Term goals
 Failure to teach the PHILOSOPHY of MBO: Self Control and Self Direction
 Difficulty in setting SMART goals
 Danger of INFLEXIBILITY
Peter Drucker: ―Its just another tool it is not the great cure for management inefficiency.
MBO works if you know the objectives, 90% of the time you don‘t‖

OPERATIONAL RESEARCH
Definition:
―Application of scientific methods of investigation to the study of complex human
organizations and services‖.
―Discipline of applying advanced analytical methods to help make better decisions‖.
―is the use of systematic research techniques for programme decision making to
achieve a specific outcome‖.
Steps in Operational Research
1. Formulation of the problem 2. Collection of the relevant data
3. Analysis of data and formulation of hypothesis
4. Deriving solutions from the hypothesis
5. Choosing the optimal solution and forecasting results
6. Testing of solution- pilot projects 7. Implementing the solution in the whole system.
How to do operational research
1. Identification of the program problem
2. Identification of possible reasons and solutions and the testing of potential solutions
3. Results utilization
4. Results dissemination
Operational Research Team
- Director - Public health administrator
- An epidemiologist - A statistician
- Social scientist - Ancillary workers
OR Techniques
• Probability models
• Optimization models
• Differential equations
• Decision analyses
Public health applications
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1. Health facilities management

2. Regional health planning
3. Clinical decision making
4. Programme evaluation and policy analysis
1. Health facilities management
• Outpatient appointment systems- Relationship between patient waiting time and
provider idle time, Patient and provider punctuality, Fraction of patients who arrive
without appointments, Fraction who fail to keep appointments, Service times
• In patient admission/ discharge scheduling -Overcrowded facilities, Under utilized
facilities, Admission
• Facility sizing- No. of labor, delivery and post partum beds required, No. of
appendicectomies, cholecystectomies, and tonsillectomies performed
• Staffing
• Patient flow models
• Ancillary and support services- Radiology,Laboratories, Pharmacy, Operation of
telemedicine, Medical record storage, Inventory control:
2. Regional health planning
• Population based needs assessment- Determination of health needs – difficult, Past
utilization for health services-used, Epidemiological data- Incidence and prevalence
• Facility location- Minimize travel time, Maximize consumer preferences
• Ambulance system design and operation
• Epidemic control
3. Clinical decision making
• Decision analysis - Diagnosis and treatment of disease
• Statistically based algorithm
• Computer based decision aids in medical training and medical practice
4. Programme evaluation and policy analysis
• Public health decisions- future directions for National Health Policy
• Decision makers confront
• Conflicting objectives
• Competing interest groups
– Mathematical models useful in
• Organizing the problem
• Analyzing the relevant data
• Evaluating consequences of action
Problems with Operational research
1. Problem of ―optimization‖

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2. Problem of inputs and outputs

3. Difficulty in quantifying parameters
4. Gap between Academic OR ( theory) and Applied OR (practice)
Conclusion: OR models are not Decision Making machines but an Aid to effective Decision
Making

MEDICAL AUDIT
Definition: An audit is an evaluation of a person, organization, system, process, project or
product.
Audits are performed to ascertain the validity and reliability of information, and also
provide an assessment of a system's internal control.
 Traditional audits are financial audits.
 A set of financial statements are said to be true and fair - free of material
misstatements - a concept influenced by both quantitative and qualitative factors.
Medical audit: "Medical audit is the systematic analysis of the quality of healthcare,
including the procedures used for diagnosis, treatment and care, the use of resources and the
resulting outcome and quality of life for the patient."
Need for a Medical audit
 Profound impact on the delivery of healthcare in India.
 Change in society‘s attitude towards the quality of care that a patient expects a
hospital to deliver.
 Increased emphasis on the provision of quality healthcare systems, in large part, from
the increasing number of malpractice and negligence suits against the providers of
healthcare.
 This also puts additional pressure on organisations and practising physicians to
evaluate the quality of care provided.
Types of clinical audit
1. Standards-based audit
2. Adverse occurrence screening and critical incident monitoring
3. Peer review
4. Patient surveys and focus groups
1. Standards based audit- Defining standards, collecting data to measure current practice
against those standards, and implementing any changes deemed necessary.
2. Adverse occurrence screening and critical incident monitoring:
 Peer review cases which have caused concern or from which there was an unexpected
outcome.

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 The multidisciplinary team discusses individual anonymous cases to reflect upon the
way the team functioned and to learn for the future.
 In the primary care setting, this is described as a 'significant event audit'.
3. Peer review
 An assessment of the quality of care provided by a clinical team with a view to
improve clinical care.
 Individual cases are discussed by peers to determine, whether the best care was given.
 Include 'interesting' or 'unusual' cases rather than problematic ones.
 Unfortunately, recommendations made from these reviews are often not pursued as
there is no systematic method to follow.
4. Patient surveys and focus groups
 To obtain ―users‖ views about the quality of care they have received.
 Surveys carried out for their own sake are often meaningless, but when they are
undertaken to collect data they can be extremely productive.
Stage 1: Identify the problem or issue
Stage 2: Define criteria & standards
Stage 3: Data collection
Stage 4: Compare performance with criteria and standards
Stage 5: Implementing change
Re-audit: Sustaining Improvements
MEDICAL AUDIT
Definition : Johnson- ―A means of quality control for medical practice by which the
profession shall regulate its activities with the intention of improving overall patient care‖
A medical is the evolution of quality of medical care as reflected in medical records.
This definition elicits the response that the result is the audit of medical records, not of
medical care. But however improvement of medical record itself is beneficial because good
records are an essential part of good practice.
History
The history of medical audit can be traced to Dr. George Gray Wood (1918), a noted
Gynaecologist at Women‘s Hospital, New York. He considered medical audit a systematic
review and analysis of all patients who were treated by him.
India
Dr. Susheel Nair, the Health Minister of India (1969) suggested medial audit as regular
feature for all Govt. Hospitals.
Aim of Medical Audit: To improve quality of medical care by – comparing actual medical
practice with agreed standards of practice. The purpose is simply to evaluate the quality of
practice and not the practitioner.
It acts a stimulus to the practice of scientific medicine.

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Medical audit then helps in streamlining hospital procedures, by exposing the bottlenecks in
the diagnostic, therapeutic and supportive services of the hospital.
Typrs of Audit:
Medical Audit & Clinical Audit
Clinical Audit: Is the review of all the medical events surrounding the treatment of the
patient. This includes Nursing, Physiotherapy, Social aspects etc.
The boundaries between the two are blurred and medical audit is just a subset of clinical audit
focusing only on medial aspects.
Protocol
Committee – A medical audit committee should be constituted comprising the following
professionals from medical section.
Directors of medical service
HODs (Medicine, Surgery, OBG, Paediatrics)
HOD Pathology
Nursing Superintendent
Administrative Section – CEO/MD
- Administrator
If they are non medial they are only observers at the committee meetings
2.Frequency of Audit:

Periodic/Regular – Regular monthly audit of cases (Death cases). The periodicity depends on
the patient turnover in the hospital.
Surprise checks – Checks of medical records conducted fortnightly.

Areas of Audit:
a. Case audit:
Mortality review – Autopsies of death cases is done and the cause of death must be given by
the expert. The records are sealed immediately after the death and no alteration should be
done.
The validity of administering drugs, dosage, any reaction to the drug, complication arising
out of the disease etc. are discussed.
Complication audit- Complication arising with drug therapy or change in therapy and lab and
radiological findings are debated here.
Antibiotic utilization – A minimum trial of 3 days is mandatory before changing an
antibiotic.
Dosage and acceptance of drug is checked here.
Overstay audit – All interventional and surgical procedures have a fixed period of stay. If the
length of stay is beyond the acceptable limit, cause of overstay need to be examined.
Investigation audit: The relevevance of any investigation prescribed needs to be examined.
Check sheet: Preoperative, Preanaeshthetic, Preprocedural assessment and documentation are
examined here.
b. Infection control audit : Hospital acquired infection and environmental infection
Regular swab collection from environment, samples from patients, personal equipment are all
examined to find infection rate.
Cleaning disfection, air-conditioning policy and so on are examined here.

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c. Critical area audit: ICUs, OT, burn units, dialysis

d. Medical Record Audit: To ensure accurate and complete medical records
e. Resource utilization: Frequencies of - consultation/sample collection/usage of
consumables of OT, Lab, Physiotherapy
f. Equipment audit: Anayse the need of equipment in a scientific manner

Ways of Auditing:
Physician specialized in Medical Audit – Visits hospital once/twice a year and examins and
writes a confidential report.
By Medical Audit Committee
Types of Auditing
Direct – Done by consultant, aided by 2 senior members of medical staff. After completing
the audit, they meet the medical and nursing staff and discuss the results.
Indirect – Consists of a team of HODs, Nursing Supervisor who visit the hospital and write a
report.
Audit Methods:
Statistical Methods – Includes bed occupancy rates, length of stay, infection rate, consultation
rate etc. done ward wise and unit wise on monthly basis.
Death or Mortality Review Committee Method – Gross death rate is calculated by
determining the number of deaths with in 24hrs. Death occurring 48hrs after admission have
to be reviewed critically to rule out the slightest possibility of preventable death.
Random Table Method – Case sheets are taken from Medical Record Department (MRD) at
random and scrutinized.
Scoring Method – A score is worked out for each disease and then selected case sheets of
patients with that disease is scored and evaluated.
On the spot Medical Audit Method – The medical committee meets on a particular day in a
particular Dept., based on random selection and then case sheets are evaluated against set
standards.
Audit Monitoring:
In all the methods, monitoring plays a key role in determining the success/failure of medial
audit.
1. Surveys – Patient satisfaction survey
2. Pear Review
3. Comparison of small groups in the same field i.e. general practitioner with the
treatment rendered by a specialist.

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TELEMEDICINE
• What Health care services delivery
• By Health Care Professionals
• Where Distance - critical factor
• Using Info and Communication technologies
• For Diagnosis, Treatment, Prevention Research and Evaluation, Education
• In Individuals and Communities
Utility of Telemedicine
Patient/ Citizen
• Easy access
• Decreased Time and cost (transport)
• Awareness
• Empowerment
• Increased Quality care
Health Care Provider
• Easy Access
• Monitoring /Home care
• Time and cost
• Communication
• Quality care
Utility of Telemedicine
Public Health System
• Disease surveillance
• Program monitoring and evaluation
• Standardization and equity in the provision of Health care across geographic areas
• Tool for public awareness
• Disaster management
• Continuing education and training of Health care providers
Types of Telemedicine
1. Store and Forward: Teleradiology,Teledermatology, Telepathology
2. Real time: Pediatrics, Internal Medicine, OB & G, Surgery, Neurology,
Cardiology
Examples
• National Rural Tele Network for India
• NH Bangalore, ISRO, District Hospital Chamarajnagar – Telecardiology, CCU

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• Karuna Trust
• Onconet Kerala – Teleoncology
• Shankar Netralaya - Mobile Units
• Sanjeevani – developing software
Challenges Faced in India
• Patient and Care Provider fear - Adaptability and Adoptability of the system
• Training of personnel
• Lack of basic amenities – transport, electricity, drinking water, health care facilities
• Literacy
• Language diversity
• Finance
• Government Support
• Security
• Quality aspect – care, program
A Telemedicine program must be
• Efficient
• Enabling information exchange and communication
• Enhancing quality of care, including preventive care
• Empowering of citizens and patients
• Education of health care personnel and citizens
• Extending scope of health care
• Ethical
• Equitable
• Evidence based
• Easy-to-use
• Entertaining/ Exciting
In order to be widely applicable.

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COMMUNITY BASED REHABILITATION

Rehabilitation: 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
 Institutions based rehabilitation (IBR)
 Out reach programme for rehabilitation
 Community based rehabilitation (CBR)
Areas of concern in rehabilitation
 Medical rehabilitation
 Vocational rehabilitation
 Social rehabilitation
 Psychological rehabilitation
Introduction to CBR
 Many people in the world-have/face problem to get help for their disability
 City institution are far away and cost too much
 Idea of CBR is that disabled people should have the right to a good life
 Help they need should be offered –at a low cost
 Help offered to them and their family should suit their usual way of living
 They should be able to take up jobs and earn their living
 They should be able to take a full part in all the activities of their village, town or city
 They should be respected for being men and women, girls and boys
 Information should be given to people in a way they understand
CBR is a strategy within general community development for rehabilitation, equalization
of opportunities and social inclusion of all children and adults with disabilities.
CBR is implemented through the combined efforts of people with disabilities themselves,
their families and communities, and the appropriate health, education, vocational and social
services
Community based rehabilitation is characterized by the active role of people with
disabilities, their families and the community in the rehabilitation process.
Knowledge and skills for the basic training of disabled people are transferred to disabled
adults themselves, to their families and to the community members
Personnel skilled in rehabilitation technology train and support community workers, and
provide skilled intervention as necessary
It calls for the full and coordinated involvement of all levels of society
 Community
 Intermediate
 National

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At the community level

 Seen as a component of an integrated community development programme
 Should be based on decisions taken by its members
 Should rely as much as possible on the mobilization of local resources
 Family of the disabled person is the most important resource
 Community should support the basic necessities of life and help the families who
carry out rehabilitation at home
 A community structure (committee) should be set up to provide the local management
At the intermediate level
 Network of professional support services should be provided by the government
 Its personnel should be involved in the training and technical supervision of
community personnel
 Should provide services and managerial support
 Should liaise with referral services
At the national level
 Seeks the involvement of the government in the leading managerial role
 Concerns planning, implementing, coordinating and evaluating the CBR system
 In cooperation with the communities, the intermediate level and the non-
governmental sector
Definition: ―A strategy within community development for the rehabilitation, equalization of
opportunities and social integration of all people with disabilities‖
Principles of CBR
 Inclusion
 Participation
 Sustainability
 Empowerment
 Self advocacy
Components of CBR
 Health – Promotive, Preventive, Curative, Rehabilitative, Assistive devices
 Education
 Livelihoods- Skills training, Access to capital, Income generating activities,
Economic contribution and social protection
 Empowerments - Self help groups, Disabled peoples organizations (DPOs), Social
mobilization, Political empowerment
 Social - Legal protection, Relationships, marriage and family

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INDIAN RED CROSS SOCIETY

History of Red Cross and Red Crescent Movement
Young Swiss businessman, Jean Henry Dunant was appalled by the condition of the wounded
soldiers he happened to see in the battle field of Solferino, Italy in 1859 during the Franco -
Austrian war. He arranged relief services with the help of the local community immediately.
He wrote the book 'Memory of Solferino' suggesting that a neutral organization be
established to aid the wounded soldiers in times of war. Just a year after the release of this
book, an international conference was convened in Geneva to consider the suggestions of
Henry Dunant and thus the Red Cross Movement was born. International Red Cross
Movement was established by Geneva Convention of 1864. The name and the emblem of the
movement are derived from the reversal of the Swiss national flag, to honor the country in
which Red Cross was found.
Origin of Indian Red Cross Society
During the first world war in 1914, India had no organization for relief services to the
affected soldiers, except a branch of the St. John Ambulance Association and by a Joint
Committee of the British Red Cross. Later, a branch of the same Committee was started to
undertake the much needed relief services in collaboration with the St. John Ambulance
Association in aid of the soldiers as well as civilian sufferers of the horrors of that great war.
A bill to constitute the Indian Red Cross Society, Independent of the British Red Cross, was
introduced in the Indian Legislative Council on 3rd March 1920 by Sir Claude Hill, member
of the Viceroy's Executive Council who was also Chairman of the Joint war Committee in
India . The Bill was passed on 17th March 1920 and became Act XV of 1920 with the assent
of the Governor General on the 20th March 1920 .
On 7th June 1920 , fifty members were formally nominated to constitute the Indian Red
Cross Society and the first Managing Body was elected from among them with Sir Malcolm
Hailey as Chairman.
Indian Red Cross Society is a member of the International Federation of Red Cross and Red
Crescent Movement. Relations between the IRCS and the India Delegation of the Federation
are strong.
Indian Red Cross Society has partnership with National Red Cross and Red Crescent
Societies, St.John Ambulance, International Federation of Red Cross and Red Crescent
Movement (IFRC), International Committee of the Red Cross (ICRC ), Multinational firms.
Individuals and others in supporting IRCS activities. It also coordinates with Indian
Government and other agencies ( UNDP, WHO etc )
The Indian Red Cross Society (IRCS) is the largest independent humanitarian
organization of India. It is a huge family of 12 million volunteers and members and staff
exceeding 3500. It reaches out to the community through 700 branches spread throughout the
country. With a variety of activities in health, disaster and organizational development, it is
also working towards achieving the Global Agenda and Millennium Development goals.
IRCS is a recognised force in the disaster management sector in the South Asia region.
During the natural disasters in 2009 it released relief items to the tune of Rs. 15 crores to the
affected States such as Andhra Pradesh, Karnataka, West Bengal and others. It also deployed
Water & Sanitation Units for providing clean drinking water. With each unit 5000 to 10,000
litres of clean drinking water were made available within one hour. It also established video-
conferencing system in Red Cross State Branches 11 most disaster prone States and six IRCS
regional warehouses. During the reporting period, the Society continued its HIV/Aids
activities under which Youth Peer Education, Stigma & Discrimination and care for children

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of HIV positive parents was conducted. Services have been scaled up with the launch of Red
Cross Global Alliance on HIV on 1st December 2008.
The Society started grass root level work in three states to create awareness and
advisory to the people against Tuberculosis which is being supported by USAID. Since the
first case of avian flu in Maharashtra 0.5 million information brochure (11 languages) have
been distributed and taskforces activated in all the vulnerable and affected states. The
maternity and child welfare services continued throughout the services under the Red Cross
banner by its 440 centres. Human Pandemic Preparedness (H2P) and malaria control
programmes have also been started in states such as Andhra Pradesh, Maharshtra, Uttar
Pradesh, Punjab and Bihar. During the reporting period i.e. April 2009 to January 20101 the
Society collected 21590 units of blood from volunteer and replacement donors. Also, the
Blood Bank at the National Headquarters was recognized as a Model Blood Bank by NACO,
Government of India which was made possible with the state of art infrastructure that has
been created. The Society has been able to increase is voluntary blood donation to 86%
during the year. Under the capacity building and organizational development, focus was on
human resource development and 300 IRCS personnel and volunteers were given formal
induction. The National Headquarters in cooperation with International Committee of the Red
Cross took forward emblem seminars to minimize the misuse of Red Cross Emblem, Conflict
Preparedness, First Aid programmes and Mine Risk Education training programme at
State/District level. Under Restoring Family Links 250 Red Cross Messages were delivered
to the addressees and over 100 fishermen were repatriated to Myanmar. The Society has
started a 50 hours (three months, part time) health promotion through Ayurveda and Yoga
course with 50 students on 2nd February, 2010 in collaboration with CCRAS and Morarji
Desai National Institute of Yoga which is supported by Department of Ayush, Ministry of
Health and Family Welfare. Fourth batch of forty officials and others admitted for the Post
Graduate Diploma Course in Disaster Preparedness and Rehabilitation started in 2006-07.
During the period the Society developed a new strategic plan for 2009-12, wherein priorities
and focus are on strengthening activities in areas such as disaster management, health care,
organizational development and humanitarian values and prestigious publication
Empowering Communities through Red Cross Activities, with the message of Hon‘ble
Chairman and HFM was also published.

Seven Fundamental Principles of Red Cross

1. Humanity : The International Red Cross and Red Crescent Movement, born of a desire to
bring assistance without discrimination to the wounded on the battlefield, endeavors, in its
international and national capacity, to prevent and alleviate human suffering wherever it may
be found. Its purpose is to protect life and health and to ensure respect for the human being. It
promotes mutual understanding, friendship, cooperation and lasting peace amongst all
peoples.
2. Impartiality : It makes no discrimination as to nationally, race, religious beliefs, class or
political opinions. It endeavors to relieve the suffering of individuals, being solely by their
needs, and to give priority to the most urgent cases of distress.
3. Neutrality : In orders to enjoy the confidence of all, the Movement may not take sides in
hostilities or engage in controversies of a political, racial, religious or ideological nature.
4. Independence : The Movement is independent. The National Societies, while auxiliaries
in the humanitarian services of their governments and subject to the laws of their respective
countries, must always maintain their autonomy so that they may be able at all times to act in
accordance with the principles of the Movement.

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 Dr. Shashidhar S B

5. Voluntary service : It is voluntary relief movement not prompted in any manner by desire
for gain.
6. Unity : There can be only one Red Cross Or Red Crescent in any one country. It must be
open to all. It must carry on its humanitarian work throughout its territory.
7. Universality : The International Red Cross and Red Crescent Movement, in which all
societies have equal status and share equal responsibilities and duties in helping each other, is
worldwide.

MALE CONTRACEPTION
Methods of male contraceptives
1. Heat methods- Suspensories, external heat
2. Vas occlusion method – Vasectomies, Injectable silicone plugs, pre-formed silicone
plug called the IVD, RISUG
3. Hormonal methods
4. Other pharmaceutical methods – Gossypol, Nifedipine
5. Condoms
Suspensories / Internal heat - Suspensories are specially designed briefs that hold the testes
closer to the body, raising their temperature. They simulate cryptorchidism, Warming the
testes by a few degrees has a significant negative impact on spermatogenesis.
Male hormonal contraceptives
Commonly known as the ―male pill‖, a hormonal contraceptive for men will probably not be
delivered as a pill. Researchers are coming closer to a marketable male hormonal
contraceptive (MHC) delivered by injection or implant, but there is nothing commercially
available right now. Researchers have found several effective formulations and delivery
methods – shots, implants, gels and pills. Several MHC formulations are as effective and safe
as the female birth control pill.
How would it work?
Male hormonal contraceptives attempt to block or severely reduce the production of sperm.
They accomplish this by stopping the secretion of a man's reproductive hormones in the brain
and testes. When levels of testosterone in the testes are low, sperm production slows or halts.
Typical MHC formulations provide replacement testosterone to the man‘s bloodstream to
maintain male characteristics like muscle mass and facial hair.
How effective would it be?
The ultimate goal of all MHC methods is azoospermia, or the complete absence of sperm in
the ejaculate. Researchers agree that severely oligospermic men with fewer than 1 million
sperm per milliliter of semen are functionally infertile. For a sense of scale, a normal man has
anywhere from 200 to 20 million sperm/ml. The contraceptive efficacy of severe
oligospermia is 99%, which is better than the typical use of the female pill.

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 Dr. Shashidhar S B

The effectiveness of each hormonal method varies depending on its formulation, delivery
method and dosage. There are many different formulations, each with their own
effectiveness..
How long would it take?
The fastest possible onset of efficacy that a man taking an MHC could hope for would be 1½
- 2½ months. Once spermatogenesis is halted, it takes an average of 2½ months for the last
spermatids produced to travel through and exit the epididymis. Some of the methods partially
halt the maturation of these last spermatids through an unknown mechanism, delivering the
faster 1½ month onset of efficacy.
How would an MHC be delivered?
The issue of most concern for the convenience of MHCs is how they are delivered, and how
frequently. Some of the androgens used in MHCs are only effective when they are injected
into a muscle. Intramuscular injections must be administered by a qualified nurse or doctor,
requiring a visit to a clinic. Researchers are aiming for a formulation they could inject every
2-3 months. Between infrequent injections, some formulations provide uneven levels of
active androgen in the blood stream, which can result in unpleasant side effects and reduced
effectiveness. It is also important to maintain even levels of testosterone because unusually
high levels, such as a spike immediately following an injection, are associated with the
reappearance of sperm in the ejaculate.
Researchers are investigating alternatives to injections: implants, pills, patches and creams.
Implants are active for many months, and deliver a very steady dose of the androgen. They
require minor surgery to put in and remove, and there is a 3 - 7% risk of the implant breaking
the skin above it. Pills, patches and creams have all had disappointing clinical results. Right
now there are no good options for a self-administered formulation like the female pill. Most
studies on new formulations are carried out with very small groups of men (10 or fewer),
which makes it difficult to draw generalized conclusions
The World Health Organization and the Population Council have both worked to develop
new androgens such as testosterone buciclate and MENT. The WHO actually dropped
testosterone buciclate development due to the requirement of a chemical evaluation much
more rigorous than that required for female hormonal contraception.
What side effects would be expected?
Lean muscle weight gain, increased acne and changes in mood. These side effects are caused
by the synthetic androgen in the MHC regimen.
A more serious side effect of altering a man's androgen metabolism is a depressed level of
high-density lipoprotein cholesterol (HDL-C) in the blood. HDL-C is a healthy type of
cholesterol which has been correlated with reduced risk of atherosclerosis.
Researchers were originally concerned that high levels of androgen might over-stimulate the
prostate gland, but in trials up to 18 months long no one has observed this side effect
How long would it take to reverse?
The contraceptive effect of all MHC regimens is completely reversed within 4 to 6 months.
Once treatment stops, it takes a while for a man's body to begin making hormones in
pretreatment quantities. Once the pretreatment levels of hormones are restored, the first
immature sperm are produced in the seminiferous tubules. It takes 2½ months for these first
immature sperm to become fully functional as they travel through the epididymis.

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 Dr. Shashidhar S B

It‟s a mystery: Some men do not respond to MHCs

Researchers have a major mystery to solve before they can bring male hormonal
contraceptives to market: some men simply do not respond to hormonal contraceptive
treatments. Depending on the formulation and delivery method, 5 to 20% of men in MHC
trials have not had effective contraceptive protection. Researchers refer to these men as "non-
responders".
There are many theories about what might cause men‘s bodies not to respond to MHC
treatments, but the mechanism remains unknown. They have found that non-responders have
higher levels of 5-alpha-reductase, an enzyme which converts testosterone to the potent
androgen dihyrdotestosterone (DHT). However, men given a drug to suppress the action of
this enzyme do not respond any better than before. New evidence shows that non-responders
have a higher level of insulin-like factor-3 (INSL3) than responders, but whether this is a
causal relationship remains unclear.
One interesting clue in the non-response mystery is the striking difference in the response
levels of men of different ethnicities. Asian men in the WHO and other studies ‖consistently
show… a higher prevalence of azoospermia than Caucasian men‖.
Researchers recently found that men with higher fat body mass were more likely to be non-
responders. It could be that Asian men are receiving higher overall doses of androgen
because their fat body mass tends to be lower than some Caucasian men. If this is the case,
researchers should be able to provide a dose of androgen tailored to a man‘s weight and body
composition, making an MHC effective.

HORMONAL MALE CONTRACEPTION

Androgens alone
Results from a landmark ten-centre WHO study, as reported in 1990, demonstrated the
physiological effects of a weekly injectable testosterone ester (200 mg of testosterone
enanthate -TE). The administration of this androgen inhibited pituitary gonadotrophin -
luteinizing hormone (LH) and follicle stimulating hormone (FSH) - secretion, suppressed
sperm counts dramatically, and maintained peripheral testosterone at levels high enough to
preserve libido and potency. While the regimen demonstrated proof of concept, it required
weekly intramuscular injections and was not effective enough to reliably suppress sperm
counts in non-Asian men.
A more detailed follow-on study established that the spermatogenic suppression to
azoospermia or severe oligozoospermia induced by weekly TE resulted in sustained but
reversible contraception with pregnancy rates of 0/230 person-years and 4/50 person-years,
respectively. Sperm counts were suppressed more slowly in the Asian than in the non-Asian
men in the first two months of injections, although by 6 months high levels of suppression
were achieved. In this clinical trial, the regimen was reported to be acceptable by both the
users and their partners, in spite of the need for weekly injections. However, many of the men
indicated that a longer-acting preparation, which could be given at less frequent intervals,
would be more attractive.
Testosterone undecanoate (TU) is a unique testosterone ester which, in its injectable
formulation, has a pharmacokinetic profilemore favorable than that of TE. It offers the
promise of a one-monthly or two-monthly injectable product for use alone or in combination
with a progestin. A WHO-supported multicenter trial in China evaluated the contraceptive
efficacy of an initial dose of 1000 mg TU, followed by 500 mg maintenance (treatment)

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doses given either every four or six weeks. Of the 308 men who participated in the study, 290
became and remained azoospermic or severely oligozoospermic; no pregnancies were caused
by any of these men in the 6 month efficacy phase of the study. An acceptability study
involving the trial participants and their wives was conducted concurrently with the efficacy
study; the results indicate that men and women were generally supportive of the concept of
male contraception. Most participants reported ―no change‖ in their overall well-being as a
result of participation in the study; side effects such as pain at the injection site and
inconvenience due to the frequency of injections were cited as the main complaints.
This regimen is now being tested in a phase III contraceptive efficacy trial in 1000 Chinese
volunteers. It is expected that the data collected during this study will inform policy makers
and family planning service providers before any introduction of male hormonal
contraception in China is initiated.
Based on the need for longer acting androgens and improved delivery systems – to reduce the
burden on men and the service delivery systems - WHO, in collaboration with the United
States National Institutes of Health, has worked to develop and test several novel forms of
testosterone. One of these, testosterone buciclate (TB), has a very favorable pharmacokinetic
profile, superior to that of TE and TU. Following an injection, circulating levels of TB are
expected to remain at effective levels for approximately 3 months. Preliminary clinical
research has indicated the potential use of this androgen in contraceptive applications.
Toxicology studies would be required before clinical studies could begin. Other androgens
being tested for contraceptive applications include 19-Nortestosterone, testosterone
biodegradable pellets, and a novel androgen 7α-methyl-19-nortestosterone (MENT).

Androgen and progestin combinations

Following the presentation of evidence that androgens alone provided some promise as
contraceptive agents, a series of studies demonstrated that the combination of an androgen
with a progestin was more effective in suppressing spermatogenesis than an androgen alone.
A progestin can act synergistically with an androgen to suppress gonadotrophin synthesis and
release; there is also some evidence that progestins can exert their negative effects directly at
the level of the testis. The goal of combining these two classes of steroids is to accelerate and
increase the extent of spermatogenic suppression. In addition, the use of a progestin allows
lower does of androgens to be administered, reducing the possible negative effects of
exogenous testosterone administration on the cardiovascular system and on the prostate;
androgen administration must be adequate to provide complementary suppression and to
maintain appropriate circulating testosterone concentrations.
Most trials conducted on androgen and progestin combinations have evaluated the responses
of only small numbers of men. These limited trials have provided evidence that the level of
spermatogenetic suppression achieved varies according to the steroidal compound(s) and
route(s) of administration chosen. Several regimens have produced excellent results,
indicating that a combined hormonal approach can be used to induce azoospermia and severe
oligozoospermia in a high percentage of men.
In one clinical trial of a promising combined regimen, TU was administered in combination
with depot medroxyprogesterone acetate (DMPA) to male volunteers in Indonesia. Results
demonstrated that injections of TU alone did not adequately suppress sperm counts in
Indonesian men, but that adding DMPA to the regimen caused all the volunteers to achieve
levels of sperm suppression that would indicate infertility (fewer than 1 million sperm/ml
semen) within 12 weeks of initiating the study. The effect was long-acting, but reversible.

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Other progestins that are being or have been considered as potential components in a
combined male hormonal contraceptive include levonorgestrel, especially in the form of an
implant such as Norplant; cyproterone acetate; Net-Enanthate; desogestrel; and a novel
compound being developed by WHO and NIH, levonorgestrel butanoate.

Androgens and gonadotrophin-releasing hormone (GnRH) receptor ligands

Gonadotrophins can be suppressed by either continuous occupation of the pituitary GnRH
receptors or by a blockade of the normal stimulation of this receptor. These results can be
accomplished by the use of either a GnRH agonist or antagonist, respectively. Either of these
approaches can lead to rapid and reversible gonadotrophin suppression. Agonists require
several weeks to down-regulate the receptors, while the administration of antagonists results
in fully suppressed LH and FSH levels almost immediately. The use of either of these classes
of receptor ligands requires the administration of replacement androgens.
While these synthetic peptides are still considered experimental, administration of such
combinations has demonstrated promising results in monkeys and in small scale clinical
trials, as measured by the frequency and rate of sperm suppression. The use of antagonists
appears to offer better promise as a potential male method. The cost of these compounds is
quite high and they are currently formulated to be administered as daily injections. Such a
product may not be appropriate for or feasible in developing countries or in the public sector,
unless the cost could be decreased and the frequency and route of administration made more
flexible. Current research is geared toward the investigation of new protocols for drug
administration and the development of a less expensive, long-acting or oral preparation.

Immunocontraception
Studies to identify appropriate antigens for a male immunocontraceptive have focused on at
least four classes of targets. Antibodies have been raised against GnRH, gonadotrophins and
their testicular receptors, sperm-specific proteins, and epididymal proteins. In vitro results
have provided some promising data on sperm, sperm behavior, and ability to penetrate
oocytes when certain sperm or epididymal proteins are ―immunoneutralized‖ by an antibody.
However, animals and humans immunized against GnRH or FSH demonstrate inconsistent
immune responses and sperm suppression, and no reliable decrease in fertility. It is unlikely
that one single molecule would be necessary and sufficient for male fertility; redundancy
seems a more likely possibility, and it may be that the only way to develop an
immunocontraceptive would be to evaluate the combined effects of multiple antibodies
against a range of proteins.

NO SCALPEL VASECTOMY
The No Scalpel Vasectomy (NSV), a modified male sterilization technique, was introduced in
1997 in the National Family Welfare Program as a simple and safe technique with very little
chance of complications compared to female sterilization.

Camp approach for male sterilization was adopted initially to re-popularize male sterilization
method. Based on the experiential lessons from male sterilization camps in states like
Madhya Pradesh, Andhra Pradesh, Punjab and Uttar Pradesh, a strategy on advocacy and
community mobilization for increasing NSV acceptance through camps was introduced in the

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Family Planning Programme in 2005 and guidelines were disseminated to all states/UT
Governments.

Simultaneously, strategy for human resource development in NSV was developed and
implemented to increase the pool of service providers and operationalize FDS in male
sterilization services. The three pronged strategy for human resource development in NSV
includes:

Surgical faculty training: A new strategy of hands on training of Surgical Faculty of

medical colleges in NSV has been started to empower them in pre service NSV training of
undergraduates and postgraduates, which will in turn help in increasing the pool of trained
service providers. Seven medical colleges with experienced NSV providers have been
identified and designated as ‗Surgical Faculty Training Centres‘ for this purpose.

District NSV Trainers Training: This was started with objectives of having at least one
district trainer per district in all the districts of the country and decentralization NSV training
to district level to accelerate the training of service providers in NSV. In order to facilitate
good quality and standardized training of District NSV Trainers, Maulana Azad Medical
College, New Delhi was designated as the training centre and district trainers from all the
states were trained at this centre.

NSV providers training at the district level using trained district NSV trainers through funds
released from RCH II flexi pool is being conducted by various states

Percentage of male sterilization out of the total sterilization is showing a healthy positive
trend since the turn of the century, especially after 2006. Male sterilization as a percentage of
total sterilization had reached a low of 1.89% in 1999 and was hovering around 2.5% until
2006without much improvement. As a result of intensive efforts from the public health
system to increase male participation, the proportion of male sterilization out of total
sterilization rose to 4.3% in 2007-08; recorded a high of 5.15% in the year 2008-09 and it
has maintained 5% level for the period ending September 2009-10.

RISUG (REVERSIBLE INHIBITION OF SPERM UNDER GUIDANCE)

RISUG is an injectable compound that partially blocks the vasa deferentia (tubes that carry
sperm), providing effective contraception for up to 10 years per dose. It is effective
immediately, has few side effects, and has proven to be reversible in primate studies. This
contraceptive has completed Phase I and II clinical trials in India. Our research has convinced
us that RISUG is the most promising of the potential male contraceptives.
How does it work?
It is composed of styrene maleic anhydride (SMA) complexed with the solvent
dimethylsulfoxide (DMSO). (RISUG has two contraceptive effects: partial blockage of the
vasa deferentia and disruption of the sperm that pass through it.

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Sperm that are present in the ejaculate after RISUG has been administered have broken cell
membranes. (The membrane carries molecular keys that are needed to attach to an egg. It also
contains packets of enzymes that are needed to dissolve the outer coating of an egg. Without
those keys or enzymes, the sperm are functionally infertile. Researchers postulate that RISUG
ruptures the membranes by stressing their ion exchange mechanisms.
How is it delivered? How long does it take?
The first clinical trial of RISUG determined that an injection of 60 milligrams is the
therapeutic dose. The men who participated in that first trial have had RISUG implanted for
15 years and counting with no complications. The Phase II clinical trial volunteers have now
been using RISUG for more than ten years. When RISUG was properly implanted, no
pregnancies occurred during the 1-3 years of the study , and informal follow ups with the
volunteers have confirmed no pregnancies since. It's possible that smaller doses could
provide shorter periods of contraception.
The compound can be injected using a no-scalpel procedure into the vasa deferentia, where it
coats the walls within a matter of minutes. Practitioners of no-scalpel vasectomy should be
able to adopt the technique relatively easily. Less skilled practitioners should be able to inject
the compound after making a tiny incision that can be closed with one suture. Either
technique would be an outpatient procedure completed within 15 minutes.
Once injected, the compound is anchored to the tiny folds on the inner surface of the vasa
deferentia within 72 hours. Dr. Guha recommends that his patients use condoms for 10 days
following the procedure. This is by far the fastest acting of the potential male contraceptives;
even a vasectomy can take up to 3 months to become fully effective.
What side effects are expected?
Some of the participants in the Phase II clinical trial reported slight swelling of the testes with
no associated pain. The swelling resolved itself within 2 weeks of the injection with no
treatment. None of the RISUG trial participants have asked to leave the study because of
uncomfortable side effects. By contrast, attrition rates during male hormonal contraceptive
trials can be as high as 20% of participants.
RISUG does not cause the common side effects of a vasectomy: granulomas and an
autoimmune response. A granuloma is an inflamed and sometimes painful nodule of tissue
where sperm have leaked from the reproductive tract into the surrounding tissues. Men whose
bodies form granulomas are having an auto-immune response to their own sperm. Once they
exit the reproductive tract, the sperm are treated by the body as a foreign substance to be
removed. Researchers hypothesize that RISUG does not cause these side effects because it
does not fully block the vasa deferentia.
Another concern commonly associated with vas occlusion is decreased prostate health. But 8
years after receiving a RISUG injection, men from the Phase II clinical trials all had healthy
prostates.
How long does it take to reverse?
Primate studies have shown that RISUG is readily reversible, but reversal has not yet been
tested officially in humans. Researchers have even shown that multiple injections and
reversals are effective in primates. Since RISUG does not cause the type of auto-immune
response associated with vasectomy, RISUG reversal should be much more reliably
successful.

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The compound can be removed by flushing the vasa deferentia with an injection. One study
showed effective reversal using an injection of baking soda dissolved in water. Another study
reported a successful non-invasive reversal technique involving massage, vibration and low
electrical current.
Primate studies suggest that it would take several months for a complete reversal of RISUG‘s
contraceptive effects. Primates treated with RISUG for 1.5 years who underwent non-
invasive reversal showed normal sperm production levels within 2-3 months. Cellular-level
changes seen in the vasa deferentia and testes during treatment are reversed within 3-5
months.
RISUG is moving forward in the US & India
In February 2010, a non-profit organization completed a technology transfer agreement for
the use of RISUG in the United States. They plan to make RISUG in the US and conduct
preclinical tests to ensure its safety by the end of 2011. If all goes well with the
manufacturing and testing, RISUG could begin clinical trials among US men within the next
5 years.
RISUG has been in Phase III clinical trials in India since 2002. If the trial has positive results,
RISUG can begin India‘s regulatory approval process, the final step before selling the
product. Phase III trials are designed to establish the safety and efficacy of a drug in a variety
of body types. Over 100 men were participating in the Phase III RISUG trial when it was
delayed for a number of reasons.
In October 2002, government officials aired concerns about RISUG in India's national press.
Their concerns have since been resolved, but the controversy stalled the clinical trial for six
months. The next delay was due to concerns about RISUG's initial toxicology tests. The
Indian Council for Medical Research (ICMR) has reviewed the toxicology data three times
and approved it each time. However, in February 2002, World Health Organization scientists
stated that the 25-year-old toxicology studies did not meet more recent international
standards. RISUG was submitted for a new round of tests at a US lab, and approved in July
2005. In March 2006, the trial was slated to resume at 4 centers around India. Then a
manufacturing delay halted progress. The pharmaceutical company making RISUG was
finally able to deliver a batch produced to the World Health Organization‘s Good
Manufacturing Practice (GMP) standards in March 2007. The trial resumed in earnest in
April 2007. The trial‘s data collection, analysis and publication process will take several
years to complete.
In the meantime, another study of RISUG began in India. This study will follow up with the
men who received RISUG in 2001 and 2002, providing information on the safety and
effectiveness of RISUG after more than 5 years of use. Informal reports suggest that RISUG
could be a safe, effective, and inexpensive contraceptive which works for many years in a
single dose. Establishing RISUG‘s long-term safety and effectiveness in formal clinical
studies will make the case for its development and introduction that much stronger.

GOSSYPOL
Gossypol is a chemical found in the seeds of cotton plants. Cotton plants produce gossypol in
order to slow down the reproduction of the insects that eat cotton bolls and seeds; the
compound also affects reproduction in mammals. Pressed cakes of cotton seeds, a by-product
of the cotton industry, are sometimes fed to livestock with unintentional contraceptive effects.

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The effect of gossypol on human male fertility has been known in China for many years. In
1929, a study of couples who used crude cottonseed oil for cooking showed that they had
smaller than average families. Specifically, researchers showed that the oil affected male
fertility. Eventually researchers isolated the contraceptive compound gossypol from the
cotton seed oil.
This discovery led to large scale testing of gossypol as a male contraceptive in China during
the 1970s. The studies involved over 8,000 men, and continued for over a decade. The
researchers found that men taking a daily gossypol pill had reliable contraception and no
complaints about change in libido. However, the studies revealed two serious flaws:
disruption of potassium uptake and incomplete reversibility.
What side effects are expected?
The large-scale trials of gossypol in Chinese men reported an abnormally high rate of
hypokalemia among subjects, varying from 1-10%. Symptoms of low blood potassium
include fatigue, muscle weakness and at its most extreme, paralysis. Hypokalemia is usually
the result of kidney malfunction, and can be caused by excessive consumption of diuretics.
Researchers do not understand exactly how gossypol affects the kidneys.
Several studies of gossypol as a contraceptive in male monkeys tried to remedy potassium
loss by giving the monkeys a daily potassium supplement. The supplement did not stop the
monkeys from losing potassium and the researchers concluded that hypokalemia was an
inescapable side effect.
However, the dose the monkeys received was higher than the equivalent dose given to men,
and there is evidence that the incidence of hypokalemia depends on dosage. Two more
studies of gossypol as a low-dose contraceptive in men report no incidences of hypokalemia
Dr. Elsimar Coutinho of Brazil contends that previous reports of hypokalemia were the result
of ―the Chinese diet, which is poor in potassium, and not to the effect of gossypol on the
kidneys.‖
Regardless of gossypol‘s possible causal relationship with hypokalemia, researchers at the
World Health Organization (WHO) have other concerns about side effects. Gossypol is a
known toxin, and a toxic dose is less than 10 times the contraceptive dose. Some argue that
this alone should disqualify it from further study.
How long does it take to reverse?
Lack of complete reversibility was the second major concern raised by the Chinese trials.
Some men in those studies remained azoospermic after stopping treatment. The longer the
men had taken the gossypol and the higher their overall dosage, the more likely they were to
lose part or all of their fertility. Various studies reported between 5 and 25 percent of the men
remained infertile up to a year after stopping treatment. A long-term follow up study of men
who had taken gossypol showed that 61% of the men regained normal fertility with "a
median recovery time of 1.1 years" However, 22% remained azoospermic after 3 years.
Where does gossypol stand now?
In the late 1990s, the WHO's Research Group on Methods for the Regulation of Male
Fertility reviewed the studies to date on gossypol and concluded that contraceptive research
should be abandoned. Some researchers have contested this, arguing that the data on
hypokalemia were misinterpreted, and that diet and genetic predisposition are responsible for
this side effect. No one has contested the concerns over irreversibility, but gossypol research
has continued in China, Brazil, Kenya and Nigeria.

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Gossypol as an alternative to vasectomy

Some researchers propose taking advantage of gossypol‘s lack of reversibility by using it as a
non-surgical alternative to vasectomy, gossypol ―should be prescribed preferably to men who
have completed their families or for those who would accept permanent infertility after a few
years of use.‖ Even this type of use for gossypol may be controversial unless the WHO
changes its stance.

GREAT SANITARY AWAKENING

During the 19th century Britain was transformed by the industrial revolution. In 1801, at the
time of the first census, only about 20% of the population lived in towns. By 1851 the figure
had risen to over 50%. By 1881 about two thirds of the population lived in towns.
The industrial revolution of the 18th century while bringing affluence also brought new
problems - slums, accumulation of refuse and human excreta, overcrowding and a variety of
social problems. Frequent outbreaks of cholera added to the woes Chadwick‘s report on ‗The
Sanitary Conditions of Labouring Population (1842)‘ focussed the attention of the people and
Government on the urgent need to improve public health. Filth and garbage were recognised
as man‘s greatest enemies and it lead to great sanitary awakening bringing Public Health Act
of 1848 in England, in acceptance of the principle that the state is responsible for the health
of the people. The act was made more comprehensive in 1875 when Public Health Act 1875
was enacted. The public health movement in USA followed closely the English pattern. The
organised professional body, American Public Health Association was formed in 1872.
Many different disciplines contributed to the growth of Public Health; physicians diagnosed
diseases; sanitary engineers built water and sewerage systems; epidemiologists traced the
sources of disease outbreaks and their modes of transmission; vital statisticians provided
quantitative measures of births and deaths; lawyers wrote sanitary codes and regulations;
public health nurses provided care and advice to the sick in their home; sanitary inspectors
visited factories and markets to enforce compliance with public health ordinances; and
administrators tried to organise everyone within the limits of the health departments budgets.
Public Health thus involved Economics, Sociology, Psychology, Law, Statistics, and
Engineering as well as biological and clinical sciences. Soon another important and emerging
branch of medicine i.e., Microbiology became an integral part of Public Health. Public Health
during the 19th Century was around sanitary regulations and the same underwent changes.
Edwin Chadwick (1800-1890)
 pioneer in "sanitary awakening" in England
 wrote Sanitary Condition of the Labouring Population of Great Britain (1842)
o principal cause of disease is miasma
o disease cannot be cured
o must rely on prevention
o government can and must remove the causes of disease
o need for ceramic water pipes
o need for straightline water and sewer networks
o need for water-closets for private homes and public places
o need to end practice of storing night-soil in cellars

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GIS IN HEALTH

The ability of GIS to "overlay" different entities based on their common geographic
occurrence that makes it a very valuable tool in epidemiological research.

The idea that place and location can influence health is a very old and familiar concept in
Western Medicine. As far back as the time of Hippocrates, (460-370 BC), the father of
Modern Medicine, physicians have observed that certain diseases seem to occur in some
places and not in others. Hippocrates was constantly seeking the causes of disease. He studied
such things as climate, water, clothing, diet, habits of eating and drinking and the effect they
had in producing disease. The Hippocratic concept of health and disease stressed the relation
between man and his environment. People have also been aware of the process of disease
diffusion across geographic regions for centuries, even during times when the cause of the
disease - aetiology - was a mystery. Frequently, attempts to understand why certain diseases
seem to only occur in certain places and not others has led to new insights into the nature of
the disease itself.
In a classic study undertaken in 1854, John Snow demonstrated the utility of mapping
disease outbreaks to gain insights as to their cause - or to coin a phrase, to "get a handle on a
disease and off the water pump". Snow, an anaesthesiologist, mapped the distribution of
cholera cases in Soho, London during an epidemic. He discovered that the highest density of
cases occurred in households, which used the public pump on Broad Street as their water
source.

Epidemiology and Medical Geography

As the study of epidemiology matured, simultaneously the discipline of Medical Geography
(defined as the branch of Human Geography concerned with the geographic aspects of health
(status) and health care (systems). Epidemiology, on the other hand, has been defined
variously through times: as the branch of medical science which treats epidemics; the study
of the distribution and determinants of disease frequency in man and now as the study of the
distribution and determinants of health-related states and events in populations, and the
application of this study to control health problems. Thus it can clearly be seen that both
these disciplines have depended heavily on some form of mapping and understanding of the
health, diseases and systems in different populations.

Inherent in the definition of epidemiology is measurement of 'frequency', 'distribution',

'determinants' of disease. All of these require GIS application to make the information easy to
understand, interpret and take action. Until relatively recently, doctors and public health
professionals measured health strictly in terms of indicators of ill-health such as morbidity
and mortality. There is however, a long tradition in the allied fields of Medicine viz.
Epidemiology, Public Health and Medical Geography to examine the distribution of disease
and death at various geographic scales, in an attempt to determine if the presence or absence
of particular illness is associated with some factor(s) in the social or physical environment. In
the case of infectious diseases, there is the added dimension of examining the diffusion of
disease through space over a given period of time. Although mapping of disease can be
relatively straightforward, interpreting spatially referenced disease data can sometimes be
challenging. Regardless of the difficulties in data acquisition, map representation, scale,
statistical analysis, and the interpretation and utility of results, the study of disease
distribution may well be the most challenging and fascinating research area. Generally, the
objectives of a GIS are the management (acquisition, storage and maintenance), analysis

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(statistical and spatial modelling), and display (graphics and mapping) of geographic data.
GIS is a valuable tool to assist in health research, in health education, and in the planning,
monitoring and evaluation of health programmes and health systems.

Buffer Zones Creation

Another process that is very useful in health research and planning is the benefit to the
investigation of illness at or near pollution and other hazardous sites, is the ability to create
buffer zones around the lines or points which represent those locations. The user can specify
the size of the buffer and then intersect or merge this information with disease incidence data
to determine how many counts of the illness fall within the buffer. This technique has been
used extensively for many conditions - e.g. to understand the association between prevalence
of childhood leukemia in northern England and the proximity to nuclear power stations. This
technique also provides answers to questions such as "How many persons live within a 10 km
radius from a particular PHC or within how many kilometres from a community is a First
Referral Centre for attending to complex emergencies such as Caesarian section during
childbirth.

The generation of distance/proximity surface, taking into account the distance, and the
resistance to get there in terms of costs which may be measured in rupees or time or even
transportation means that may not be available on the one hand, and the allocation modelling
i.e. assignment of every point of an area to the nearest set of designated features, for example,
the First Referral Centres are other geographic analysis tools that can be used in health
research and planning.

Spatial Analytic Techniques

As discussed earlier, spatial variation in health related data is well known, and its study is a
fundamental aspect of epidemiology. There are many types of spatial analysis : Point patterns
- As the name implies, these are dot maps, which display the distribution of health events as
data locations. A classic example is the identification of the source of cholera spread shown
in Figure 1. An alternative is the use of dynamic graphics such as associating the dot map
with a histogram of case occurrence. Selecting the upper tail of the histogram automatically
highlights the corresponding cases on the map thus allowing characterisation of the regions
by high incidence of the disease. Line patterns Vectors or lines that aid in the analysis of
disease diffusion and patient-to-health care facilities flow. The lines can indicate the presence
of flow between two sub-regions or if the arrows have widths proportional to the volume of
flow, they can represent quantification. Francis and Schneider in 1984 designed an interactive
graphic computer programme called FLOWMAP, to produce a variety of maps of origin-
destination data. Area patterns Chloropleth maps are used to embed histograms into the
polygons of maps. Another alternative is to use stem-and-leaf plots to classify data before
area pattern analysis. Surface and contour patterns To overcome the limitation of
administrative regions for mapping, surface, and contour pattern maps allow the variable
under study as continuous process throughout the region. This analysis assumes that the event
is a continuous process and thus we get the maps, which are called isoline or isopleths.

Temporal Analytic Techniques

Most of the techniques described earlier can be used not only in health but in other areas as
well. However, surveillance of diseases requires continuous systematic collection and
analysis of a series of quantitative measurements. The detection and interpretation of changes
in the pattern of the constructed time series is very important and therefore this presents a
major challenge to the public health systems, as late detection of the 'disease' may result in

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missed opportunities for intervention. Quality Control Charts are useful methods for mapping
surveillance data. The methods commonly used for such mapping include - the Shewhart test,
the simple cumulative sum test and the V-mask. These methods are based on a comparison of
incoming values from the time series with constant values, usually defined empirically from
historical data. The advantages of such methods are that they can provide graphic
information, and as such can be incorporated into an information system, helping the public
health systems in the process. These are techniques poorly developed in our country but are
found widely used in the US, France and some of the European countries. Statistical
Monitoring Epidemiologists like to use the concept of ratio of case numbers at a particular
time to past case occurrence using the mean or median. Based on this concept, the Centers for
Disease Control and Prevention of the US Government has developed a technique in which
the expected values are calculated based on a five year average. Public health professionals
directly report the incidence of diseases to a central registry through a dedicated extranet
environment and the analysed maps are available readily, sometimes even in the public
domain.

GIS for Advocacy and Communication in Health

Since mapping is an excellent means of communicating a message clearly even to those who
are not necessarily familiar with the methodology, GIS can be used effectively with
leadership at various levels - panchayats, nagarpalika, districts, states and national
administration to convey the priorities, the problems and provide an analysis and evidence
based menu of options for programme implementation. Mapping is also used in participatory
learning and evaluation techniques for community health projects. Small or large maps may
be drawn or painted by groups or individuals to represent the context in which they are living.
These maps, showing the location of the community structures - the houses, the wells, pumps,
latrines, roads, PHCs, sub-centres and anganwadi centres give participants a wider view of
where they are living. Such maps can help in discussion, assessment, analysis and decision
making.

These maps when posted in public places and if updated provide a mirror for review and
continuous updation of decisions at the community level. Such efforts have been tried out in
different parts of India not only for decisions in the health sector but also for critical decisions
on siting of handpumps, sub-centres and even primary schools.
Some resources related to GIS in Health:Anyone interested in the geography of disease
will need a good understanding of the basics of epidemiology, or at least of health statistics.
The World Health Organization website (www.who.int) is a good place to start. The WHO
collects mortality and morbidity data from member countries, allowing international and
inter-regional comparisons of health and disease. They publish the annual World Health
Report, the Weekly Epidemiological Record, WHO Statistical Information System
(WHOSIS), and a wealth of other useful publications. The Noncommunicable Disease
Division of WHO describes the global epidemiology of diseases such as cardiovascular
diseases and diabetes.

Data on the global epidemiology of cancer can be found at CANCERmondial,

(www.dep.iarc.fr/dephome.htm) a website of the International Agency for Research on
Cancer (IARC).

After the eradication of smallpox, poliomyelitis is slated for eradication. As of end of 1999,
only 33 countries including India continue to have cases of Polio being reported. In studying
the surveillance of Polio, it is important to determine, which type of polio is occurring in

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which parts of the world as these have important implications for the disease eradication
strategy employed. The map (fig. 4) produced by WHO, thus has very important application.
Further, in each of the countries, specific geographic areas are identified for concerted action
and additional rounds of polio drops to the children below 5 years. Thus in addition to the
NIDs for eradicating polio from India, which is carried out throughout the country, the states
of Delhi, Uttar Pradesh, Bihar and West Bengal require special focus and additional attention.
These interpretations become possible when GIS is used effectively.

In recent years, there has been a great deal of research on the geography of AIDS diffusion,
particularly in the United States.

The AIDS Data Animation Project is a project of the Consortium of Earth Sciences
Information Network (CIESIN). The still frames and animations illustrated at this web site
document US disease trends for the years 1981 to 1993 using mortality data from the US
National Centers for Health Statistics. The US Centers for Disease Control and Prevention
(CDC) provide a wealth of information for public health professionals, including this series
of slides on the epidemiology of AIDS. For a dramatic illustration of the impact of the AIDS
pandemic worldwide, visit the UNAIDS AIDS Clock.

EpiMap - No treatise on GIS in Health is complete without a description of EpiMap.

EpiMap is a programme for IBM compatible microcomputers that displays data using
geographic or other maps. Data values may be entered from the keyboard or supplied in Epi
Info or dBASE files. The data may be counts, rates or other numeric values. In colour or
patterns maps, the values are represented as shading or colour patterns for each geographic
entity. In Dot density maps, randomly placed dots proportional in number to the values are
placed in each entity. Epi Map also produces cartograms, in which the value for each
geographic entity is allowed to control the size of the entity. Available in the public domain,
it is freely available for researchers, practitioners from CDC, Atlanta, now for over 10 years.
Outline maps are supplied with the software. It is designed to work both independently or as
a companion to Epi Info.

HealthMap - It is a joint WHO/UNICEF programme based within the Department of

Communicable Diseases of WHO. Created in 1993, to establish a GIS to support
management and monitoring of the Guineaworm Eradication programme, it has been
expanded to a much wider range of public health applications and now includes the
promotion and use of GIS for other disease control programmes and in public health
departments of a number of countries. Some of the specific applications of HealthMap
include the Programme on Onchocerciasis in Africa, Surveillance and screening for African
trypanosomiasis, Severe trachoma in Morocco, Mali and Gambia and Surveillance for
Malaria stratification in Ethiopia. The HealthMap provides an excellent means of analysing
epidemiological data, revealing trends, dependencies and inter-relationships that would be
more difficult to discover in tabular format. It allows policy makers to easily visualise the
problems in relation to the resources and more efficiently target resources to those
communities in need. Public Health resources, the specific diseases and other health events
can be mapped in relation to their surrounding environment and existing health and social
infrastructures. Such information when mapped together creates a powerful tool for
monitoring and management of disease and other public health programmes.

ChildInfo - ChildInfo is a database initially developed in India as a database on indicators

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related to nutrition and eventually expanded to include over 100 indicators on women and
children. The database developed by UNICEF has simple tools to link with features that
allow users to easily make tables, graphs and maps based on the data, without having to learn
any mapping technology. Graphs and maps on a variety of indicators can be developed by
users with average computer literacy in minutes and can be directly imported into documents,
reports and presentations. The database for India has indicators and mapping facility down to
the district level. ChildInfo is currently available from UNICEF as a LAN version and will be
developed and available in the public domain as an internet version early next year. The tool
has already expanded to cover not only all countries of the SAARC region of the sub-
continent, but has also expanded to countries of East Asia, Pacific, Southern and Eastern
Africa. Experience with ChildInfo has led the UN community in India to conceive a common
UN Database called DevInfo, on indicators derived from various UN conferences and World
Summits. The DevInfo when fully developed and released will have mapping facility right
upto the block level for India.

BERKSONIAN BIAS
A special example of bias is Berkesonian bias, termed after Dr. Joseph Berkson who
recognized this problem. The bias arises because of the different rates of admission to
hospitals for people with different diseases (i.e. hospital cases and controls)
Association observed in the group studied may differ from those in the general
population if admission rates to the study group are connected to variables whose
associations are studied. This is a common form of bias (Berksonian Bias) in studies of
hospital or clinic patient and autopsy samples
Berkson‟s paradox
• In 1946, Berkson constructed a theoretical argument that hospital samples may
systematically differ from general populations because of factors that influence the
likelihood of hospitalization
• As a result, hospital samples may exhibit spurious associations between two variables,
even though these variables are independently distributed in the general population
• This occurs when their combination of exposure and disease under study increases the
risk of admission to hospitals, leading to a systematically higher exposure rate among
the hospital cases than the hospital controls; this in turn, systematically distorts the
Odd‘s ratio

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 Dr. Shashidhar S B

A schematic representation of the Berkson paradox

creating a spurious association

ED E’D ED E’D
Selective
Hospitalization
ED’ E’D’
ED’ E’D’

Hospital Population
General Population
OR>1
OR= 1

E = exposed D = case
E’ = unexposed D’ = control

Walter (1980) has specified two particular circumstances for which the Berkson paradox will
be negligible
1. The exposure under investigation is not a direct cause of hospitalization
2. The case and control population are mutually exclusive
These two conditions can be used as guidelines for evaluating the potential of a Berkson
paradox in any particular hospital-based case-control study
Example: Doctors who care for women with salphingitis were more likely to recommend
hospital admission for those using an intrauterine device (IUD) than for a hormonal method
of contraception.
In a hospital-based case-control study, this would stack the deck (or gynecology
ward) with a high proportion of IUD –exposed cases, spuriously increasing the Odd‘s ratio
Berkson's paradox or Berkson's fallacy is a result in conditional probability and
statistics which is counter-intuitive for some people, and so has been described as a paradox.
It is a complicating factor arising in statistical tests of proportions. Specifically, it arises when
there is an ascertainment bias inherent in a study design. The result is that two independent
events become conditionally dependent given that at least one of them occurs.

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 Dr. Shashidhar S B

IDEAL MALARIA VACCINE

An ideal malaria vaccine would prevent all infection by priming the immune system to
destroy all parasites, whether free sermonizing in the blood, while in the liver, or even,
theoretically, while in red blood cells.
Challenges Encountered
1. The size & genetic complexity of the parasite mean that such infection presents
thousands of antigens to the human immune system. Till date about 40 antigens have
been identified.
2. The parasite passes through several life stages even while in the human, presenting a
different subset of molecules for the immune system to combat at each stage. It is
possible to have multiple malaria infections of not only different species but also of
different strains at the same time.
 Feasibility of Malaria Vaccine
1. Feasibility of developing a malaria vaccine under 3 specific findings.
Infected sporozoite model : Irreachated sporozoites were delivered mosquito bites to
volunteers when subsequently challenged with infected mosquitoes, the volunteers were
protected.
2. Gradual onset of natural protection from severe disease in humans living in malaria
endemic in humans living in malaria endemic areas and exposed to repeated
infections.
3. Experiments that demonstrate the effectiveness of passive transfer of immunity these
show that an immune response that protects from disease is possible the challenge is
to define those segments of the immune response that are required and the antigens
that can generate a protective immune response.
Vaccines Developed So Far
Type 1 Vaccine:
Recommended to exposed mostly to P, falciparum malaria in sub- Saharan Africa , with
the primary objective to reduce the number of severe malaria cases and deaths in infants
& children exposed to high transmission rates.
Type 2 Vaccine
As a ― traveler's Vaccine‖, aiming to prevent all cases of clinical symptoms in individuals
with no exposure.
First Vaccine developed that has undergone field trails, is the spf 66, developed by
Manuel Elkin Patastroyo in 1987. SPf66 – Synthetic ―cocktail‖ vaccine for P.
falciparum
Combination of antigens from the sporozoite (issuing CS repeats) and meteorite
parasites. During phase-1 trials a 75% efficacy rate was demonstrated & the vaccine
appeared to the well tolerated by subjects & immunogenic . Phase II b & Phase III trails
were less promising, efficacy of 38.8% & 60.2%.
Ciraim Sporozoite Protein
CSP was the next vaccine developed that initially appeared promising enough to undergo
trails. It is also based on circumsphorozoite protein, recombinant protein covalently bound
to a purified psensomonas aerngeniosa foxin (A9).

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 Dr. Shashidhar S B

The NYVAC – PF7 multistage vaccine attempted to use different technology,

incorporating seven P.falciparum antigenic genes.
The NYVAC – PF7 multistage vaccine attempted to use different technology,
incorporating seven P.falciparum antigenic genes.
1. CSP & sporozoite surface protein
2. Z (called pf sspz) were delivered from sporozoite phase
3. The liver stage antigen (LSA – 1)
4. Thou from erythrocyte stage (Merozoite surface protein 1
5. Serine repeat antigen & AMA 1
6. One sexual stage antigen. (the 25-KDa pfs 25)
In 1995, a field trail involving NANP 19-5.1 proved successful.
Out of 194 children – none developed symptomatic malaria the 12 wk follow – up period &
only 8 failed to have high level of antibody. Consists of schizont export protein (5.1%) & 19
repeats of the sporozoite surface protein (NANP)
RTS,S
Recently developed recombinant vaccine consists of P.falciparum circumsphorozoite protein
from pre – erythrocytic stage prevents the invasion of hepatocytes & additionally elicits a
cellular response enabling destructing of infected hepatocytes. RTS,s was fused with a
surface antigen from Hepatitis B, hence creating a more potent & immunogenic vaccine.
When tested in trials an emulsion of oil in water & the added adjutants of monophosphoryl A
& QS21 (SBASZ), the vaccine gave 7 out of 8 volunteers challenged with P.falciparum
protective immunity.
The Future malaria vaccine therapy vaccine development strategies
Novel approach is the use of sub-unit vaccine the use of live, inactivated whole parasite
vaccines not much antigenic.
Sub unit raciness are being tested with adjuvants & specialized delivery systems to increase
the variable level of immune response.
Recent advances are the DNA vaccines.
It involves removing segment of the of DNA from parasitic genome & insisting the
sequences into a vector eg:- Plasmid genomes attenuated viral genomes, liposome or
proteoliposes & other carrier complex molecules
It produces high rate of cellular response but poor level of antibody production.
The advantage of DNA vaccines over the classical attenuated vaccines are numerous &
include being able to mimic MHC class 1 CD8+ T cell specific response, reduces the safety
concern, provide a substantial reduction in production cost & due to the nature of DNA
vaccines, increased case of storage.
Most Successful Candidate Developed to date is the RTS,s recombinant vaccine.
RTS,s / ASOZA, one of the vaccines, produced using this technique, has been used in field
trials in the Gambia. 3 repeat doses were administered in the 6 months leading up to the
period of highest malaria transmission. The vaccine efficacy was reported at 71% during first
2 months of follow-up , get falling to 0% in the last 6 wks in 250 male volunteers.
On further analysis it was noticed that majority of control subjects had become
infected towards the end of the follow-up period. Thus only the remaining subjects were

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included in the comparison against as efficacy, of the vaccine decreased, it was being tested
against an increasingly immune cohort of controls, explaining the massive decrease in
protective immunity seen.
The Vaccine Trials so far…..
 Pre erythrocyte Stage Vaccines
 Asexual Stage Vaccines
 Transmission Blocking Vaccines
 Multistage Vaccine
 Recent Advances
Preerythrocytic Vaccine
Antigens
1. Spf66-The 1st vaccine trial. Phase 2 trial-38.8%,Phase 3-60.2 %
2. CSP(circumsporozoite protien)-p.knowlesi strain ,recombinant protein covalently bound
to P.aeruginosa Antigen. Unsuccessful with a low efficacy- Phase 2 Trail-18%.
Asexual stage Vaccines
Antigens
1.Merozoite Surface Protein(MSP-1,2)
2.EBA-175 & RESA.
Efficacy-Phase2 Trail 33.8%
-Phase3 Trail 27.5%
Transmission Blocking Vaccines

Goal-To interrupt malaria transmission from human to mosquitoes by preventing parasite

development in mosquito gut.
Antigens
1.Pfs230 2.Pfs48/45
Efficacy-Low.
Multistage Vaccine
NYVAC-pf7-
A multistage vaccine vaccine was tried using several P.faiciparum antigens-
1.CSP-sporozoite phase
2.Pf SSp2 –Sporozoite phase
3.LSA-1
4.MSA-1
5.Serine Repeat Antigen
6.AMA-1

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 Dr. Shashidhar S B

7.Pfs25-Gametocytic Phase.
Efficacy-90%;But poor Antibody response.
Recent Advances
 RTS,S/AS02A
It is A Circumsporozoite vaccine used with a surface antigen from Hepatitis B virus
Phase 1-71%;Phase 2-0%;Phase 3-65%
Adjuvants –Adjuvants are being coupled with older vaccines to improve their efficacy.
Efforts are being made to improve efficacy testing methods ELISAPOT.

Stage of Antigens Salient features

Plasmodium

Pre-erythrocytic Irradiated sporozoites, Stage/species specific; antibody blocks

Circum Sporozoite infection of liver; large immunising dose
Protein or peptides, required; can abort an infection
Liver stage Antigens -1

Merozoite and Erythrocyte Binding Specific for species and stage; Cannot
Erythrocytes Antigen (EBA-175), abort an infection; Prevents invasion of
Merozoite Surface erythrocytes, thus reducing severity of
Antigen 1&2 (MSA- infection
1&2);

Gametocytes & Pfs 25, 48/45k, Pfs 230 Prevents infection of mosquitoes; antibody
gametes to this antigen prevents either fertilization
or maturation of gametocytes,; antibody
blocks transmission cycle

Combined SPf 66 (based on pre- Based on incorporation of antigens from

vaccine (cocktail) erythrocytic and asexual different stages into one vaccine to produce
blood stage proteins of an immune response, blocking all stages of
Pf) the parasite development

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 Dr. Shashidhar S B

LEPROSY VACCINE
Leprosy bacilli is not cultivable, Multidrug therapy provided a sufficient solution to
the clinical problems of leprosy. Disappointing results with the heat-killed M. leprae vaccine
developed under the IMMLEP programme these are the added factors for non existence of
leprosy vaccine.
BCG Vaccine: Although developed for protection against M. tuberculosis, it has shown
efficacy against the M. Leprae also but the protective efficacy varied from study to study but
the protective efficacy was better in multibacillary leprosy compared to the paucibacillary
leprosy and the protection offered is boosted by a second BCG vaccination
ICRC BACILLUS
ICRC bacillus belongs to the M.leprae intracellulare (MAI) complex. it is isolated from
lepromatous leprosy. It has been possible to isolate the organism successfully from six
different leprosy patients and the extensive studies carried out in vitro have shown several
points of its close similarity with M. Leprae. It is named after the first of its isolation i.e. in
Indian cancer research centre, Bombay. A two-arm double blind, randomized, controlled
clinical trial of the ICRC vaccine was recently completed at the Cancer Research Institute,
Mumbai. The study was conducted in south-eastern Maharashtra, (Latur, Osmanabad, and
Sholapur districts) in which the relative efficacy of the ICRC vaccine (0.5 x 109 bacilli per
dose) was compared against one fifth the standard dose of BCG. The immunoprophylaxis
trial was launched in August 1986. Nearly 34,000 healthy household contacts of leprosy
patients formed the study population. The vaccinees were between 1-65 yr of age, of both
sexes, and received either of the two vaccines. Four resurveys were carried out in 1993, 1994,
1997 and 1998 for detection of new cases.
Distribution of vaccinees according to age (child and adult), sex, and BCG scar status was
similar in the 2 arms. There were 62 eligible incidence cases (29 belonged to ICRC group and
33 to BCG group) giving an attack rate of 2.1 per 10,000 person years, as against the
expected rate of 3.5 per 10,000 person years. The overall protection offered by ICRC vaccine
was 18% (95%CI - 35% to 50%, statistically not significant), more than the one fifth dose of
BCG vaccine.
The immunotherapeutic efficacy of the ICRC vaccine was analysed in LL patients who were
clinically classified as non responders to MDT as they had not shown any fall in BI despite 3-
4 years of MDT. Immune functions and clinical parameters were monitored in these patients
before and 6-12 months after vaccination. Laboratory investigations focused on analysis of
lymphocyte proliferative responses, cytokine production (IL-2, IFN-
dilution analysis to determine the frequency of ICRC/M.leprae reactive T cells in peripheral
blood of LL and TT patients and in ICRC vaccinated LL patients. Lymphocytes from LL
patients showed poor responses to M.leprae antigens but good response to ICRC antigens.
Using the above immunological parameters of T cell function, it was noted that the patients
exhibited a marked improvement in T cell responses after vaccination with a concomitant fall
in BI and histological upgrading. An increased frequency of M.leprae/ICRC reactive T cells
was observed in peripheral blood of vaccinated LL patients.
It was also observed that in the vaccinated group there was clonal expansion of lymphocytes
expressing T cell receptors Vb6, Vb7 and Vb11 indicating that T cell anergy could be
reversed after vaccination.
The reaction of several clones with ICRC bacilli suggests a close relationship with M.leprae
with reference to T cell antigens. Studies also show that the antigens of the ICRC bacilli are
also more accessible, making the organism a stronger immunogen.

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 Dr. Shashidhar S B

Although M.leprae is yet to be cultivated, it grows profusely in armadillos. The

immunogenicity of M.leprae (which is a weak immunogen) is enhanced by the addition of
BCG and subsequently established the concept of a mixed vaccine containing a mixture of
heat-killed armadillo-derived M.leprae (M.leprae-A') + BCG. The mixed vaccine induces
immunological changes both in leprosy patients and in health persons but either organism
given alone is ineffective. No information is available on the stability of the immune
conversion and on antigenic variation, if any, between M.leprae obtained from different
armadillos. This mixed vaccine is currently undergoing trials in Venezuela and Malawi.
A vaccine prepared from Mycobacterium welchii (M.W.) has been shown to induce lepromin
conversion in BL/LL patients. M.W.,a rapid growing mycobacterium is said to be a cultivable
saphrophytic soil bacillus. The vaccine has been used in patients with multibacilliary leprosy
and the results are similar to those obtained with the ICRC vaccine. But this should not be
surprising because ICRC and M. W. are similar with reference to cell antigens
Lacunae in leprosy vaccine studies
1. Very few well performed double blind randomized controlled trials with
proper follow up
2. The largest vaccine trial conducted in recent times has maximum efficiency of
67% (BCG +HKML) which still does not meet the criteria of usage.
3. Scientifical analysis of the data has shown that observational studied over
estimate the protective efficacy of vaccines

HIV VACCINE
There are three major scientific challenges for HIV vaccine development
1. The immunological correlates of HIV/AIDS protection are not known
A major stumbling block for the rational development of HIV vaccines has been the lack of
information on the immunological correlates of protection against HIV/AIDS. With most
vaccine preventable diseases, naturally occurring (or vaccine induced)immune responses
correlate with protection against infection or disease. In contrast, even though most people
infected with HIV develop abroad range of immune responses against the virus, these
responses neither eliminate the infection nor prevent progression to AIDS. Ongoing HIV
vaccine development strategies are targeted at the two major types of immune responses,
humoral and cell mediated immunity and include strategies to induce both of them.
2. The genetic variability of HIV
Genetic analysis of HIV strains isolated from different parts of the world has revealed that
several HIV genes exhibit extensive sequence heterogeneity, particularly in the gene coding
for the viral envelope proteins, gp120 and gp41.a This heterogeneity has been used to classify
HIV type 1 (HIV-1) strains into groups and subtypes; most HIV infections are caused by
viruses belonging to HIV-1 group M (or ‗‗major‘‘)which, in turn, is divided into at least nine
genetic subtypes (A–J).b Viruses from different subtypes can also recombine among
themselves, generating unique and circulating recombinant forms (CRFs).
HIV subtypes and CRFs have unequal geographical distributions. For example, in the
Americas most infections are caused by subtype B, whereas subtype E causes the major
HIV/AIDS epidemic in Thailand. In Africa, several subtypes cause the epidemic, but most
are of subtype C. Although much is known about the genetic variability of HIV, it is unclear
how the genetic variability relates to potential vaccine-induced protection. For example, it is

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not known whether the genetic subtypes define immunological types, or whether specific
vaccines will need to be designed for each subtype. The results of human trials with candidate
vaccines that are based on different genetic subtypes may provide the answer to this (5).
3. The lack of good animal models
Several experimental HIV vaccines have induced different degrees of protection in primate
models, including chimpanzees challenged with HIV or monkeys challenged with the
analogous simian immunodeficiency virus. The problem is that different experimental
vaccines produce different results in these two animal models. It is also unclear whether the
animal results will be predictive of
Candidate vaccines
Despite the uncertainties, a number of experimental vaccines have been developed in the
laboratory and are being tested in animal models (and some inhuman volunteers). For safety
and ethical reasons, the two classic approaches for developing viral vaccines — using whole
inactivated or live-attenuated viruses — have not been seriously considered for HIV. Instead,
the effort has concentrated on developing subunit vaccines, which contain only part of the
virus obtained using genetic engineering techniques. The first-generation HIV candidate
vaccines were based on the envelope proteins of HIV, especially gp120. These vaccines,
which are designed to induce the production of neutralizing antibodies, may have the
limitation that the gp120 protein is the most variable component of the virus. Second
generation candidate vaccines are being designed to induce cell-mediated immunity, using
either live vectors (such as vaccinia, canary pox, and others) or ‗‗naked‘‘ DNA that codes for
different HIV genes. Third-generation vaccines, based on regulatory non structural proteins
of HIV, such as Tat (a trans activator of HIV gene expression) and Nef(a multifunctional
myristylated protein), are also emerging. Some immunization protocols use a combination of
two different vaccines to induce broader and/or stronger anti-HIV immune responses. Many
of these experimental vaccines and their combinations are being tested in primate models,
with different degrees of success, and it is expected that several will eventually move to
clinical trials in humans.

SURVIVAL ANALYSIS
Analytical methods used to draw inferences regarding the chances of developing the
―outcome of interest‖ over the various points of time is answered by Survival Analysis.
• In Survival Analysis the outcome of interest is time to an event
Example: ―What are the chances that a case of HIV infection acquired due to blood
transfusion would be surviving at the end of 6 years?‖
What is the risk of developing disease (ex- re-infarction) after surgery?
Survival data - from clinical and epidemiologic studies
Objective
 To estimate time to event for a group of individuals.
 To compare time to event between 2 or more groups.
 To assess the relationship of co-variables to time to event.

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If patients suffering from a life threatening disease ‗A‘ are treated with treatment
modalities and followed over specific time period say 5 years
Following three situations may occur.
• 1. The event of interest (death of patient due to disease ‗A‘) (outcome of interest are
―uncensored‖ data)
• 2. The patient is lost to follow up or withdrawn from the study or patient died due to
other cause. (Censored)
• 3. The patient is alive when the study is terminated. (Censored)
What is censoring?
• Complete survival times are unknown (subject does not experience the event of
interest)
-study closes before the event of interest
-lost to follow-up during the study
-patient experiences a different event that makes further follow-up impossible

1, 5 , 6 - uncensored ( event of interest)

Survival time is generaly described as

• Survivorship or survival function-
probability that a subject survives longer than a specified time ‗t‘ from the time origin.
S(t)= Number of patients surviving longer than ―t‖
Total number of patients
• Hazard function-
• Probability that a person fails in a time interval, given that he survived to the
beginning of the time interval.
h(t) = Number of patients dying in the interval
Number of patients surviving at the beginning of the interval
Application of Survival Analysis
• Mortality studies ( when death is the event)

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 Dr. Shashidhar S B

• Remission of symptoms ( Therapy trials)

• Disease surveillance ( when the diseases occurs)
Analytical techiniques
• Life table technique or Actuarial method
• Kaplan-Meier survival estimate
Life table
• Special type cohort analysis which takes into account the life history of a
hypothetical group or cohort of people that diminishes gradually by deaths.
• First given by John Graunt
• Edmund Halley in 17th century developed a life table for the city of Breslau
Types of life tables
• Based on reference year, life tables are of two types-
• Current life table and
• Cohort or generation life table.
• Based on presentation-
• Complete life tables and
• Abridged life tables.
Assumptions made in using Life Tables:
 The withdrawals will have the same probabilities of the event (death, relapse) as that
of the non-withdrawals.
 No change in the effectiveness of treatment or in survivorship during the study.
 The value of probability is obtained from patients who entered the study at different
points of time assuming that these probabilities remain constant over time.

Actuarial method of calculating - Risk

5-year follow up of a Hypothetical Cohort of 12 subjects for assessing
the risk of re-infraction at different time interval after cardiac surgery

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 Dr. Shashidhar S B

Assumption – All surgery on same day(0) time

Estimation of risk® of developing Re-infraction for the 12

subjects after cardiac surgery - 5year follow-up study
No j Ij Wj Oj rj sj Sj Rj
No of Number New With Effective (I j /O j) (1- r j) cumulati (1- S j)
year at start cases drawals No(j-1/2 w j) ve
1 12 1 1 11.5 0.087 0.913 0.913 0.087

2 10 1 2 9 0.111 0.889 0.811 0.189

3 7 2 3 5.5 0.364 0.636 0.515 0.485

4 2 1 0 2 0.5 0.5 0.257 0.743

5 1 0 1 0.5 0 1 0.257 0.743

Kaplan-Meier Survival Estimate

• Also known as product-limit formula
• In 1958, Product-Limit (P-L) method was introduced by Kaplan and Meier (K-M)
• Predetermined intervals, such as 1 month or 1 year are not used.
• Information on the exact time of death is needed - this data are used to define the
intervals
• number of persons who died at that point______________________
Number alive up to that point (including those who died at that time point)
A few critical features of Kaplan-Meier Survival Estimator
• This method assumes that censoring is independent of the survival times
• For censored observations survival curve remains unchanged.

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 Dr. Shashidhar S B

• At the next event the number ‗at risk‘ is reduced by the number censored between the
two events.

Survival curve based on KM estimate

Generates the characteristic “stair step” survival curves
For censored observations survival curve remains
unchanged

Statistical test applied

• Log rank & Cox Proportional Hazards Regression
• Most widely used for comparing two or more survival curves
• To test the null hypothesis that there is no difference between the populations in the
probability of an event (Death) at any time point
• Log-Rank test does not control for confounding
• To control for confounding we use Cox Proportional Hazards Regression

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 Dr. Shashidhar S B

RAINWATER HARVESTING
Rainwater harvesting for domestic use and as drinking water source is becoming increasingly
popular and necessary as the availability of good quality water declines. Rainwater is
acknowledged as a sustainable source of water that has less impact on the environment.
Households and communities have augmented or substituted their household supplies with
rainwater for reasons of scarcity, salinity, quality of service and for risk substitution. While
rainwater may not always provide a full-year round of supply, it enhances water security in
the house and generally provides a good quality water. Rainwater may be the sole source of
water in countries like the Maldives and upland Sri Lanka, provide an alternative to arsenic-
laden ground water in Bangladesh and augment inadequate urban supplies from Chennai to
Kathmandu and scattered households in the mountain ridges in Bhutan. Its use is nowadays
promoted by NGOs and authorities alike for numerous domestic applications like drinking,
cooking, bathing, laundry, toilet flushing and for gardening purposes. Infiltration to sustain
local aquifers is suggested as well.
Rainwater harvesting basically means capturing rainwater from the roofs of buildings on the
residential areas, courtyards, playgrounds, hill slopes, places of worship, institutions etc.
However, rainwater can also be harvested by those who do not have a proper roof by creating
temporary collection surface by using a clean cloth piece.
A rainwater harvesting system consists of; catchment area (Roof), conveyance system
(guttering, downspouts and piping), filtration (screen), storage (cistern), disinfection
(filtration, chlorination) and distribution system. Water harvesting can be done at the
household level or in a community which gives them ownership and responsibility over water
projects.

Harvested rainwater
Could be stored for ready use in tanks (above or below ground)
Could be charged into the soil and thus could control declining water table (Groundwater
recharging)
Additionally, storage of significant quantities of safe water at the household level is a suitable
preparation for disasters that interrupt water supplies. Therefore, roofvwater harvesting has a
possible role both in emergency responsiveness and in disaster relief. It is a significant source
for water for an individual, family or a community

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Rainwater harvesting is widely practiced in Maldives, India, Sri Lanka (it especially
benefited the Tsunami hit populations), Myanmar (more so, after the cyclone Nargis),
Bhutan, Bangladesh (as an alternate drinking water source for arsenic affected areas) and
Thailand.
Water quality and health risk
Rainwater is relatively free from impurities except those picked up by rain from the
atmosphere, but the quality of rainwater may deteriorate during harvesting, storage and
household use. Wind-blown dirt, leaves, faecal droppings from birds and animals, insects and
contaminated litter on the catchment areas can be sources of contamination of rainwater,
leading to health risks from the consumption of contaminated water from storage tanks. Poor
hygiene in storing water in and abstracting water from tanks or at the point of use can also
represent a health concern. However, risks from these hazards can be minimized by good
design and practice. Well designed rainwater harvesting systems with clean catchments and
storage tanks supported by good hygiene at point of use can offer drinking-water with very
low health risk, whereas a poorly designed and managed system can pose high health risks.
Microbial contamination of collected rainwater indicated by E. coli (or, alternatively,
thermotolerants coliforms) is quite common, particularly in samples collected shortly after
rainfall. Pathogens such as Cryptosporidium, Giardia, Campylobacter, Vibrio, Salmonella,
Shigella and Pseudomonas have also been detected in rainwater. Higher microbial
concentrations are generally found in the first flush of rainwater, and the level of
contamination reduces as the rain continues. A significant reduction of microbial
contamination can be found in rainy seasons when catchments are frequently washed with
fresh rainwater. Storage tanks can present breeding sites for mosquitoes, including species
that transmit dengue virus.
Rainwater is slightly acidic and very low in dissolved minerals; as such, it is relatively
aggressive. Rainwater can dissolve heavy metals and other impurities from materials of the
catchment and storage tank. In most cases, chemical concentrations in rainwater are within
acceptable limits; however, elevated levels of zinc and lead have sometimes been reported.
This could be from leaching from metallic roofs and storage tanks or from atmospheric
pollution. Rainwater lacks minerals, but some minerals, such as calcium, magnesium, iron
and fluoride, in appropriate concentrations are considered very essential for health. Although
most essential nutrients are derived from food, the lack of minerals, including calcium and
magnesium, in rainwater may represent a concern for those on a mineral-deficient diet. In this
circumstance, the implications of using rainwater as the primary source of drinking-water
should be considered. The absence of minerals also means that rainwater has a particular taste
or lack of taste that may not acceptable to people used to drinking other mineral-rich natural
waters. Water quality should be managed through development and application of WSPs that
should deal with all components from catchment areas to point of supply.
System risk assessment
Important factors in collecting and maintaining good quality rainwater include proper design
and installation/construction of rainwater harvesting systems. Materials used in the catchment
and storage tank should be suitable for use in contact with drinking-water and should be non-
toxic to humans. Rooftop catchment surfaces collect dust, organic matter, leaves and bird and
animal droppings, which can contaminate the stored water and cause sediment build up in the
tank. Care should also be taken to avoid materials or coatings that may cause adverse taste or
odour, and some metals can dissolve to give high concentrations in water. Regular cleaning
of catchment surfaces and gutters should be undertaken to minimize the accumulation of

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debris. Wire meshes or inlet filters should be placed over the top of down-pipes to prevent
leaves and other debris from entering storages. These meshes and filters should be cleaned
regularly to prevent clogging. The first flush of rainwater carries most contaminants into
storages. A system is, therefore, necessary to divert the contaminated first flow of rainwater
from roof surfaces. Storages will require periodic cleaning to remove sediment. Storages
without covers or with unprotected openings will encourage mosquito breeding, and sunlight
reaching the water will promote algal growth. Covers should be fitted, and openings need to
be protected by mosquito-proof mesh. Cracks in the tank and withdrawing of water using
contaminated pots can contaminate stored water. Storages should preferably be fitted with a
mechanism such as a tap or outlet pipe that enables hygienic abstraction of water. Some
households incorporate cartridge filters or other treatments at the point of consumption to
ensure better quality of drinking-water and reduce health risk.
Operational monitoring
Sanitary inspections should be a focus of operational monitoring. This should include
checking the cleanliness of the catchment area and storage, the structural integrity of the
system and the physical quality of rainwater (turbidity, colour and smell). The level of pH
should be monitored frequently in case of new concrete, ferrocement or masonry storage
tanks.
Verification
Microbial quality of rainwater needs to be monitored as part of verification. Rainwater, like
all water supplies, should be tested for E. coli or thermotolerant coliforms. The levels of lead,
zinc or other heavy metals in rainwater should also be measured occasionally when it is in
contact with metallic surfaces during collection or storage.
Management
Management plans should document all procedures applied during normal operation as well
as actions in the event of failures. In the case of rainwater harvesting, remedial actions will
generally involve physical repair of faults and cleaning of catchment areas, filters or storage
systems. Disinfection of rainwater should be practised when microbial contamination is
detected or sanitary inspections indicate a likelihood of contamination. Disinfection with
chlorine can make rainwater safe for drinking.
Surveillance
Independent surveillance is desirable for ensuring the quality, safety and acceptability of
water supply based on rainwater. The principal focus of surveillance apart from verification
of compliance should be geared more towards evaluation of hygienic practices in collection,
storage and use of rainwater and needs for development and refinement for improving water
safety by the use of a WSP.

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VERBAL AUTOPSY
Very little scientifically based information is available on cause-specific mortality rates for
many developing countries.
A verbal autopsy is a method of finding out the cause of a death based on an interview with
next of kin or other caregivers. In order for verbal autopsies to be comparable, they need to
be based on similar interviews, and the cause of death needs to be arrived at in the same way
in all cases. In recent years, verbal autopsies have been used more widely to provide
information on cause of death in areas where civil registration and death certification systems
are weak, and where most people die at home without having had contact with the health
system. This type of interview is often the only way to find out about the cause of death.
Verbal autopsy has been used for a variety of purposes, all of which require arriving
at a diagnosis for the cause of death:
-To provide data on mortality by cause.
-To evaluate health interventions aimed at reducing mortality from specific causes of death,
when these interventions are being introduced into a limited geographic area on a trial basis.
-To identify ways to reduce unnecessary deaths. For example, combining a verbal autopsy
questionnaire with a household questionnaire asking about steps taken by the family and by
the health services during the illness preceding death can make it possible to identify
problems relating both to health-seeking behaviour and health service provision.
-To facilitate research into factors associated with mortality from specific causes of death.
Underlying assumptions of the verbal autopsy method
An underlying assumption of the verbal autopsy method is that each cause of death
investigated has a set of observable features that can be recalled during a verbal autopsy
interview. Furthermore, it is assumed that the features of one cause of death can be
distinguished from those of any other cause of death.
Open-ended history of final illness versus close-ended questions
Two different interview methods can be used to obtain a verbal account of the injury or
illness that led to death. One method uses an in-depth open-ended history of the final illness.
The interviewer asks the mother, next-of-kin or caregiver to tell about the events leading up
to death in their own words, and probes freely to follow up particular aspects. This
descriptive account is then read by medical experts who code the interview in terms of cause
of death. The other interview technique is to ask a series of closed-ended (often pre-coded)
questions, which are usually coded using systematic pre-determined algorithms for cause of
death.
The open-ended histories, when used as a stand-alone method, need to be conducted by
highly trained interviewers, because the questions asked are left to the judgement of the
interviewer. Sometimes the interviewers are medical doctors. In any case the interviewers
require special training to do the interview. Most studies that use open-ended histories have
been coded by medical doctors, since the histories do not easily lend themselves to coding by
non-medical persons or by pre-defined algorithms. This requires substantial amounts of time
from relatively senior staff and adds a subjective element into the coding process. Closed-
ended questions, which ask about whether specific symptoms and signs have been present
during the final illness, are more objective than open history questions. They also lend
themselves better to the development of standard pre-defined algorithms for specific causes
of death. Coding can be done by computer, since the algorithms are already defined.

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However, this method has the disadvantage of being relatively inflexible, so that information
that has not been included in the questionnaire is lost, no matter how relevant it might be for
determining the cause of death in a particular case. However using a combination of an open
history question followed by a series of closed ended questions is better. In this way it takes
advantage of each approach.
Multiple versus single causes of death
Many verbal autopsy studies allow only one cause for each death - usually the underlying
cause of death. This means that the total number of causes of death is equal to the total
number of deaths themselves. This seems intuitively satisfying, and the results are relatively
easy to present. On the other hand, it commonly happens that the death of a child is the result
of more than one cause. The standard verbal autopsy questionnaire for children used in the
present document allows for multiple causes of death, because it was considered to be
impractical to distinguish between underlying and contributory causes of death in a
questionnaire used for verbal autopsies in children. The use of a standard questionnaire also
avoids the situation where the definition of a disease or cause of death affects the definitions
of other diseases or causes of death. For example, if all children who die within one month of
having measles were to be counted as deaths due to measles only (which is the WHO
standard definition of a measles death), then the other more immediate causes of death such
as ALRI or diarrhoea would be under-counted. By allowing multiple causes of death, we do
not have to choose between measles and ALRI or diarrhoea as a sole cause of death. This
makes intuitive sense, because many children who die from a combination of causes could
have survived if any one of the causes of death had been either prevented or treated early
enough. One disadvantage of assigning multiple causes by algorithm is that ranking of the
importance of causes is not possible. For example, a death primarily due to diarrhoea with
concurrent pneumonia is indistinguishable from a death primarily due to pneumonia with
concurrent diarrhoea. When interpreting the results of a verbal autopsy questionnaire, it is
important to know whether multiple causes of death are allowed for in the coding, since the
expected proportions of deaths for each cause will generally be higher when multiple causes
of death are allowed.
Causes of death for which verbal autopsy is best suited
Verbal autopsy questionnaires and algorithms need to distinguish between different possible
causes of death using only information that can be recalled by caregivers. Naturally, verbal
autopsy does best at identifying causes of death with distinctive features that are not found in
other causes of death. Many injuries fit this requirement well. If a cause of death is
characterized only by vague symptoms and signs that overlap with many other causes of
death, it is very difficult to identify that particular cause of death accurately when using
verbal autopsy. One way to establish how well a set of verbal autopsy questions and
algorithms identify a particular cause of death is to do a validation study in a setting where
there is a medical diagnosis for the final illness. Results obtained from a verbal autopsy
questionnaire, answered by caregivers of children who died, are compared to the medical
diagnosis. In some validation studies, the verbal autopsy questionnaire was administered to
all children admitted to hospital with life-threatening conditions, in order to study a wide
range of life-threatening conditions existing in the community, and not only the conditions
that cannot easily be treated in hospital. This also decreases the amount of time needed for
case finding, since survivors of severe illness are included in the study as well. Other studies
are restricted to children who died in hospital. Validation studies in hospital settings have
important limitations. First, children taken to hospital and caregivers who take children to
hospital may not be representative of the general population in terms of socio-demographic

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characteristics, health-seeking behaviour, causes and clinical presentation of illness, severity,

etc. Secondly, when a child is taken to hospital, or at the time of death or discharge, the
caregiver is usually interviewed by the staff and often learns the medical diagnosis
(especially when the child dies, when they may be given a copy of the death certificate). This
may affect the caregiver‘s answers to the verbal autopsy questionnaire. None the less, from a
practical point of view, hospital validation studies are the only feasible way to validate a
verbal autopsy questionnaire.
Sensitivity and specificity of verbal autopsies and their effect on cause-specific mortality
estimates.
Since verbal autopsies rely solely on information recalled by the next-of-kin for determining
the cause of death, and are not based on clinical or laboratory evidence, they may be subject
to relatively high misclassification errors. (Although, even diagnoses based on clinical and
laboratory evidence may have substantial misclassification.) This can have a profound effect
on the verbal autopsy estimate of the proportion of deaths due to a specific cause.
The traditional way to validate a screening test is to measure sensitivity and specificity by
comparing the screening test result to the true value from a so-called gold standard. This was
a very important part of the validation studies carried out using the standard verbal autopsy
questionnaire presented in this document. For some causes of death there are several different
algorithms. Sensitivity and specificity for particular causes of death obviously vary with the
algorithm used to establish cause of death. However, given the inverse relationship between
sensitivity and specificity, it is not possible to select the algorithm with both the highest
sensitivity and the highest specificity. It is measured by the difference between the verbal
autopsy estimate of the cause specific mortality fraction and the true cause-specific mortality
fraction. For example, if the sensitivity and specificity of a verbal autopsy algorithm are both
70% for a fairly common cause of death (e.g. one which is responsible for 30% of deaths),
the verbal autopsy would over-estimate the proportion of deaths due to that cause by
approximately 12 percentage points (i.e. the verbal autopsy would classify 42% of the deaths
as due to that particular cause, while in fact, only 30% of the deaths were really due to that
cause). Even if the specificity were as high as 80% and sensitivity still 70%, the verbal
autopsy would overestimate the proportion by 5 percentage points (35% vs 30%).
It indicates that algorithms with only moderate levels of sensitivity and specificity are not
suited for measuring rare causes of death, whereas they could provide approximate values for
relatively common causes of death. Less common causes of death require very high rates of
specificity (but can tolerate low levels of sensitivity). For example, a cause of death
responsible for 5% of deaths, for which the specificity is 95%, would result in an
overestimate of only between 3 and 5 percentage points, for sensitivities ranging between
60% and 90% It would be possible to adjust for this misclassification if the sensitivity and
specificity of the verbal autopsy algorithms were known.10 The collaborating group has
considered whether or not it might be advisable to correct for misclassification errors in
future verbal autopsy studies using the validated questionnaire by using the sensitivities and
specificities for specific algorithms resulting from the validation studies. One major problem
with this approach is that it is not known if the sensitivities and specificities from a verbal
autopsy validation study in a hospital setting are likely to be the same in a particular
community setting. Even within the same cultural settings, one would expect some variation
due to differences in the circumstances and characteristics of people who bring their children
to the hospital and those who do not. One would also expect sensitivity and specificity to
differ substantially across cultural and geographic settings.

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Misclassification not only affects estimates of levels of cause-specific mortality

fractions but it also affects estimates of: (1) changes in cause-specific mortality fractions over
time and (2) differences in cause-specific mortality fractions between two population groups.

STRATEGIES FOR FILARIASIS ELIMINATION

Line listing of filarial cases and analysis of data
Prevalence of filarial disease cases in the community should be enquired from community
heads, key informers and opinion leaders. Since lymphoedema is recognizable, the
information can easily be obtained. The reported cases are to be confirmed by visiting their
houses. It is to be enquired whether any other person in the family or in the neighbourhood
also suffers from the disease. The details are to be compiled at
village/subcentre/PHC/District/State levels including similar compilation in urban areas. This
will be useful to identify high-risk areas and more accurate estimates of disease burden could
be made. Such information would be useful in chalking out strategies for elimination of
lymphatic filariasis by prioritising areas within each district for more intensive IEC activities,
morbidity management and monitoring the effectiveness of health care delivery services on
disease burden. The line listing of cases should include the following particulars: A patient
card will be provided to the health workers to make record of persons having manifestations
of filaria such as lymphoedema, hydrocele, etc. The information should be noted.

INTRODUCTION TO MDA AS LF ELIMINATION STRATEGY

The concept of MDA is to approach every individual in the target community and administer
annual single dose of anti-filarial drugs (DEC or DEC+Albendazole). This annual dose is to
be repeated every year for a period of 5 years or more aiming at minimum 85 % actual drug
compliance.

APPROACHES FOR DRUG ADMINISTRATION

The following are the options for the delivery of the drugs:
House to house approach: Every individual is administered with the drugs at his/ her
doorstep. Booth approach: People are asked to come at predetermined place (booth) for
receiving the drug. The booths should not be located more than one kilometre walking
distance away from the community.
Group approach: Special population groups in places like schools, hospitals, offices,
industries, prisons, etc. including community aggregations like developmental projects,
market places, bus stands, railway stations, fairs, agriculture fields, etc. – are approached for
delivery of the drug.
The recommended approach based on the past experience is ―supervised drug
administration by door to door visit supplemented with drug administration at booths and
groups‖ preferably on a single day with two-day mopping up operations, instead of mere
distribution of drugs.
Drug administrator is to administer the drugs in his/her presence (supervised
administration). It is preferred not to administer the drug on an empty stomach. The schools
could be visited during lunch recess or any other suitable time. The local programme
manager should adopt suitable drug delivery strategy in consultation with community leaders,

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school teachers, managers and supervisors of the workplaces to achieve high drug intake. The
drug should not be left with the individual or relatives for swallowing it later.

DOSAGE SCHEDULE OF DRUGS

For operational convenience, age-wise dosage of single dose of 6 mg DEC per kg body
weight, adjusted to average weight has been streamlined. Albendazole is to be given to all the
eligible individuals as a single dose of 400 mg irrespective of age and weight. Both the
recommended doses of DEC+Albendazole are to be taken together as a single dose.

PREPARATORY ACTIVITIES
The activities that are necessary in implementation of Annual Mass Drug Administration can
be grouped into:
_ Pre-MDA (preparatory)
_ During MDA
_ Post-MDA
5 . PRE-MDA ACTIVITIES AT DIFFERENT LEVELS
5.1 Projection of DEC and Albendazole Requirements
LYMPHOEDEMA MANAGEMENT
Filaria patients with damaged lymphatic vessels often have more bacteria on the skin than
usual. The large number of bacteria on the skin, multiple skin lesions, slow lymph fluid
movement and the reduced ability of the lymph nodes to filter the bacteria cause
inflammation characteristic of an acute attack. Repeated bacterial infections precipitate
frequent acute attacks, which further damage the tiny lymphatic vessels in the skin, reducing
their ability to drain fluid. This vicious cycle continues, aggravating the condition of the
patient.
The lymphoedema management involves the following components:
_ Washing,
_ Prevention and cure of entry lesions,
_ Elevation of the foot,
_ Exercise,
-Wearing proper footwear,
_Management of acute attacks.
WASHING
Good hygiene and treatment of entry lesions are important measures for managing
lymphoedema. The patients should be encouraged to practise skin care and hygiene.
2.1. Supplies needed
(i) Clean water at room temperature, (ii) Soap (least expensive soap without perfume is
usually the best), (iii) Basin, (iv) Chair or Stool, (v) Towel, (vi) Footwear within easy reach.
2.2. Check skin for

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(i) Entry lesions, including very small lesions between the toes that can hardly be seen, (ii)
Entry lesions between the toes may cause itching. Scratching can further damage the skin and
can provoke an acute attack; tell patients to avoid scratching, (iii) Toe nails should be
trimmed in such a way that the skin is not injured. Do not try to clean under the nails with
sharp objects as these can cause entry lesions. It is important to check the skin every time the
leg is washed because entry lesions allow bacteria to enter the skin and this will cause acute
attacks. If entry lesions are found, they should be cleaned carefully.
2.3. Wash the leg
(i) Wet the leg with clean water at room temperature. Do not use hot water to wash the leg,
(ii) Begin soaping at the highest point of swelling (usually around the knee),
(iii) Wash down the leg towards the foot,
(iv)Gently clean between all skin folds and between the toes, preferably using a small cloth
or cotton swab, and paying particular attention to the entry lesions. Brushes should not be
used as they can damage the skin,
(v). Rinse with clean water,
(vi). Repeat this careful washing until the rinse water is clean,
(vii). Wash the other leg in the same way, even if it looks normal.
2.4. Dry the skin
(i). Pat the area lightly with a clean towel. Do not rub hard because this can cause damage to
the skin Carefully dry between the toes and
between skin folds using a small cloth, gauze or cotton swab. Wet areas between the toes,
skin folds and entry lesions promote bacterial and fungal growth leading to frequent acute
attacks.
Entry lesions
are common in patients with lymphoedema and are most frequently found between the toes
and deep skin folds and around the toe nails. Entry lesions, such as wounds, can also be found
on the surface of the skin. Both fungi and bacteria can cause entry lesions. Fungal infections
frequently damage the skin and create entry lesions, especially between the toes, and may
cause itching. The entry lesions allow bacteria to enter the body through the skin and this can
cause acute attacks. Fungi and bacteria can cause bad odour.

SURGICAL MANAGEMENT OF HYDROCELE DUE TO LYMPHATIC FILARIASIS

Hydrocele is one of the commonest manifestations seen in the endemic districts. Surgical
management of hydrocele not only gives great relief to the patients but also augments
community compliance for success of ELF in the country.The first level peripheral health
centres (PHCs) will be able to diagnose cases needing surgical intervention, while most of the
second level health centres (CHCs) have facilities for undertaking hydrocelectomy.

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REGISTRATION OF VITAL EVENTS

Introduction: A person entry into the world by birth & a person departure from it by death
are considered to be vital events, these events make its beginning and the end of persons life.
During the span of life between birth and death a change may take place in an
individual civil like marriage, divorce etc these are also considered as vital events.
Vital registration system (civil registration) is a tool for studying dynamics of
population. It is compared to cinematograph film, where as census is a snap shot.
The vital registration system is almost perfect in developed countres like UK, USA, Austria
etc. in many developing countries like India, Pakistan, Kenya it is incomplete and imperfect.
Historical background: In earlier times registration of births & deaths in most Europeans
countries was done by the churches and other religious bodies,
In India it was introduced by British more than a hundred years ago. In 1873, GOI
passes the Births, Deaths & marriage registration act only in a few states later extended to
whole of India. Failure to register such an event is punishable under the act.
Method of collection:
There was no uniform & standardized method collection of vital statistics. The state adopted
different systems of registration depending on their convenience
In villages, village officials from Revenue, Panchayath, health or police department,
village accountant.
In towns & cities the municipal authority was responsible & was a part of duties of
health department officials lke sanitary inspectors & health assistant.
After the enactment of RBD act 1969, system of registration is unified. The present
flow of registration organization in the state is
Chief registrar of birth & death – director of economics & statistics
Joint chief registrar – Joint director of civil registration system
District registrar – deputy commissioner
Additional District registrar – district statistical officer
Registrar (rural) – village accountant
Registrar (Urban) – Health officer, Health inspector, sanitary inspector.
Problems of civil registration
1. Coverage is low, not satisfactory because of underreporting- due to illiteracy,
ignorance
2. Lack of concern & motivation
3. Lack of uniformity in collection
Developments in registration system:
Office of registrar –general of India came into effect in 1960. They suggested few measures
to improve vtal statistics registration.
Later in 1963 foreign experts studied the problem & made suggestions & recommended for 2
types of attack they are

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1. Short term plan aimed at obtaining quick & reliable estimate of birth & death in a
sample basis which included sample registration separetly for rural & urban areas and
Model registration system in selected areas under PHC‘s to give reliable cause of
death.
2. Long term plan- to revitalize the existing machinery.

SAMPLE REGISTRATION SYSTEM

INTRODUCTION
In India, the need for dependable demographic data was felt soon after independence
heralding the era of five year planning. The registration of births and deaths started on
voluntary basis and there was no uniformity in statistical returns resulting in both under-
registration and incomplete coverage. In order to unify the civil registration activities, the
Registration of Births & Deaths Act, 1969 was enacted. Despite having the registration of
birth & death compulsory under the statute, the level of registration of births and deaths under
the Act has continued to be far from satisfactory in several states/UTs. With a view to
generate reliable and continuous data on these indicators, the Office of the Registrar General,
India, initiated the scheme of sample registration of births and deaths in India popularly
known as Sample Registration System (SRS) in 1964-65 on a pilot basis and on full scale
from 1969-70. The SRS since then has been providing data on regular basis. The SRS in
India is based on a dual record system. The revision of SRS sampling frame is undertaken in
every ten years based on the results of latest census.
OBJECTIVE
To provide reliable estimates of:
 Birth and death rates
 Fertility and mortality like total fertility, infant mortality etc.
 Causes of deaths through Verbal Autopsy
 Risk Factors (Smoking, Drinking, Veg./Nonveg.)
The main components of SRS are:
 Base-line survey of the sample units to obtain usual resident population of the sample
areas
 Continuous (longitudinal) enumeration of vital events pertaining to usual resident
population by the enumerator
 Independent retrospective half-yearly surveys for recording births and deaths which
occurred during the half-year under reference and up-dating the Houselist, Household
schedule and the list of women in the reproductive age group along with their
pregnancy status by the Supervisor;
 Matching of events recorded during continuous enumeration and those listed in course
of half-yearly survey
 Field verification of unmatched and partially matched events.
 Filling of Verbal Autopsy Forms for finalized deaths.

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Baseline Survey: The base-line survey is carried out prior to the start of continuous
enumeration. This involves preparation of a notional map of the area to be surveyed, house
numbering and house listing and filling-in of a household schedule. Wherever a sound system
of house numbering exists the same is adopted. Otherwise, the house numbering is done by
the enumerator/supervisor with the help of chalk and tar, etc. at a conspicuous place near the
entrance of the house. The supervisor prepares a notional map with the help of the
enumerator showing important landmarks and location of the houses covered by the sample
unit. He then prepares a list of houses/households covered by the sample in the House List
(Form 1) and fills-in the Household Schedule (Form 2) wherein he records the residential
status and demographic particulars of each individual residing in the household viz. name,
sex, age, educational/marital status and relation to head of household, etc. The inmates of
public institutions like hotels, inns, schools and hospitals and excluded, but households living
permanently within the compound of such institutions are covered. A list of pregnant women
(Form 3) is also prepared at the time of the base line survey.
Continuous enumeration: The enumerator maintains a Birth Record (Form 4) and a Death
Record (Form 5) in respect of his area. The enumerator is expected to record all births and
deaths occurring within the sample unit, as well as those of the usual residents occurring
outside the sample unit. The events in respect of visitors occurring within the sample unit are
also listed, but these are not taken into account while calculating rates. Thus the evens to be
enumerated by the enumerator are those pertaining to: (i) usual residents inside the sample
unit; (ii) usual residents outside the sample unit; (iii) immigrants present; (iv) immigrants
absent; (v) visitors inside the sample unit.
For ensuring complete netting, the enumerator uses different sources to get information of
the occurrence of vital events in the sample unit. These include the help of the village priest,
barber, village headman, midwife and such other functionaries. The enumerators maintain
contact with these informants at frequent intervals and collects information about the
occurrence of births and deaths. On being informed about the occurrence of an event, he
visits the concerned household and records the prescribed particulars. He also keeps in touch
with other socially important persons and visits local or nearby hospitals, nursing homes,
cremation or burial grounds, at frequent intervals to keep himself updated about the
occurrence of events. E maintains a list of pregnant women (Form 3) which helps him in
netting of all the births. Despite all these efforts, the enumerator may miss out information
about some of the events. Therefore, he is required to visit all the households once in each
quarter (in rural areas) and once a month (in urban areas) so as to ensure that all the events
have been recorded.

Half-yearly survey: Half-yearly survey is carried out independently in each sample unit by a
full-time supervisor. The supervisor belonging to the statistical cadre of the State Census
Directorates (either a Compiler or a Sr. Compiler or Statistical Investigator or any suitable
official) visits each household in the sample unit and records the particulars of births and
deaths in Forms 9 & 10 respectively in respect of all the usual residents and visitors (only
those occurring within the sample unit) which had occurred during the half-yearly period
(January-June or July-December) under reference. Simultaneously, he updates the house-list,
the household schedule and the pregnancy status of women by making entries of changes, if
any. While carrying out this survey he does not have access to the birth and death records of
the enumerator for the same periods which are withdrawn from the field before the
supervisor‘s visit for the half yearly survey.

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Matching: On completion of the half-yearly survey, the Forms 9 & 10 filled-in by the
supervisors are compared with those in the Forms 4 & 5 (filled-in by the enumerators). This
is done at the office of Directorate of Census Operations for all states except for rural areas of
Kerala and Maharashtra, where it is done at the office of Directorate of Economics and
Statistics of the respective states. Selected important entries in the enumerator's and
supervisor's record are matched item by item and events are classified as fully matched,
partially matched and unmatched. The items generally considered for matching are:
Identification code of the head of Household and mother, Relationship of the mother to head,
date of live birth, month in case of still birth/abortion, sex in case of live birth /still birth(for
birth) and identification code of the head of household and mother in infant death,
relationship of the deceased to head, date of death and sex
Field verification of unmatched and partially matched events: Every unmatched or
partially matched event is verified by a visit to the concerned household. This is done either
by a third period or jointly by the supervisor and the enumerator, depending upon the
availability of staff.

Sample design: The Sample design adopted for SRS is a uni-stage stratified simple random
sample without replacement except in stratum II (larger villages) of rural areas, where two
stages stratification has been applied. In rural areas of bigger states (population with ten
million or more as per Census 2001), natural division is the first geographical stratification or
in rural areas of a smaller states, the stratification has been done on size of villages with
villages having population less than 2,000 forming Stratum I and villages with population
2,000 or more forming Stratum II. Smaller villages with population less than 200 were
excluded from the sampling frame in a manner that the total population of villages so
excluded did not exceed 2 per cent of the total population of the concerned natural division in
the state. The number of sample villages in each state was allocated to the substrata
proportionally to their size (population). The villages within each size stratum were ordered
by the female literacy rate based on the Census 2001 data, and three equal size substrata were
established. The sample villages within each substratum were selected at random with equal
probability. In the case of villages of Stratum 2, each sample village with a population of
2,000 or more was subdivided into two or more segments in a way that none of the segments
cut across the Census Enumeration Blocks (CEBs) and the population of each segment
formed by grouping the contiguous CEBs was approximately equal and did not exceed 2000.
A frame of segments was prepared and selection of one segment was done at random at the
second sampling stage for the SRS enumeration.
In urban areas, the categories of towns/cities have been divided into four strata based
on the size classes in contrast to the six strata in the earlier sampling frame. Towns with
population less than one lakh have been placed under stratum I, towns/cities with population
one lakh or more but less than 5 lakhs under stratum II, towns/cities with population 5 lakh or
more under stratum III and four metro cities of Delhi, Mumbai, Chennai and Kolkata as
separate strata viz. stratum IV. The sampling unit in urban area is a Census Enumeration
Block. The Census Enumeration Block within each size stratum was ordered by the female
literacy rate based on the Census 2001 data, and three equal size substrata were established.
The sample Census Enumeration Block within each substratum was selected at random with
equal probability. A simple random sample of these enumeration blocks have been selected
within each sub-strata without replacement from each of the size classes of towns/cities in
each State/Union Territory.

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Sample size: The Infant Mortality is the decisive indicator for estimation of sample size at
Natural Division, the ultimate level for estimation and dissemination of indicators for rural
areas. The permissible level of error has been taken as 10 prse (percentage relative standard
error) at Natural Division level for rural areas and 10 prse at state level for urban areas, in
respect of major states having population more than 10 million as per Census 2001. For
minor states, 15 prse has been fixed at the total state level. By and large, the above criteria
has been followed, however, there have been a few exceptions, on account of operational
constraints. Based on the above criteria, the number of units has been increased from 6671 to
7597 with 4433 in rural and 3164 in urban areas.

Newer Initiative: Premier Institutes as long term technical partners with SRS (CGHR
(University of Toronto), NIMHANS (Bangalore),PGI (Chandigarh),ICMR, TIFR
(Mumbai),ERC (Chennai)
 Premier Institutes help in
 Training/Refresher Training to RGI Staff on verbal Autopsy
 Conducting VA in 10 percent resample units
 Assignment of causes of deaths
 Epidemiological analyses
 New SRS provides vital rates at NSS Natural Division level for rural areas.
 Use of female literacy as a stratifying factor.
 Separate estimates for four metros viz. Delhi, Kolkata, Chennai & Mumbai.
 Introduction of Verbal Autopsy instrument for determining the cause specific
mortality by sex and age.
 Enhancing the scope of data
 Morbidity data
 Family planning practices data
 Data on abortion
 Personal habits – use of pan, tobacco, alcohol, food habits: veg / non-
veg
 Data on reasons of migration
 Data on school attendance (up to 16 years)
 Data on disability
 Introduction of Identification Code
 Easy storage and retrieval of data
 Aggregation at different levels
Cross-classification of various determinants with fertility and mortality indicators

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HEALTH HAZARDS OF FOUNDRY WORKERS

Founding, or casting, as it is commonly called, involves the pouring of molten metal
into a mould made to the external shape of the article to be cast. The mould may contain a
refractory core which determines the dimensions of any internal cavity or hollow. Molten
metal is introduced into the mould. After cooling occurs, the mould is subjected to a
‗shakeout‘ procedure which releases the casting and removes the core. The casting is then
cleaned and any extraneous metal is removed from it.
Ferrous foundries produce iron and steel castings. Non- ferrous founding includes the
casting of copper-based alloys (brass and bronze), aluminium, lead, zinc, magnesium and
other alloys.
Moulding and pattern making
Sand moulds are commonly used for ferrous founding. To produce the depression in the sand
into which the metal is poured, a pattern of the object to be cast is formed. Hardwoods,
metals or resins are used by pattern makers in this forming process. The majority of ferrous
castings are produced by ‗green‘ sand moulds. The moulding mix usually contains silica
sand, coal dust, and organic binders such as dextrine and carbon oil. The moulding sand may
also contain metal fragments from previous pourings as the sand is recycled. Water and
binder are normally added to the sand before it is re-used. Synthetic resins are sometimes
used in mould making. The casting of non- ferrous metals often utilises graphite or metal dies
in the moulding operation. The use of such dies requires specific procedures and safety
precautions.
Coremaking: Cores are traditionally formed of sand, with an organic binding agent added.
The processing of these traditional cores involves oven curing, which releases acrolein, if oils
are used, and produces a disagreeable, choking odour. Several new binding systems contain
various synthetic resins such as phenol formaldehyde, urea formaldehyde, furfuryl alcohol
(furan), polyurethanes and various amines. The curing of these resins is achieved by chemical
reaction or heating. Gases may be used as catalysts for reactions.
The mixing of sodium silicate with sand, and the passing of carbon dioxide through the
mixed core, is also utilised. Silica gel and sodium carbonate are formed through this process
which forms a rigid core. The completed, cured cores are sprayed with a coating material
prior to pouring. This may involve a combination of alcohol and graphite.
Melting and pouring
A variety of furnaces are used for melting metals prior to casting. Electrically powered
induction furnaces are used to process higher grades of cast iron and steel. These furnaces are
almost noise free and generate little nuisance heat. Some iron foundries utilise cupola
furnaces. They are fuelled by coke, and compressed air is introduced to enhance the
combustion. If the air is pre-heated, to about 300°C, the furnace is known as a ‗hot-blast‘
cupola. Large amounts of carbon monoxide are generated during cupola operations.
Non-ferrous operations utilise electric furnaces, simple blast furnaces or, more commonly,
reverberatory-type furnaces. Fume and dust collectors are incorporated into non-ferrous
furnaces. Roasting ovens are used, in addition to furnaces, for refining copper and zinc.
Electric holding furnaces are also used in foundries, to maintain the metals in the molten state
prior to pouring. The molten metal is poured from the furnace by tilting or tapping the
furnace, and the metal is then passed to the moulds. In old or small foundries, the pouring of
metal into moulds may be carried out manually. Larger foundries often have mechanised
systems.

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Shakeout (knockout)
The removal of the cooled casting from the mould is termed ‗shakeout‘. The moulding sand
is dry and friable at this stage, and particles of metal, sand and core material can become
airborne during this process. While new foundries may have automated shakeout facilities,
many smaller foundries do not, and the shakeout is performed manually. When the technique
of ‗jobbing‘ moulding is utilised, the moulds are knocked out by hand, usually with a
hammer. If coal dust is incorporated into a sand mould, carbon monoxide will be generated
during cooling and shakeout.
Dressing and cleaning
Following the shakeout or knockout procedure, the formed castings are cleaned and dressed
to remove any extraneous metal, sand or other material left from the moulding process. The
castings are often sent to an allied machine shop at this stage for buffing and polishing.
Various methods are employed in dressing and cleaning. Tumble blasting is now used
extensively. In this process, the castings are mechanically tumbled with metallic abrasives in
an enclosed drum. Abrasive blasting techniques are still utilised. A variety of non- metallic
(corn husks, pecan shells, glass beads, silicon carbide and aluminium oxide) and metallic
(steel grit or shot) abrasives are used. Water or air under pressure is used to deliver the
abrasive to the surface of the casting. A great deal of dust is generated by this blasting, and it
is usually carried out in an enclosure equipped with special ventilation and particle recycling
facilities. Pneumatic grinding and chipping tools may be used for cleaning castings.
Hydraulic blasting or vibration processes may be employed to remove cores from the
castings. In some foundries, additional grinding, polishing and buffing operations are carried
out to develop a smooth polished surface on the metal.
Health Hazards
Airborne contaminants: dusts
Silica dust
The lung disease silicosis can result from prolonged exposure to excessive concentrations of
respirable, free crystalline silica dust. This dust is generated during mixing, moulding,
shakeout and dressing operations, and during sand conditioning for re-use. The dust arises
from quartz in the sand, and the concentration of free silica in the air varies with the handling
process, the efficiency of dust control, the chemical composition of the sand and the physical
state of the sand, that is, whether the sand is screened or unscreened, wet or dry. Used sand is
either dumped or re-milled with water and binder added before it is re-used. The amount of
respirable dust is increased by such re-use.
Sand is dry at the mixing or ‗mulling‘ stage prior to mould making, and at the shakeout stage;
this dry sand is potentially more hazardous than wet sand. Screened sand does not produce as
much silica dust as unscreened sand and pure quartz sand is more hazardous than olivine
sand. Formation of scar tissue, due to dust inhalation, interferes with lung function.
Conditions such as tuberculosis and bronchitis may be complications of silicosis.
Abrasive blasting processes may involve the use of sand containing high concentrations of
free silica. The sand being cleaned from the castings may also present a silica hazard. Metal
dust which may be toxic, will be recycled along with the abrasive particles. Evaluation and
control of such hazards therefore deserve particular attention.
Other dusts

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Dusts other than silica, such as those arising from the use of chromite or olivine sand, have
also been implicated as causing bronchitis and reduced lung function in foundry workers.
Airborne contaminants: gases, vapours and other contaminants
In addition to dusts, the air in foundries may contain the potential irritants formaldehyde,
furfuryl alcohol, isocyanates, various amines and phenol. These contaminants are generated
primarily bythe coremaking and moulding processes, and may irritate the eyes and the
respiratory tract. Some hardwoods used in pattern making can release products which may
cause asthma in exposed workers. Vapours from various resins can initiate severe allergic
reactions. Carbon monoxide gas is produced in substantial amounts by a variety of furnaces.
It may also be released during the pouring of molten metal. Inhaled carbon monoxide
prevents the blood from carrying a normal supply of oxygen. Exposure to concentrations of
500 to 1000 parts per million (ppm) for approximately 30 minutes may precipitate headache,
accelerated breathing, nausea, dizziness and mental confusion. Thus a possible secondary
effect of exposure is an increased risk of accident and injury to the worker. Exposure to
higher concentrations (several1000 ppm) may result in the appearance of symptoms after
several minutes, or unconsciousness may occur rapidly without any warning symptoms.
Various metal fumes may be generated during founding processes, especially during me lting
and pouring operations. Lead, magnesium, zinc, copper, aluminium, cadmium, antimony, tin
and beryllium fumes are commonly present in non-ferrous foundries. Iron oxide is the major
fume generated in iron and steel operations.
‗Metal fume fever‘ may result from exposure to these contaminants. This is an acute illness
of short duration which commences some hours after inhalation of the metallic fumes. The
initial symptoms are flu-like: nausea, headache, dry throat and coughing, and muscular pains.
Chills and sweating may occur later. Recovery is usual within 24 hours after removal from
exposure. The fumes of zinc and copper are the most common causes of metal fume fever.
The fumes and dust of cadmium, beryllium, nickel and chromium, contained in some alloys,
are very toxic. The melting and casting of lead-bronze and leaded steel may result in the
emission of significant quantities of lead fumes. The lead hazard in furnace cleaning, dross
disposal and the fettling of lead alloys deserves particular attention.
Exposure to vanadium pentoxide, a residual by-product, during oil- fired furnace and flue
cleaning represents another substantial risk.
Skin irritants
Formaldehyde, isocyanates, various resin products, hardwoods and acids associated with
pattern making and coremaking processes can irritate the skin and may precipitate allergic
skin reactions.
Potential carcinogens
There is evidence from the International Agency for Research on Cancer that workers in iron
and steel foundries may have an increased risk of developing lung cancer. The exact
substance responsible has not been identified, but the risks appear to be associated with dusts
and/or fumes present in the foundry atmosphere. The potential carcinogenic effects of dusts
and fumes are a further reason for minimising atmospheric contamination.
Noise and vibration
Noise

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Surveys of foundries have shown that dressing, fettling and shakeout operations give rise to
considerable noise levels, with potentially harmful effects on the hearing of exposed workers.
In addition to the workers immediately involved in these processes, people working in the
vicinity may be exposed to noise levels well in excess of 85 dB(A). Extraction fans,
diecasting machines, core-making and shell-making equipment may also be sources of
excessive noise.
Vibration
Pneumatic grinding and chipping tools used in dressing the cooled castings may cause
vibration induced health effects in operators.
Heat and heat stress
Radiant heat is the major contributor to the heat load imposed on the worker by the
environment. Convective heat transfer adds to this radiant heat. Protective clothing is worn
for protection against the heat radiating from the heat sources and against contact with molten
metal. Such clothing greatly restricts the potential for body heat loss via evaporation.
The foundry worker experiences a total heat load which is determined by the time spent at
each workstation, the intensity of work, the clothing worn and the immediate workstation
environment, including air circulation. If the heat load is sufficiently severe, effects on health
and performance will occur. These range from decreased concentration to painful cramps,
fainting, heat exhaustion and heatstroke. These signs and symptoms require immediate
medical attention. Heat stress can also aggravate the effects of exposure to other agents such
as noise and carbon monoxide.
Physical injuries
Serious burns may result from splashes of molten metal in the melting and pouring areas of
foundries. Frequent, unprotected viewing of white-hot metals in furnaces and pouring areas
may cause eye cataracts. Eye injuries from molten metal or fragments of metal may occur in
pouring and dressing areas. During continuous casting processes, non-ferrous molten metals,
such as copper and aluminium, may explode violently if they contact water. Such explosions
can occur in water-cooled furnaces; whenever spillages of molten metal occur; during the
charging of furnaces with wet ingots or scrap metal; and whenever moist tools, moulds or
other material come into contact with molten metal. Injuries related to the manual handling of
materials, and injuries due to falls, may occur. Grinding wheels used for dressing small
articles may result in hand injuries.
Prevention and Control Measures
Following the identification of a hazard, evaluation of work practices and conditions must be
undertaken so that effective prevention and control measures can be implemented. This
should be considered an integral part of management's responsibilities.
Evaluation
Evaluation of the workplace environment should be included in an established program
addressing prevention and control measures. Attention should be given to gases, vapours,
fumes and dusts. Environmental sampling and analysis should be undertaken at regular
intervals by qualified occupational health and safety professiona ls in accordance with the
methods recommended by the appropriate occupational health authority.
Monitoring

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Monitoring may be used for the evaluation of a hazard and for assessing the effectiveness of
control measures. The design and implementation of a monitoring program should be carried
out by, or in consultation with, a properly qualified person.
Monitoring of the work environment involves the measurement of atmospheric contaminants
at selected locations in the workplace (static, positional monitoring). Personal monitoring
involves the measurement of atmospheric contaminants in the breathing zone of the
individual worker.
Biological monitoring involves measurement of the concentration of a contaminant, its
metabolites or other indicators in the tissues or body fluids of the worker. In some cases,
biological monitoring may be required to supplement static or personal monitoring.
When developing a monitoring program in foundries, due consideration should be given to
heat stress, exposure to noise, gases, for example, carbon monoxide, vapours, fumes, for
example, zinc and copper fumes, and dusts, for example, silica and olivine sand dusts.
In the control of health hazards due to a specific contaminant, where it has been demonstrated
that the exposure of the employee to the contaminant is approaching the relevant exposure
standard, or where biological monitoring indicates that an unacceptable exposure is
occurring, immediate action must be taken to reduce the health hazard and intensive
monitoring should continue. Records of the results of any monitoring should be maintained
and employees should be informed of these results.
Exposure standards
Worker exposure to dusts, gases and vapours should be kept as low as workable. Every
attempt should be made to keep exposures well below the exposure standards recommended
in the National Commission publication, Exposure Standards for Atmospheric Contaminants
in the Occupational Environment (latest edition).
The exposure standards represent airborne concentrations of individual chemical substances
which, according to current knowledge, should neither impair the health of, nor cause undue
discomfort to, nearly all workers. Additionally, the exposure standards are believed to guard
against narcosis or irritation which could precipitate industrial accidents.
Except where modified by consideration of excursion limits, exposure standards apply to
long term exposure to a substance over an eight hour day for a normal working week, over an
entire working life.
Control measures
Where there is a likelihood of worker exposure to foundry hazards, steps should be taken to
minimise that exposure as far as workable. A thorough examination of work practices is
essential.
Procedures should be adopted to ensure that workers are not unnecessarily exposed to the
hazard.
Control measures include, but are not limited to, the following, which are ranked in priority
of their effectiveness:
 elimination/substitution and process modification;
 engineering controls;
 administrative controls; and
 use of personal protective equipment.

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Preventing physical injuries

An understanding, appreciation and application of prevention and control measures can
contribute greatly to the minimisation of the risk of physical injury in foundry work. Some
general principles are outlined below:
 Mechanically propelled vehicles or machinery should be inspected regularly, kept in
efficient working order, and operated only by trained personnel.
 Maximum loads for winches, hoists, lifts and cranes should be clearly marked on the
equipment. These maximum capacities must never be exceeded.
 Contact between molten metal and water must be avoided. All ladles and other
equipment used for handling metal should be completely dry before contacting molten
metal.
 Work areas should be checked regularly to ensure that good housekeeping practices
are being followed.
 Any defective equipment should be repaired immediately or removed from service.
 Floors around furnaces should be of slip-resistant, non-combustible material, kept free
of obstructions and cleaned regularly.
 Operating instructions for each furnace should be clearly displayed in the furnace area
and issued to the person responsible for the furnace.
 Suitable protective clothing and equipment, including eye protection such as goggles,
should be worn by furnace operators. This clothing and equipment should comply
with the relevant Australian Standards.
 Eye protection should be required in all metal cleaning/dressing areas and should
comply with the relevant Australian Standard.
 Barriers or other suitable shields against molten metal splashes should be installed
where necessary.
 Persons should be prohibited from entering furnace areas when the temperature
exceeds 50°C, except in cases of emergency.
 Foundries should be equipped with safety blankets, automatic emergency showers or
hoses to extinguish burning clothing.
 Adequate lighting should be provided in all working areas in accordance with
Australian Standard AS 1680.
 When machinery or equipment is being cleaned or maintenance carried out, lock-out
devices or procedures should be employed to prevent the starting of the equipment.
 Workers who cannot be protected against falls from heights in any other way should
be protected by wearing approved safety harnesses and lifelines.
 Self-contained breathing apparatus must be used in emergencies when high carbon
monoxide concentrations are suspected.
Minimising exposure to dusts
Concentrations of silica dust, coal dust, metal fragments and other airborne contaminants
should be controlled.
It may be necessary to substitute less hazardous sands, such as olivine sand, for quartz sand to
reduce free silica concentrations. Local exhaust ventilation should be provided at the mixing
or mulling stage as the sand is dry. This also applies to the shakeout operation. Sand, metal
and coal dust at this point represent a major hazard. Carbon monoxide gas, from the
combustion of coal dust, may be released at shakeout. It is desirable, therefore, to contain the
shakeout process and exhaust the enclosure. If the mechanical ventilation in the foundry is
not adequate in removing the dust at all points of contamination, the wearing of personal

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respiratory protective equipment, such as a face mask/respirator, is a complementary

preventive measure. Such equipment should only be necessary when the provision of
adequate exhaust ventilation is highly impractical, the materials or process cannot be replaced
by less hazardous operations or during maintenance procedures.

Abrasive blasting and cleaning operations require special consideration. Silica-based

polishing pastes should not be used in metal cleaning operations. Total enclosure of abrasive
and cleaning operations should be provided, together with local exhaust ventilation. If
operators are required to work inside the enclosure, a continuous- flow, air- line respirator
must be worn. All such equipment must be regularly maintained.
Minimising exposure to gases and vapours
Carbon monoxide
Carbon monoxide, being colourless and odourless, has no warning properties. The only way
to determine the concentration of the gas is by regularly monitoring the foundry air.
Automatic alarms are a good means of warning workers of dangerous carbon monoxide
levels, provided that they are correctly adjusted.
Exhaust ventilation is a means of controlling carbon monoxide emissions at their source. For
cupola furnaces, the exhaust intake should be located well behind the stack.
All potentially exposed workers should be instructed in the dangers, recognition and
treatment of carbon monoxide poisoning. The biological monitoring of carbon monoxide via
blood sampling or in exhaled air samples may be a useful technique. The samples should be
taken at the end of a working shift.
Other gases and vapours
Potentially irritant vapours or fumes generated in core making or moulding processes should
be collected by exhaust ventilation at the point of emission and disposed of in accordance
with environmental protection requirements. Special consideration should be given to
combustion products formed during the pouring of moulds. Metal fumes should be removed
in the same way. Exhaust ventilation should be provided at the top of the pot in the founding
of non-ferrous metals such as aluminium, magnesium and copper. It may be possible to
substitute less hazardous substances, or otherwise modify the process, to minimise the
generation of hazardous fumes, gases or vapours. The use of gases such as sulphur dioxide or
chlorine for degassing molten metals requires special attention to safety and ventilation.
Skin irritants
Gloves complying with the relevant Australian Standard should be worn by moulders when
handling synthetic resins or any other materials which are skin irritants or sensitisers.
Minimising the risk of heat illness
Workers in furnace and pouring areas are often exposed to high levels of heat. People who
have any history of heat intolerance or a circulatory disorder, anyone recovering from a fever,
and any dehydrated worker must be regarded as being in a high-risk category for heat illness.
All workers who are exposed to heat at work should be encouraged to be physically fit and to
achieve their ideal body weight. Certain tranquillisers, motion sickness medications and
alcohol may impair temperature regulation mechanisms. Even a very fit person who has not
been previously exposed to hot conditions may display intolerance to working in the heat.
Unacclimatised persons must be given time to acclimatise to work in the heat. It is

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recommended that those who have not previously been exposed to work in hot conditions
should begin with half of the anticipated workload and half of the normal exposure time on
their first day. The exposure can then be gradually increased to the total workload/time
combination on the sixth day. Previously acclimatised personnel who return to work in the
heat after an absence of approximately nine or more consecutive days should undergo a four
day re-acclimatisation period.
Planned job rotation can assist in reducing exposure to heat. It may be necessary to place
some workers at cooler workstations for periods of time or to transfer them permanently to
more moderate environments. Cool water should always be available in close proximity to
hot working areas and encouragement given for the use of these facilities.
The exposure of workers to radiant heat can be reduced by the strategic positioning of
shields between workstations and heat sources. Clothing should be carefully selected so that a
balance between protection and facilitation of heat loss through evaporation is achieved.
Attention to ventilation and the provision of adequate air movement is essential. Some hot
processes, for example, pouring, may be partially or fully enclosed to reduce heat exposure.
Noise reduction / occupational hearing conservation
The reduction of noise at the source or in the transmission path should be achieved wherever
workable. A complete hearing conservation program, incorporating education, engineering
controls and routine audiometric tests, should be implemented. Australian Standard AS 1269
provides information on the measurement, evaluation and control of noise.
Vibration
Engineering controls or substitution of processes should be utilised wherever possible to
minimise worker exposure to vibration. The wearing of padded gloves is a complementary
control measure.
Manual handling
Various foundry operations involve the lifting, carrying and stacking of heavy objects.
Attention should be given to ergonomic principles and the proper methods of manual
handling should be followed.
Personal protective equipment
In certain circumstances, personal protection of the individual may be required as a
supplement to other preventive action. It should not be regarded as a substitute for other
control measures and must only be used in conjunction with substitution and elimination
measures. Personal protective equipment must be appropriately selected, individually fitted
and workers trained in their correct use and maintenance. Personal protective equipment must
be regularly checked and maintained to ensure that the worker is being protected.
Education and training
All employees working with foundry hazards must be informed of the hazards and the
precautions necessary to prevent damage to their health. Employees exposed to contaminants
should be trained in appropriate procedures to ensure that they carry out their work so that as
little contamination as possible is produced, and in the importance of the proper use of all
safeguards against exposure to themselves and their fellow workers.
Special attention should be given to ensuring that all personnel understand instructions,
especially newly recruited employees and those with English- language difficulties, where
they are known. Material safety data sheets should be obtained for all substances from the

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suppliers of such materials before handling. A management representative should be

nominated as responsible for personal protective equipment supply, maintenance and
training.
Health assessment
In some occupations, health assessment may form part of a comprehensive occupational
health and safety strategy. Where employees are to undergo health assessment, there should
be adequate consultation prior to the introduction of any such program. Where medical
records are kept, they must be confidential. It is particularly valuable to be able to relate
employee health and illness data to exposure levels in the workplace.
First Aid
First aid procedures and facilities relevant to the needs of the particular workplace should be
laid down and provided in consultation with an occupational physician or other health
professional. Due to the nature of foundry work, medical emergencies such as burns, heat
stroke, eye injury or carbon monoxide poisoning are sufficiently probable to warrant the
development of special procedures and the provision of emergency equipment.

GENE THERAPY
A gene contains the set of instructions that a cell needs to produce a particular gene
product (usually a protein).
• Proteins are large molecules that perform various essential functions in the body.
• Genetic diseases are caused by malfunctioning gene(s). Malfunctions can be inherited,
occur at birth or be randomly acquired due to environmental or lifestyle factors, such as
exposure to toxins.
• Single gene disorders, such as Cystic Fibrosis are caused by a single gene malfunctioning
and are usually inherited.
• Complex genetic diseases, such as Parkinson‘s disease, cancer or cardio-vascular diseases
result when environmental factors cause malfunctions in genes, or combine with the presence
of one or more malfunctioning genes. These diseases have a genetic component, but are not
necessarily inherited.
Definition: Gene therapy is ‗the use of genes as medicine‘ involving the transfer of a
therapeutic or working copy of a gene into specific cells of an individual in order to repair a
faulty gene copy. The technique may be used to replace a faulty gene, or to introduce a new
gene whose function is to cure or to favourably modify the clinical course of a condition
The first clinical gene transfer (albeit only a marker gene) in an approved protocol
took place on 22 May 1989 for the transfer of gene-marked immune cells (specifically,
tumor- infiltrating lymphocytes, or TIL) into patients with advanced cancer. The protocol had
two primary objectives: (i) to demonstrate that an exogenous gene could be safely transferred
into a patient and (ii) to demonstrate that the gene could be detected in cells taken back out of
the patient
Gene therapy was used in 2000 by a French research group in the treatment of a form
of immune deficiency due to a mutation in a gene located on the X chromosome (Severe

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Combined Immune Deficiency). When two of the children treated developed leukaemia in
2002 and 2003, caused when the virus used to deliver the therapeutic gene activated a cancer-
causing gene, the clinical trials were stopped but have now been resumed only for patients
with no other treatment options
SOMATIC GENE THERAPY: It will only change cells in the body of the person being
treated, and not be passed on to children. Somatic gene therapy can be targeted to, for
example, the liver, blood or lungs, to correct a medical problem which already exists and
which can be treated by the gene or its protein product, such as an inherited disease or cancer.
Sperm and egg cells are different.
GERM CELL GENE THERAPY
They are the cells which go to form the individuals of the next generation and pass the genes
from both parents to the offspring. It would involve the deliberate insertion of a gene into the
germ cells, deletion of a gene from them, or alteration of a gene already there. Most people
agree that germ line therapy raises serious ethical issues, since changes would be inherited.
Procedure: Genetic therapy uses purified preparations of a gene or a fraction of a gene to
treat a disease. This can be done either by correcting the functioning of a cell in which a
single gene does not work properly from birth or sometimes by killing a cell which is out of
control. Therefore diseases such as cystic fibrosis, diabetes, Parkinson's, Alzheimer's, heart
disease and cancer are the candidates for this.
There are several approaches to the introduction of genetic material into a somatic
cell. These include direct injection of the gene into the cell, using a VIRUS to carry a gene
into a human cell, or merging it into the cell with a fat particle called a LIPOSOME, or an
antibody like protein that can recognise the cell surface. These techniques are in their infancy,
but are already being used in trials to attempt to treat several rare inherited diseases such as
cystic fibrosis, and some cancers.
Several approaches for correcting faulty genes:
 A normal gene may be inserted into a nonspecific location within the genome to
replace a nonfunctional gene. This approach is most common.
 An abnormal gene could be swapped for a normal gene through homologous
recombination.
 The abnormal gene could be repaired through selective reverse mutation, which
returns the gene to its normal function.
 The regulation (the degree to which a gene is turned on or off) of a particular gene
could be altered.
Viral vectors used in gene therapy trials
Viral vectors are most commonly used, as viruses have evolved a way to deliver their genes
to specific human cells. Vectors can be rendered harmless by removing viral genes and
replacing them with therapeutic genes. Some types of viral vectors include modified versions
of the following:
• Pox viruses that normally cause pox diseases
• Adenoviruses that, unmodified, are responsible for mild respiratory infections, such as colds
• Retroviruses that normally cause disease in mice but that can also infect human cells
• Herpes viruses that can affect the skin and nervous system (used in 10% of UK trials);

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• Lentiviruses, a type of retrovirus that normally causes HIV/AIDS

The challenge of developing successful gene therapy for any specific condition is
considerable:
– The condition in question must be well understood
– The underlying faulty gene must be identified and a working copy of the gene involved
must be available
– The specific cells in the body requiring treatment must be identified and accessible
– A means of efficiently delivering working copies of the gene to these cells must be
available
What factors have kept gene therapy from becoming an effective treatment for genetic
disease?
 Short-lived nature of gene therapy - Before gene therapy can become a permanent
cure for any condition, the therapeutic DNA introduced into target cells must remain
functional and the cells containing the therapeutic DNA must be long-lived and stable
 Immune response - Anytime a foreign object is introduced into human tissues, the
immune system is designed to attack the invader. The risk of stimulating the immune
system in a way that reduces gene therapy effectiveness is always a potential risk.
 Problems with viral vectors - Viruses, while the carrier of choice in most gene
therapy studies, present a variety of potential problems to the patient --toxicity,
immune and inflammatory responses, and gene control and targeting issues
 Multigene disorders - Conditions or disorders that arise from mutations in a single
gene are the best candidates for gene therapy. Unfortunately, some the most
commonly occurring disorders, such as heart disease, high blood pressure,
Alzheimer's disease, arthritis, and diabetes, are caused by the combined effects of
variations in many genes.
Ethical and Social Implications
There is now a general consensus that somatic cell gene therapy for the purpose of treating a
serious disease is an ethical therapeutic option. However, considerable controversy exists as
to whether or not germline gene therapy would be ethical The issues are both medical and
philosophical. The medical concern is that genetic manipulation of the germline could
produce damage in future generations. Medicine is an inexact science; we still understand
very little about how the human body works. Well-intentioned efforts at treatment with
standard therapeutics can produce unexpected problems months or years later. Altering the
genetic information in a patient's cells may result in long-term side effects that are
unpredictable at present. Until the time comes that it is possible to correct the defective gene
itself by homologous recombination (rather than just inserting a normal copy of the gene
elsewhere in the genome), the danger exists of producing a germline mutagenic event when
the "normal" gene is inserted. Therefore, considerable experience with germline manipulation
in animals, as well as with somatic cell gene therapy in humans, should be obtained before
considering human germline therapy.

The Future

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Gene therapy will have a major impact on the health care of our population only when
vectors are developed that can safely and efficiently be injected directly into patients as drugs
like insulin are now. Vectors need to be engineered that will target specific cell types, insert
their genetic information into a safe site in the genome, and be regulated by normal
physiological signals. When efficient vectors of this type are produced-retroviral, viral,
synthetic, or a combination of all three-then gene therapy will probably have a profound
impact on the practice of medicine. As information from the Human Genome Project is now
available concerning the entire library of genetic information in our cells, gene therapy
probably be used not only to cure an array of diseases, but also to prevent many disorders by
providing protective genes before the diseases become manifest. Although the medical
potential is bright, the possibility for misuse of genetic engineering technology looms large,
so society must ensure that gene therapy is used only for the treatment of disease.

POPULATION GENETICS
Population genetics is concerned with the study of the genetic composition of
populations. This composition may be changed by segregation, selection, mutation,
recombination, mating structure, migration, and other genetic, ecological, and evolutionary
factors. Therefore, in population genetics these mechanisms and their interactions and
evolutionary consequences are investigated.
Traditionally, population genetics has been applied to animal and plant breeding, to
human genetics, and more recently to ecology and conservation biology One of the main
subjects is the investigation of the mechanisms that generate and maintain genetic variability
in populations, and the study of how this genetic variation, shaped by environmental
influences, leads to evolutionary change, adaptation, and speciation.
Mathematical models and methods have a long history in population genetics, tracing
back to Gregor Mendel, who used elementary mathematics to calculate the expected
frequencies of the genes in his experiments. Mendel's (1866) prime achievement was the
recognition of the particulate nature of the hereditary determinants, now called genes. A gene
may have different forms, called alleles. From his experiments with peas he concluded that
genes are present in pairs, one member of each pair having been inherited from the maternal
parent, the other from the paternal. The allelic composition is called the genotype, and the set
of observable properties derived from the genotype is called the phenotype.

HARDY-WEINBERG LAW
A population that is not changing genetically is said to be at Hardy–Weinberg
equilibrium
Assumptions of Hardy-Weinberg Model
 Diploid organism
 Sexual reproduction
 Non-overlapping generations
 Random mating

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 Large population
 Equal allele frequency in the sexes
 No migration
 No mutation
 No natural selection
HARDY-WEINBERG & EVOLUTION
 Biologists can determine whether an agent of evolution is acting on a population by
comparing the population‘s genotype frequencies with Hardy–Weinberg equilibrium
frequencies.
 If there is no change in frequencies, there is no evolution
 Conversely, if there have been changes in the frequencies, then evolution has
occurred.
 Evolution is change of allelic frequencies
Mathametically
 In a population at Hardy–Weinberg equilibrium, allele frequencies remain the same
from generation to generation, and genotype frequencies remain in the proportions p2
+ 2pq + q2 = 1.
 Two equations
 p+q=1
 A + a = 1, where A and a equal gene percentages
 All dominant alleles plus all recessive alleles add up to all of the alleles
for a particular gene in a population
 Allele frequencies
 p2 + 2pq + q2 = 1
 AA + 2Aa + aa = 1
 For a particular gene, all homozygous dominant individuals plus all
heterozygous individuals plus all homozygous recess individuals add
up to all of the individuals in the population
 Genotype frequencies

ALLELE FREQUENCY VARIATIONS

 Hardy-Weinberg applies only if there is genetic equilibrium or no allele frequency
changes
 Causes of allele frequency variations
 Mutation
 Migration
 Non-random mating
 Genetic drift
 Natural selection

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 How often in nature do NONE of these occur?

 Rarely, if ever.
Natural selection: It is the process by which heritable traits that make it more likely for an
organism to survive and successfully reproduce become more common in a population over
successive generations.
The natural genetic variation within a population of organisms means that some individuals
will survive more successfully than others in their current environment. Factors which affect
reproductive success are also important, an issue which Charles Darwin developed in his
ideas on sexual selection
Natural selection acts on the phenotype, or the observable characteristics of an organism, but
the genetic (heritable) basis of any phenotype which gives a reproductive advantage will
become more common in a population (see allele frequency). Over time, this process can
result in adaptations that specialize organisms for particular ecological niches and may
eventually result in the emergence of new species.
Natural selection is one of the cornerstones of modern biology. The term was introduced by
Darwin in his groundbreaking 1859 book On the Origin of Specis in which natural selection
was described by analogy to artificial selection, a process by which animals and plants with
traits considered desirable by human breeders are systematically favored for reproduction.
The concept of natural selection was originally developed in the absence of a valid theory of
heredit; at the time of Darwin's writing, nothing was known of modern genetics. The union of
traditional Darwinian evolution with subsequent discoveries in classical and molecular
genetics is termed the modern evolutionary synthesis. Natural selection remains the primary
explanation for adaptive evolution.
Genetic drift: It is the change in the relative frequency in which a gene variant occurs in a
population due to random sampling and chance. That is, the alleles in the offspring in the
population are a random sample of those in the parents. And chance has a role in determining
whether a given individual survives and reproduces. A population's allele frequency is the
fraction or percentage of its gene copies compared to the total number of gene alleles that
share a particular form.
Genetic drift is an important evolutionary process which leads to changes in allele
frequencies over time. It may cause gene variants to disappear completely, and thereby
reduce genetic variability. In contrast to natural selection, which makes gene variants more
common or less common depending on their reproductive success, the changes due to genetic
drift are not driven by environmental or adaptive pressures, and may be beneficial, neutral, or
detrimental to reproductive success.
The effect of genetic drift is larger in small populations, and smaller in large populations.
Vigorous debates wage among scientists over the relative importance of genetic drift
compared with natural selection.
Mutation: Mutations are changes in the DNA sequence of a cell's genome and are caused by
radiation, viruses, transposons and mutagenic chemicals, as well as errors that occur during
meiosis or DNA replication Errors are introduced particularly often in the process of DNA
replication, in the polymerization of the second strand. These errors can also be induced by
the organism itself, by cellular processes such as hypermutation.
Mutations can have an impact on the phenotype of an organism, especially if they occur
within the protein coding sequence of a gene. Error rates are usually very low (1 error in
every 10 million–100 million bases) due to the "proofreading" ability of DNA polymerases

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Without proofreading, error rates are a thousandfold higher. Chemical damage to DNA
occurs naturally as well, and cells use DNA repair mechanisms to repair mismatches and
breaks in DNA. Nevertheless, the repair sometimes fails to return the DNA to its original
sequence.
Gene flow: It is the exchange of genes between populations, which are usually of the same
species. Examples of gene flow within a species include the migration and then breeding of
organisms, or the exchange of pollen. Gene transfer between species includes the formation
of hybrid organisms and horizontal gene transfer.
Migration into or out of a population can change allele frequencies, as well as introducing
genetic variation into a population. Immigration may add new genetic material to the
established gene pool of a population. Conversely, emigration may remove genetic material.
As barriers to reproduction between two diverging populations are required for the
populations to become new species, gene flow may slow this process by spreading genetic
differences between the populations. Gene flow is hindered by mountain ranges, oceans and
deserts or even man-made structures such as the Great Wall of China, which has hindered the
flow of plant genes.
Gene flow is the transfer of alleles from one population to another. Migration into or out of a
population may be responsible for a marked change in allele frequencies. Immigration may
also result in the addition of new genetic variants to the established gene pool of a particular
species or population.
There are a number of factors that affect the rate of gene flow between different populations.
One of the most significant factors is mobility, as greater mobility of an individual tends to
give it greater migratory potential. Animals tend to be more mobile than plants, although
pollen and seeds may be carried great distances by animals or wind.
Maintained gene flow between two populations can also lead to a combination of the two
gene pools, reducing the genetic variation between the two groups. It is for this reason that
gene flow strongly acts against speciation, by recombining the gene pools of the groups, and
thus, repairing the developing differences in genetic variation that would have led to full
speciation and creation of daughter species.
For example, if a species of grass grows on both sides of a highway, pollen is likely to be
transported from one side to the other and vice versa. If this pollen is able to fertilise the plant
where it ends up and produce viable offspring, then the alleles in the pollen have effectively
been able to move from the population on one side of the highway to the other.

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LIFE TABLE
Introduction: A life table is a particular way of expressing death rates which is expressed by
some particular population during a chosen period of time.
After acquiring knowledge about morbidity, mortality & fertility we can develop/
predict the average number of years a newly born baby can survive in the world – life
expectancy at birth. Similarly it is also possible to define life expectancy at one year, five
year of life this is obtained by uses of life table.
Types of life table
 Current life table
 Cohort life table
 Construction of life/ survivorship table
Current life table: Describes the survival pattern of a group of individuals subjected
throughout life to the age specific death rates currently observed in a particular community.
Ex; it can be used as an alternative to methods of standardisation for comparison between the
mortality patterns of different communities.
Cohort life table: Shows actual survival experience of a group/ cohort of individuals born at
about the same time ie it summarises the mortality at different ages at the times when the
cohort would have been at these ages
Ex: occupational mortality
Construction of life/ survivorship table: for estimating survival rates after radiotherapy or
neurosurgery or antimalignancy treatment in the patients (modified table is used here)
Uses of life tables:
William Fare called life table the biometer of the population. It is an important basic material
in demographic & public health studies.
1. Find out expectancy of life at birth or any age. By this we can assess a countries
socio-economic & health development as mortality will go on decreasing naturally
average expectation of life will increases.
2. Estimating number of males who can healthy (ie achieve age at 22 years for legal
marriage) & hence become target for family planning methods. Similarly no of
children requiring high school education facilities. Number of old people requiring
social support can be estimated. Probable no. of future widows/ orphans etc.
3. Life insurance companies to fix their premium & policies which is based entirely on
the prevailing mortality pattern in the region as evident in the life table
4. Estimating the survival rates after radiotherapy or neurosurgery or antimalignancy
treatment in the patient.
5. Life table techniques are being increasingly applied to follow up studies of chronic
diseases of hospital patients Ex; cancer, kidney transplant, MI
6. Others- study the trends in age distribution of a population. Estimation of the size of
a future labour force.
Construction of Life table
1. The basic element of the life table is the probability of dying between one age to the
next.
2. The number of survivors at any given age out of those starting at age zero.

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3. The probability of surviving from one age to another (the ratio of the survivors at a
given age to the survivors at a previous age)
4. Expectancy of life:
In practice it is not often possible to construct a life table by the method described above
since they require knowledge of the population & death in a single year of life.
Alternatively there are available for public health work excellent shall methods of making
a life table from actual death rates observe in different age groups.
Life tables are usually worked out after each decennial census to represent mortality
condition during the previous decennium or during shorter period covering the date of census.

ROLE OF HOSPITALS IN PRIMARY HEALTH CARE

Introduction : despite tremendous strides in health sciences technology the health status of
the majority of the world (40% -60%) population remains poor, large no. of world‘s
population still has limited access to health services/ no access at all
The available services are often provide mainly curative & isolated manner ―Medical
care system.‖
There was a lack of proper balance among promotive, preventive, curative,
rehabilitative & socio-medical care. All this led to major problems – (criticism of hospitals)
• Low level of effectiveness
• Escalating costs
• Isolation in community – an ivory towers of disease
Historically there are 2 crucial events – comprehensive approach to development of
national health system
1. WHA in 1977 the adoption of concept of Health for all by 2000 AD
2. International conference at Alma Atta 1978 – concept of primary health care as
leading strategy in achieving ―health for all‖
Within this picture hospitals have a very important role to play in promoting, supporting
& providing primary health care not only in developing countries but also in any country
whatever be the degree of social & economic development.
*Write briefly about PHC, elements, principles.*
Development of hospital:
The term hospital is derived from the word ―hospitum‖ which was an house of stopping
place for strangers & traveller later on this became a place for segregation & care of the
sick & poor mostly those suffering from terminal or chronic illness.
Main objective
• To provide adequate care & treatment of the patients
• Highly personalised service to individual patient
WHO Definition: organisation that mobilises the skills and efforts of widely divergent
group of professional, semi-professional & non-professional personnel to provide highly
personalised service to patients.

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Functions of hospitals:
1. Curative: diagnosis, treatment, rehabilitation and provides emergency care
2. Prevention of disease & promotion of health: Immunization, supervision of
MCH & family welfare, control of various communicable & NCD & health
education
3. Surveillance centre: For both communicable & NCD they generate reliable
mortality and morbidity data to which the hospitals are rendering services.
4. Education & Research: Basic education in- service training for graduate & post
graduate doctors and other Para-medical staff
5. Early detection of epidemics: OPD‘s play an important role in early detection of
epidemic along with the definite geographical mapping of that area & the
population at risk.
6. Professional support: to medical practitioners
7. PHC programme:
Need for hospital involvement in PHC:
• Primary health care can‘t work without the effective support to deal with the referred
patients – who need more special care
• Hospitals can play and should play a very important & vital role for providing
primary health care to the community.
Specific role of hospital
Health promotion: includes activities like lifestyle change or improvement programme,
physical fitness, dental care, nutrition education stress control, dental care, youth
counselling, marriage counselling, motherhood preparation, eye care.
Preventive health care: immunization, school health services, stop-smoking clinic
Family planning: Health education, family planning services, training of the health
workders.
Health education: Through radio programme, telemedicine, posters,
Rehabilitation programme: Leprosy/polio rehabilitation, day care centres, nutrition
rehabilitation de-addiction and alcohol rehabilitation.
Administrative supportive for PHC:
Conclusion: A general hospital can‘t work in isolation & it must be a part of social &
medical segment that provides complete health care

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REMOTE SENSING IN VECTOR BORNE DISEASE CONTROL

Literal meaning to sense any object from a distance
Human‘s eyes & camera also act as remote sense devices
Scientists of NASA ( National aeronautics & space administration) of USA used colour
infrared aerial photography to identify the habitats of a nuisance mosquito (Aedes) in 1971
Principle: Every object absorbs some part of radiation received from sunlight. This depends
in its physical & chemical properties and it varies from object to object.
• After the object absorbs some part of the radiation it reflects the remaining part in
specific wave length of electromagnetic spectrum (EMS)
• The reflected energy is channelized through telescope to detectors / sensors present on
board of satellite
• The sensors are sensitive to different bands of EMS & they convert the light energy
electrical voltages producing 2 dimensional picture.
• When satellite passes over a particular part of the earth at fixed time interval
repeatedly it helps to monitor the changes in the land use categories.
• Ex. Water bodies, human settlements etc.
Application
• Urban development
• Road network
• Lives
• Crop estimation
In India National remote sensing agency Hyderabad in collaboration with ISRO (Indian
space research Organisation) has carried out the remote sensing
Viz: water bodies & vegetation with mosquito density
This is used as a tool for surveillance of vector borne disease
Ex; their habitats, densities of vectors, prediction of incidence of disease can be done
Uses: prioritizing the control measure in a cost effective way.

ANTIMICROBIAL RESISTANCE:
Antimicrobial agent: Chemical that kills or inhibits the growth of microorganisms
Definition: Relative or complete lack of effect of antimicrobial against a previously
susceptible microbe
Antimicrobial resistance is a public health threat driven by healthcare practices, most
notably the overuse of antimicrobials in conditions for which they provide no benefit.
It is said that ―Doctors are men who prescribe medicines of which they know little; to
cure diseases of which they know less; in human beings of whom they know nothing‖ -
Voltaire
Factors promoting antimicrobial resistance

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• Exposure to sub-optimal levels of antimicrobial

• Exposure to microbes carrying resistance genes
• Inappropriate Antimicrobial Use
o Prescription not taken correctly
o The Poverty Paradigm: Drug Access and Resistance
o Misdiagnosis, Antibiotics for viral infections, broader-spectrum antibiotics
prescribed unnecessarily
o Antibiotics sold without medical supervision and also without prescription
o Spread of resistant microbes in hospitals due to lack of hygiene
o Counterfeit Drugs, Lack of quality control in manufacture or outdated
antimicrobial
o Inadequate surveillance or defective susceptibility assays
• Antibiotics are used in animal feeds and sprayed on plants to prevent infection and
promote growth
o Farmers, fish-farmers and livestock producers have used antimicrobials in everything
from apples to aquaculture. Currently, only half of all antibiotics produced are slated
for human consumption. The other 50% are used to treat sick animals, as growth
promoters in livestock, and to rid cultivated foodstuffs of various destructive
organisms. This ongoing and often low-level dosing for growth and prophylaxis
inevitably results in the development of resistance in bacteria in or near livestock, and
also heightens fears of new resistant strains "jumping" between species. Vancomycin-
resistant Enterococcus faecium (VRE) is one particularly ominous example of a
resistant bacterium appearing in animals that may have "jumped" into more
vulnerable segments of the human population.
o Multi drug-resistant Salmonella typhi has been found in 4 states in 18 people who ate
beef fed antibiotics
Microbiological aspect of resistance development: Pathogens develop resistance to
antimicrobials through a process known as natural selection. When a microbial population is
exposed to an antibiotic, more susceptible organisms will succumb, leaving behind only those
resistant to the antimicrobial onslaught. These organisms can then either pass on their
resistance genes to their offspring by replication, or to other related bacteria through
"conjugation" whereby plasmids carrying the genes "jump" from one organism to another.
This process is a natural, unstoppable phenomenon exacerbated by the abuse, overuse and
misuse of antimicrobials in the treatment of human illness and in animal husbandry,
aquaculture and agriculture. Our challenge is to slow the rate at which resistance develops
and spreads.
Some Leading Resistant Pathogens
Bacteria - Community
 Escherichica coli
 Mybocaterium tuberculosis
 Neisseria gonorrhoeae
 Salmonella Typhi
 Staphylococcus aureus, including community-associated MRSA (Methicillin-
Resistant S. aureus)
 Streptococcus pneumonia

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Bacteria - Hospitals
 Acinetobacter baumannii
 Enterococcus faecium and Enterococcus faecalis, including VRE (Vancomycin-
resistant enterococci)
 Multidrug-resistant enteric pathogens, including Escherichia coli and Klebsiella
pneumoniae producing ESBL and KPC enzymes
 Pseudomonas aeruginosa
 Staphylococcus aureus, including MRSA (Methicillin-Resistant S. aureus)
 Stenotrophomonas maltophilia
Bacteria - Zoonotic disease
 Campylobacter species, Salmonella species
Fungi
 Candida albicans
Parasites
 Leishmania species, Plasmodium species, Trypanosoma species
Viruses
 Cytomyegalovirus, Herpes simplex virus, HIV
Big guns of resistance
 Pneumonia
 Diarrhoeal Diseases
 AIDS
 Tuberculosis
 Malaria
 Viral Hepatitis
 Hospital-Acquired Infections
Consequences of antimicrobial resistance
 Mortality: resistant infections are more often fatal
 Morbidity: prolonged illness, greater chance for resistant organisms to spread to
other people
 Cost: Increased costs of care, newere, more expensive drugs.
 Limited solutions: Few new drugs on the horizon
Measures to Combat Antimicrobial Resistance
• Adopt WHO strategies and policies
• Use the correct drug by the best route in the right amount at optimal intervals for the
appropriate period after an accurate diagnosis.
• Educate health workers and the public on the use of medicines
• Contain resistance in the hospital
• Reduce the use of antimicrobials in animals
• Increase research for new drugs and vaccines
• Increase availability of essential drugs
• Make effective medicines accessible to the poor

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• Track resistance data nationwide

• Direct observed dosing (TB)
• Use more narrow spectrum antibiotics
Way forword:
 The Threat of Antimicrobial Resistance is Growing
 The Window of Opportunity is Closing
 A Massive Effort is Required

EVOLUTION OF CONCEPT OF IUCD

The practice of contraception is likely as old as humanity itself. Ancient writings
describe the use of vaginal & barrier contraception some 4000 years ago. The papyrus dating
back to 1850 BC and the oldest written document referring to contraceptive techniques
describes a pessary of crocodile dung.
IUCD- the past
The modern IUD is a 20th century development. In 1902 German physician Carl
Hollweg developed the first IUD. In 1909 another German doctor, Dr. Richard Richter
described the first true IUD. The device consisted of 2 coarse strands of silkworm gut made
into a ring shape and capped with celluloid. These devices did not make ground possibly
because of German laws prohibiting birth control.
In 1929 Ernst Grafenberg became the first doctor to report the clinical performance of
an IUD – a 3% pregnancy rate among 1100 women using his silk suture wrapped in silver
ring without the knowledge of copper contamination of his silver ring Grafenberg performed
this experiment. Copper‘s role in increasing IUD efficiency was made known only 40 years
later. Nazi regime & World War II brought a halt to all contraception research work in
germany and elsewhere.
In 1962 the population council organised the first international conference on IUD. In
this conference a US physician Jack Lippes presented data on his Lippes Loop a winding
serpentine device with a monofilament tail to facilitate removal. The IUD‘s trapezoid shape
conformed better to the uterine cavity than its predecessors. This became the most widely
accepted IUD in the US during 1970.
Further IUD advances included the development of copper bearing and hormone
releasing devices. In 1969 Chilean physician Jaime Zipper described the first copper bearing
IUD, a T shaped device with 200 m of exposed copped wire wound round the vertical shaft
IUCD the present & future:
Lippes loop is considered as first generation IUD. Copper containing IUD‘s are called second
generation IUD‘s the newer devices in use today are
1. Variants of the T device – T Cu 220 C, T Cu 380 A or Ag
2. Nova T
3. Multiload device – ML-Cu-250, ML – Cu -375

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The numbers included in the names of the devices refer to the surface are (in sq m) of
the copper on the device. Nova T & T Cu 380 Ag are distinguished by a silver core over
which is wrapped the copper wire.
Third generation IUD‘s: these are based on the principle of hormone release and not routinely
used in India. The most widely used is progestasert which is a T shaped device filled with 38
mg of progesterone, the natural hormone. The hormoneis release slowly in the uterus at the
rate 65 mcg daily. Another hormonal device LNG-20 (Mirena) is a T shaped IUD releasing
20mcg of levonorgestrel.

MEDICAL OFFICER AS A MANAGER OF HEALTH TEAM

The medical officer is the person in charge of PHC and involved in preventive, promotive,
curative and rehabilitative services. The Alma Ata conference envisaged health for all by
2000 AD taking primary health care approach. PHC is the pivotal link in the health care
delivery systems. The role of medical officer has undergone a paradigm shift since the Alma
Ata conference. Medical officer is defined as ―A doctor, trainer, counsellor and leader. He
also considered as health manager, the emphasis has shifted from the clinician role (technical
role) to managerial role (team leader role).
The medical officer heads a team comprised of medical, auxiliary medical and non
medical personnel, supervisor of their work is very important job responsibility of MO as a
technical worker. The MO is doing some of the following works
1. Diagnosis and treatment of ailments
2. Preventive and monitoring services
3. Training office staff and others
As a manage the medical officer is doing the following
1. Planning, organising and evaluating various national health programmes
2. Supervision of the staff
3. Maintaining adequate supply and equipment
4. Health information system
5. Personnel management and conflict resolution
6. Financial administration
The above responsibilities can be effectively discharged when there is co-operation
between the members of the health team.
The performance of the health team depends upon the commitment and
communication of the MO. The MO is bound to be confronted with several managerial issue
which may not be directly related to his curative responsibilities.
Some of the issues of MO are
1. Non attainment of target under national health programme
2. Insufficient and irregular supplies including drugs
3. Lack of properly trained personnel
4. Difficulty in supervising the peripheral areas due to terrain or lack of transport
5. Lacking behind implementation schedules.
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The above problems may be related to faulty planning direction and supervision,
monitoring and evaluation and implementation of services
The resources in a PHC setup are always in short supply which requires Good
managerial skills on the part of MO to achieve desired results. Management of human
resource happens to be biggest challenge for any MO
Essentially a MO should be well versed in the following managerial functions.
1. Planning: plan the work that needs to be done in keeping view the priorities after
making situational analysis.
2. Organising: bring the plan some shape and establish the formal structure of action
through which works sub-division are arranged.
3. Staffing: the process of recruiting, training and maintenance of favourable conditions
of work
4. Directing: the continuous task of making decision and giving instructions.
5. Co-ordinating: the all important duty by interrelating the various parts of the work
6. Reporting: effective usage of HIS in both direction
7. Budgeting: planning, accounting and control of financial resources.
The above role of MO shows that he is more of a health manager than just a curative
person.

HOSPITAL ACQUIRED INFECTION (NOSOCOMIAL INFECTION)

Infections arising while a patient is in a hospital or arising as a result of being in
hospital/ health care facility, in whom the infection was not present or incubating at the time
of admission.
Includes infections appeared after discharge but acquired during hospital stay. Also
includes infections among staff.
History: -Semmen wellis
-Joseph lister
- Ambrose pare
- some hospitals were burnt due to Hospital acquired infection problem
Prevalence – 7-12%
Epidemiology
Agent: possibly includes the entire spectrum of microbes – gram positive/ negative bacteria,
virus, ricketsia, fungi and protozoa.
20-50% of all HAI are due to gram negative organisms
0.5-5% due to staphylococci
Virus- RSV important in children
Others include proteus, E Coli, Salmonella, Shigella, Klebsiella & psedumonas

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Drug resistance- MRSA, B lactum producing gram negative organisms due to over use,
misuse and abuse of drugs.
Host factors: Extremes of age
Primary ailment with DM, chronic nephritis, malignancy /PEM
Therapeutic procedures- whole body radiation, use of cytotoxic & immunosuppressive drugs
Diagnostic procedures – venepuncture, aspirations, catheterisations & lengthy operative
procedures.
Endogenous infections
Environment:
Humans – staff, other patients, visitors, inanimate environment
Factors increasing the risk of health care-associated infections:
 poor hygiene and waste disposal,
 inadequate infrastructure and equipment,
 understaffing
 overcrowding
 lack of basic infection control knowledge and implementation,
 unsafe procedures, and
 a lack of guidelines and policies
Prevention- Breaking the chain of transmission *(diagram of chain of transmission)*
 At the source
o Coordinated planning & administration –infection control policy & procedure
(committee)
o Placement evaluation
o Personal health & safety education
 In service training
 Pre exposure prophylaxis
o Surveillance
o Isolation
o House keeping, waste management
o Sterilisiation
o Monitoring
 To interrupt the mode of transmission
o Hand washing
o PPE
o Universal precaution
o Barrier nursing
o Screening
o Use of disinfectants
o Good ventilation
o Insect proofing
 Protect susceptible host
o Good nursing & medical management
o Short hospital stay

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o Community based treatment

o Removal of intrusive devices as early as possible
Conclusion: hospital is a complex & changing environment (Dynamic)
Respond to new challenge. Implementing system-wide surveillance, training, education and
good communication, using devices appropriately and following proper procedures, and
ensuring optimal hand hygiene practices

CYBER MEDICINE
Introduction: The evolution of the "information age" in medicine is mirrored in the
exponential growth of medical web pages, increasing numbers of databases accessible on
line, and expanding services and publications available on the internet Medical information is
often said to be one of the most retrieved types of information on the web. In fact, according
to a survey 27% of female and 15% of male internet users say that they access medical
information weekly or daily. More than 100 000 medical websites exist, and their number is
still growing rapidly. The internet revolution in health care is largely driven by a massive
consumer demand for online health resources
Definition: ―The science of applying internet and global networking technologies to
medicine and public health, of studying the impact and implications of the internet, and of
evaluating opportunities and the challenges for health care."
 The fact that patients have access to the same databases as clinicians leads to
increased consumer knowledge, which is pushing clinicians to higher quality
standards and evidence based medicine
 Problems of cyber medicine include the quality of online information, lack of
standards, and lack of social equity
 Cyber medicine is distinctive from telemedicine, although there are overlapping
issues, especially as the internet can also be used as a medium for telemedical
applications. While telemedicine focuses primarily on a restricted exchange of
clinical, confidential data with a limited number of participants, for the most part
between patient and physician or between physician and physician, in cyber medicine
there is a global exchange of open, non-clinical information, mostly between patient
and patient, sometimes between patient and physician, and between physician and
physician
 Telemedicine for the most part is applied to diagnostic and curative medicine, while
cyber medicine is applied to preventive medicine and public health.
In cyber medicine the new role of the consumer redefines the traditional concept of
"prevention" and "health promotion" (that is, the process of enabling people to increase
control over the determinants of health and thereby prevent disease or reduce the impact of
disease), which traditionally implied a formal communication process between the health
professional as sender and the consumer as receiver, whereas on the internet, health
promotion and prevention becomes largely a process between consumer and consumer.
Advantages:
Bridging of gap in healthcare: between the highly developed countries with adequate
healthcare facilities and the developing countries with inadequate healthcare facilities
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Convenience: proximity problem between patients and doctors, difficulties in reaching out to
doctors at odd hours, queuing to see doctors, doctor‘s unavailability round the clock etc are
tackled
Greater access to information
Confidentiality: HIV patients and others
The role of consumers: While most physicians still lag behind other professions in their use
of modern information technology in many parts of the world consumers have taken the lead
in adopting new media for retrieving and exchanging health information. While telemedicine
is often driven by a "technological push," cyber medicine is characterised by a remarkable
"consumer pull."
Problems:
"Cyberhypochondriac": Some patients can translate the knowledge gained from cyber
medicine directly into better health, whereas some may misinterpret the information and get
lost in the thinking of existence of a disease.
Quality issues and other problems
The quality of information is a critical factor for the use of cyber medicine for consumer
empowerment, patient support, health education, and evidence based medicine
After seeing the most available information reliability, accessibility, and completeness of
information and advice found on the internet are extremely variable, ranging from the useful
to the dangerous. While a similar problem is also known from traditional media such as
magazines, newspapers, and television, the internet adds a new dimension because, firstly,
everybody can be a publisher (often without any quality or editorial control at the stage of
production), secondly, originators of messages and their credibility are difficult to assess for
readers, many rating systems on the web are "incompletely developed instruments
The illegal drug sales: By the e-pharmacy companies
The doctor-patient relationship
The doctor-patient relationship though not an ethical principle, is an important relation in
healthcare that goes a long way in helping the healing of patients. There are doubts if doctor-
patient relationship exists in cyber medicine
Future developments: towards a universal medical knowledge base
 The internet will change radically in the coming millennium. One major revolution on
the web will be a "quantity leap," The next generation internet will operate at speeds
up to a thousand times faster than today. Sight, sound, and even touch will be
integrated through powerful computers, displays, and networks. Patients will be able
to videoconference with their healthcare providers, security problems will be
resolved, and the internet will increasingly be used for transmitting clinical data,
linked with and integrated into educational resources.
 The second revolution will lead to a "quality leap." Up to now, the web has been
primarily used for human to human communication. The vision of the web, however,
goes beyond this the second side to the web, yet to emerge, is that of "machine
understandable information."
Conclusion:

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A newer technology adopted by field of medicine doing the equal harm as benefit to the
society at present.
The real beneficiaries should be those where there is lack of health facility like in
underdeveloped countries. The tragedy is lack of internet facility is an addendum in such
places.

CANCER REGISTRIES
History: until 1964 information on cancer occurrence in India was available from survey.
Initiation of population based cancer registries at Bombay in 1964, Pune in 1973, at
Aurangabad in 1978 and at Ahmadabad & Nagpur in 1980 started the availability of data on
cancer incidence on a continuous basis. However the boost of cancer registration in India was
in 1982 through the initiation of National cancer registry programme (NCRP) by ICMR. The
NCRP began with three population based registry (existing Bombay & new registries at
Bangalore and Madra) & three hospital based registries at (Chandigarh, Dibrugarh,
Trivandrum) further expansion saw initiation of urban population based registry at Bhopal &
Delhi & rural in Barshi (Maharashtra) & hospital based registry at main hospitals of
population based registries at Bangalore, Bombay and Madras in 1986.
Cancer registration is a mechanism to collect & classify information on all cancer cases in
order to produce statistics on the occurrence of cancer & to provide framework for assessing
& controlling the impact of cancer on the community.
Types:
1. Population based registries collect & process data relating to a defined
geographical area
2. Hospital based collect & process data relating to specific hospitals
Population based cancer registries record all the new cancer cases occurring in a
defined population (generally a geographical area) with epidemiological & public health
aspects in mind.
Population based cancer registries collects information on all cancer case be able to
all distinguish the residents of the defined geographical area from persons residing outside
have acess to all sources diagnosing or treating cancer in that area, should be able to detect
multiple registration, should have population figure by sex, five years age group. And should
be large enough to provide meaningful figure (most cover population between 1-5million)
Hospital based cancer registries record information on cancer patients attending a
particular hospital with focus on clinical care & hospital administration
Methodology: cancer registration is active in that staff of registries visit hospital on a routine
bases & scrutinize the records in various departments (pathology, radiology, radiotherapy, in-
patient wards & OPD) death certificates are also verified. Information collected in a
prescribed format with specified guidelines and data collected entered on a computer. All
malignant neoplasms are coded as per ICD for oncology (ICD-0)
Certain basic checks for duplication verification & matching with mortality records
are carried out. After this data is sent to the co-ordinating unit.

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META ANALYSIS
Defintion: the statistical analysis of a large collection of analysis results for the purpose of
integrating the findings.
The basic purpose of meta analysis is to provide the same methodological rigor to a literature
review that are required from experimental research.
Direct investigation of human or animal data is called a primary research. Providing a report
of primary research using statistical methodology & analysis is called quantitative synthesis
meta analysis.
Types:
1. Meta-analysis to describe the overall strength of the effect.
2. Metanalytic summaries – Meta-analysis used to provide information
supporting a specific theoretical statement usually about the overall strength or
consistency of a relationship with in the studies being conducte.
Criticism;
1. Meta-analysis adds to apples & oranges. Over generalisation can occur in meta-
analysis.
2. Publication bias - if unpublished findings not received
Rationale: In today‘s world where no one has the time & patience to go through the volume
of research being done, met-analysis summarises the results of various studies done in a
scientific & methodical manners.
Steps:
1. Defining the question: the question should be focussed. It should not be too broad
2. Detailing the selection criteria: prepare a checklist so that criteria can be applied in a
uniform fashion. Include all the reasons for accepting or rejecting articles.
3. Doing search: searching the literature using computerized databases such as medline,
PsycINFO, EMBASE, CINAHL etc, but we may miss many of the relevant articles. A
number of studies have found that even small changes in the search strategy result in
very different sets of articles being retrieved hand-searching the five to 10 most
relevant journals, Cochrane data base of systematic revies and DARE, (the Database
of Abstracts of Reviews of Effectiveness) are useful in searching. Dissertation
abstracts, unpublished results by writing to the authors. Proceedings of meetings.
Writing to drug manufactures who have sponsored the trials
4. Selecting the articles: The article obtained from search should be selected according
to the selection criteria Independent reviewers can be used to evaluate each article.
This should be done till the reliability is over 90%. Studies published in many places
with little modification, multicentre studies each centre data is published, the interim
reports an ongoing study. Then use only the last publication.
5. Appraising the articles: once the articles are included the articles need to be
appraised. Not all studies are equal looking at internal & external validity of the study.
Number of checklists are available that allow people to evaluate the design and
execution of a study
6. Abstracting the results: key elements of each study now have to be abstracted from
the articles and entered into a spreadsheet, or a program specifically designed to do
meta-analyses; One decision that should be made before the articles are abstracted is
which outcome measure to use when two or more are reported. If there are many
outcomes – pooled into one measure or select one outcome.

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7. Calculating the effect sizes: One major problem in combining various studies is that
they often use different outcome measures. Thus a common yardstick has to be
found so that all the results are reported using the same metric. For therapy trials the
most commonly used measure is the effect size. ES- continuous measures calculating
using means, standard deviation. Qualitative variables( Dichotomous – OR – case
control, RR – RCT, Cohort)
8. Checking for publication bias: The most widely used method for determining the
publication bias may be operating is to draw a funnel plot. Effect size on x-axis and
an index of the study‘s size on the Y-axis. This could be the sample size itself, or the
reciprocal of the standard error (if we used the standard error itself, the funnel would
be upside down). The rationale for the plot is that smaller studies have less precise
estimates of the true ES, and so their results would vary from one study to the next.
With larger sample sizes (or smaller standard errors), the estimates of the ES should
cluster closer to the true ES, resulting in the pyramidal shape.

If publication bias is present then the funnel is asymmetrical because non-significant

studies are excluded.
9. Testing for homogeneity: It is important to determine how similar their results are
before combining the results of the individual studies. If all of the studies report ESs
in the same ballpark, then we are more confident that they‘re all reporting the same
phenomenon and that the pooled ES is a good estimate of what‘s really going on.
10. Combining the studies: Once the ES has been derived for each study, we have to
summarize (or ―pool") them in some way to get an estimate of the mean; that is, an
overall estimate of the effectiveness or ineffectiveness of the intervention. The
simplest way is to add them up and divide by the number of ESs But this method
gives equal weight to studies that looked at 10 patients and those that looked at 1,000.
Intuitively, it seems obvious that we should give more credit to larger studies, because
their results are more stable. We do this by weighting each effect size. The weight that
is applied to each study is the reciprocal of its squared standard error(SE):
11. Looking for influential factors: Even if the test for homogeneity is not statistically
significant, there will be some degree of variability among the ESs. We can now look
to see what accounts for the differences. Basically, we run a multiple regression,
where the ESs are the dependent variable, and the design features we coded in Step 6
are the predictors
12. Selecting the type of analysis: There are two general approaches to analyzing the
results of met analyses: a fixed-effects model and a random-effects mode. A fixed-

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effects model assumes that there is a ―true‖ effect size that underlies all of the studies,
and that they differ among each other only because of sampling error. A random-
effects model makes the assumption that there is a population of effect sizes, from
which the studies in the meta analysis are a random sample the two types of analyses
yield different results. A fixed-effects model is less conservative and may give
statistically significant results in some situations when a random-effects model will
not. A fixed-effects model is appropriate if we want to draw conclusions about the
particular set of articles in the meta-analysis. That is, it does not allow us to say
anything about studies that may have been missed or those that will be done in the
future. Random-effects model is perhaps more realistic in two regards. First, by
saying that there is a population of effect sizes, the model acknowledges the fact that
studies differ with respect to the sample, the procedures used and other aspects of the
design, all of which may result in different findings. Second, it allows us to generalize
from this particular set of articles to studies of this phenomenon in general; studies we
did not include and studies yet to be done.
Summary: Meta-analysis is neither the answer to all of the world's ills, nor the greatest
scourge visited upon humanity since the Black Plague. Carefully done and used intelligently
it can be a very powerful tool for synthesizing the literature in a field, sometimes bringing
clarity where there had been confusion. This is particularly true when the effect we are
looking for is small, and even very large trials may not have sufficient power to tease out a
definitive conclusion. Meta-analyses should not be regarded as ―truth,‖ only as a better
approximation of it than individual studies. Used in this way, and tempered by clinical
experience, they can assist the clinician in deciding what may work and what won‘t for a
particular patient.

FRAMINGHAM HEART STUDY

Historical background: The scourge in infectious diseases was replaced in the 1940‘s and
1950 by a mounting epidemic of CVD. With the end of world II the alarming risk in CVD
became evident. It had become the leading cause of death in USA. All over the world there
was a problem of atherosclerosis, CVD problem. There was little known about the
determinants of the disease process itself.
The secrets of the aetiology of CVD were not being uncovered the basic laboratory &
clinical research so a continuous process to treat & reverse the process was in order. The type
of study needed to achieve the above was an epidemiological study.
By December 1946 it was decided to begin projects the cardiovascular hygiene
demonstration in Newton mass and the epidemiological heart disease study in Framingham.
The latter study was started as a demonstration programme designed to develop case finding
procedure for heart disease. The first examination was conducted in 1948 September 29. On
July 1, 1949 it was transferred to national heart institute (now National heart, lung & blood
institute, NLBHI)
Aims:
Main aim: To secure epidemiological data on atherosclerosis, hypertensive CVD.
Subsidiary aim: To secure prevalence of all forms of CVD in representative population

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To test the efficiency of various diagnostic procedures.

Hypothesis: CVD were the result of multiple causes which worked slowly on an individual
to produce disease. Factors which potentially may related to CVD were listed in terms of
hypothesis.
CVD increases with age, associated with elevated blood cholesterol, hypertension, smoking,
habitual alcohol, high haemotocrit.
Increase in physical activity associated with decrease in development of CVD.
Why Framingham?: town was adequate size to provide enough subjects
Continued variety of socioeconomic status- either groups
Major population was stable to enable follow-up
Major portion of the medical care was provided by single hospital
It had been the part of community study of TB with successful participation from the towns
people.
Study population: it was decided that examinations would be given every 2 years & & 6000
examination could be given & thus 6000 became sample size. Subjects between 30 -59
Original cohort: consisted of 5209 respondents of a random sample of 2/3 of the adult
population of Framingham 30-62 years of age by household. examination 30 for the original
cohort began in may 2008 and ends by Feb 2010 (5209).
Omni cohort: in 1994 the need to establish a new study reflecting a more diverse community
of Framingham was recognised and the first omni cohort consisted of 506 men & women of
African. American, Hispanic, Asian, Indian, pacific island & native American origins who
ate the time of enrolments were residents of Framingham & surrounding towns.
Offspring cohort:
In 1971 with a need of establishing a prospective epidemiological study of young adults
recognised. A sample of 5124 men & women consisting of the offspring of the original
cohort & their spouses were recruited. Offspring examination 8 began in March 2005
concluded in Jan 2008. 9 will begin in 2011.
Third generation cohort: in April 2002 the study entered a new phase the enrolment of third
generation cohort, the grandchildren of original cohort. (4095)
Second Omni cohort in 2003. Study design – longitudinal study.
Change to the design:
Major change was addition of volunteers
The original plan was to follow only those without CVD later it became apparent that some
forms of CVD were precursors for other form of coronary heart diseases after proceeds to
stroke
Addition of questions on smoking
Biases:
The formal cohort was not random & t was healthier than the general population
Response rate was only 68.7%
Contribution:

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1. Prevalence & incidence rates of various types of CVD

2. Natural history of risk factors and the disease that followed
3. Identified risk factors- high BP, Cholesterol, smoking, Obesity, DM, Physical
inactivity.
4. Enhancing research capabilities by using new diagnostic technologies
5. Expands their research into role of genetic factors in CVD
Post mortem brain tissue donation programme. The Framingham study has been conducting
research in neurological disorders for decades in 1997 it began a post mortem brain tissue
donation programme. More than 600 participants have enrolled, over 100 brain analyses.
Systems approach to biomarker research in cardiovascular disease (SABRE) in CVD
initiative.

NON-PARAMETRIC TESTS
Parameters are measures computed from all the observations in a population –
examples are the population mean and standard deviation. Statistics are measures computed
from a sample, in order to estimate parameters.
Many statistical tests require that data should follow a normal distribution. In some
instances it is not possible or the sample size might be so small that it is difficult to ascertain
whether or not the data a normally distributed. In such cases it is necessary to use a statistical
test that does not require the data to follow a particular distribution. Such a test is called a
non-parametric or distribution free test.
 Non-parametric tests do not rely on the estimation of parameters.
 They do not require that the data fit a normal distribution.
 They allow for the analysis of categorical as well as ranked data.
For this reason, they are often used in place of parametric tests when one feels that the
assumptions of the parametric test have been violated. There is non-parametric equivalent for
each parametric test.
Statistical procedures that allow us to process data of
 ―Low quality‖,
 From small samples, variables about which nothing is known about their distribution.
 Specifically, non-parametric methods were developed to be used in cases when the
researcher knows nothing about the parameters (hence the name non-parametric).
Sample size:
A factor that limits the applicability of tests based on the assumption that the sampling
distribution is normal is the size of the sample. One can assume that the sampling distribution
is normal even if one is not sure that the distribution of the variable in the population is
normal, as long as the sample is large enough (e.g., 100 or more observations). However, if
our sample is very small, those tests can be used only if one is sure that the variable is
normally distributed, and there is no way to test this assumption if the sample is small
Problems in measurement:
Most common statistical techniques such as ANOVA (and t- tests), regression, etc. assume
that the underlying measurements are at least of interval level. However, this assumption is

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very often not tenable, and the data rather represent a rank ordering of observations (ordinal)
rather than precise measurements.
Why not use NP tests all the time?
Parametric tests are often preferred because:
 They are more robust.
 They have greater power relative to the sample size.
 Parametric and non-parametric tests often address two different types of questions.
Large data sets & nonparametric methods
Nonparametric methods are most appropriate when the sample sizes are small. When the data
set is large (e.g., n > 100) it often makes little sense to use nonparametric statistics at all.
Because, when the samples become very large, the sample means will follow the normal
distribution even if the respective variable is not normally distributed in the population, or is
not measured very well. Thus, parametric methods, which are usually much more sensitive
(i.e., have more statistical power) are in most cases appropriate for large samples

Sign test
The sign test is designed to test a hypothesis about the location of a population distribution.
It is most often used to test the hypothesis about a population median. This test can be applied
when the observations in a sample of data are ranks.
Mann -Whitney U test
Mann-Whitney U Test is used in place of the two sample t test when the normality
assumption is questionable. This test can also be applied when the observations in a sample
of data are ranks, i.e., ordinal data rather than direct measurements. It is based on a statistic U
which is linked to the sum of the ranks of each of the conditions.
Wilcoxon test: This is the non-parametric counterpart to the correlated samples t-test for
equality of means. It is suitable for use with the matched pairs or e=repeated measures
designs. In the sign test we only take into account the sign of the difference between a pair of
scores: in the t-test the actual size of the difference is used in computation. The Wilcoxon test
uses the sign of difference and additionally orders the sizes of these differences.

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Kruskal -Wallis test

It is a non-parametric test used to compare three or more samples. It is the analogue to the F-
test used in analysis of variance. While ANOVA tests depend on the assumption that all
populations under comparison are normally distributed, the KW test places no such
restriction on the comparison. The null hypothesis is that the k samples come from the same
population, or from populations with identical medians.

Chi-square test: It is a test of significance in which the test statistic has a chi-square
distribution, when the null hypothesis is true. Chi Square test for three different types of
analysis
1) Goodness of fit,
2) Test for Homogeneity,
3) Test of Independence.
Merits of nonparametric procedures..
 Nonparametric test make less stringent demands of the data.
 Nonparametric methods can be used when there is no universally recognized scale for
the original data and there is some concern that the results of standard parametric
techniques would be criticized.
 There is no parameter estimation involved.
 If the sample size is very small, there may be no alternative to using a nonparametric
statistical test.
Limitations of nonparametric procedures.
 There are no parameters to describe and it becomes more difficult to make
quantitative statements about the actual difference between populations.
 The second disadvantage is that nonparametric procedures throw away information.
 Some tests use only the signs of the observations. Ranks preserve information about
the order of the data but discard the actual values.
 Because information is discarded, nonparametric procedures can never be as powerful
(able to detect existing differences) as their parametric counterparts

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ROGI KALYAN SAMITIS

In most developing countries, provision of basic preventive, promotive and curative
services is a major concern of the Government and decision makers. With growing
population and advancement in the medical technology and increasing expectation of the
people especially for quality curative care, it has now become imperative to provide quality
health care services through the established institutions. In public Sector 15,393 allopathic
hospitals (Health Information of India 2003) are functioning. In the rural areas, the secondary
level care is being provided through 3222 CHCs with 30 beds each with specialist services of
physicians, paediatricians, O & G specialists, and surgeons being made available. However,
these services have not been successful in gaining the faith and confidence of the people
because of lack of specialists, facilities and accountability, along with the paucity of
resources and non-involvement of the community.
Upgradation of CHCs to Indian Public Health Standards (IPHS) is a major strategic
intervention under the National Rural Health Mission (NRHM). The purpose is to provide
sustainable quality care with accountability and people‘s participation along with total
transparency. However, there is a general apprehension that this may not be possible unless a
system is evolved for ensuring a degree of permanency and sustainability. This requires the
development of a proper management structure which may be called as Rogi Kalyan Samiti
(RKS) (Patient Welfare Committee) / Hospital Management Society (HMS). There have
some experience of these RKS‘s functioning in some of the States like Madhya Pradesh with
good results and feasibility of replication. The project in Madhya Pradesh was started on a
pilot basis and it has now been adopted in over 450 institutions across the State and has
proved equally successful in extremely backward tribal and rural areas, which proves its
replicability cutting across the regions. To take the concept across sections of the community,
local representatives and political regime, the project concept has to be simple, appealing and
easy to replicate across the State.
2. Concept
Rogi Kalyan Samiti is a simple yet effective management structure. This committee,
which would be a registered society, acts as a group of trustees for the hospitals to manage
the affairs of the hospital. It consists of members from local Panchayati Raj Institutions
(PRIs), NGOs, local elected representatives and officials from Government sector who are
responsible for proper functioning and management of the hospital / Community Health
Centre / FRUs. RKS / HMS is free to prescribe, generate and use the funds with it as per its
best judgement for smooth functioning and maintaining the quality of services.
3. Basic Structure
The suggested composition of RKS / HMS is as follows:
RKS / HMS would be a registered society set up in all District Hospitals / Sub District
Hospitals / CHCs / FRUs. It may consist of the following members:-
§ People‘s representatives – MLA / MP
§ Health officials (including an Ayush doctor)
§ Local district officials
§ Leading members of the community
§ Local CHC/ FRU in-charge
§ Representatives of the Indian Medical Association

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§ Members of the local bodies and Panchayati Raj representative

§ Leading donors
The RKS/HMS will not function as a Government agency, but as an NGO as far as
functioning is concerned. It may utilize all Government assets and services to impose user
charges and shall be free to determine the quantum of charges on the basis of local
circumstances. It may also raise funds additionally through donations, loans from financial
institutions, grants from government as well as other donor agencies. Moreover, funds
received by the RKS / HMS will not be deposited in the State exchequer but will be
available to be spent by the Executive Committee constituted by the RKS/HMS. Private
organizations offering high tech services like pathology, MRI, CAT SCAN, Sonography
etc. could be permitted to set up their units within the hospital premises in return for
providing their services at a rate fixed by the RKS/ HMS.
4. Need for Devolution of Responsibility
Participation of local staff along with representatives of local population is considered
of prime importance to improve accountability and keep pace with rapidly growing service
requirements. It is also necessary to evolve a suitable framework within which the existing
staff and local population along with administration can establish such a motivated
performing asset. The new body or the apex entity has to be responsible for the singular
aspect of provision of services to all classes of the society. The right of independence for
performance and management has to be provided in order to boost performance.
5. Framework For Rogi Kalyan Samiti (RKS)/Hospital Management Society (HMS)
Objectives the RKS / HMS
 Ensure compliance to minimal standard for facility and hospital care and protocols of
treatment as issued by the Government.
 Ensure accountability of the public health providers to the community;
 Introduce transparency with regard to management of funds;
 Upgrade and modernize the health services provided by the hospital and any
associated outreach services;
 Supervise the implementation of National Health Programmes at the hospital and
other health institutions that may be placed under its administrative jurisdiction;
 Organize outreach services / health camps at facilities under the jurisdiction of the
hospital;
 Display a Citizens‘ Charter in the Health facility and ensure its compliance through
operationalisation of a Grievance Redressal Mechanism;
 Generate resources locally through donations, user fees and other means;
 Establish affiliations with private institutions to upgrade services;
 Undertake construction and expansion in the hospital building;
 Ensure optimal use of hospital land as per govt. guidelines;
 Improve participation of the Society in the running of the hospital;
 Ensure scientific disposal of hospital waste;
 Ensure proper training for doctors and staff;
 Ensure subsidized food, medicines and drinking water and cleanliness to the patients
and their attendants;
 Ensure proper use, timely maintenance and repair of hospital building equipment and
machinery;
Functions and Activities

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 Identifying the problems faced by the patients in CHC/PHC;

 Acquiring equipment, furniture, ambulance (through purchase, donation, rental or any
other means, including loans from banks) for the hospital;
 Expanding the hospital building, in consultation with and subject to any Guidelines
that may be laid down by the State Government;
 Making arrangements for the maintenance of hospital building (including residential
buildings), vehicles and equipment available with the hospital;
 Improving boarding / lodging arrangements for the patients and their attendants;
 Entering into partnership arrangement with the private sector (including individuals)
for the improvement of support services such as cleaning services, laundry services,
diagnostic facilities and ambulatory services etc.;
 Developing / leasing out vacant land in the premises of the hospital for commercial
purposes with a view to improve financial position of the Society;
 Encouraging community participation in the maintenance and upkeep of the hospital;
 Promoting measures for resource conservation through adoption of wards by
institutions or individuals; and,
 Adopting sustainable and environmental friendly measures for the day-to-day
management of the hospital, e.g. scientific hospital waste disposal system, solar
lighting systems, solar refrigeration systems, water harvesting and water recharging
systems etc.
5.3. Constitution of the RKS / HMS
Governing Body:
Chairperson : District Magistrate
Member-Secretary : Medical Superintendent of the hospital
Members:
§ Chief Executive Officer, Municipal Corporation
§ Chief Medical and Health Officer
§ Director, AYUSH of the District
§ Up to 2 representatives of PRIs
§ Up to 3 eminent citizens nominated by the District Collector
§ MNGO representative
§ Representative of local Medical College
§ Representative of corporate sector / NGO hospitals in the city as may be nominated
by District Collector
§ Local MP/MLA
§ Associate members : An individual who makes a one time donation of.a specified
amount [e.g. Rs 5,000/- or as may be determined by the District Health Society], may
be made eligible to become a Member of the Governing Body of the Society.
§ Institutional members: Any institution, which donates a specified amount [e.g. Rs.
50,000/- or more or as may be determined by the District Health Society] or adopts a
ward of the hospital and bears the cost of its maintenance, may be made eligible to
nominate a person from the institution as a member of the Governing Body of the
society.

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5.4 Proceedings of the Governing body

The meetings of the Governing Body shall be held at least once in every quarter and at
such time and place as the Chairperson shall decide. If the Chair-person receives a
requisition for calling a meeting signed by one-third members of the Governing Body, the
Chair-person shall call such a meeting as soon as may be reasonably possible and at such
place as s/he may deem fit.
Following minimum business shall be brought forward and disposed off in every meeting
of the Governing Body:
· Compliance to Standards and Protocols issued by Government.
· Review of the OPD and IPD service performance of the hospital in the last quarter
and service delivery targets for the next quarter.
· Review of the outreach work performed during the last quarter and outreach work
schedule for the next quarter.
· Review of efforts in mobilizing resources from the community, trade / industry and
local branches of professional associations like IMA and FOGSI etc.
· Review the reports submitted by the Monitoring Committee.
· Review the status of utilization of funds, equipment and drugs received under
different programmes of the Government.
· Review compliance to Citizens‘ Charter displayed in the Hospital and the
effectiveness of the Grievances Redressal Mechanism.
In addition to the above regular items, the Annual Report of the Society relating to last
financial year shall also be taken up for discussion in the quarterly meeting falling due after
the close of every financial year.
Powers of the Governing Body
The Governing Body will have full control of the affairs of the Society and will have
authority to the exercise and perform all the powers, acts and deeds of the Society consistent
with the aims and objects of the Society.
In particular and without prejudice to the generality of foregoing provision, the
Governing Body may:
Make, amend, or repeal any bye laws relating to administration and management of the
affairs of the Society subject to the observance of the provisions contained in the Act,
provided that:
Proposals for amendments shall be placed before the Governing Body of the District
Health Mission for its consideration and endorsement;
Proposals for amendment shall also be sent to the designated authority of the State
Government for endorsement; and
Proposals shall be brought to the Governing Body after completing the above
endorsement / approval process.
Consider the annual budget and the annual action plan, its subsequent alternations placed
before it and to pass it with such modifications as the Governing Body may think fit.
Monitor the financial position of the Society in order to ensure smooth income flow and
to review annual audited accounts.

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Accept donations and endowments or give grants upon such terms as it thinks fit.
Delegate its powers, other than those of making rules, to the Chair-person, Vice-Chair-
person or other authorities as it may deem fit.
Authorize the Member Secretary to execute such contracts on behalf of the Society as it
may deem fit in the conduct of the business of the Society.
Recruit medical and paramedical staff for the hospital and execute such other contracts
for the improvement of hospital services as it may deem fit.
Do generally all such other acts and things as may be necessary or incidental to carrying
out the objectives of the Society or any of them, provided that nothing herein contained shall
authorize the Governing Body to do any act or to pass any bye-laws which may be repugnant
to the provisions hereof, to the powers hereby conferred on the Governing Body and other
authorities, or which may be inconsistent with the objectives of the Society.
Ensure compliance to Indian Public Health Standards and to Citizens‘ Charter.
Establish a system of public grievance redressal at facility level.
Undertake measures to increase transparency in financial and operational
management of the hospital.
Regular Agenda
§ Review of the OPD and IPD service performance of the hospital in the last month
and service delivery targets for the next month.
§ Review of the outreach work performed during the last month and outreach work
scheduled for the next month.
§ Consider reports of the Monitoring Committee for remedial action
§ Implementation of the Citizens‘ Charter
The minutes of the Executive Committee meetings will be placed before the Governing
Body at its next meeting.
Monitoring Committee A Monitoring Committee could be constituted by the Governing
Body to visit hospital wards and collect patient feedback. The Committee would send a
monthly monitoring report to the District Collector and Chairperson, Zilla Parishad.
Provision of enabling rights, vesting assets & authorizing services
The Govt. may authorize transfer of existing facilities and assets free of cost and
without any liability to the RKS / HMS of the concerned hospital. In most hospitals, the
principle reasons for malfunctioning and deteriorating services are the inability to spend on
new infrastructure for upgradation & modernization, paucity of funds for emergencies, gross
mismanagement of resources and lack of motivation. Being a service oriented facility, it
needs to permit and grant specific rights to allow freedom for operations and management.
The RKS / HMS should be enabled with the decision making right to invest in order to meet
service requirements. As mentioned above, user charges should be introduced, as it is
believed that excellent health care on a continuous basis cannot be ensured without adequate
financial provisions. Appropriate relaxations for BPL patients to be ensured, as per State
policy.
5.12 Resource Mobilization
The funds of the Society shall consist of the following:

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Grant-in-aid from the State Government and/or State level society (societies) in the
health sector and/or District Health Society.
Grants and donations from trade, industry and individuals.
Receipts from such user fees as may be introduced for the services rendered by the
hospital.
· Receipts from disposal of assets.
5.13 Accounts and Audit
The Society shall cause regular accounts to be kept of all its monies and properties in
respect of the affairs of the Society.
The accounts of the Society shall be audited annually by a Chartered Accountant firm
included in the panel of Chartered Accountants drawn by the designated authority of the State
Government.
The report of such audit shall be communicated by the auditor to the Society, which shall
submit a copy of the Audit Report along with its observation to the District Collector.
· Any expenditure incurred in connection with such audit shall be payable by the
Society to the Auditors.
The Chartered Accountant or any qualified person appointed by the Govt. of
India/State Government in connection with the audit of the accounts of the Society shall
have the same rights, privileges and authority in connection with such audit as the
Auditor General of the State has in connection with the audit of Government accounts and
in particular shall have the right to demand the production of books, accounts, connected
vouchers and other necessary documents and papers.
Bank Account
The account of the Society shall be opened in a bank approved by the Governing Body.
All funds shall be paid into the Society‘s account with the appointed bank and shall not be
withdrawn except by a cheque, bill note or other negotiable instruments signed by the
Member-Secretary of the Society and such one more person from amongst the Executive
Committee members as may be decided by the Governing Body.
Annual Report
A draft Annual Report and the yearly accounts of the Society shall be placed before the
Governing Body at its ensuing meeting that may be held in the first quarter of every financial
year.
A copy of the annual report and audited statement of accounts as finally approved by the
Governing Body shall be forwarded within six months of the closure of a financial year to the
following:
· District Collector.
· Chair-person, Governing Body.
· Chair-person, Executive Body.
· Chair-person, Zilla Parishad.
· Chair-person, Urban Local Body [ Nagar Nigam].
Contracts

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All contracts and other instruments for and on behalf of the Society shall be subject to the
provisions of the Act, be expressed to be made in the name of the Society and shall be
executed by the persons authorized by the Governing Body.
No contracts for the sale, purchase or supply of any goods and material shall be made for
and on behalf of the Society with any member of the Society or his/her relative or firm in
which such member or his/her relative is a partner or shareholder or any other partner or
shareholder of a firm or a private company in which the said member is a partner or director.

VACCINES FOR PARASITIC DISEASES

Introduction:Parasitic diseases caused by helminths and protozoa are major causes of human
disease and misery in most countries of the tropics. They plague billions of people and kill
millions annually, and inflict debilitating injuries such as blindness and disfiguration on
additional millions. WHO estimates that one person in every four harbors parasitic worms.
Attempts to develop vaccines against these pathogens have been hampered by the difficulty
to cultivate them in vitro, the complexity of their multicellular organization and/or multistage
development, added to their impressive antigenic variability. Although remarkable progress
has been made in the last decade in the cloning and expression of protective antigens from a
large number of parasites, the prospect of using these antigens for the development of
preventive vaccines has been met with little enthusiasm from industrial vaccine
manufacturers, due to general scepticism as to the capacity for defined antigens to elicit
sterilizing immunity against complex organisms, especially metazoan organisms. Definite
scientific and technical advances have nevertheless been made in recent years in the field,
including the complete sequencing of the genome of Plasmodium falciparum, and quite a
number of groups are now supporting research on vaccine development against parasitic
diseases. Significant progress has been made over the past five years in the development of
vaccines against malaria and leishmaniasis. Vaccine development efforts for Chagas‘ disease
(American trypanosomiasis) have been curtailed because of successful efforts at vector
control, whereas vaccine development for African sleeping sickness (African
trypanosiomiasis) still is hampered by the phenomenon of antigenic variability.
Amoebiasis
Amoebiasis is due to invasion of the intestinal wall by the protozoan parasite Entemoeba
histolytica. Amoebic colitis results from ulcerating mucosal lesions caused by the release of
parasite-derived hyaluronidases and proteases. Hepatic infection occurs as a consequence of
entry of the parasite into the afferent bloodstream. The disease is prevalent throughout the
developing nations of the tropics, at times reaching a prevalence of 50% of the general
population and is estimated to cause more than 100 000 deaths per year.
Evidence from a cohort of Bangladeshi children suggests that mucosal IgA directed against
the major amoebic adherence molecule, a 170 kD lectin, correlates with resistance to
reinfection with E. histolytica. Gerbils immunized with this lectin antigen were reported to
show significant decrease of liver abscesses following parasite challenge, suggesting that a
subunit vaccine might elicit protective immunity.
Hookworm disease Vaccine
The feasibility of developing a human anti-hookworm vaccine is based on the previous
success of using live, irradiated L3s as a vaccine for canine hookworm infection. The Human
Hookworm Vaccine Initiative (HHVI), a programme of the Sabin Vaccine Institute, together
with the George Washington University (USA), the Oswaldo Cruz Foundation (FIOCRUZ,

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Brazil), the Chinese Institute of Parasitic Diseases, the Queensland Institute of Medical
Research (Australia), and the London School of Hygiene and Tropical Medicine (UK), has
identified, isolated, cloned, and expressed the major L3 antigens, and then tested them as
recombinant vaccines. The leading candidate, the Ancylostoma-secreted protein (ASP), was
selected because it can be recognized in a subset of individuals who have low intensity
hookworm infection, and is partially protective in laboratory hamsters and dogs against
challenge with A. ceylanicum and A. caninum, respectively. With support from the Bill and
Melinda Gates Foundation, as well as additional support from the NIAID, NIH, and the
March of Dimes Birth Defects Foundation, the HHVI has completed manufacture of the Na-
ASP-2 hookworm vaccine. A Phase I dose-escalating trial of the vaccine is tentatively
planned to take place in the USA in early 2005. Further planning is in progress for a Phase
IIb trial to determine the vaccine‘s ability to protect against high intensity hookworm
infection in Brazil. It is anticipated that industrial-scale manufacture of the vaccine will take
place in Brazil.
Additional studies are in progress to develop a second antigen from adult hookworms.
Candidates of choice are the haemoglobin-degrading proteases found to line the brush border
membrane of the hookworm gastrointestinal tract. These have been expressed in eukaryotic
expression systems such as yeasts or baculovirus, to keep their native conformation intact for
better immunogenicity. Work is in progress to combine them with ASP in a multivalent
vaccine.
Leishmaniasis Vaccine
There is as yet no effective vaccine for prevention of any form of leishmaniasis. A first
generation vaccine was prepared using whole killed parasites combined or not with BCG.
The combination of autoclaved L. major promastigotes with BCG as adjuvant was tested in
Iran against CL and in Sudan against VL. A limited efficacy was noted in converters to
positive skin reaction to leishmania antigen (leishmanin) and unexpectedly in boys. Similar
observations had been made earlier in Brazil using killed promastigotes without BCG. Alum
precipitated autoclaved L. major promastigotes plus BCG have demonstrated safety and
substantial immunogenicity in Phase I studies in Sudan. Additional trials are under way to
test new formulations with IL-12. It is of note that treatments combining administration of
antimonials and first generation leishmania vaccines in patients suffering from ―post-kala-
azar‖ dermal leishmaniasis (PKDL) have shown benefit to the patients, suggesting that even
suboptimal leishmaniasis vaccines could have a role in the therapeutic setting.
Various subunit recombinant candidate vaccines also have been tested in mice and provided
some degree of protection against infection. These vaccines were based on:
 recombinant surface antigen gp63, a glycoprotein with protease activity,
 lipophosphoglycan, a surface glycoconjugate;
 a 46 kD promastigote antigen derived from L. amazonensis;
 or the Leishmania-activated C kinase (LACK), among others.
Protection against L. major infection in mice was provided by DNA constructs encoding a
number of Leishmania antigens, including gp63 and LACK.
It has been demonstrated in experimental animal models that a dominant Th1 lymphocyte
response (IL-2, IFN-γ) is associated with self-limited disease, whereas a dominant Th2
response (IL-4, IL-5) is linked to progressive disease. Addition of Th1-driving adjuvants such
as IL-12 or oligodeoxynucelotides (CpG) to leishmanial antigens (TSA, LeIF, LmSTI-1)
resulted in complete protection of susceptible mice against progressive disease, whereas no

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protection was observed in the absence of adjuvant. The Bill and Melinda Gates Foundation
has funded the development of a chimeric vaccine made of these three recombinant
leishmanial antigens (LeIF, LmSTI-1 and TSA) in the form of a fusion protein combined
with monophosphoryl lipid A in squalene oil as adjuvant. Phase I trials of this vaccine in
healthy volunteers in the USA and initial efficacy testing as a therapeutic vaccine in patients
in Latin America suggest the safety and immunogenicity of the vaccine.
Recent evidence indicates that a 15 kD protein antigen derived from the salivary glands of the
sandfly vector also could be protective in mice when given as a vaccine. Generally, recovery
from CL leads to protection against future infections. For centuries, in some of the hyper-
endemic areas of the Middle East, the pus of an active lesion was used to inoculate young
children to protect them against future lesions on the exposed parts of the body, especially the
face. L. major promastigotes grown in culture under good manufacturing practice (GMP)
guidelines, rather than the exsudates from active lesions, have been used for inoculation as a
live vaccine. The practice is known as leishmanization. Genetically manipulated parasites
with attenuated virulence or high sensitivity to chemotherapy might represent the ideal form
of a live vaccine.
Schistosomiasis Vaccine
The administration of radiation-attenuated cercariae to laboratory animals provided
protection against experimental S. mansoni infection by blocking the migration of the
parasite out of the lung. IFN-γ and Th1 cellular immune responses appear to play a key role
in this process.
Great attention has been paid to the use of antigens from schistosomules, with disappointing
protection results so far. Somewhat better results have been obtained with antigens that are
shared between schistosomules and schistosomes, such as the 63 kD parasite myosin, the 97
kD paramyosin, the 28 kD triose phosphate isomerase (TPI), a 23 kD integral membrane
protein (Sm23), and the 26 and 28 kD glutathione-S-transferases (GSTs). In recent Phase I
and II clinical trials, the 28 kD S. haematobium GST (Sh28GST) developed by Institut
Pasteur de Lille (France), was safe and showed good immunogenicity in human volunteers in
France, Niger and Senegal.
The Schistosomiasis Vaccine Development Programme (SVDP), based in Egypt and
supported by USAID, has focused on two S. mansoni antigens: paramyosin and a synthetic
peptide construct containing multiple antigen epitopes (MAP) from the triose phosphate
isomerase (Bachem Company, Los Angeles, USA). Another candidate vaccine, which is
developed by FIOCRUZ (Rio de Janeiro, Brazil), is based on the use of Sm14, a 14 kD fatty
acid-binding S. mansoni protein with cross-reactivity with Fasciola hepatica. In mice, Sm14
provided a 67% protection against challenge with S. mansoni cercariae and full protection
against F. hepatica metacercariae.
None of the above candidate vaccines has, however, been able so far to provide more than a
partial reduction in challenge-derived worm burdens relative to non-immunized controls. It is
hoped that better success can be achieved using cocktails of recombinant antigens.
Another approach to vaccination against schistosomiasis has been to target the fecundity of
the female schistosome in order to diminish egg excretion. Success with this approach has
been reported in mice and large animal reservoir hosts, including pigs and water buffaloes,
using S. japonicum 26 kD GST and paramyosin. The suggestion was made, and the hope
entertained, that vaccination of the reservoir host might be sufficient to reduce S. japonicum
transmission to humans.

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MICROPLANNING
What is a Micro plan?
Work-plan and estimate of requirements
Helps you identify
 What services need to be provided
 Who will provide
 When to provide
 Where to provide (including hard to reach)
 How to provide
 How many to provide for (beneficiaries)
 How much to provide (vaccines & logistics)
Process of Microplanning: Bottom Up

How to plan number of sessions

Fixed Sites (SC / PHC / CHC etc.)
 40 – 70 injections = one session per month
 > 70 injections = two sessions per month
Outreach:
 25-50 injections = one session per month
 > 50 injections = two sessions per month
 < 25 injections = one session in alternate month
Steps in preparation of Micro plan
 Step 1 – List all villages and hamlets
 Step 2 – Write the population of each village
 Step 3 – Write the number of beneficiaries
 Step 4 - Prepare a map of the sub center / PHC

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Prepare the Sub Centre Map, Session Plan & Work Plan.
Tracking Bag and Tickler Box
Estimating Beneficiaries In a Sub-centre Area
1. No. of Live Births  Birth Rate x Population of the Area
30
x5000  150
1000

2. No. of Preganant Women  No. of Live Births  10%

150  15  165
Calculating Beneficiaries for each Vaccine
 TT = No. PW X 2
 BCG = No. infants X 1
 OPV = No. infants X 4
 DPT = No. infants X 4
 Measles = infants X 1
 DT = No. children at 5 yrs X 1
Estimation of vaccine vials
 Each session should have one vial of BCG
No. beneficiaries / session * 1.33
 TT = ------------------------------------------------
10
No. beneficiaries / session * 1.33
 BCG = --------------------------------------------
10
No. beneficiaries / session * 1.33
 OPV = ---------------------------------------------
20
Estimation of ADS and Disposable Syringes
 0.1 ml = (No. of beneficiaries for BCG) + 10 %
 0.5 ml = (Beneficiaries of DPT + Measles + DT + TT ) + 10 %
 5 ml reconstitution = (No. of BCG vials + No. of Measles vials )+ 10 %
Regular monitoring and review of Micro plan
 Analysis of Monthly reports
 Sessions held vs planned
 coverage and drop outs
 Regular Review meeting

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 coverage monitoring chart

 Review missed sessions
 other problems
 revise session plan and work plan (if needed)
 Supportive supervisory visits
 monitoring the work in the field,
 providing on-the-job training,
 taking notes for future discussion at review meetings.
Group Work
 Draw map of the area showing the villages with immunization site; distance of village
from the sub-centre; total and target population
 Prepare the micro plan as per the format given
 From your monthly reporting forms of previous 6 months, calculate and plot DPT-1
and DPT-3 coverage and dropouts on the monitoring chart.

ROTARY INTERNATIONAL
1.History
The world's first service club, the Rotary Club of Chicago, was formed on 23 February 1905
by Paul P. Harris, an attorney who wished to capture in a professional club the same friendly
spirit he had felt in the small towns of his youth. The Rotary name derived from the early
practice of rotating meetings among members' offices.
Rotary's popularity spread, and within a decade, clubs were chartered from San Francisco to
New York to Winnipeg, Canada. By 1921, Rotary clubs had been formed on six continents.
The organization adopted the Rotary International name a year later.
As Rotary grew, its mission expanded beyond serving club members‘ professional and social
interests. Rotarians began pooling their resources and contributing their talents to help serve
communities in need. The organization's dedication to this ideal is best expressed in its motto:
Service Above Self.
By 1925, Rotary had grown to 200 clubs with more than 20,000 members. The organization's
distinguished reputation attracted presidents, prime ministers, and a host of other luminaries
to its ranks — among them author Thomas Mann, diplomat Carlos P. Romulo, humanitarian
Albert Schweitzer, and composer Jean Sibelius.
The Four-Way Test
In 1932, Rotarian Herbert J. Taylor created The Four-Way Test, a code of ethics adopted by
Rotary 11 years later. The test, which has been translated into more than 100 languages, asks
the following questions:
Of the things we think, say or do
1. Is it the TRUTH?
2. Is it FAIR to all concerned?

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3. Will it build GOODWILL and BETTER FRIENDSHIPS?

4. Will it be BENEFICIAL to all concerned?
Rotary and World War II
During World War II, many clubs were forced to disband, while others stepped up their
service efforts to provide emergency relief to victims of the war. In 1942, looking ahead to
the postwar era, Rotarians called for a conference to promote international educational and
cultural exchanges. This event inspired the founding of UNESCO.
In 1945, 49 Rotary club members served in 29 delegations to the UN Charter Conference.
Rotary still actively participates in UN conferences by sending observers to major meetings
and covering the United Nations in its publications.
"Few there are who do not recognize the good work which is done by Rotary clubs
throughout the free world," former Prime Minister Winston Churchill of Great Britain once
declared.
Dawn of a new century
As it approached the 21st century, Rotary worked to meet society‘s changing needs,
expanding its service efforts to address such pressing issues as environmental degradation,
illiteracy, world hunger, and children at risk.
In 1989, the organization voted to admit women into clubs worldwide and now claims more
than 145,000 female members in its ranks.
After the collapse of the Berlin Wall and the dissolution of the Soviet Union, Rotary clubs
were formed or re-established throughout Central and Eastern Europe. The first Russian
Rotary club was chartered in 1990, and the organization underwent a growth spurt for the
next several years.
More than a century after Paul Harris and his colleagues chartered the club that eventually led
to Rotary International, Rotarians continue to take pride in their history. In honor of that first
club, Rotarians have preserved its original meeting place, Room 711 in Chicago‘s Unity
Building, by re-creating the office as it existed in 1905. For several years, the Paul Harris 711
Club maintained the room as a shrine for visiting Rotarians. In 1989, when the building was
scheduled to be demolished, the club carefully dismantled the office and salvaged the
interior, including doors and radiators. In 1993, the RI Board of Directors set aside a
permanent home for the restored Room 711 on the 16th floor of RI World Headquarters in
nearby Evanston.
Today, 1.2 million Rotarians belong to over 32,000 Rotary clubs in more than 200 countries
and geographical areas.
2.Guiding principles
The Object of Rotary
The Object of Rotary is to encourage and foster the ideal of service as a basis of worthy
enterprise and, in particular, to encourage and foster:
 FIRST. The development of acquaintance as an opportunity for service;
 SECOND. High ethical standards in business and professions, the recognition of the
worthiness of all useful occupations, and the dignifying of each Rotarian's occupation
as an opportunity to serve society;

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 THIRD. The application of the ideal of service in each Rotarian's personal, business,
and community life;
 FOURTH. The advancement of international understanding, goodwill, and peace
through a world fellowship of business and professional persons united in the ideal of
service.
Avenues of Service
Based on the Object of Rotary, the Avenues of Service are Rotary‘s philosophical
cornerstone and the foundation on which club activity is based:
 Club Service focuses on strengthening fellowship and ensuring the effective
functioning of the club.
 Vocational Service encourages Rotarians to serve others through their vocations and
to practice high ethical standards.
 Community Service covers the projects and activities the club undertakes to improve
life in its community.
 International Service encompasses actions taken to expand Rotary‘s humanitarian
reach around the globe and to promote world understanding and peace.
Mission
The mission of Rotary International, a worldwide association of Rotary clubs, is to provide
service to others, to promote high ethical standards, and to advance world understanding,
goodwill, and peace through its fellowship of business, professional, and community leaders.
Moving toward the future
In 2001-02, Rotary International began developing a strategic plan to guide the organization
as it entered its second century of service. In June 2007, the Board of Directors approved the
RI Strategic Plan 2007-10, which identifies seven priorities:
 Eradicate polio.
 Advance the internal and external recognition and public image of Rotary.
 Increase Rotary‘s capacity to provide service to others.
 Expand membership globally in both numbers and quality.
 Emphasize Rotary‘s unique vocational service commitment.
 Optimize the use and development of leadership talents within RI.
 Fully implement the strategic planning process to ensure continuity and consistency
throughout the organization.
3. Rotary's work with the UN and other organizations
Throughout its history, Rotary International has collaborated with the United Nations,
governments, and nongovernmental organizations to improve the human condition.
The greatest example of Rotary‘s effective collaborations is its flagship program, PolioPlus,
which aims to eradicate polio worldwide. Working with spearheading partners UNICEF, the
U.S. Centers for Disease Control and Prevention, and the World Health Organization, Rotary
has contributed over US$600 million and countless volunteer hours to help immunize more
than two billion children against the crippling and often fatal disease. Learn more.

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Cooperative efforts are also a key element of Rotary‘s local service. Rotary clubs in Toronto,
for example, have worked with Habitat for Humanity to build houses for deserving families
in the community. Similar collaborations have helped Rotary‘s 1.2 million club members
promote goodwill, service, world understanding, and peace in more than 200 countries and
geographical areas.
Rotary and the United Nations
Rotary and the United Nations have a long history of working together and sharing similar
visions for a more peaceful world.
In 1942, Rotary clubs from 21 nations organized a conference in London to develop a vision
for advancing education, science, and culture after World War II. That event was a precursor
to UNESCO. In 1945, 49 Rotarians went to San Francisco to help draft the UN Charter.
Rotary and the UN have been close partners ever since, a relationship that‘s apparent through
PolioPlus and work with UN agencies.
Rotary currently holds the highest consultative status offered to a nongovernmental
organization by the UN‘s Economic and Social Council, which oversees many specialized
UN agencies. Rotary maintains and furthers its relationship with a number of UN bodies,
programs, commissions, and agencies through its representative network. This network
consists of RI representatives to the United Nations and other organizations.

SRIVASTAVA COMMITTEE (1974-75)

This committee was convened under the chairmanship of Dr. J B Shrivastava, Director
General of health services.
This is known as the ―Group on Medical education & support manpower” constituted in
1974 by the government. The concept of community participation originated which has given
concept of people‘s health in people‘s hand.
Need for the committee:
The essentially urban orientation of medical education in India, which relies heavily on
curative methods and sophisticated diagnostic aids, with little emphasis on the preventive and
promotional aspects of community health, the failure of the programmes of training in the
fields of nutrition, family welfare planning and maternal and child health to sub serve the
total needs of the community because of their development in isolation from medical
education, the deprivation of the rural communities of doctors, in spite of the increase of their
total stock in the society, the need to re-orient undergraduate medical education to the needs
of the country, with emphasis on community rather than on hospital care, and importance of
integrating teaching of various aspects of family planning with medical education.
Objectives:
 To devise a suitable curriculum for training cadre of Health Assistant with basic
medical, preventive MCH, family welfare & nutritional services so that they can serve
as a link between the qualified medical practitioners and multipurpose workers.
 To suggest steps for improving the existing medical educational process as to provide
due emphasis on the problems particularly relevant to national requirement.
 To make any other suggestions to realise the above objectives and matters incidental
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Recommendations:
1. A national wide network of efficient & effective health services. The government
should take tasks of evolving national consensus on the subject.
2. Paraprofessional or semi-professional health workers in the community itself.
Creation of village health guide or community health worker from the community
itself like teachers, postmasters etc who can provide comprehensive health services as
Para-professional. They work on part time basis. Primary health care be provided
within the community itself through trained workers so that the health of the people is
placed in the hands of people themselves.
3. From community to PHC: Between community (& local paraprofessional health
worker) & PHC creation of two cadre of health worker & health assistant. The male &
female HW for 5000 population, who are trained & equipped to give simple specified
remedies. Between HW and PHC there should be a cadre of Health Assistant. One
male & female HA for 2 male & 2 female HW respectively. HA should be located at
Subcentre and not at the PHC trained & equipped to give simple treatment. PHC itself
strengthed by an additional doctor to look after maternal and child health.
4. Referral complex: the PHC, CHC, DH, & medical colleges should develop living &
direct links with the community around them as well as with one another. For training
the interns, the districts, taluk hospitals should be used as outreaches of the medical
colleges for entering into the community. Involvement of medical colleges in health
care of selected PHC‘s with the objective of reorientation of medical education to the
rural population (ROME)
5. Establishment of the medical & health education commission: To determine the
objectives of under graduate medical education. Positive orientation to the entire
programmes. Revision of the UG curriculum. Adequate provision for the continuing
education of the doctors in the medical pool of the country.
Based on these recommendation rural health scheme was launched by the government in
1977-78.
ROME programme launched
Training of Village health guide launched.

MUDALIAR COMMITTEE (1962)

During the second five year plan government decided to relook at the health needs and
resources of the country to provide necessary guidelines to national health planning. Also to
review the progress made since submission of Bhore committee report. Government of India
appointed ―Health survey and Planning commission‖ under the chairmanship of Dr.
Lakshmanswami Mudaliar in 1959 to make future recommendations for development &
expansion of health services.
Objectives:
1. Assessment (or evaluation) in the field of medical relief and public health since the
submission of Health survey and development committee‘s report (Bhore committee)
2. Review of the first and second five year plan health projects and
3. Formulation of recommendations for the future plan of health development in the
country.

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The committee decided to set up six sub-committees for the following purposes
 Professional education and research
 Medical relief (Urban and Rural)
 Public health including environmental Hygiene
 Communicable diseases
 Population problem and family planning and
 Drugs and medical stores
It admitted that the basic health facilities had not reached at least half the nation and there
was gross mal distribution of hospitals and beds in favour of urban areas. The committee
found that the quality of servides provided by the PHC‘s were grossly inadequate with poor
functioning, lack of referral system & gross understaffing due to insufficient resources.
Recommendations:
Medical care:
 Strengthening of existing PHC‘s and development of referral centres before new
centres are established.
 Strengthening of sub divisional & district hospitals.
 The PHC medical officer should not be allowed private practice & should be given
non practising allowance
 Each taluks should have 10-15 beds for isolation of YB cases, each districts should
have psychiatric clinic.
 Mental hospitals should be developed on regional basis.
 Ophthalmic hospitals for each state
Tribal & backward areas: training local tribal candidates to become HS, sanitary inspectors,
technicians‘ doctors etc.
Public health
1. Water supply & sanitation: fully fledged public engineering organisation established.
2. Maternal & Child health: develop & expand network of maternity health centres.
3. School health – Bureau of school health services to plan & initiate school heath
service programme.
4. Nutrition: nutrition policy, increasing production of protective foods. Clinical
research units set-up in medical colleges.
5. Mental health services-providing preventive mental health services.
6. Vital statistics; state bureau of health intelligence should be established. model public
health act be framed.
Communicable diseases:
1. Setting up infectious disease hospitals in every municipality with population of 50,00.
Smaller municipalities it can be attached to general hospitals
2. Chain of public health laboratories in each states
3. Each state should have a fully equipped mobile epidemiological unit to provide to any
part of state on short notice for outbreak investigation.
Professional education:
 UG - one medical college for every 5 million population. Recommendations for site,
duration, allocation of seats, emphasis on integrated teaching pay scales for teachers
etc.

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 Postgraduate- setting up post graduate training centres, selection.

 Schools of public health to be established in every state.
Indigenous system of medicine: recommendation for establishing schools of indigenous
system of medicine. Establishing chain of Indian system of medicine in all medical colleges.
Administration: Health intelligence bureau in DGHS. Constitution of an ―All India Health
service‖ in the pattern of Indian administrative services.

KARTAR SINGH COMMITTEE (1973)

The Government of Indian constituted a committee in 1972 known as ―The committee on
Multipurpose workders under health and family planning‖. The committee headed by the
additional secretary MOH & FW, Sri Karta Singh.
Need for the committee: Various health programmes and family planning programmes were
launched at different times and each was conceived to run vertical with its own staff.
Whereas this has resulted in proliferation of staff, it has also yielded some results ( like
control of Malaria and small pox). It is however disquietening to note a growing demand for
increase of staff under each programme. The justification offered for this demand is the need
to reduce population/ area covered by each worker. The demand; being logical, a question
however raised many quarter‘s whether the same objective cannot be achieved by
coordinating these programmes and pooling the personnel. Could not such and integration
reduce the population/ area of each worker thus making his coverage smaller and
consequently more effective. This has resulted in the committee.
Objectives: To study & make recommendation on.
1. The structure for integrated health services at peripheral & supervisory levels.
2. Feasibility of having multi-purpose/bi-purpose workers in the field
3. Training requirements for such workers and
4. Utilization of mobile service units set up under family planning for integrated
medical, public health and family planning services operating from tehsil/taluk
level
Recommendations:
1. A new designation for Multipurpose health worker (male & female) ANM – Female
health worker.
Basic health workers, malaria surveillance worker, vaccinators, family planning
health assistant – Male health worker.
2. 2 health worker, 1 male and 1 female at the subcentre level.
3. PHC- 50,000 population with two doctors one should be female.
4. 16 sub centres each covering a population of 3000 -3500
5. One male & one female supervisor at PHC to supervise the activities of staffs of 3-4
sub centres
6. Medical officer of PHC will be overall in charge of all peripheral staff.
Training for all workers engaging in the field of health & FP & nutrition should be integrated.
Qualification for FHW – minimum matriculation or equivalent with science and biology
MHW- higher secondary with science should be main qualification.

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BAJAJ COMMITTEE
The Ministry of Heath and Family Welfare, Government of India, set up an Expert Review
Committee for Health Manpower Planning and Development with major emphasis on the
creation of additional facilities for vocational training dated the 8th May 1986 with the
chairmanship of Prof. J.S. Bajaj, Professor of Medicine AIIMS New Delhi.
The terms of reference of the Committee
1. To provide an assessment of existing and projected national health manpower requirements
for the primary and intermediate level health care programmes, and to recommend the
establishment of mechanism(s) through which such projections could be continuously
reviewed in the context of evolving socio-epi-demiological needs and demographic
requirements.
2. To recommend the type of health-related courses of instruction that should be incorporated
at the +2 stage for vocational education and to recommend appropriate educational content at
the pre-vocational level which would stimulate and encourage the students to enter health
related vocational courses.
3. To recommend the essential educational infrastructure including establishment of
educational institutions and facilities or strengthening of such facilities in already existing
educational institutions that would facilitate the production of appropriate categories of health
manpower.
4. To recommend such modifications in the education and health systems that would facilitate
the establishment of essential inter linkages between health manpower production,
deployment and utilisation.
5. To make recommendations that would safeguard the career prospects of various categories
of health manpower at the primary and intermediate level, through the development of bridge
courses for horizontal mobility and vertical progress.
6. To recommend the establishment of mechanisms or agencies so as to ensure an expeditious
development of educational objectives, curricular contents and learning settings for the
course of instruction recommended by the Committee.
Summary of Recommendations-
 A National Policy on Education in Health Sciences (NPEHS) must be enunciated. The
essential components of NPEHS should be entirely consistent with, and subservient to
thestated objectives of the National Health Policy, 1983 and the National Policy on
Education, 1986. A major focus of NPEHS should be policy guidelines for health
manpower development. Indeed, a commitment to this effect has already been made
in the National Health Policy and a reference framework has also been defined.
 A realistic health manpower survey should be carried out.
 In order to launch an effective vocationalisation. the educational infrastructureshould
also take into account availability of teachers training courses, continuous production
of teachers, upgrading of instructional technology and educational software. National
institutes such as NCERT may be requested to develop educational technology and
software‘s including text-books for each course in English as well as in local
languages.
 Education Commission for Hearth Sciences should be established as a central
organisation in the field of professional education in health related fields. It should be
constituted on the lines of UGC.

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The operational framework of the Commission should include:—

(1) To provide realistic projections for national health manpower requirements and to
recommend the establishment of mechanism(s) through' which such projections could be
continuously reviewed in context of evolving socio-epidemiological needs and demographic
requirements.
(2) To initiate action for the, creation of educational institutions and facilities, or
strengthening of such facilities in already existing educational institutions, that would
facilitate the production of projected health manpower, and to consider the establishment of
one or more Universities of Health Sciences.
(3) To implement desired changes required to be brought about in the curricular contents and
training programmes of health personnel and "allied" 'health professionals, at various levels
of functioning.
(4) To plan and implement appropriate changes in the educational system that would
facilitate the establishment of essential interlinkages between health functionaries of various
grades.
(5) To establish a continuing review mechanism for the strengthening of health-related
pedagogic and communication technologies, and to recommend the development of such
health-related community educational programmes that could effectively and optimally
utilize these technologies.
(6) To develop in-built mechanisms of review, monitoring and mid-course corrections so as
to ensure expeditious implementation of recommendations and decisions.
(7) To coordinate intersectoral research by interlinking the education and training of suitable
manpower with mission oriented research needs.
 Education Commission for Health Sciences should liaise with all existing professional
councils and recommend, if necessary establishment of councils for other categories
of health professionals, in case such councils are considered essential as a support
mechanism for the Commission.
 The professional councils should concentrate on :—
(a) Recognition or derecognition of degrees or diplomas" granted by Universities
orInstitutions.
(b) Development of interlinkages and reciprocities with corresponding councils in other
countries.
(c) Registration of qualified professionals and maintenance of an all India register.
(d) Inspection and certification of standards of examinations and available facilities for
education and training.
(e) Monitoring of professional ethics, and
(f) Regulation and surveillance of professionals conduct.
 Health Sciences Universities be established in each State and in groups of Union
Territories as the implementing arm of E.C.H.S. for production, evaluation and
sustenance of health manpower policy. However, till such time that a University of
Health Sciences can be established in each state and Union Territory a beginning may
be made in the Eighth Plan to establish such Universities on a regional basis.

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 Health Sciences Universities (HSU) should affiliate all medical and related colleges
and award degrees in these fields.
 Cognisant of the fact that the scope of medical and health education has evolved
considerably in the recent years, newer faculties should develop such as health
management, health economics, social and behavioural sciences, educational
reprographics and health information systems.
 To coordinate the implementation of health manpower policy at the centre and the
states, Health Manpower Cells may be created at the centre and in the states.

MUKERJI COMMITTEE
Need for the committee: In 1963, a Special Committee was appointed by the Government of
India under the Chairmanship of the then Director General of Health Services to study the
arrangements necessary for the maintenance phase of the National Malaria Eradication
Programme. This Committee, popularly known as the Chadha Committee, recommended a
certain measure of strengthening of the rural health services which, apart from providing
certain other basic health services to the rural population, could also take care of the
maintenance phase of the National Malaria Eradication Programme and gradually also of the
other mass campaigns, such as smallpox eradication, when these entered the .maintenance
phase. The pattern of the basic health service recommended by this Committee was accepted
by Government, The 1963 Reorganised Family Planning Programme and the staff added on
its account were to function in an integrated manner with the rest of the basic health service.
With the increasing importance of the Family Planning Programme and the necessity
to implement this programme as a crash programme all over the country as speedily as
possible, the need became apparent for reviewing the 1963 Reorganised Family Planning
Programme and its strategy. The Central Council of Health at its meeting held on the 31st
December, 1965, in Madras appointed a Committee under the Chairmanship of the Union
Health Secretary to undertake this review. This Committee, popularly known as the Mukerji
Committee.
Recommendations:
Primary Health Centre Level
1. There should be one basic health worker for a population of 10000 in normal areas but in
areas with difficult terrain or very sparse population, the population coverage per basic health
worker should be suitably reduced. It would be necessary to lay down in details the job chart
of the basic health worker. The job chart should consist of specific and concrete items of
work which should be related to clear objectives aimed under the different programmes under
active implementation and it should ensure adequate attention to the different fields of work.
2. Recommended that a leave and training reserve of 5% of the total number of basic health
workers should be provided.
3. For every four Basic Health workers, there should be a health inspector who should
provide close supervision and guidance to the Basic Health Workers. He should be in
addition to the existing Sanitary Inspector already provided in the staffing pattern of the
Primary Health Centre The existing Sanitary Inspector provided for the Primary Health
Centre should concentrate on environmental sanitation.

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4. Technical staff, particularly the medical staff at all levels should be relieved, as much as
possible, of administrative, routine and clerical work by providing non-technical workers for
taking over such work.
5. The staff recommended above will be in addition to the normal staffing pattern of the
Primary Health Centre and sub-centres and the staff sanctioned under the Family Planning
Programme. All the staff should work under the overall control of the Medical Officer of the
Primary Health Centre.
6. The Medical Officer of the Primary Health Centre should devote sufficient attention to
supervising the work of the Basic Health Workers and the. Health Inspectors.
7. At the Primary Health Centre level there should be facilities for simple laboratory
examination. This would need a laboratory technician with a microscope.
District Health Organisation
1. The District Health Organisation, including the hospital and other ancillary services, has to
be gradually strengthened by being adequately staffed ii including specialists in various
branches, by being adequately equipped with X-ray, laboratory and other diagnostic facilities,
and by being provided with adequate ambulance and transport facilities, dental unit, blood
transfusion facilities, facilities for treatment of mental cases etc.
2. The Head of the Organisation should be a Chief Medical Officer of Health who should be a
whole time non-practising medical officer with training and experience in community
organisation, in health administration and planning and preferably also in hospital
administration.
3. At the District level there should be as much integration of the general health programme
with the family planning programme as possible, ensuring at the same time, however, that the
family planning programme continues to receive adequate attention, and profits from such
integration.
4. For a more detailed supervision of the work of the Basic Health Workers and the Sanitary
Inspectors working at the Primary Heal Centre level, the Deputy C,M,0.(Health) should be
assisted by one Health Supervisor for every 10 Primary Health Centres.
5. Since a large number of Auxiliary Nurse Midwives or nurse will be employed in Maternity
and Child Health and Family Planning, there is a need for a Nursing Supervisor at the district
level who will supervise the M.C.H. and Family Planning work and the nursing and
immunisation services in the district, including these in the Primary Health Centre.
Arrangement for Urban Areas
1. There should be one Basic Health Worker for every 15,000 of population, as against one
per
10,000 population recommended for the rural areas, the higher population coverage in the
urban areas being possible because of the greater density of population and compactness of
the area.
2. There should be one Inspector for every five Basic Health Workers for supervising the
work of the latter.

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JUNGALAWALA COMMITTEE (1967)

Formed under the chairmanship of Dr. N. Jungalwalla, Additional Director General of
Health Services.
History: The Central Council of Health, in its meeting in 1964, recommended the
constitution of a committee to examine the various problems including those of service
conditions, elimination of private practice and submit the report to the Government of India
For the purpose of this report, the committee defined integrated health services as:
i) A service with a unified approach for all problems instead of a segmented approach for
different problems and
ii) Medical care of the sick and conventional public health programmes functioning under a
single administrator and operating in a unified manner at all levels of hierarchy with due
priority for each programme obtaining at a point of time.
Advantages of an integrated health service are many. The health of the community is looked
after more effectively and economically than otherwise. A basis for comprehensive health
care for every family is established the single administrator has a better overall perspective
and insight into problems, Solutions and programmes and-strengthens health administration
competitively among all governmental agencies. Prevention avoid unnecessary illness, it is
cheaper than are and also complementary to cure.
Parallel services are wasteful and are primarily the result of lack' of planning or bad
planning. Health care services should not only be integrated but distributed on regional
basis.The concept of regionalisation has extended beyond the idea of coordinated system for
delivering health care services to connote continuing education of health care profession and
the development of the technical consciousness of the consumer public. An. administrative
district forms a convenient "basis for- organising local health administration.
Health administration, like all administrations, is a means to an end, not an end in
itself. Though only a tool, it is an essential tool. The test of good health administration must
be pragmatic.
Recommendations:
1. Nothing the advantages of integration of curative and preventive health services;
2. Considering that the reason of non- integration of the services which are mainly
administrative and psychological are neither formidable nor insurmountable;
 Recommends that the States should reorganize their health services in such a manner
that integration of curative and preventive services including the research and
teaching departments cadres is effected.
 Realising that integration of services alone will not be effective unless all medical
officers are brought in one cadre.
Recommends that (i) unification of cadre should be immediately effected and (ii)terms and
conditions of service should provide
A) Uniform scales of pay:
b) Drawl of pay according to the- grade to which he' may belong irrespective of the
appointment;
c) Inter-change and rotation of officers between clinical, public health, teaching and research
branches,

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d) A common seniority;
e) Chances of promotion on an overall consideration of years of service, merit, administrative
capability etc.
f) Special allowances for specialists and for special Programmes and administration;
g) Orientation training, post-graduate studies and staff courses for medical officers;
h) Adequate financial and other incentives to medical officers posted in rural areas or areas
declared by the state as attended with any special hazard or risk.

1. Recognising that private practice deprives a medical officer of giving full attention to the
work he is assigned to;
2. Noting the difficulties, administrative and financial, in eliminating immediately private-
practice among the medical officers in service; Recommends that(i)private practice be
eliminated on a gradually increasing phase, beginning with teaching, research and
supervisory posts in the Health Directorate, Regional and District health organisation, special
programmes, ho health officers and health centre doctors,
(ii) Non-practice allowance should be a realistic and reasonable compensation for loss of
private practice.

CHADHA COMMITTEE (1963)

Under the Chairmanship of Dr. M S Chadah, The Director General of Health Services.
Background: Malaria, till 1950‘s had been the greatest handicap to the socioeconomic,
development of the country. The only known methods of control viz., anti-larval and drainage
schemes were Expensive and as such it had not been possible to include in the pre-DDT
period the rural India in any large scale control programme. Meanwhile, malaria control
programme undertaken in several countries using DDT as a residual insecticide brought two
technical points into focus
(1) The possibility of fortuitous eradication of the disease even in countries where such an
aim was not in specifically planned in the first Instance; and
(2) Precipitation of resistance in the mosquitoes to insecticides. The risk of resistance urged
countries to plan eradication which has been shown to be possible before the resistance
developed in malaria-carrying mosquitoes. The newer concept of total eradication of the
disease grew as a result of impact of world opinion channeled through accredited
International Organizations like the W.H.O. and U.S. Agency‘ for International
Development.In 1958 the Indian programme changed its objective from control‘ to
eradication. In 1962 after 4 years of activities, 140.47 units entered the consolidation phase
and another 87.83 more units in 1963. The preparation for entry into the maintenance phase
has been under Consideration since 1962. A Sub-Committee formed by the Government of
India under the Chairmanship of the Director General of Health Services, meeting on the 3rd
and 4th September 1962,
Objectives:

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(a) The absorption of the activities of the maintenance phase into the general health services; '
(b) Strengthening of the basic rural health services and
(c) Training of personnel engaged in specialized mass campaigns to become multi-purpose
workers to that they can continue to follow up the measures required for the maintenance
phase as a part of the routine health activities.
On the basis of the recommendations of the Subcommittee a Special Committee was
constituted in April 1963 under the chairmanship of Director General of Health Services, The
Committee met thrice. It considered that the maintenance is the responsibility of the general
health services, which should be adequately strengthened, particularly the rural health
services.
As the malaria eradication programme advanced towards consolidation and
maintenance, it became clear that eradication cannot be sustained without the support of the
general health services, capable of taking over the entire responsibility for vigilance, during
the maintenance phase. Unless malaria has been eradicated from the world the risk of
reestablishment of malaria is far too great. Failure in Consolidation of eradication will be
disastrous to the country in general and to the health organization in particular. The health
services in the areas entering the maintenance phase will have to be suitably augmented to
meet the needs for vigilance for sustaining eradication. What is of utmost importance in the
vigilance is the total coverage of the population. It is thus necessary to consider not only the
distribution‘ and the number of the ‗static dispensaries, 'health centers, etc. but also what
proportion, of the population is at present, utilizing these facilities.. It is imperative that in
addition to, the: establishment of the rural health centers dispensaries and hospitals me form
of multipurpose domiciliary health service is necessary as an intrinsic part of the basic health
services to absurd total coverage such a domiciliary service will form the basic not only for
integrating- other mass campaigns such as smallpox‘ eradication in their maintenance phase
into the general also, for undertaking newer health programmes. This will be an investment
towards building of rural health services particularly for sustaining mass programmes. It is
also necessary to comply with those basic needs of vigilance, viz.
(1) Prompt detection, radical treatment of parasite carriers and their follow-up.
(2) Epidemiological, investigation; of positive cases and measures to eliminate foci, and
(3) Periodic review of the status of ordination and the adequacy of the vigilance, system.
The recommendations of the Committee are:
(l) Vigilance-through medical institutions must be developed to the fullest extent. All medical
institutions Government or non-government, private medical practitioners, irrespective of the
system of medicine they practice and all professional and other health workers should be
harmessed. The members of panchayats, block development committees, mahila mandal
youth clubs, other voluntary agencies, to teachers, etc. should participate and efforts should
be so made that every village, hamlet or locality has one 'Voluntary collaborator;
(2) All efforts should be made to establish primary health centers provided for in the current
plan period particularly in the areas entering the maintenance phase. The States that have a
plan, programme for establishing a certain number of midwifery or maternity and child health
centers every year should give priority to their establishment in the areas, deficient of
adequate medical coverage.
(3) In urban areas, institutional case detection should be the mainstay. The major medical
institutions with heavy out-patient attendance should have a person specially detailed to take

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clinical samples including blood smears. These institutions should have a separate clinical
side-room. Additional staff will be required for -
(a) Activation of institutional case detection,
(b) Domiciliary case detection, in slum areas including collection of blood smears and
dispatch to laboratories, and
(c) Special investigation of foci.
(4) In rural areas owing to incomplete and uneven coverage by medical institutions and
liberal representation by proxy at primary health centers and dispensaries, there should be
facilities for detection of fever cases and for taking blood smears from all suspected malaria
and inadequately explained fever cases through domiciliary services.
(5) Domiciliary services should be developed for all health programmes including malaria,
smallpox, control of other communicable diseases, health education, etc.
(6) The basic service unit should cover not more than 5000 population. However, owing to
limitations of financial and material resources at present the basic service unit should cover
about 10,000 populations. This‘ may form a sub-centre of a primary health Centre. The
number of such subcenters will naturally vary depending on the population and area covered
by a health centre.
(7) It should be staffed by a midwife or auxiliary nurses midwife and a health assistant or
auxiliary health worker. There should be a midwife or auxiliary nurse mid-wife for every,
5,000 population. However, in view of the limited number available, as an interim measure,
only one is recommended for entry 10,000 population. The staff required over and above that
approved in the family Planning Programme should be provided by the general health
services.
(8) The Extension Educator (Family Planning) should be, utilized in strengthening education
aspects of all programmes.
(9) The existing one Sanitary Inspector at the block level is very inadequate. Although we
should have one Sanitary Health inspector for10,000 populations, this may not be feasible at
present. "In addition to the existing one at the block level, there should be at least one
Sanitary Health, Inspector, for, 20,000‐25,000 population. He will provide supervision to all
health activities including domiciliary services. The senior-most of them may be designated
as Senior Sanitary/Health Inspector.
(10) Each primary health centre should have a microscope and laboratory technician who
shall conduct all simple laboratory examinations giving particular attention to examination of
blood smears for malaria parasites. In the block whore there is no primary health centre, a
suitable dispensary may be, selected to have the facilities of a microscope and a laboratory
technician until such time a primary health centre is established.
(11) Wherever possible, there should be an extra-medical officer for a Primary Health Centre.
(12) At the district level-there should be, in addition to the District Health Officer another
medical Officer trained in malaria. He will be in charge of general epidemiology but during
who next two to three years he should concentrate mainly on malaria. He should be assisted
by a reasonable number of Health Supervisors approximately on the ratio of one- per six or
seven blocks.

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(13) Existing State Regional or Division Health Officers should be strengthened by a officer
trained' in epidemiology and malaria. In the States not having regional offices, the existing
zonal level National Malaria Eradication offices should be converted into regional offices.
(14) State levels: A state Malaria Officer preferably of the rank of Deputy Director is
required for overall guidance and supervision. He should continue for at least two years after
the entire state has entered the maintenance Phase. Afterwards he will be in charge of control
of Communicable diseases including malaria. The State Malaria laboratory should be merged
into the State Public Health laboratory so that every Public Health laboratory has a malaria
section. The laboratory at the State level should have at least one-medical officer for
epidemiological work, one entomologist, 2or3 entomological assistants and a number of
microscopists for undertaking-.special investigation and 'serve as‘ the Central
IntelligenceBureau, for malaria in the State.
(15) Labora tory- services:- Facilities should be provided at each district, headquarter hospital
or district laboratory for examination of blood smears which should be kept a separate entity
under the direct supervision of the assistant District-Health Officer for a period of two to
three years. A senior-laboratory technician should supervise the work of laboratory
technicians at lower levels.
(16) Central Levels The Regional Coordinating Organizations should continue to provide
inter-state coordination technical guidance, assistance, in training and laboratory services.
After the eradication has been achieved, those organizations should be de-eloped into the
regional offices of the Directorate General of Health Services.
(17) Logistics: Equipment and stores should remain at the district level under the direct
control of the District Health Officer. However, a few sprayers and 9 small quantity of DDT
should be kept at lower level.

CENSUS 2011
Definition: Population Census is the total process of collecting, compiling, analyzing or
otherwise disseminating demographic, economic and social data pertaining, at a specific time,
of all persons in a country or a well-defined part of a country. As such, the census provides
snapshot of the country's population and housing at a given point of time.
History: The earliest literature 'Rig-Veda' reveals that some kind of population count was
maintained in during 800-600 BC in India. The celebrated 'Arthashastr' by 'Kautilya' written
in the 3rd Century BC prescribed the collection of population statistics as a measure of state
policy for taxation. It contained a detailed description of methods of conducting population,
economic and agricultural censuses. During the regime of the Mughal king Akbar, the
administrative report 'Ain-e-Akbari' included comprehensive data pertaining to population,
industry, wealth and many other characteristics.
A systematic and modern population census, in its present form was conducted non
synchronously between 1865 and 1872 in different parts of the country. This effort
culminating in 1872 has been popularly labeled as the first population census of India
However, the first synchronous census in India was held in 1881. Since then, censuses have
been undertaken uninterruptedly once every ten year. Census 2011 will be the 15th National
Census of the country.

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Uses: This is the only source of primary data at village, town and ward level. It provides
valuable information for planning and formulation of polices for Central & State
Governments and is widely used by National & International agencies, scholars, business
people, industrialists, and many more. The delimitation/reservation of Constituencies -
Parliamentary/Assembly/Panchayats and other Local Bodies is also done on the basis of the
demographic data thrown up by the Census. Census is the basis for reviewing the country's
progress in the past decade, monitoring the on-going schemes of the Government and most
importantly, plan for the future. That is why the slogan of Census 2011 is "Our Census, Our
Future".
National population registry: The NPR would be a Register of usual residents of the
country. The NPR will be a comprehensive identity database that would help in better
targeting of the benefits and services under the Government schemes/programmes, improve
planning and help strengthen security of the country. This is being done for the first time in
the country. The Census is a statutory exercise conducted under the provisions of the Census
Act 1948 and Rules made there under. The NPR is being created under the provisions of the
Citizenship Act and Rules.
NPR Process: Details such as Name, Date of Birth, Sex, Present Address, Permanent
Address, Names of Father, Mother and Spouse etc will be gathered by visiting each and every
household. All usual residents will be eligible to be included irrespective of their Nationality.
Each and every household will be given an Acknowledgement Slip at the time of
enumeration. The data will then be entered into computers in the local language of the State
as well as in English. Once this database has been created, biometrics such as photograph, 10
fingerprints and probably Iris information will be added for all persons aged 15 years and
above. This will be done by arranging camps at every village and at the ward level in every
town. Each household will be required to bring the Acknowledgement Slip to such camps.
The National Population Register would have the data of every person enumerated
during the Census operations irrespective of age. It would also have the biometric data and
UID Number of every person of age 15 years and above. National Identity Cards will be
given in a phased manner to all usual residents by the Office of the Registrar General and
Census Commissioner, India. The issue of Cards will be done in Coastal Villages to start
with. After this the coastal Towns will be covered and so on till the entire country is covered.
Census Process: The gigantic task of census taking will be completed in two phases. In the
first phase, known as House -listing Operations, all building and structures, residential,
partly residential or non- residential will be identified and listed and the uses to which they
were put recorded. Information on houses, household amenities and assets were also
collected.
In the second phase, known as Population Enumeration, more detailed information
on each individual residing in the country, Indian national or otherwise, during the
enumeration period will be collected.
The information collected about individuals is kept absolutely confidential. In fact this
information is not accessible even to Courts of law. After the field work is over the forms are
transported to data processing centres located at 15 cities across the country. The data
processing will be done using sophisticated software called Intelligent Character Recognition
Software (ICR). This technology was pioneered by India in Census 2001 has become the
benchmark for Censuses all around the globe. This involves the scanning of the Census
Forms at high speed and extracting the data automatically using computer software. This

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revolutionary technology has enabled the processing of the voluminous data in a very short
time and saving a huge amount of manual labour and cost.
Logo of census 2011

CONFIDENCE INTERVALS
Confidence intervals provide different information from that arising from hypothesis
tests. Hypothesis testing produces a decision about any observed difference: either that the
difference is statistically significant or that it is statistically non-significant. In contrast
confidence intervals provide a range about the observed effect size. This range is constructed
in such a way that we know how likely it is to capture the true - but unknown - effect size.
Thus the formal definition of a confidence interval is: a range of values for a variable
of interest constructed so that this range has a specified probability of including the true value
of the variable. The specified probability is called the confidence level, and the end points of
the confidence interval are called the confidence limits. It is a widespread convention to
create confidence intervals at the 95% level - so this means that 95% of the time properly
constructed confidence intervals should contain the true value of the variable of interest.
Hence, more colloquially, the confidence interval provides a range for our estimate of the true
treatment effect that is plausible given the size of the difference actually observed.
Assessing significance from a confidence interval
One useful feature of confidence intervals is that one can easily tell whether or not statistical
significance has been reached, just as in a hypothesis test. If the confidence interval captures
the value reflecting no effect, this represents a difference that is statistically non-significant

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(for a 95% confidence interval, this is non-significance at the 5% level). If the confidence
interval does not enclose the value reflecting no effect this represents a difference that is
statistically significant (again, for a 95% confidence interval, this is significance at the 5%
level). Thus statistical significance can be inferred from confidence intervals - but, in
addition, these intervals show the largest and smallest effects that are likely given the
observed data. This is useful extra information.
Examining the width of a confidence interval
One of the advantages of confidence intervals over traditional hypothesis testing is the
additional information that they convey. The upper and lower bounds of the interval give us
information on how big or small the true effect might plausibly be, and the width of the
confidence interval also conveys some useful information.
If the confidence interval is narrow, capturing only a small range of effect sizes, we can be
quite confident that any effects far from this range have been ruled out by the study. This
situation usually arises when the size of the study is quite large and hence the estimate of the
true effect is quite precise. Another way of saying this is to note that the study has reasonable
power to detect an effect. However, if the confidence interval is quite wide, capturing a
diverse range of effect sizes, we can infer that the study was probably quite small. Thus any
estimates of effect size will be quite imprecise. Such a study is low powered and provides us
with less information.
Errors in interpretation
Confidence intervals, like p-values, provide us with a guide to help with the interpretation of
research findings in the light of the effects of chance. There are, however, three important
pitfalls in interpretation.
Getting it wrong: seeing effects that are not real
First of all, we may examine the confidence interval and observe that the difference is
statistically significant. From this we will usually conclude that there is a difference between
the two treatments. However, just because we are unlikely to observe such a large difference
simply by chance, this does not mean that it will not happen. By definition, about one in 20
significant findings will be spurious Ð arising simply from chance. Thus we may be misled
by chance into believing in something that is not real Ð technically, this is called a „type I
error‟.
Statistical significance and clinical significance
Statistical significance is also sometimes misinterpreted as signifying an important result: this
is a second important pitfall in interpretation. Significance testing simply asks whether the
data produced in a study are compatible with the notion of no difference between the new and
control interventions. Rejecting equivalence of the two interventions does not necessarily
mean that we accept that there is an important difference between them. A large study may
identify as statistically significant a fairly small difference. It is then quite a separate
judgement to assess the clinical significance of this difference. In assessing the importance of
significant results, it is the size of the effect not just the size of the significance that matters.
Getting it wrong again: failing to find real effects
A further error that we may make is to conclude from a non-significant finding that there is
no effect, when in fact there is - this is called a „type II error‟. Equating non significance
with no effect is a frequent and damaging misconception. A non-significant confidence
interval simply tells us that the observed difference is consistent with there being no true

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difference between the two groups. Thus we are unable to reject this possibility. This is
where confidence intervals are much more helpful than simple p-values: the observed
difference will also be compatible with a range of other effect sizes as described by the
confidence interval. We are unable to reject these possibilities either and must then assess
whether some of these possibilities might be important. Just because we have not found a
significant treatment effect does not mean that there is no treatment effect to be found. The
crucial question is how hard have we looked?

DESIGNING A RESEARCH STUDY TO TEST A NEW ANTIMALARIAL DRUG

Any drug before its approval for regular clinical use must undergo rigorous clinical trial. The
clinical trials generally have 4 phases. So the new anti-malarial drug in question must satisfy
basic criteria of safety, efficacy and potency to prove itself a candidate for regular clinical use
Phase I – animal models are used to establish the safety of the new anti-malarial drug.
Phase II- safety of this drug is confirmed in a few healthy volunteers.
Phase III- the drug is tested in health as well as people with disease to establish efficacy and
potency.
Phase IV- it is the study of the rare side effects over a long period of time when the drug is
already marketed.
Steps in Phase III- testing for efficacy and potency. The best study design to establish the
usefulness of the new antimalaria drug is multicentric, double blind randomized clinical trial.
This method happens to be the best available design for assessing any new drug, vaccine or
procedure.
Scrupulous ethical norms must be maintained in the clinical trial at all levels.
Following are the important steps in the design of trial (* draw the flowchart)
1. Preparation of study protocol which clearly delineates the modus operandi of the trial
this also ensures uniformity in everything.
2. Selection of study centres. In case of drug for malaria it is important to select areas
where malaria rampant like north-eastern states and also areas where malaria is not a
public health problem.
3. After the protocol development and finalisation of study centres, investigation teams
are constituted. The teams are properly apprised of the protocol and ethical issues
involved.
4. Pilot study is conducted to establish the operation feasibility of the study/
5. Study proper:
a. Selection of study population: in this study the reference population happens to
be the general population itself. People reporting to the study centre with the
history of fever are screened for malaria. The diagnosis is confirmed by the gold
standard test that is demonstration of malaria parasite in peripheral smear and if
needed QBC (quaternary blood culture). After the diagnosis the study population
are informed about the purpose, procedure and probable adverse effects of the
study and those willing are enrolled and informed consent is taken.

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b. Randomization: This step is the heart of RCT. The study population are
allocated randomly into 3 groups. There are several methods used for random
allocation. Computer assisted random allocation is the best one. Both the
investigator and the participants are blinded which means they are not aware of
the drugs given to the groups. The process of randomization takes care of chance
factor and the process of blinding takes care of observer and subject bias while
selecting the study population confounders like age sex nutritional status are
taken care of
c. The two groups (let us assume A & B) compromising of study population given
antimalarial treatment in the following way. Group A is given standard anti-
malaria treatment ie, treatment with choloroquine with primaquine depending on
the species of the parasite. It is also important to decide before hand whether we
are testing the new drug for plasmodium palciforum or other species. Group ‗B‘
is given the new drug that is being tested, for the stipulated time and stipulated
dose. Blinding becomes difficult if the duration of treatment varies between the 2
drugs.
d. The cure rates in the 2 groups are documented and are compared. If the cure rates
in group ‗A‘ are very high when compared to group ‗B‖ then the new antimalarial
drug is not taken seriously and requires further validation for consideration. If the
cure rates in group ‗B‘ is higher than group ―A‖ then the observed difference is
tested for statistical significance. If the observed difference turns out to be
statistically significant then the efficacy of the new drug is accepted.
6. Malaria is a public health problem in India and many sub Saharan African
countries. The parasite is acquiring fast resistance to all the known drugs. So any new
drug for this disease is definitely welcome. But the proof of efficacy in a single trial
will not warrant the acceptance of the new drug. Consistency of the association should
be established by repeated studies in different settings. Biological plausibility must be
established by laboratory testings. Pharmacokinetics and drug interactions and
efficacy is special conditions like pregnancy, lactation and infants must be
established.
7. All said & done it should be acceptable, easily available and cost effective (cheap).
If all these criteria are satisfied then the new anti-malarial will find a place in the
routine treatment of malaria.

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COST EFFECTIVENESS ANALYSIS

Cost effectiveness analysis is the most common form of economic evaluation in health care
because of its relative simplicity.
Cost effectiveness analysis deals with technical efficiency and seeks to answer the following
questions.
 Given that it has been decided that a goal is to be achieved what is the best way of
doing so or
 What is the best way of spending a given budget?
Its use does not require benefits to be valued in monetary terms.
 If the health outcomes of the alternatives to be compared are known to be equivalent,
only cost difference need to be analysed. The least costly alternative is obviously most
efficient as resources are saved which can be put to some other beneficial use without
reducing health outcome of client being studied. This is often referred to as cost
minimization analysis.
 In the second form of cost-effectiveness analysis alternatives may differ in terms of cost
and effect. A ratio is produced for each alternative in which numerator are cost and the
denominator is the health under consideration. Health effects are measures of final
outcome. They might be life years save, heart attacks prevented or improved physical
function. The cost effectiveness ratio produced for each alternative is a measure of cost
per unit of health effect. The alternative with lowest cost-effectiveness ratio is best.
Measures used in cost effectiveness analysis
Cost effectiveness analysis is the simplest form of evaluation in health care in its simplest
form in which costs only are compared, it is necessary to know that the outcomes of
alternatives aare equivalent or that the less costly alternative is no less beneficial. In such
situation it does not matter if outcomes are one dimensional or multidimensional
Ex; in a study comparing different methods of providing long-term care for elderly people, no
difference in survival and activities of daily living were found alternatives subsequent study
focussing on cost effectiveness was able to concentrate on cost difference only.
However in situation in which cost-effectiveness ratios are used the outcome (or benefit) is
always one-dimensional the appropriate measures depends upon the programme being
compared. For programmes major effect to external life, life years gained would generally be
used. In contrast if the major effect of the programme is to improve quality of life rather than
quantity of life then some other measure would be more appropriate.
Ex: comparing programmes for prevention of CHD, net reduction in serum cholesterol might
be an appropriate measure. Concentration o such narrow measures of benefit may mean that
other important benefit are overlooked.
Ex; dialysis compare with transplantation for treatment of CRF. Quality of life follow
transplant is better than dialysis. However if life years gained is chosen as the measure of
outcome, these effects of quality of life cannot be incorporated explicitly into the evaluation.
Various outcomes: QALY, DALY
Advantages: It is simple
 Does not require befits to valued in monetary terms
 Useful for addressing issues of technical efficiency

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Disadvantages:
 Cannot take account of multiple effects or consequences
 It cannot tell how large a programme should be
 Use of natural measures of outcome in evaluating different treatment for CRF, quality
of life is as important an outcome as improving life expectancy. Thus using life years
gained as outcome in CE ratio may mean other important aspects of outcomes are
missed.

CHICKENPOX (VARICELLA) VACCINE

Introduction: Varicella (chickenpox) is an acute, highly contagious viral disease with
worldwide distribution. In temperate climates of the Northern Hemisphere, varicella occurs
mainly in the period from late winter to early spring. Secondary attack rates reach close to
90% in susceptible household contacts. Varicella-zoster virus (VZV) is the causative agent
and is transmitted by droplets, aerosol or direct contact, and patients are usually contagious
from a few days before rash onset until the rash has crusted over. Sometimes, mild clinical
infections may not be recognized or may be misdiagnosed. Thus, in temperate regions the
majority of adults with a negative history for varicella are seropositive when tested.
In temperate climates most cases occur before the age of 10. Varicella is characterized by an
itchy, vesicular rash, usually starting on the scalp and face, and initially accompanied by
fever and malaise. As the rash gradually spreads to the trunk and extremities, the first vesicles
dry out. It normally takes about 7–10 days for all crusts to disappear.
Although varicella is usually a benign childhood disease, the course may occasionally be
complicated by VZV-induced pneumonia or encephalitis, sometimes resulting in persistent
sequelae or death. Disfiguring scars may result from secondary bacterial infections of the
vesicles, and necrotizing fasciitis or septicaemia may occur from such infections. The rarely
congenital varicella syndrome and perinatal varicella of newborns can occur.
In about 10%–20% of the cases, varicella is followed later in life by herpes zoster, or
shingles, a painful vesicular rash with dermatomal distribution. Most cases of zoster occur
after the age of 50 or in immunocompromised persons. It is a relatively common
complication in HIV-positive persons. Zoster may occasionally result in permanent
neurological damage such as cranial nerve palsies and contralateral hemiplegia, or in visual
impairment following zoster ophthalmia. Nearly 15% of zoster patients have pain or
parasthesias in the affected dermatome for at least several weeks and sometimes permanently
(postherpetic neuralgia). Disseminated, sometimes fatal zoster may occur in patients suffering
from malignancies,
The pathogen
VZV is a double-stranded DNA virus belonging to the herpesvirus family. Only one serotype
is known, and humans are the only reservoir. VZV enters the host through the
nasopharyngeal mucosa, and almost invariably produces clinical disease in susceptible
individuals. The incubation period is usually 14–16 (10–21) days. Following varicella, the
virus persists in sensory nerve ganglia, from where it may later be reactivated to cause zoster.
Serum antibodies against viral membrane proteins and glycoproteins are utilized in diagnostic
tests, but are less reliable as correlates of immunity, particularly to zoster.

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Immune response
Natural infection induces lifelong immunity to clinical varicella in almost all
immunocompetent persons. Newborn babies of immune mothers are protected by passively
acquired antibodies during their first months of life. Temporary protection of non-immune
individuals can be obtained by injection of varicella-zoster immune globulin within three
days of exposure. The immunity acquired in the course of varicella prevents neither the
establishment of a latent VZV infection, nor the possibility of subsequent reactivation as
zoster.
The justification for vaccine control
Except for vaccination, no countermeasures are likely to control the dissemination of
varicella or the frequency of zoster in a susceptible community. Varicella-zoster immune
globulin and antiherpesviral drugs are very costly, and mainly applied for post-exposure
prophylaxis or the treatment of varicella in persons at high risk of severe disease. Due to its
extremely contagious nature, varicella is experienced by almost every child or young adult in
the world. On the other hand, the public health impact of varicella and zoster may be
increasing in regions with high rates of HIV endemicity.
It is not yet sufficiently documented that the varicella vaccine, administered either in
childhood or in adult populations, will protect against zoster. However, several indications,
including the results of vaccination studies in certain immunodeficient groups, are
encouraging in this regard. The public health as well as the socioeconomic impact of this
vaccine would increase drastically if it was proved to protect against zoster in the general
population. In industrialized countries considerable amounts are spent on medical care in
complicated cases of zoster in immunocompromised or elderly persons, and the increasing
incidence of zoster in HIV-affected areas is well documented.
Varicella vaccines
The currently marketed varicella vaccines are based on the Oka strain of VZV, which
has been modified through sequential propagation in different cell cultures. Various
formulations of such live, attenuated vaccines have been tested extensively and are approved
for use in Japan, the Republic of Korea, the United States and several countries in Europe.
Following a single dose of the above-mentioned vaccines, seroconversion is seen in
about 95% of healthy children. The optimal age for varicella vaccination is 12–24 months. In
Japan and several other countries one dose of the vaccine is considered sufficient, regardless
of age. In the United States, two doses, four to eight weeks apart, are recommended for
adolescents and adults, in whom 78% were found to have seroconverted after the first, and
99% after the second dose of the vaccine. Children below 13 years of age receive only one
dose.
Small studies, using formulations different to that currently licensed in the United States,
show that when the vaccine is administered within three days after exposure to VZV, a post-
exposure protective efficacy of at least 90% may be expected. Varicella in persons who have
received the vaccine ("break-through varicella") is substantially less severe than the disease
in unvaccinated individuals.
As judged from the Japanese experience, immunity to varicella following vaccination lasts
for at least 10–20 years. In the United States, childhood vaccination against varicella provides
70%–90% protection against infection, and more than 95% protection against severe disease
7–10 years after immunization.

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In immunocompromised persons, including patients with advanced HIV infection, varicella

vaccination is currently contraindicated for fear of disseminated vaccine-induced disease.
Vaccine safety is however being evaluated in asymptomatic HIV-infected children with CD4
counts of more than 1000, and a killed varicella vaccine has been studied in VZV-positive
bone marrow transplant patients where a multiple-dose schedule has been shown to reduce
the severity of zoster.
Vaccine-associated adverse events
In healthy children some local swelling and redness at the site of injection during the first
hours following vaccination (27%), and in a few cases (fewer than 5%) the vaccinees
experience a mild varicella-like disease with rash within four weeks. Rare occasions of mild
zoster, encephalitis, ataxia, pneumonia, thrombocytopenia, arthropathy and erythema
multiforme occurring after vaccination have been reported. These events may not be causally
related and they occur at much lower rates than following natural disease.
WHO position on varicella vaccines
The current varicella vaccines seem to meet the above WHO guidelines as far as their use in
industrialized countries is concerned. However, from the global perspective, there are
limitations in terms of price and storage. For example, one of the currently available vaccines
requires storage at –15°C and use within 30 minutes of reconstitution.
The likelihood that every child will contract varicella, combined with a socioeconomic
structure that implies high indirect costs for each case, make varicella relatively important in
industrialized countries with temperate climates. Routine childhood vaccination against this
disease is estimated to be cost-effective in such areas. Varicella vaccine may be used either at
an individual level to protect susceptible adolescents and adults, or at a population level, to
cover all children as part of a national immunization programme. Vaccination of adolescents
and adults will protect at-risk individuals, but will not have a significant impact on the
epidemiology of the disease on a population basis. On the other hand, extensive use as a
routine vaccine in children will have a significant impact on the epidemiology of the disease.
If sustained high coverage can be achieved, the disease may virtually disappear. If only
partial coverage can be obtained, the epidemiology may shift, leading to an increase in the
number of cases in older children and adults. Hence, routine childhood varicella
immunization programmes should emphasize high, sustained coverage.
There is little information from developing countries on the disease burden of varicella and
zoster, and on the incidence and impact of secondary infections. It is unlikely; however, that
varicella will be among the priority vaccine-preventable diseases in most developing regions.
Decision-makers considering the use of varicella vaccine in routine immunization
programmes must take into account the epidemiology and the public health and
socioeconomic impact of varicella relative to other health concerns competing for scarce
resources.
 Most developing countries have other vaccine-preventable diseases that cause
significantly greater morbidity and mortality, and varicella vaccine is not a high
priority for routine introduction into their national immunization programmes.
 Routine childhood immunization against varicella may be considered in countries
where this disease is a relatively important public health and socioeconomic problem,
where the vaccine is affordable, and where high (85%–90%) and sustained vaccine
coverage can be achieved. (Childhood immunization with lower coverage could

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theoretically shift the epidemiology of the disease and increase the number of severe
cases in older children and adults.)
 Additionally, the vaccine may be offered in any country to individual adolescents and
adults without a history of varicella, in particular to those at increased risk of
contracting or spreading the infection. This use in adolescents and adults entails no
risk of an epidemiological shift, as childhood exposure to VZV remains unaffected.
Administration summary

Type of vaccine Live attenuated virus, Oka strain

Number of doses One dose for persons aged under 13 years; two doses in adolescents
and adults four to eight weeks apart, subcutaneous
12–24 months of age for early childhood immunization*
Schedule
Pregnancy; reaction to previous dose (including reaction to a
component such as gelatin); any advanced immune disorder or
Contraindications cellular immune deficiency; symptomatic HIV infection; severe
illness
Mild local reaction; mild illness with rash
Adverse reactions Beware of confusion between vaccine and varicella-zoster immune
Special globulin
precautions

*Not recommended for developing countries

COMMUNITY CARE CENTRES

Function as a bridge between hospital and home care for the patients living with
HIV/AIDS patients.
Introduction: People living with HIV/AIDS (PLHA) require a range of HIV services
including care, treatment and support depending on the progression and stage of the HIV
infection. The progression of the infection and consequent weakening of the immune system
will result in PLHA being vulnerable to various opportunistic infections. The PLHA will
require care and treatment for opportunistic infections (OI) and some of these illnesses may
require in-patient care in a hospital or other centres that provide this facility.
Under the National AIDS Control Programme Phase- II, 122 Community Care
Centres (CCC) were set up to provide treatment for minor OIs and provide psychosocial
support through sustained counselling. CCC were intended to function as a bridge between
hospital and home care. Hence, CCC were envisaged as stand-alone short-stay homes for
PLHA. These were not linked to other activities of the programme. The introduction of
Antiretroviral Therapy (ART) has brought about a change in the role to be played by the
CCC. The CCC needs to be transformed from a stand-alone short-stay home to playing a
critical role in enabling PLHA to access ART as well as providing monitoring, follow-up,
counselling support to those who are initiated on ART, positive prevention, drug adherence,

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nutrition counselling etc. The monitoring of PLHA who do not require ART yet (Pre-ART
care) will also be a critical function that needs to be carried out by CCC.
Under NACP III, it is proposed to set up 350 CCC over the period 2007-12. PLHA networks,
NGO and other civil society organizations need to promote setting up of CCC to strengthen
community care and support programmes. The CCC will be established on priority, in
districts which have high levels of HIV prevalence and high PLHA load and will be linked to
the nearest ART centre.
Objectives of Community Care Centres:
Under the national programme, a Community Care Centre (CCC) is a place with facilities for
out-patient and inpatient treatment where a PLHA receives the following services:
1 In-Patients:
i. All PLHA started on ART (at the ART center), will be sent to the CCC for a minimum of 5
days of inpatient care where the following action will be taken:
a. PLHA without OI should be placed separately from PLHA with OIs.
b. Medical monitoring for side effects and tolerance to ART regimen and/or stabilisation of
OIs as initiated by the ART centre/higher level facilities
c. Verification of patient address: The ART centre will verify the address of all PLHA being
enrolled at the ART centre. In case of PLHA whose address could not be verified, the CCC
will be informed of the same. The outreach worker at the CCC will undertake home visit to
verify the address. The home visit will be undertaken with informed consent of the PLHA
regarding time, day and person to be contacted.
d. Follow-up home-visits to ensure home care and to monitor well-being and treatment
adherence.
e. Preparing family and/or spouse for acceptance of test status of PLHA, counselling for
supervised administration of drugs, home based care etc.
f. Psychosocial and counselling support on drug/treatment adherence, patient education,
nutrition counselling, positive prevention including consistent use of condoms, reproductive
health counselling for HIV-positive women and couples etc.
g. In case of PLHA requiring stay for over five days, discharge of PLHA would be
determined by the treating physician.
ii. Treatment of OIs.
iii. Following assessment at the ART centre, PLHA who do not require ART, will be
followed up for pre- ART care such as routine regular monitoring of CD4 testing and other
medical concerns.
The PLHA will also receive psychosocial support and counselling, treatment literacy,
positive prevention etc.
2 Referrals to:
i. ICTC for confirmation of HIV status in patients with unconfirmed or unknown status,
spouses and family members of PLHA etc.
ii. PPTCT for care of HIV-positive pregnant women

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iii. Paediatric HIV services/ART centre for children living with HIV/AIDS for routine
monitoring including growth, HIV/PCR diagnostic testing, immunization, prevention and
care of opportunistic infections, assessment for ART initiation etc.
iv.ART Centre for the CD4 test and other laboratory investigations and if required, initiation
of ART at the ART Centres Medical facilities for specialised services as required.
vi. DOTS for treatment for TB.
vii. Other services as required e.g. welfare-legal services, harm reduction programmes for
IDUs, peer support networks etc
3 Out-patient facility for
i. Consultation of illnesses related to HIV/AIDS
ii. Treatment of OIs
iii. Counselling for adherence and Home Based Care (HBC)
4 Home based care:
i. Outreach facility for PLHA who required home care or additional psychosocial support.
ii. Counselling for Home Based Care (HBC)
5 Some CCC may also serve as a Link ART Centre for patients on ARV treatment.
These CCC have to be accredited by NACO.
6 ICTC facility: A CCC may also provide ICTC service as per the ICTC Operational
Guidelines of NACO. For CCC providing ICTC service-
1. A ICTC could be set-up within the CCC.
2. This will offer HIV testing to
 Spouse and children of PLHA
 HRGs
 Clients reporting to the CCC with TB
 Any client referred to the centre.
 Direct walk-in clients seeking a HIV test.
3 PPTCT service: The CCC will provide the range of PPTCT service to
a. Pregnant women referred to the CCC
b. Spouse of PLHA
c. Positive pregnant women.
7 DOTS Facility:
In the absence of a nearby DOTS center or based on the client load requiring TB treatment,
the CCC can function as a DOTS centre or serve as a drug dispensing centre for TB patients
following the criteria set by the RNTCP.
8 Condom Distribution:
i. All PLHA should be counselled for risk reduction
ii. Condoms should be made available at the CCC
Functions of community care services:

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Parameters to establish CCC on Priority basis:

1. Prevalence of HIV infection in the State/ District and estimated number of persons with
HIV/AIDS (preference given to category ―A‘ & ‗B‘ Districts).
2. Availability of existing ART services in the State/Region/District
3. Availability of adequate space for setting up CCC
4. Agreeing to follow NACP technical and operational guidelines prescribed by GOI
5. Commitment to regularly furnish information on facilities, services and outcomes in
prescribed formats to SACS and NACO.

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LINK ART CENTRES

Rationale of the concept of Link Centres
The ART roll out is being done through ART centers which are located mainly in Medical
Colleges, Tertiary Hospitals and District Hospitals in some states. As a result, many a times,
patients from periphery have to travel long distances to reach the ART centre. Since the
treatment is life long and drugs are provided once a month, it means the patient has to come
to ART centre every month for rest of his life, even when he is stable on treatment. This may
lead to missing of visits, particularly when patient is traveling or is otherwise feeling healthy.
Also monthly visits lead to lot of rush at ART centers, leading to long waiting hours and
inconvenience to patients. The monthly visits may also entail the patient‘s stay in the city
leading to escalation of costs in addition to travel cost. Many a times these costs may be more
than cost of drugs that patient is provided. All these factors have been perceived as potential
barriers to an optimal adherence for ART.
To minimize the travel need for the patients stable on ART, it is envisaged to have authorized
Drug Distribution Centers that will be called Link ART centers and shall be located near
the patients residence. These centers will be linked to a Nodal ART center within accessible
distance.
Objectives of setting up the Link ART Centre:
1. To integrate ART services with the Primary / Secondary Health Care system.
2. To build the capacity of the health care staff at the Primary Health Care Level in ART
treatment.
3. To increase the access of ART services to the PLHA.
4. To improve the adherence of patients to ART.
5. To reduce the travel cost and travel time of PLHA to access services.
6. To reduce the load at the Nodal ART Centre.
Functions of the Link ART Centre:
Functions of ART center can be categorized as medical, psychological and social as indicated
below:
Medical Functions:
 To monitor the patients on ART in terms of OIs, Side Effects , Adherence and
Weight.
 Back referral to the ART center w.r.t Symptoms suggestive of OI, Side effect of
drugs, Pregnancy and ANC care, etc.
Programmatic Functions:
 The LAC will be considered important CST providing units under NACP III and
they need to provide regular monthly reports and if necessary other relevant
information to Nodal ART Centre/ SACS/ NACO on demand.
 To facilitate linkages between other service providers such as ICTCs, NGOs and
CBOs.
Psychological Functions
 To provide psychological support to PLHA accessing the Link ART center.

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 To provide counseling for adherence to ARV drugs

 To educate PLHA on proper nutrition.
 To advise for risk reduction behavior including usage of condoms.
Social Functions
 To facilitate PLHA to access available resources provided by government and
NGO agencies.
 To facilitate linkages between other service providers and patients, like
educational help for the children and Income generation programmes.
Eligibility Criteria for setting up a Link ART Centre:
Link ART centers shall be established on priority on the basis of following criteria:
 High Prevalence (Category A & B districts).
 ART centers where patient load is high (>1000 PLHAs on ART).
 ART centers where patients are coming from neighbouring districts in large numbers.
 ART centers where drug adherence is reported to be > 90 %, and long distance to be
traversed by PLHA has been documented to be the major cause of default and
transferring out of PLHA is not possible to any ART centre. This inability to transfer
out may be due to lack of other ART services in vicinity or unwillingness of the
PLHA to leave the Nodal ART centre.
 There are minimum of 50 PLHAs on ART from the catchments area of LAC (relaxed
to 25 PLHAs in hilly / desert areas where population is low. It has now been decided
that LAC can be established in any district at a location where there are minimum 10
patients on ART or 50 HIV positive persons as per ICTC data, in the catchment area
Staff at the LAC: Doctor, Counsellor, Staff Nurse, Pharmacist/ Nurse
Linkages and Referrals:
In view of the functions to be performed by Link ART centre it needs to have well developed
linkages with:
1. Nodal ART Center: The Nodal officer / SMO of Nodal ART centre and Link ART
Centre In charge should communicate Mobile numbers of each other as well as e
mails of both the centers.
The link ART centre shall have communication with the Nodal ART Centers
through telephone & email with regards to:
i. Number of patients shifted to Link ART center in that week.
ii. Number of patients referred to Nodal ART center each week, reasons of
referral and their subsequent management at the Nodal ART centre.
Formats to be used are at Annexure ‗1‘
The counterpart staff at Nodal ART Centre and LAC (i.e. Doctors, Counselors, Nurse and
Pharmacist) should communicate regularly (weekly) by phone and email for smooth
functioning of the linkage.

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2. Regional PLHA Networks: In order to ensure ART drug adherence among the
PLHAs and follow up of PLHAs not attending Link ART centre regularly.
3. Non – Governmental Organizations and Community based Organizations: The
Link ART centre shall involve the organizations (esp. those working with
ART programme ) and also those already working with ICTC and also may envisage
new partnerships with other organizations to carry out home visits for the patients
who are irregular on the treatment.
Eligibility Criteria for transfer of patients from Nodal ART centre to LAC:
Patients satisfying all of the following conditions will be shifted to Link ART centers:
1. Patients stabilized on ART for minimum 6 months at the Nodal ART centre.
2. Those who have exhibited weight gain, and increase in CD4 count after 6 months
after initiating ART.
3. Do not have any active OI.
4. The patient is a resident of an area closer to the LAC than to the NAC.
5. Those who are willing to be shifted and collect their ARV from the LAC, once the
above conditions are fulfilled.
Link ART center shall not initiate ART in any patient.

INTEGRATED VECTOR MANAGEMENT

Introduction: Diseases transmitted by mosquitoes and other insect vectors continue to place
a critical burden on the world‘s poor, particularly in tropical and subtropical areas. Malaria
remains the most important vector-borne disease in public health, and the current
intensification of malaria-control efforts includes the delivery of a package of vector-control
interventions aimed at controlling transmission. Several other important vector-borne
diseases are neglected tropical diseases, and WHO’s Global plan to combat neglected
tropical diseases 2008–2015 addresses the challenges of delivering multi-intervention
packages that include the promotion of integrated vector management (IVM).
Vector control strategies have a proven track record of successfully reducing or interrupting
disease transmission when coverage is sufficiently high. However, vector control also has
proven weaknesses that are contextual in nature and relate especially to technical and
managerial deficiencies and obstacles. Development of insecticide resistance played a role in
the breakdown of the malaria eradication campaign of the 1960s. Any particular intervention
may not be suitable for every setting; additionally, over-reliance on a single intervention may
undermine the flexibility needed by health services to use an adaptive management approach
to the control of vector-borne diseases.
Bringing together different types of vector-control interventions is not simply a matter of
adding them up. It requires careful consideration of synergies and antagonisms to achieve
vector control goals in specific settings. It also requires reconsideration of these combinations
over time, as contexts change and needs evolve. Vector control is well suited for integrated
approaches because some vectors are responsible for multiple diseases, and some
interventions are effective against several vectors. The concept of IVM was developed as a

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result of lessons learnt from integrated pest management, which is used in the agricultural
sector; IVM aims to optimize and rationalize the use of resources and tools for vector control.
What is integrated vector management?
IVM is ―a rational decision-making process for the optimal use of resources for vector
control‖. Its goal is to make a significant contribution to the prevention and control of vector-
borne diseases. Implementation of IVM requires institutional arrangements, regulatory
frameworks, decision-making criteria, and procedures that can be applied at the lowest
administrative level. It also requires decision-making skills that support inter sectoral action
and are able to establish vector control and health-based targets. The cost effectiveness of
vector-control measures is central to IVM.
Cost–effectiveness
At the core of the IVM concept is the need to obtain maximum value for money. This implies
that the vector control measures selected to be used as part of the IVM approach need to be
tested for their cost effectiveness, both individually and, taking into account possible
synergies, collectively. For this reason, national vector control programmes must have the
capacity to carry out cost-effectiveness analyses.
Intersectoral action
The environmental and social determinants of health change constantly as a result of decision
making that takes place outside the health sector. For instance, irrigation schemes change the
environmental receptivity for vectors, new transport infrastructure allows parasites and
vectors to travel greater distances, and population resettlement may introduce parasite carriers
to receptive areas or to those who are not immune to pathogens transmitted by vectors. There
are opportunities, within the context of IVM, to include measures undertaken by other sectors
to help reduce transmission risks through project design, implementation and operation.
Moreover, in other economically productive sectors, resources are often orders of magnitude
larger than those available in the health sector.
Regulatory and operational measures
The intersectoral framework within which IVM must operate underscores the need for
regulatory as well as operational measures. Traditionally, vector-control professionals have
been predominantly operations-oriented. However, lessons from the environment sector show
that results may often be achieved much more effectively and efficiently by regulating the
actions of others. Establishing standards and norms that are supported by sound legislation
gives vector-control programmes a strong instrument to engage others within the scope of
IVM.
Subsidiarity
Vertical vector-control programmes, often exclusively based on chemical interventions, have
a top-down decision-making structure and are often challenged by the need to obtain the
cooperation of local communities. In IVM, the involvement of local communities is a critical
element. Therefore, the concept of subsidiarity is a key component of IVM: it foresees
decision making at the lowest possible levels (that is, any decision-making higher up in the
administrative structure than strictly necessary is subsidiary to local decision-making). This
concept also reconfirms the need to assign different responsibilities to different levels:
centrally, there should be a core group with strong technical capacities; regionally, there
should be quality-control entities; and at the local level, the operational units should exist.
Decision-making

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Decision-making on vector control actions at the lowest possible level requires criteria that
are relevant to the local eco-epidemiological setting and the inclusion of those control
measures that can be locally applied. Clearly, not all necessary expertise will be available at
all times at all places, and therefore a regional or national core group should be able to
provide technical support to local vector-control operators. Similarly, independent quality
control of vector-control operations will be required to ensure that the health-based targets set
for IVM are met in an optimal way. Responsibility for such quality control may be efficiently
placed at the administrative mid-level – for example, with the provincial authorities.
Sustainability
Sustainability as defined by the World Commission on Environment and Development
(1987) refers to intergenerational equity: the current generation should use natural resources
to fulfil their needs in a way that will permit future generations to use them to fulfil their
needs. This has a bearing on vector control, for example, when it comes to possible
environmental modification, to the impact of the use of insecticides and the introduction of
new species as predators of vectors in stable ecosystems. In addition, there is the need to
ensure that vector control is economically sustainable. One of the weaknesses of global
efforts to eradicate malaria through the use of indoor residual spraying was that it could be
only a time-limited effort, since the level of investment required was impossible to sustain.
This led to the premature reduction of activities and the rechannelling of vector-control
resources to other health-sector priorities before the outcome of the effort was fully
consolidated.
A growing need for IVM
The health status of a population is strongly influenced by social and environmental
determinants that are perpetually changing. IVM provides an opportunity to address these
changes effectively in an intersectoral context as part of a broader plan to manage public
health. IVM will help consolidate and sustain public-health achievements that result from the
investment in and scaling-up of the global malaria initiative. Concerns about the
environmental impact of over-reliance on chemical control methods continue to haunt policy-
makers. The World Health Assembly and the Stockholm Convention on Persistent Organic
Pollutants advocate reducing reliance on pesticides for vector control. IVM provides the
wherewithal to reduce this reliance. The arsenal of insecticides is limited, and there are few
prospects for new candidate compounds coming to market. At the same time, there is a
growing problem with insecticide resistance. The application of IVM principles to vector
control will contribute to the judicious use of insecticides and extend their useful life.

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STIMULUS VARIATION IN CLASSROOM TEACHING

Introduction: For the success of any lesson it is essential to secure and sustain the attention
of the pupils (learning is optimum when the pupils are fully attentive to the teaching) learning
process. How to secure and sustain the attention is main theme of this skill. It is known on the
basis of psychological experiments that attention of the individual tends to shift from one
stimulus to other very quickly. It is very difficult for an individual to attend to the same
stimulus for more than a few seconds. Therefore, for securing and sustaining the attention of
the pupils to the lesson it is imperative to make variations in the stimulus. This is because
attention is the necessary pre-requisite for learning.
Skill of Stimulus Variation: Stimulus variation is described as deliberate change in the
behaviors of the teacher in order to sustain the attention of his learners throughout the lesson.
Stimulus variation determines teacher liveliness in the classroom. The components of this
skill are:
i. Body Movement: The physical movements of the teacher in the class is to attract the
attention of the learners. Sudden body movement and suddenly stopping the same
helps in gaining learner‘s attention at high level. The teacher without these activities
is like a stone-idol. Excess movement is undesirable.
ii. Gestures: Gesture involves the movements of the head, hand, and facial gestures
(laughing, raising eyebrows, emotions, etc) signals. This technique helps the teacher
to be more expressive and dynamic in presenting his lesson in the class.
iii. Change in Voice: Teacher should bring fluctuations in his voice. The pupils feel
boredom with the speech at the same pitch, and pupils get deviated from the lesson.
iv. Focussing: Focussing implies drawing the attention of the learners towards a
particular point which the teacher wishes to emphasize. Such technique involves
verbal focusing, gestural focusing, or verbal-gestural focusing.
v. Eye-contact and eye-movement: Both the eye-contact and eye-movement play very
important role in conveying emotions and controlling interaction between the teacher
and taught. In a classroom situation, this technique implies that the teacher should
maintain eye-contact with the learners in order to sustain the attention of the latter.
vi. Pausing: Pausing refers to short and deliberate intervals of silence used while
delivering ideas, explaining, lecturing, etc. Deliberate use of short pauses help the
teacher to attract and sustain the attention of his learners. But too long pauses may be
irritating.
vii. Change in Interaction Style: When two or more persons communicate their views
with each other, they are said to be interacting. In the classroom the following three
styles of interaction are possible :
1. Teacher↔ class (Teacher talks to class and vice versa)
2. Teacher↔ Pupil (Teacher talks to pupil and vice versa)
3. Pupil↔ pupil (Pupil talks to pupil)
All types of interaction should go side by side to secure and sustain pupils‘ attention.
viii. Oral-Visual Switching: The teacher gives information to the class verbally about
something. This is called oral medium. When the teacher is showing maps, charts and
object without saying something. This is called visual medium. If the teacher is giving
information to the pupils through any one medium (oral, visual, oral visual) for a long
time., it is possible that the students may lose attention to what the teacher is
conveying to them. Therefore it is essential for the teacher to change medium rapidly

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in order to secure and sustain pupils‘ attention to what he says. There are three types
media :
1. Oral⇄ oral –visual:- when the teacher while speaking shows objects, charts and
models and explains their various parts. It is switching from oral to oral-visual.
2. Oral⇄ visual:- when the teacher while speaking, shows objects, maps, charts,
globe etc. It is switching form oral to visual.
3. Visual⇄ oral – visual when the teacher demonstrates the experiment silently and
then explains the phenomenon with the help of charts, maps, diagram etc. It is
visual-oral switching.
These devices are used interchangeably to secure and sustain pupils‘ attention to the lesson.

DROP IN CENTRE
The care of HIV infected people is the most challenging aspect in HIV/AIDS prevention. The
experience shows that to mobilize the Community Support, the advocacy among PLWHAs
and networking among them for creating an enabling environment is essential. It is a good
sign that Community Support groups of PLWHAs are coming forward to provide emotional
and social support to themselves, such community based organisations have the committed
responsibility in developing the positive attitudes in the community towards individuals and
families living with HIV/AIDS. Apart from our continuous efforts still the stigma and
discrimination exists in the society. There are many people living with HIV/AIDS hesitate to
disclose their status due to fear of isolation and discrimination. It is important to address
sustainable integrated approaches to improve quality of life and increase the quality of life of
the PLWHAs.
Objectives:
The objectives of the PLWHA drop in centres is
1. To promote positive living among PLWHAs and improve the quality of life of the infected.
2. To build the capacity and skills of PLWHAs to hope with the infection
3. To create an enabling environment for the PLWHAs
4. To establish linkages with PLWHAs with the existing health services, NGOs, CBOs and
other welfare and development programmes.
5. To protect and promote the rights of the infected.
Criteria for the selection of the CBO
1. PLWHA group should be registered organisation. These types of CBOs have to be
encouraged immediately after their registration.
2. PLWHA groups must have minimum 10 people and should be addressing 100 people
living with HIV/AIDS and their families.
PLWHA networks have to be exempted from the 10% NGO contribution.
The coverage may have flexibility of 100 PLWHAs on one large programme (minimum
membership –100). It does not mean that PLWHAs at small proportion need not be

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encouraged. The PLWHAs even if they are small in-group may also be encouraged and they
have to networking among 100 PLWHAs during the project period.
This CBO have to constitute a committee of PLWHAs and SACS and religions and other
important care providers and various relevant department representatives as the core group,
which can continuously provide technical inputs.

FEMALE FOETICIDE
Female foeticide is a social malady of severe magnitude which needs to be addressed
urgently. If not it has the potential of causing a socio-demographic catastrophe in the near
future. Female foeticide is the most important reason for the adverse sex ratio prevailing in
India. The trends in the sex ratio in India over a period of time are as follows:
Year Females/1000 males
1901 972
1951 946
1981 934
1991 927
2001 933
So, throughout it is adverse for women and the alarming fact is that it is declining.
Kerala has a sex ratio of 1058 females per 1000 males in 2001. The BIMARU states have
severely adverse sex ratios. Among the plethora of reasons responsible for this, the most
important one happens to be female foeticide.
Female foeticide: Reasons:-
The broad reason for this heinous act is the deep-rooted gender bias prevailing in
Indian society. The women are designated as the ―weaker sex‖ and have always played
second fiddle to men. All the reasons stated below are the by-products of the gender bias:
1) Patriarchal system prevalent in most Indian societies.
2) Dowry system: This social evil is the largest contribution to female foeticide. A girl-child
is seen as a liability right from birth.
3) Male children are seen as future bead-winners and supporters of the family during old age
of parents so when it comes to limiting family size they would like to eliminate the girl-
children in the womb itself.
4) Erosion of ethical standards among the medical profession and the increasing greed , has
made the task of female foeticide easy. The technology has been misused and abused in this
area and indiscriminate sex detection is rampant across the country. USG centres and
abortion clinics have mushroomed in the country and are available even in small towns.
Female foeticide: Remedy:-
Curbing this menace is easier said than done. Probably a gender sensitive approach in all
activities and programmes may help the cause the 3 ―e‖‘s recommended by Nobel laureate
Amarthya Sen will help. He recommended education, empowerment and equity for women.
We have a national policy for the empowerment of women which was developed in 2001.

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1. Social empowerment of women

 Education
 Health & nutrition
 Provision of contraceptive services
 Participation in decision and policy making right from village
panchayath to parliament
 Additional programmes for women difficult circumstances
 Awareness about rights of the girl child
2. Economic empowerment of women
 Poverty alleviation
 Micro-credit & soft loans
 Self help groups
 Creating special job opportunities for women
3. Legislation: dowry act should be strictly enforced and culprits should be
brought to book. The prenatal sex detection act which is in force since 1996
must be strictly enforced.
Finally it has been proved that improvement of womens status in a community is the
solution. So we can conclude that ‗making every mother & child‘ count will help in
decreasing the reduced count of female children.

PRENATAL DIAGNOSIS
Indications:
1. Chromosomal abnormalities
a. Mothers over the age of 35 years
b. Previous child with a chromosomal abnormality
c. Balanced translocation carrier parents. In about 50% of cases balanced
translocation arises de novo in the affected child.
d. Habitual abortions: chromosomal abnormalities are about 12 times higher in
this group than general population
2. X-linked disorders: haemophilia, agammaglobulinemia, mental retardation
3. Inborn errors of metabolism: individually these are rare. 0.8% of newborn infants
have an IEM. One must distinguish between affected carrier and normal foetuses
Ex: Lipid metabolism disorders – Nieman Pick, Gaucher, Hurler, Hunter,
Carbohydrate metabolism disorders – Galactosemia
4. Neural tube defects: those who have previously given birth to a child with NTD.
Prenatal diagnostic techniques:
1. Amniocentesis: withdrawl of a sample of fluid from the intra uterine sac of fluid
contained within the amnion & chorionic membranes.
Timing: 16weeks of pregnancy. The uterine fundus is midway between symphysis
pubis and umbilicus. Amniotic fluid volume is 200 ml and there is adequate time to
complete the required studies by 20th week. A chance of obtaining fluid in a single tap
is 95%.
Risks: Rarely vaginal bleeding or else safe procedure.
2. Ultrasound
3. Chorionic villas sampling.
Ethical, social and legal issues

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1. The programmes should be designed to reach well defined groups of pregnant women
at risk
2. High quality laboratory services are a pre-requisite.
3. Proper counselling of parents before & after the procedure.
4. Treatment if required should be made available to women.

SOCIAL DIAGNOSIS
Whenever we are dealing with disease we are dealing with health because disease is a
part of the wide spectrum of health.The most important duty of a healthcare provider is to
make a diagnosis.This diagnosis has to be done at several levels i.e. at the individual level, at
the family level and at the community level.Whatever is the setting or level,the physician
should come with a diagnosis which encompasses all dimensions of the problem.We should
remember that these diagnoses are not mutually exclusive.For eg.: The clinician has to make
a clinical diagnosis ,social diagnosis, laboratory diagnosis and epidemiological diagnosis.
The relevance of a social diagnosis for a disease (communicable or non-
communicable) lies in the fact that each disease has a social aetiology and a social
pathology.Though we have established aetiologies for communicable diseases, the underlying
or predisposing factors for the disease are social and behavioural factors.eg.: For
communicable diseases the social factors influencing the disease are poverty, illiteracy which
governs the KAP of people, poor personal hygiene, poor housing, overcrowding,poor
sanitation etc.
For non-communicable diseases the social factors are stress, sedentary lifestyle, poor
eating habits, addiction to tobacco products, alcohol and drugs.
These social factors act as risk factors and predispose a person to develop a disease.So
when we make a clinical diagnosis of PEM we should make a social diagnosis of poverty and
illiteracy.When we make a diagnosis of STD we should make asocial diagnosis of high-risk
health behaviour due to alcoholism,stress,brokrn families etc.
When we make a social diagnosis we should keep in mind the social pathology
factors like alcoholism, crime, suicides, accidents, prostitution, begging, drugs, gambling etc.
Social diagnosis helps in addressing the problem in the wider context. Clinical diagnosis is
followed by management of a case by using pharmacology or a surgical intervention whereas
social diagnosis is followed by counseling procedures and intervention aimed at behaviour
modification. It also involves strengthening social security system, healthcare delivery system
and public health.It sometimes calls for formulation of public health policy. So social
diagnosis prevents recurrence of the disease in the same individual and also helps to prevent
spread of a communicable disease.
Social diagnosis can be done at the community level also, which involves studying
the KAP of the community w.r.to the disease in question and documenting the socio-
economic and cultural factors pertaining to the study population.
If we are aiming at positive health for larger percentage of population at lower cost,
then social diagnosis is a must at all levels.

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IEC IN CANCER
Health communication (information, education, communication) now known as BCC
(behavioural change communication is a powerful tool at all levels of prevention. It is the life
blood of programmes meant for any disease. Appropriate use of IEC will have a remarkable
effect on the incidence, morbidity and mortality associated with cancers.
Mainly two approaches can be adapted in cancer IEC. 1. Population strategy 2. High risk
strategy.
Population strategy: This is meant for informing and education general public. Here health
communication is a primary strategy. National and International health observances such as
days, weeks and months that are devoted to increasing awareness of knowledge about a
particular cancer.
Ex: world no tobacco day 31st May
Breast cancer day & week in March
The population strategy aims at health promotion & primordial prevention. It helps in
cultivating or adopting health behaviour and life style among the community. In so doing it
brings down the cumulative risk in the population.
Another successful example for population strategy in cancer IEC is the Great American
smoke cut (GAS), sponsored by American cancer society. The GAS is an annual event held
in November with the purpose of encouraging smokers to quit tobacco use for just one day, in
anticipation that they will become permanently smoke free. Different settings and channels
are used tor this purpose. Educational pamphlets, brochures, pledge cards, presentations,
success stories, health fairs are used. Resources spent on this strategy will field rich dividends
in the long run.
High risk strategy: this helps in early detection of cancers. It also aims at specific protection
against developing specific cancers (eg; some coccupations cancers). The high risk people
should be educated about the early warning signs (danger signs) of cancer
1. A lump or hard area in the breast
2. A change in the wart or mole
3. A persistent change in digestive and bowel habits.
4. A persistent hoarseness and cough
5. Excessive loss of blood at the monthly period or loss of blood outside usual dates/
6. Blood loos from any natural orifice
7. A swelling or sore that does not get better
8. Unexplained weight loss
Effective use of IEC for high risk group may help in early detection of various cancers
through effective screening programmes. The advantage of early detection in certain cancers
is well established.
IEC for cancer patients: the term cancer rings death bells for a layman who is been
diagnosed. He needs information about the possible treatment avenues, expenditure involved,
attendant complications, 5 year survival rates etc. so effective IEC & counselling at this stage
will improve the quality of life in all cancer patients and helps to achieve cure in many.
Information imparted about the medical, social, vocational & psychological rehabilitation
available for them will be of tremendous use.
Support groups, help lines for cancer patients, NGO‘s and charitable institutions
operating for that particular cancer needs to be communicated to the patients.

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Since complete cure is not available for many cancers and even if available is
expensive, IEC is the most effective (cost effective also) tool for our battle against cancer.

TRIBAL HEALTH
Definition: They are people living in isolation in Nature and unpolluted surroundings far
away from civilization with their traditional values, customes, beliefs and myths intact. They
are commonly known as tribals. They are also called as nature‘s uncivilized peple,
aboriginals, adivasis, indigenous people. In India we mostly refer them as adivasis or
Girijaus.
Distribution of Tribals: Tribals are a social group residing in definite area away from
civilization ? in a unifying social organization.
In technical terms Article 342 of the Indian constitution relates to a special provision
in respect of ―scheduled tribes‖ which are defined as the ―tribes or tribal communities on
parts of or on areas within tribal communities which the President may specify by Public
notification.‖
The main concentration of tribal in India is the central tribal belt in the middle part of
India and in the north-eastern states.
Tribal areas lack infrastructure particularly relating to drinking water, electicity,
educational and health services. The literacy status of the tribal population continues to be
very low.
Child born in a tribal belt is 1 1/2 times more likely to die before 5 yrs than children in
other groups. Children below 3 yrs are twice as likely to be malnourished.A tribal mother is
12 times less likely to be delivered by a medically trained person.
Communicable disease are responsible for significant morbidity and mortality
among tribals.The important ones are TB,STDs, malaria skin diseases & diarrheal diseases.
Malnutrition is a Public health problem among tribals. The problem of HIV is yet to be
estimated among tribals.
Fever prevalence (malaria) is high in tribal areas when compared to national average.
The prevalence of malaria in India is average 3700 per lakh population,whereas in tribal
population it is more than 10000 per lakh population.
Sickle cell anaemia and glucose-6-phosphate deficiency are the 2 most common genetic
disorders highly prevalent in most tribal populations in India. There is high prevalence of
endogamous marriages among these groups.
The health seeking behaviour is guided by superstition and prevailing cultural practices.
Utilization of healthcare services is very poor among tribals. This could be attributed to
poverty, ignorance, socio-cultural practices and lack of access.
Traditionally the tribal was able to medicate himself from the wealth of herbs, leaves ,
roots and plant juices available to him from the forest. Now deforestation has resulted in
dependence of tribal on allopathic medicine. The tribal lifestyle is undergoing a transition and
some of them are trying to join mainstream of society.
The tribal community in India is disadvantaged. Tribal community is not one
homogenous group but they belong to more than 400 different ethno-linguistic , religious and

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cultured groups. There are 6 predominantly tribal states wher >50% population is tribal &
another 9 states where the majority of the scheduled tribe population lives.
Burden of disease:
The health & education indicators for tribal population are poorer than for the rest of
the population. Women and girls are particularly under-privileged. Table 3.10 shows
different health indicators in scheduled castes & scheduled tribes in comparison with rest of
population.
Table 3.10: Health outcomes among scheduled castes, tribes & rest of the population in India
(1998-99)
health indicators scheduled castes scheduled tribes rest of population
IMR 83 84.2 61.8
Under 5 yrs mortality 119.3 126.6 82.6
Total fertility rate 3.15 3.06 2.66
% Children underweight 53.5 55.9 41.1
Children with anaemia 78.3 79.8 72.7
% Children with 19.6 22.4 18.7
% Children with 19.8 21.1 19.1
% Women with anaemia 56 64.9 47.6
The main reasons for poor health status of tribal people are:
1. Poverty, undernutrition in both macro and micronutrients
2. Poor environmental sanitation,hygiene, lack of safe drinking water
3. lack of access to health services
4. social barriers preventing access & Utilization of healthcare services for specific
diseases such as TB,STDs, malaria, Sickle cell anaemia and thalassemia.
There is low Utilization of healthcare services in tribal areas because:
1. Sparsely distributed tribal population in difficult forest and hilly regions
2. Poorly located subcentres
3. service providers not in post
4. lack of suitable transport services for quick referral of emergency cases
5. lack of appropriate HRD policies to encourage / motivate service providers to
work in in tribal areas
6. lack of integration with other health & sector programs
7. BCC activities may be in appropriate
8. services are not client-friendly
9. There are cultural barriers preventing access
10. Non involvement of local Traditional faith healers
11. Weak monitoring and supervision system faith healers

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Objectives :
1. Assess unmet RCH needs in tribal communities
2. Provide integrated , appropriate and quality RCH services
3. Ensure equitable access to these services
4. Stimulate demand for these services
5. Improve service coverage & acceptability
6. Promote community participation and intersectoral coordination
7. provide opportunity for employment of tribal people
8. Promote & encourage tribal systems of medicine.
Strategies:
Basic health and RCH services need to be integrated in the overall development of tribal
areas. Tribal communities have many strengths such as strong community bonds, positive
value towards health and a strong faith in Traditional healing systems. The approach to
tackling tribal health problems has to be muti-pronged, area specific and need based. The
7 states of the north-east will require a different strategy since education level is high in
theses areas and economically thay are better than other tribal groups in the country. In
order to increase Utilization of healthcare services by tribal population some suggested
innovative approaches include:
1. Involving community in the planning process as well as in the management
and implementation of services & programs.
2. Using community-based workers (men and women) as social mobilizers,
educators and providers of non-clinical services.
3. Involving locally elected bodies including tribal boards
4. Involving NGOs
5. Promote & encourage tribal systems of medicine, and tribal faith healers,where
appropriate

SOCIAL MOBILIZATION
Mobilization means gathering a force of people/opinions on certain issues.
Means collective action of people for achieving the goal of health for all.
Involvement of community is important to bring about change in behavior and attitude of the
people. Eg: Pulse Polio Programme – School teacher, children, religious leaders, panchayat
and other groups – Linkegaes with Health Team.
How to Mobilize?
1. A meeting with health staff – BEE, LHV, MPHW, HW assist in preparing a list of
different social groups and social institution.
2. Specify different groups on the basis of important caste, tribal groups, religion, land
holding and employment.
3. These details will help to understand the social and economic diversity of that area.

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Plan meeting with the groups (community) from time to time will help to make health service
according to local health needs.

Chapathi/Diagrams are used – Use Chapathi/Roti as the material to analyze (complex issues)
– becomes easier for an illiterate and lay person to relate their everyday experiences and with
the help of the cut chapattis in different sizes.

NUTRITIONAL REHABILITATION
Nutritional Rehabilitation Ambulatory Treatment Rehabilitation in ―Nutrition Rehabilitation
Centres‖
Ambulatory Treatment :
Ambulatory Treatment In most cases of malnutrition, education alone is sufficient to correct
situation. Identify the most serious errors in diet eg. distribution of available food in family,
inadequate use of vegetables, etc. The problem may need assistance usually as Food
Supplements.
Nutritional Rehabilitation Centres (NRC): Severely malnourished children, after taking
treatment from hospital, may be transferred to NRCs. The objective is to teach the mother the
various methods of preparing nutritious and tasty foods so that the relapse of malnutrition can
be prevented.
Nutritional Rehabilitation Centres (NRC) :
Day care NRCs :
Day care NRCs Similar to crěche or kindergarden. Children spend 6 – 8 hrs daily for 6 days a
week in these centres, and take there 3 meals each day. Mothers may attend centre and help
preparation of meals, or may attend weekly meeting at centre.
Day care NRCs :
Day care NRCs Food stuffs and utensils used are familiar to the mothers, and available in
local market. Adequate medical supervision is essential at the centres.
Residential NRCs :
Residential NRCs Larger staff and equipments than day-care NRCs. Children & their
mothers live in these as inpatients. Serves mostly children discharged from hospital after
treatment for severe malnutrition.
Nutrition Supplementation :
Nutrition Supplementation Approach by which both prevention and treatment of malnutrition
can be met. Supplementary food supplies 300 Cal/day and 10 – 12 gm protein/day to
children, and 500 Cal/day and 25 gm protein/day to mothers for 300 days in an year.
Nutritional Surveillance : ―Data Collection for Action‖.
Objectives of Nutrition Surveillance: To aid long term planning in health and development.
To provide input for programme management and evaluation. To give timely warning and
intervention to prevent short-term food consumption crisis.

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EMERGING INFECTIOUS DISEASES

Emerging infectious diseases are diseases of infectious origin whose incidence in humans has
increased within the recent past or threatens to increase in the near future. These also include
those infections that appear in new geographic areas or increase abruptly. The new infectious
diseases and those which are re-emerging after a period of quiescence are also grouped under
emerging infectious diseases.
Reemerging infectious diseases are familiar diseases caused by well-understood organisms
that were once under control or declining but now are resistant to common drugs or gaining
new footholds in the population and increasing in incidence.
Emerging infectious diseases threaten to disrupt the health care system. Conversely, a strong
health system is a prerequisite for effectively combating emerging infectious diseases. Left
unchecked, today‘s emerging diseases can assume pandemic proportions causing social and
economic disruption and ultimately becoming endemic. This is what happened with
HIV/AIDS, which spread from a remote part of Africa to all other continents and is now
entrenched all over the world. In less than 25 years from its first isolation it has become the
fourth leading cause of death worldwide.
Major Factors Contributing to Emerging Infections
 Human demographics and behavior
More people, more crowding, Changing sexual morals (HIV, STDs)
Injection drug use (HIV, Hepatitis C)
Changing eating habits: out more, more produce (food borne infections)
More populations with weakened immune system: elderly, HIV/AIDS, cancer patients and
survivors, persons taking antibiotics and immunosuppressant drugs
 Technology and Industry- Mass food production (E.coli O157:H7, etc…)
• Use of antibiotics in food animals (antibiotic-resistant bacteria)
• More organ transplants and blood transfusions (Hepatitis C)
• New drugs for humans (prolonging immunosuppression)
 .Economic development and land use- Changing ecology influencing waterborne,
vectorborne disease transmission (e.g. dams, deforestation)
• More exposure to wild animals and vectors (KFD,Lyme disease,…)
 International travel and commerce- Persons infected with an exotic disease anywhere
in the world can be imported to major Indian city within hours (SARS, AI,…)
• Routinely imported foods from other countries (Cyclospora,….)
• Vectors hitchhiking on imported products (Aedes albopictus mosquitoes,….)
 Microbial adaptation and change- Increased antibiotic resistance with increased use of
antibiotics in humans and food animals (Penicillin- and macrolide-resistant
staphylococci, multidrug-resistant Salmonella,….)
• Increase virulence (Group A Strep?)
• Jumping species from animals to humans (avian influenza, HIV?, SARS?)
 Breakdown of public health measures- Lack of basic hygienic infrastructure (safe
water, safe foods, etc..)
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• Inadequate vaccinations (measles, diphtheria)

• Discontinued mosquito control efforts (dengue, malaria)
• Lack of monitoring and reporting (SARS)
 Human vulnerability
 Climate and weather
 Changing ecosystems
 Poverty and social inequality
 War and famine
 Lack of political will
 Intent to harm- Bioterrorism: Anthrax in US, 2001
Potential agents: Smallpox, Botulism toxin, Plague, Tularemia,
Why focus on emerging disease now
Emerging infectious diseases are associated with high mortality, widespread panic, staggering
economic loss and loss of credibility of the health system as well as the national authorities.
These aspects require the utmost attention of national health authorities. Emerging infectious
diseases are important, evolving, complex public health problems. Their prevention and
control will increasingly require application of sophisticated epidemiological and molecular
biological technologies, change in human behaviour and a national perspective. The fight
against these diseases requires a comprehensive vision and an efficient roadmap that
stimulates action at all levels of the health machinery. Emerging infectious diseases will
continue to challenge the public health infrastructure, test the credibility of the health
services, and threaten to devastate health and economic development unless a strategic vision
and an effective plan of action is developed to combat them.
Combating Emerging Diseases
 Surveillance and Response
 Detect, investigate, and monitor emerging pathogens, the diseases they cause, and the
factors influencing their emergence, and respond to problems as they are identified.
 Applied Research
 Integrate laboratory science and epidemiology to increase the effectiveness of public
health practice.
 Infrastructure and Training
 Strengthen public health infrastructures to support surveillance, response, and
research and to implement prevention and control programs.
 Provide the public health work force with the knowledge and tools it needs.
 Prevention and Control
 Ensure prompt implementation of prevention strategies and enhance communication
of public health information about emerging diseases.
 Enhance communication: locally, regionally, nationally, globally
 Increase global collaboration
 Share technical expertise and resources
 Provide training and infrastructure support globally
 Ensure political support
 Ensure judicious use of antibiotics
 Vaccines for all

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WHO DAY 2010

History:
World Health Day is celebrated every year on 7 April, under the sponsorship of the World
Health Organization (WHO).In 1948, the World Health Organization held the First World
Health Assembly. The Assembly decided to celebrate 7 April of each year, with effect from
1950, as the World Health Day. The World Health Day is celebrated to create ―awareness of
a specific health theme to highlight a priority area of concern for the World Health
Organization (WHO)‖. Activities – related to that particular theme and the resources
provided – continue beyond 7 April, that is, the designated day for celebrating the World
Health Day.
Theme 1000 cities, 1000 lives.
Cities are encouraged to work across multiple agencies with a wide range of partners to have
the most lasting impact on health. The global goal is for 1000 cities to participate in the
World Health Day campaign theme. A practical way for cities to take part is to open up
public spaces to health activities and close off portions of streets to motorized traffic,
enabling physical activity for one day from 7 to 11 April . Other activities such as town hall
meetings with mayors, clean-up campaigns, and promoting community solidarity by
encouraging residents to visit neighbours, orphanages, and patients in hospitals are also
welcomed. What is done on World Health Day is up to the creativity, desires, and priorities
of each city.
To meet the goal of 1000 lives, residents will be asked to give examples of urban health
heroes who have made a significant impact on health in their cities. These stories are
uploaded as videos on the social media website of the campaign.
Urban health threatened by inequities
For the first time in history, more people are now living in cities than in rural areas.
Worldwide, virtually all population growth over the next 30 years will be in urban areas, with
the most explosive growth taking place in Asia and Africa. By mid-century, seven out of
every ten people will live in a city.
This trend is not inherently bad for health. In general, urban populations are better off than
their rural counterparts. They tend to have greater access to social and health services,
literacy rates are higher, and life expectancy is longer. When cities are planned, managed, and
governed well, life flourishes for most residents and health outcomes surpass those seen in
rural areas.
However, average figures hide some major discrepancies, and these discrepancies are
growing. Cities concentrate opportunities, jobs, and services, but they also concentrate risks
and hazards for health.When large numbers of people are linked together in space and
connected by shared services, the consequences of adverse events are vastly amplified.
Examples range from contamination of the food or water supply, to high levels of air or noise
pollution, a chemical accident, a disease outbreak or a natural disaster.
This is part of the problem. In many countries, urban growth has outpaced the ability of
governments to build essential infrastructures and enact and enforce the legislation needed to
make life in cities safe, rewarding, and healthy.For a growing number of people in a growing
number of cities, the essential services needed for healthy living are extended to only the

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wealthier neighbourhoods or simply do not exist at all. For example, most cities in low- and
middle-income countries do not have sewers.
Cities also tend to promote unhealthy lifestyles, like cheap and convenient diets that depend
on processed foods rich in fats and sugar, yet low in essential nutrients. Like sedentary
behaviour, smoking, and the harmful use of alcohol and other substances.These lifestyle
changes are directly linked to obesity and the rise of chronic conditions like heart disease,
stroke, some cancers, and diabetes. These conditions are costly to treat, for households and
societies, and they are increasingly concentrated in the urban poor.
This is the second worldwide trend that makes urban health matter, especially for the urban
poor. The growth of urban centres in the 21st century is being accompanied by a shift in the
burden of poverty. In previous centuries, poverty was greatest in scattered rural areas. Today,
poverty has become heavily concentrated in cities.Today, around one third of urban dwellers,
amounting to nearly one billion people, live in urban slums, informal settings, or pavement
tents. More than 90% of slums are located in cities of the developing world. In many of these
cities, slums have become the dominant type of human settlement.
The threats to health are multiple: from inadequate sanitation and refuse collection to
pollution and accidents from congested traffic, from children playing barefoot in soil or water
contaminated by untreated waste, to outbreaks of infectious diseases that thrive on filth and
crowded conditions. Nearly every city everywhere has pockets of extreme deprivation
together with extreme wealth. They have people who over-consume health care, and pay too
much for it, together with people who forego the most basic and essential care for financial
and other reasons.
Cities are growing larger and larger, and their populations of the poor are growing larger even
faster. The consequences for health are immense. In fact, one of the best ways to measure
urban harm is to look at the gaps in health outcomes seen when affluent and deprived groups,
living in the same city, sometimes just a few blocks away, are compared.
Why should inequities in urban health and living standards matter? Most obviously, the
health consequences of poverty and squalid living conditions are contagious in a city setting.
They are detrimental to all city dwellers.Societies with big differences in opportunities,
income levels, and health outcomes tend to have less social cohesion and more violent crime.
Social unrest, violence, and outbreaks of disease can easily spread beyond a single
neighbourhood or district to endanger all citizens and taint a city‘s reputation.
Poor health, including mental health, is one of the most visible and measurable expressions of
urban harm. Health inequities can also be a rallying point for public demands for change that
compel political leaders to take action.In developing countries, the best urban governance can
help produce 75 years or more of life expectancy. With poor urban governance, life
expectancy can be as low as 35 years.
Scenario in India
As per Census 2001, 28.6 crores people live in urban areas. The urban population is estimated
to increase to 35.7crores in 2011 and to 43.2 crores in 20214. Urban growth has led to rapid
increase in number of urban poor population, many of whom live in slums and other squatter
settllements. As per Census 2001, 4.26 crores people lived in slums spread over 640 towns/
cities having population of fifty thousand or above. In the cities with population one lakh and
above (Appendix 1), the 3.73 crores slum population is expected to reach 6.25 crores by
20085, thus putting greater strain on the urban infrastructure which is already overstretched.

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Despite the supposed proximity of the urban poor to urban health facilities their access to
them is severely restricted. This is on account of their being ―crowded out‖ because of the
inadequacy of the urban public health delivery system. Ineffective outreach and weak referral
system also limits the access of urban poor to health care services. The social exclusion and
lack of information and assistance at the secondary and tertiary hospitals makes them
unfamiliar to the modern environment of hospitals, thus restricting their access. The lack of
economic resources inhibits/ restricts their access to the available private facilities. Further,
the lack of standards and norms for the urban health delivery system, when contrasted with
the rural network, makes the urban poor more vulnerable and worse off than their rural
counterpart.
3. This situation is further worsened by the fact that a large number of urban poor are living
in slums that have an ―illegal status‖. The ―illegal status‖ compromises the entitlement of the
slum dweller to basic services. Slum populations, obviously, ‗face greater health hazards due
to over crowding, poor sanitation, lack of access to safe drinking water and environmental
pollution7.
4. The above situation is reflected in the poor health indicators. As per the re-analysis of the
NFHS III data, Under 5 Mortality Rate (U5MR) among the urban poor is at 72.7,
significantly higher than the urban average of 51.9. About 47.1% of urban poor children
under-three years are underweight as compared to the urban average of 32.8% and 45%
among rural population. Among the urban poor, 71.4% of the children are anemic as against
62.9% in the case of urban average. Sixty percent of the urban poor children miss complete
immunization as compared to the urban average of 42%. Only 18.5% of urban poor
households have access to piped water supply at home as compared to the urban average of
50%. Among the urban poor, 46.8% women have received no education as compared to
19.3% in urban average statistics. Among the urban poor only 44 % of deliveries are
institutional as compared to the urban average of 67.5%.
5. Despite availability of government and private hospitals the urban poor prefer home
deliveries. Expensive private healthcare facilities, perceived unfriendly treatment at
government hospitals, emotionally securer environment at home, and non-availability of
caretakers for other siblings in the event of hospitalization are some of the reasons for this
preference. Poor environmental condition in the slums along with high population density
makes the urban poor vulnerable to lung diseases like Asthma; Tuberculosis (TB) etc. Slums
also have a high incidence of vector borne diseases (VBDs) and cases of malaria among the
urban poor are twice as in the case of other urbanites. Open sewers, poorly built septic tanks,
stagnant water both inside and outside the house serve as ideal breeding ground for insects.
As per the forecasting data in National Commission on Macroeconomics and Health
(NCMH) report, cases of coronary heart disease in the urban areas will continue to rise and
will be higher as compared to rural areas, similarly the load of diabetes cases in India will rise
from 2.6 crores in 2000 to 4.6 crores by 2015 particularly concentrated in urban areas.
Heterogeneity among slum dwellers caused by an influx of migrants from different areas,
varied cultures and backgrounds, existence of fewer extended family connections,
engagement and preoccupation of more women in work leads to lesser willingness and fewer
occasions that can enable the slum community as a strong collective unit.
7. The traditional temporary migration of pregnant women for delivery results in their
missing out on services at either of the residences. The mother and the infant do not receive
services in the village due to non-availability of previous record of services received.

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8. There are particular occupations such as rickshaw pullers, rag pickers, sex workers, and
other urban poor categories like beggars and destitutes, construction workers, street children
who are also a highly vulnerable group especially at greater risk to RTI/STI and HIV/AIDs.
WHO recommends the following five calls to action to build a healthy and safe urban
environment:
Promote urban planning for healthy behaviours and safety.
Local governments and civil society can design urban areas to: promote physical activity
through investment in public transport; encourage healthy eating; improve the availability of
and access to food; and reduce violence and crime through good environmental design and
regulatory controls, including control of the number of alcohol outlets.
Improve urban living conditions.
Apply healthy urban design principles with easy access to basic amenities and services,
designated commercial and non-commercial land use, with land also set aside for protection
of natural resources and recreation. One of the biggest challenges is, of course, access to
adequate shelter for all. The quality of housing and adequate services such as water and
sanitation are vital contributors to health.
Ensure participatory urban governance.
Local participatory governance mechanisms should be established to enable and encourage
communities and local governments to partner in building healthier and safer cities.
Build inclusive cities that are accessible and age-friendly.
People with disabilities make up at least 10% of the population, and access barriers prevent
participation in education, employment and public life. Globally, populations are rapidly
ageing, many of whom will experience mobility and sensory impairments. Measures such as
accessible public transport, kerb cuts, safe pedestrian crossings (e.g. tactile paving, signaled
controlled crossings) all improve safety and enhance participation for disabled and older
persons.
Make urban areas resilient to emergencies and disasters.
Improving the ability of the community to protect itself from known hazards, and involving
the health sector in community-led local emergency response planning and training, will help
to reduce risks and provide a more effective emergency response. The development of
settlements and infrastructure away from natural and technological hazard-prone areas, and
safer health facilities prepared for emergencies will make communities safer. Multi-hazard
health emergency management systems, with the ability to provide safe and secure health
services, food and water, and protection and shelter in humanitarian settings are needed to
minimize loss of life and disabilities in emergencies, disasters and other crises.
In order to effectively address the health concerns of the urban poor population, the Ministry
has launch a National Urban Health Mission (NUHM)(2008-2012)
The NUHM would cover all Cities (430 in total) with population above 1 lakh and state
capitals during phase I. District Head Quarter towns with population less than one lakh would
be covered under Phase II of the Mission. The NUHM would have high focus on
Urban Poor Population living in listed and unlisted slums
All other vulnerable population such as homeless, rag-pickers, street children, rickshaw
pullers, construction and brick and lime kiln workers, sex workers, any other temporary
migrants
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WHO DAY THEME 2009

Save lives. Make hospitals safe in emergencies
How emergencies threaten health facilities and delivery of care
Apart from their effects on people, emergencies can pose hugethreats to hospitals, clinics and
other health facilities.
Structural and infrastructural damage may be devastating exactly at the time when health
facilities are most needed. Health workers have been killed in collapsing hospitals. The
number of other deaths and injuries is compounded when a hospital is destroyed or can
function only partially. Health facilities should be the focus for assistance when disaster
strikes but, if they are damaged or put out of action, the sick and injured have nowhere to get
help.
The 2003 Algerian earthquake rendered 50% of health facilities in the affected region non-
functional due to damage. In Pakistan‘s most-affected areas during the 2005 earthquake, 49%
of health facilities were completely destroyed, from sophisticated hospitals to rural clinics
and drug dispensaries. The December 2004 Indian Ocean tsunami affected national and local
health systems that provided health services for millions of people. In Indonesia‘s northern
Aceh province 61% of health facilities were damaged.
Despite international laws, health facilities continue to be targeted or used for military
operations in conflicts. Health facilities in Bosnia and Herzegovina, Somalia, the Central
African Republic and the Gaza Strip are among those that have been caught in the line of fire.
An emergency may be limited to the health facility infrastructure – for example, fire damage,
power cut or loss of water supply. Chemical and radiological emergencies in or near a health
facility can also disrupt the delivery of care. In addition, emergencies threaten health staff –
the doctors, nurses, ambulance drivers and other staff working to save lives. When a hospital
collapses, or an artillery shell destroys a ward or an ambulance, health staff are killed or
injured.
When staffs are incapacitated and cannot do their work, health care is further interrupted.
Even if health facilities themselves are not affected during disease outbreaks and epidemics,
their services and provision of safe care may be. Increased demands for services and a
decreased workforce can impact on health care by disrupting communications, supplies and
transport. Continuity of care is then in turn disrupted, including for chronic diseases like HIV
and tuberculosis. If measures to prevent and control infection are not effective, health care
facilities may act as ―amplifiers‖ of outbreaks, generating cases of the disease among other
patients or health care workers and further decreasing the capacity to provide services. Power
cuts linked to disasters may disrupt water treatment and supply plants, thereby increasing the
risk of waterborne diseases and affecting proper hospital functioning, including preserving
the vaccine cold chain. A massive power outage in New York in 2003 was followed by an
increase in diarrhoeal illness.
Why keep health facilities safe?
Safe health facilities in emergencies are a collective responsibility
Hospitals are more than just buildings. They are a vital asset at the heart of a community, the
place where often life starts and ends. Due to the central role played by hospitals in our
communities, we all share the responsibility of making sure they are resilient in the face of
emergencies. Below are three reasons as to why we must make hospitals safe in emergencies.
1. Save lives, protect health

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As they are occupied 24 hours a day, hospitals cannot be evacuated easily. They must remain
working if their occupants – especially the most vulnerable such as newborn babies and
patients in intensive care – are to survive. When the work of hospitals and other health
facilities is disrupted or their buildings are damaged, both urgent and routine health care is
interrupted and may be halted altogether – leaving the sick and injured without the care that
they need. Health ―systems‖ rely on a range of public, private and nongovernmental facilities
to work together to serve the community. In times of emergency, this is even more important.
Hospitals, primary health care centres, laboratories, pharmacies and blood banks work with
other non-health sectors, including energy, roads and transport, and the police to ensure the
continuity of health services. Health facilities are safe havens for people during an
emergency. Hospitals and their staff must be regarded by all parties – particularly combatants
during conflicts – as neutral and must not be subjected to any form of violence. Sadly, the
provisions of international humanitarian law in this regard are often not respected.
2. Protect investment
The most costly health facility is the one that fails. Hospitals and health facilities are
enormous investments for any country and their destruction or damage imposes major
economic burdens. In some countries, up to 80% of the health budget is spent on hospitals
and other health facilities. Rebuilding a hospital that has been destroyed virtually doubles the
initial cost of the facility.
3. Safeguard social stability
Public morale can falter and political discord be ignited if health and emergency services fail
during emergencies. Conversely, an effective emergency response and functional health
service can reinforce social stability and cohesion. Hospitals are a haven for the public during
conflicts and other emergencies due to their neutrality, impartiality and ability to protect a
community‘s social and health capital Health facilities are safe havens for people during an
emergency. Hospitals and their staff must be regarded by all parties – particularly combatants
during conflicts – as neutral and must not be subjected to any form of violence. Sadly, the
provisions of international humanitarian law in this regard are often not respected.
2. Protect investment
The most costly health facility is the one that fails. Hospitals and health facilities are
enormous investments for any country and their destruction or damage imposes major
economic burdens. In some countries, up to 80% of the health budget is spent on hospitals
and other health facilities. Rebuilding a hospital that has been destroyed virtually doubles the
initial cost of the facility.
3. Safeguard social stability
Public morale can falter and political discord be ignited if health and emergency services fail
during emergencies. Conversely, an effective emergency response and functional health
service can reinforce social stability and cohesion. Hospitals are a haven for the public during
conflicts and other emergencies due to their neutrality, impartiality and ability to protect a
community‘s social and health capital
How to safeguard health facilities
Situate, design and build new health facilities
Assess the safety of existing facilities
Retrofit existing facilities

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Protect non-structural elements: essential services, equipment,Medicines

Plan and train for emergencies
Build partnerships for safe health facilities

WHO DAY THEME 2008: PROTECTING HEALTH FROM CLIMATE CHANGE

In 2008, World Health Day focused on the need to protect health from the adverse effects of
climate change. WHO selected this theme in recognition that climate change is posing ever
growing threats to global public health security.
Climate change: past and future
The basic facts are now firmly established. The earth is warming rapidly,mainly because of
emissions of greenhouse gases caused by human activity.If current patterns of fossil fuel use,
development and population growth continue, this will lead to ongoing climate change, with
serious effects on the environment and, consequently, on human lives and health.
Climate and its impact on the fundamentals of health
Climate change will affect, in profoundly adverse ways, some of the most fundamental pre-
requisites for good health: clean air and water, sufficient food, adequate shelter and freedom
from disease. The global climate is now changing faster than at any point in human
civilization, and many of the effects on health will be acutely felt. The most severe risks are
to developing countries, with negative implications for the achievement of the health-related
Millennium Development Goals and for health equity.
―Natural‖ disasters: the growing influence of climate change on heatwaves, floods, droughts
and storms
Globally, the number of reported weather-related natural disasters is mounting rapidly.
Reports of natural catastrophes have more than tripled since the 1960s. In 2007, 14 out of 15
―flash appeals‖ for emergency humanitarian assistance were for floods, droughts and storms
–five times higher than in any previous year.
Changing patterns of infection
Infections caused by pathogens that are transmitted by insect vectors are strongly affected by
climatic conditions such as temperature, rainfall and humidity. These diseases include some
of the most important current killers: malaria, dengue and other infections carried by insect
vectors, and diarrhoea, transmitted mainly through contaminated water.
All populations are vulnerable – but some are more vulnerable than others
All populations will be affected by a changing climate, but the initial health risks vary
greatly, depending on where and how people live. People living in small island developing
states and other coastal regions, megacities, and mountainous and polar regions are all
particularly vulnerable in different ways. Health effects are expected to be more severe for
elderly people and people with infirmities or pre-existing medical conditions. The groups
who are likely to bear most of the resulting disease burden are children and the poor,
especially women. The major diseases that are most sensitive to climate change – diarrhoea,
vector-borne diseases like malaria, and infections associated with undernutrition – are most
serious in children living in poverty.

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We have a common interest in facing up to health risks wherever they occur. Ongoing
climate change, coupled with globalization, will make it more difficult to contain infectious
diseases within their current ranges. Health challenges arising from population displacement
and conflict are unlikely to stay confined within national borders. Improved health conditions
for all populations, alongside more rapid and effective international disease surveillance,
constitute a vital contribution to global public health security.
Putting health at the heart of the climate change agenda
Climate change can no longer be considered simply as an environmental or a developmental
issue. It will affect the health and well-being of all populations, with impacts escalating into
the foreseeable future. A greater understanding of the health implications of climate change –
and related development choices – can lead to improved policies and more active public
engagement.

WHO DAY THEME 2007: INTERNATIONAL HEALHT SECURITY

“INVEST IN HEALTH, BUILD A SAFER FUTURE".
Threats to health know no borders. In an age of widespread global trade and travel, new and
existing diseases can cross national borders and threaten our collective security. Only through
strong collaboration among developed and developing countries, together with an increased
focus on information sharing and the strengthening of public health systems and surveillance,
can we contain their spread
International health security issues
 Emerging diseases: new, highly contagious diseases, such as SARS and avian
influenza, know no borders. Their potential to cause international harm means that
outbreaks cannot be treated as purely national issues. In the last few decades, new
diseases began emerging at an unprecedented rate of one or more per year.
 Economic stability: public heath dangers have economic as well as health
consequences. Containing international threats is good for economic well-being. With

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fewer than 10,000 cases, SARS cost Asian countries US $ 60 billion of gross
expenditure and business losses in the second quarter of 2003 alone.
 International crises and humanitarian emergencies: these events kill and maim
individuals and severely stress the health systems that people rely on for personal
health security. In 2006, 134.6 million people were affected and 21 342 were killed by
natural disasters.
 Chemical, radioactive and biological terror threats: whether deliberate or
accidental, WHO's global networks are well placed to respond to the health effects of
these threats using the same techniques employed in other disasters - rapid assessment
and response, triage and treatment, securing water, food and sanitation systems.
Anthrax-tainted letters sent through the U.S. postal system in 2001 and the release of
sarin on the Tokyo subway in 1995 remind us that although chemical and biological
attacks are rare, there are people ready to use this brand of terrorism.
 Environmental change: environmental and climate changes have a growing impact
on health, but health policies alone cannot prevent their effects. People are dying-
upwards of 60 000 in recent years in climate-related natural disasters, mainly in
developing countries.
 HIV/AIDS - a key health and security issue: the devastating impact of HIV/AIDS,
demonstrated to international security specialists the potential impact of a public
health issue on security. In 2006, an estimated 39.5 million people were living with
HIV/AIDS.
 Building health security: national compliance with the revised IHR 2005 will
underpin international health security.
 Strengthening health systems: functioning health systems are the bedrock of health
security, but the current state of systems worldwide is inadequate. As an example, the
world is currently short of more than four million health workers, with the impact
most felt in developing countries. the theme of World health Day and of the World
health report 2007 is ―international health security‖ – the need to reduce the
vulnerability of people around the world to new, acute or rapidly spreading risks to
health, particularly those that threaten to cross international borders. in a globalized
world, health issues present new challenges that go far beyond national borders and
have an impact on the collective security of people around the world. increased
collaboration among developed and developing countries will enable the international
community to be better prepared to strengthen national capacities to detect and
respond to disease outbreaks. this will provide a global safety net to deal with key
cross-border public health issues and in turn help to make the world more secure.

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WHO DAY THEME 2006: WORKING TOGETHER FOR HEALTH

In 2006, World Health Day was devoted to the health workforce crisis.
Health workers - the people who provide health care to those who need it - are at the heart of
health systems. But around the world, there is a chronic shortage of health workers as a result
of decades of underinvestment in their education, training, salaries, working environment and
management. The results are evident: clinics with no health workers and hospitals that cannot
recruit or keep key staff. This is a crisis from which no country is entirely immune.
Health workers are inequitably distributed throughout the world, with severe imbalances
between developed and developing countries. This global workforce shortage is made even
worse by imbalances within countries. In general, there is a lack of adequate staff in rural
areas compared to cities.
Sub-Saharan Africa faces the greatest challenges. While it has 11 percent of the world's
population and 24 percent of the global burden of disease, it has only 3 percent of the world's
health workers.
There is a direct relationship between the ratio of health workers to population and survival
of women during childbirth and children in early infancy. As the number of health workers
declines, survival declines proportionately
TACKLING THE CRISIS: WHAT IS NEEDED
 More direct investment in the training and support of health workers. Initial
funds will be for training more health workers. As they graduate and enter the
workforce, more funds will be needed to pay their salaries. To educate and pay the
salaries of the four million health workers needed in the 57 countries with severe
shortages, health budgets will have to increase at least US$ 10 per person per year by
the year 2025. To meet that target within 20 years is an ambitious but reasonable goal.
 A national plan for the health workforce and an increase in the number of health
workers in all countries with serious shortages. That will take political leadership,
a comprehensive plan for an effective health workforce, and commitment of the
necessary funds. Funding must not only cover health service providers, but also the
management and support workers who provide crucial services to the health system.
Governments also need to invest in training existing health workers, to keep them up
to date with changing priorities.
 More efficient use of the existing health workforce. Simple, inexpensive measures
like improving management and supervision and writing clear job descriptions would
help. Another helpful strategy is "piggy-backed" services -- meaning that workers
delivering one specific service, such as a vaccine during an immunization campaign,
can simultaneously deliver others, such as a needed dose of vitamins.
 Some simple health care tasks now assigned to highly skilled personnel delegated
to less skilled workers able to deliver them competently. With sufficient
supervision and support, volunteers, community health workers and workers, with
limited training can improve efficiency of health services.
 Protection and fairer treatment of health workers. They face difficult and often
dangerous working conditions and poor pay in many developing countries.
 Access to effective HIV prevention and treatment for all health workers. HIV has
disproportionately affected health workers in many countries. It is vital that they
receive these services under confidential conditions.

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 Encouragement of women to enter health professions. Their needs should be

accommodated through flexible work arrangements and leadership career tracks
adapted to family life.
 Decreased incentives for early retirement. Countries with serious shortages also
should provide opportunities for retirees to go back to work.
 Comprehensive preparedness plans in every country for a workforce response to
outbreaks and emergencies. They should include plans for how health workers will
collaborate with staff in the military, transport and education sectors to maximize the
efficiency of scarce human resources.
 In conflicts, reassignment of health workers to areas in need. Workers given such
assignments need protection and support; and international donors and other major
actors need to take measures to protect existing health worker networks.
 Orientation of health worker training and development of career incentives to
encourage service in rural and disadvantaged areas. These actions would help
counteract the tendency of health workers to cluster around cities.
 Better strategies to more actively engage communities and patients in their own
health care. Partnerships between patients and health workers can improve the
quality of care and health outcomes.

WORLD HEALTH DAY 2005: MAKE EVERY MOTHER AND CHILD COUNT
The theme of World Health Day 2005 was healthy mothers and children. The well-being of
societies is directly linked to the health and survival of mothers and children. Yet too many
mothers and children are dying or suffering from the effects of ill-health, poor nutrition and
inadequate health care. Nearly all these deaths occur in low- and middle-income countries,
and mainly among the poorest of the poor.
The main objectives of World Health Day 2005 are to:
 Raise awareness of the extent of illness, suffering and death among mothers and
children, and its impact on health as well as social and economic development.
 Increase understanding that solutions exist. Affordable and effective means are
known that can prevent death and suffering. The challenge is to deliver a key set of
preventive and curative interventions to the mothers and children who need them – to
translate knowledge into action.
 Generate a movement that stimulates collective responsibility and action. Families,
community-based groups, professional societies, national governments, and the
international community all need to support the delivery of programmes and services
to mothers and children, as well as fight for better access to basic health services.
Every individual within society has a role to play.
Hundreds of millions of women and children have no access to potentially life-saving care
with often fatal results, the World Health Organization (WHO) says in a report published
today. The report says the resulting death toll could be sharply reduced through wider use of
key interventions and a "continuum of care" approach for mother and child that begins before
pregnancy and extends through childbirth and into the baby's childhood.

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About 530 000 women a year die in pregnancy or childbirth, more than three million babies
are stillborn, more than four million newborns die within the first days or weeks of life, and
altogether 10.6 million children a year die before their fifth birthday, according to WHO's
latest figures.
In The World Health Report 2005 – Make every mother and child count, WHO estimates that
out of a total of 136 million births a year worldwide, less than two thirds of women in less
developed countries and only one third in the least developed countries have their babies
delivered by a skilled attendant. The report says this can make the difference between life and
death for mother and child if complications arise.
Make every mother and child count is being launched on World Health Day, which shares the
report's main theme. The event is being marked in many countries, with a major launch in
New Delhi, India.
According to the report, almost 90% of all deaths among children under five years of age are
attributable to just six conditions. These are: acute neonatal conditions, mainly preterm birth,
birth asphyxia and infections, which account for 37% of the total; lower respiratory
infections, mostly pneumonia (19%); diarrhoea (18%); malaria (8%); measles (4%); and
HIV/AIDS (3%). Most of these deaths are avoidable through existing interventions that are
simple, affordable and effective. They include oral rehydration therapy, antibiotics,
antimalarial drugs and insecticide-treated bednets, vitamin A and other micronutrients,
promotion of breastfeeding, immunization, and skilled care during pregnancy and childbirth.
To reduce the death toll, the report calls for much greater use of these interventions, and
advocates a "continuum of care" approach for mother and child that begins before pregnancy
and extends through childbirth and into the baby's childhood. This in turn requires a massive
investment in health systems, particularly the deployment of many more health professionals,
including doctors, midwives and nurses. "For optimum safety, every woman, without
exception, needs professional skilled care when giving birth," the report says, adding that
continuity of care for the newborn in the following weeks is vital.
It is being published in the "report card year" of the United Nations' Millennium
Development Goals (MDGs), two of which are to improve maternal and child health
drastically by the year 2015. The latest available data show that total public health
expenditure for the 75 countries with the biggest problems amounts to US$ 97 billion per
year. The report calculates that this amount needs to be increased by an average of US$ 9
billion a year for each of the next ten years in order to increase access to care in those
countries to a level that would permit them to move towards and even beyond the MDGs.
Exclusion from maternal, newborn and child health care is a key feature of inequity as well as
a crucial obstacle to progress towards the MDGs, the report says. The health of mothers and
children "is at the core of the struggle against poverty and inequality, as a matter of human
rights".
Lack of access to skilled care and to major obstetric interventions is the prime reason why
large numbers of mothers in rural areas are excluded from life-saving care at childbirth. For
example, in a study of 2.7 million deliveries in seven developing countries, only 32% of
women who needed a major life-saving intervention received it.
More than 18 million induced abortions each year are performed by people lacking the
necessary skills or in an environment lacking the minimal medical standards, or both, and are
therefore unsafe. As a consequence, 68 000 women a year die.
In many countries, "numerous women and children are excluded from even the most basic
health benefits: those that are important for mere survival". Some countries, often the poorest,

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show a pattern of massive deprivation, with only a small minority, usually the urban rich,
enjoying reasonable access to health care, while an overwhelming majority is excluded.
Among those left out, women and their children suffer most. "Being poor or being a woman
is often a reason for being discriminated against, and may result in abuse, neglect and poor
treatment, poorly explained reasons for procedures, compounded by views sometimes held by
health workers that women are ignorant. The care that women are offered may be untimely,
ineffective, unresponsive or discriminatory," the report says.

BHORE COMMITTEE - RELEVANCE IN 21ST CENTUARY

Universal health care is a human right. The health survey and development committee
popularly known as Bhore committee underlined this fact while constructing the national
health plan.
―….. we feel we can safely assert that a nations wealth, prosperity and achievement and
advancement, whether in the economic or the intellectual sphere are conditioned bye the state
of its physical well being.‖
―… expenditure of money & effort on improving the nation‘s health is a gilt-edged
investment which will yield not defined dividends to be collected years late, but immediate &
steady returns in substantially increased productive capacity. We need no further justification
for attending to evolve a comprehensive plan which must inevitably cover a wide field
necessarily entail large expenditure, if it is to take into account all the more important factors
which got the building up of a healthy, and dynamic people.
So that was the vision perceived by Bhore Committee when it submitted its report in
1946. The vision was futuristic and is relevant today even after 6 decades. This committee
provided the frame work for the evolution of health care delivery system in India. The
concept of universal health care through primary health approach given by WHO in 1978
(Alma Ata) was already there in Bhore Committee recommendations. The progress in the
HCDS is not proportionate to the vision envisaged by Bhore Committee is all but a sad
matter.
The Bhore committee made a global review of the developments in health care
services in Britain, Australia, Canada, USSR & USA and found an increased role of the state
in providing health care. It concluded that the ferment of ideas arising out of the world has
resulted in an increasing awareness on the part of the governments and people of the need for
measures which will ensure social security. This holds good even today.
Thus we see that the concept of UHC was well entrenched in the eve India‘s
independence. The national health plan keeping the view of the socio-economic & health
conditions in India, the Bhore committee set itself the following objectives to be achieved
through the plan they were formulating.
1. The services should make adequate provision for the medical care of the individual in
the curative & preventive field and for the active promotion of positive health
2. These services should be placed as closed to the people as possible in order to ensure
their maximum use by the community which they are meant to serve.

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3. The health organization should provide for the widest possible basis co-operation
between the health personnel & the people which is nothing but community
participation or the now famous public-private partnership.
4. In order to promote the development of the health program on sound basis the support
of the medical & auxiliary professions, paramedical workers, nurses is essential:
provisions should therefore be made for enabling the representation of these
profession to influence the health policy of the country. This is pertaining to the
importance of Para medical workers WHO‘s theme for year 2006 is working together
for health which emphasizes the importance of para-medical workers,
5. In view of the complexity of modern medical practice, from the stand point of
diagnosis & treatment, consultant, laboratory and institutional facilities of varied
character which together constitute group practice should be made available. The
above statement made 60 years back is more relevant today when we are talking about
―health team‖
6. Special provision will be required for certain sections of the population ex- mothers,
children, the mentally deficient and others.
Many programmes we have had in the recent past targeting these groups including
RCH. WHO theme 2005 was ―Make every mother & child count‖
7. No individual should fail to secure adequate medical care, curative and preventive
because of inability to pay for it.
8. The creation & maintenance of as healthy environment as possible in the homes of the
people as well as in all places where they congregate for work, amusement or
recreation. this was reinvented in millennium development goals which was meant for
21st century
The Bhore committee further recognized that vast rural-urban disparities exist in the
health services and hence based its plan with specifically rural population in mind. We
had our central government launching NRHM in the year 2005.
The 3 tier system prevailing today was recommended by Bhore committee. It
recommended 567 hospital beds, 62 doctors, 151 nurses per 1 lakh population. It
recommended primary units, secondary units, district hospital and also laid down
guidelines for them.
Bhore committee also emphasized the special programmes for diseases like malaria,
plague, smallpox, leprosy, TB, cancer, mental health etc. what is noteworthy is, it did not
recommend independent programmes but as part of the general health service in a
integrated manner. Now of course we are realizing the importance of it and endorsing
IDSP.
But unfortunately the Bhore committee was neglected and the vision remarks
unfulfilled due to piece-meal approach by the Governments. At that point of time the
capital cost for Bhore‘s plan was only 1% of GDP and the recurring cost was a mere
1.33% GDP. So it is a missed opportunity for developing a comprehensive health care
system in India.
The recommendations of the Bhore committee make sense even today, 60 years later, it
implemented over the present decade they could transform radically health & health care in
the country. However the last 2 decades have seen the wind of changes which now make the
Bhore committee recommendations, as they stand very implement. The change that comes in
the way is the increased commodification of health care, the private health sector has
developed sting vested interests which especially in the present climate of privatization &
liberalization has now become a major barrier to developing UHC system.

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COMMINITY OPHTHALMOLOGY
Definition: denotes the use of appropriate stratefies and methods to reduce the burden of eye
disease in a community.
Basic principles of community opththalmology:
1. An assessment of ocular needs of the population Ex; most prevalent eye disease,
where people seek the treatment.
2. An assessment of extent of the problem of eye disease and socio-economic impact on
community.
3. Finding and applying appropriate solutions for the specific community.
Components of primary eye care
1. Promotive
a. Nutritional education (
b. Improved maternal & child nutrition
c. Health education
d. Face washing
e. Good ANC
f. Safe water and improved sanitation
2. Curative
a. Vision screening
b. Treatment of vitamin A deficiency
c. Referral for surgery
d. Emergency treatment
e. Treatment of trachoma
f. Treatment of other common eye diseases and systemic disease (leprosy)
3. Preventive
a. Ocular prophylaxis at birth
b. Vitamin A doses
c. Measles vaccination
d. Perinatal care
e. Avoid medication in pregnancy
f. Avoid hypoxia at birth
g. Examination of neonatal eyes
h. Nutritional supplementation
4. Rehabilitation
a. Provision low vision services
b. CBR
c. Counseling for incurably blind
d. Certification of blind by eye surgeon
Assessment of blindness:
Sources: 1. Anecdotal information: preliminary information on blindness can be obtained
from health workers and eye care professionals working in a specified area and community
leader etc.
2. secondary data from hospitals: hospital statistics, OPD attendance records, inpatient
records, OT case sheets. These may not be representative of the general population.
3. blind school data: childhood blindness can be collected from institutions because
prevalence is low and thousands of children have to be screened to get a few cases .

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4. Census data
5. Social welfare / insurance records
6. Blindness registries.
7. Captive group statistics Ex; school vision screening programme.
8. Surveys for need assessment – population bases survey are the best way to collect, reliable
and accurate data on magnitude of blindness. Two major surveys have conducted in Inda and
have focused the basis for NPCB.
PRIMARY EYE CARE: This is an essential component of primary health care. Most
blindness & ocular conditions are preventable, curable. The provision of vasic eye care at
primary level will reduce the burden of ocular morbidity in community.
Concepts of PEC:
Diseases of eye Activity Who can be involved
Trachoma, vitamin A Primary prevention: in community Teachers, community
deficiency, focal through PHC leaders, TBA, health
diseases, workers, CBR workers,
Secondary prevention: Identify &
General physicians
treatment in the community
Cataract, glaucoma, Identify and refer for treatment health workers, CBR
diabetic retinopathy, workers, optometrists,
Hypertensive General physicians
retinopathy
Acute red eye (any age) Treatment or treatment and refer Health worker, general
physician

Essential drugs required for primary eye care:

1. Tetracycline eye ointment
2. Antibiotic eye drops – gentamycin/ chlormycetin
3. Vitamin A supplement
4. Homatropine / tropicamide eye drops
5. Atropine eye ointment
WHO guideline for primary eye care
1. Conditions to be recognized and treated at primary level
a. Conjunctivitis and lid infections
i. Acute conjunctivitis
ii. Ophthalmia neonatorum
iii. Trachoma
iv. Allergic & irritative conjunctivitis
v. Led lesions – stye, chalazion
b. Trauma
i. Sub-conjuctival haemorrhage
ii. Superficial foreign body
iii. Blunt trauma
c. Blinding malnutrition
2. Conditions to be recognized and referred after treatment has been initiated

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a. Corneal ulcers
b. Lacerating or penetrating injuries of the eye ball
c. Lid lacerations
d. Entropion / trichiasis
e. Burns: chemical, thermal
3. Conditions that should be recognized and referred for treatment
a. Painful red eye with visual loss
b. Cataract
c. Pterygium
d. Visual loss < 6/18 in either eye

ESSENTIAL DRUGS
Definition: essential drugs concepts aims at ensuring that all the people are able to obtain the
drugs they need which are safe, effective and of good quality at a price they and the country
can afford to.
Aim: to reduce mortality and morbidity form common illness by regular supply of safe and
effective drugs of acceptable quality at the lowest possible cost and to promote rationale drug
use.
Components:
 Selection
 Procurement
 Distribution of drugs suited to match the major health problems in corresponding with
geographical and economic access.
Objectives:
 To ensure availability and accessibility of Essential Drugs to all citizens.
 To ensure safety, efficacy and quality of drugs
 To promote good prescribing and dispensing practice
WHO‘s criteria for selection of essential drugs:
 Adoption of a list of essential drugs should be a part of national health policy
 Only those drugs for which adequate scientific data are available from controlled
studies should be selected.
 Each selected drug must meet the adequate standard of quality including when
necessary bio-availability
 Concise, accurate and comprehensive drug information drawn from unbiased sources
should accompany each list of essential drugs.
WHO has produced a model list of essential drugs of about 200 in 1977, now the list contains
about 270 drugs.
The list can be modified and adopted to meet the local requirements. Each country should
have their own list of essential drugs/
The list prepared should be appropriate for the different levels of use depending on the
expertise available. They should meet the community health workers, sub centres, PHC,
CHC, taluka hospital, teaching hospital and speciality hospital.

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Guidelines for selection:

 Each country should appoint a committee to establish a list of essential drugs.
 Selection of drug should based on results of clinical trials/ epidemiological studies/
 The international generic names should be used in the list.
 Cost is another important criteria- for comparison of drug cost the cost of total
treatment must be considered (not the unit cost)
 When several drugs are available, select the drug which has benefit/risk ratio
 The influence of local disease/conditions on the drug, pharmacokinetics and dynamic
should be considered in selection Ex: malnutrition, liver disease
 The list should be reviewed at least once a year & changes to be made if necessary.
Advantages:
Medical advantage
1. It is medically, therapeutically and scientifically sound & it ensures rational use of
drugs
2. It limits the use of irrational & hazardous drugs & the risk of iatrogenesis.
Economic advantages
1. To the nation – prevents wastage of resources
2. To the patients – it prevents wastage of on irrational non-essential drugs.
Social advantage
1. It responds to the real health needs of the people
2. Facilitates dissemination of correct information about the drugs to health personnel
Administrative advantage:
1. Helps in quality control (limited no. of drugs to be monitored)
2. Facilitates streamlining of production, storage and distribution of drugs
3. Helps in clear identification of dugs
4. Helps to fix prices
National essential drug list
In India health care is provided by both private and public sectors. At the level of central and
state government medicines are supplied free of cost or against payment to the government
employees and free of cost to weaker section of the society through primary, secondary and
tertiary level/
Drugs included in the list are generally safe & effective & currently available at affordable
price. A committee of experts constituted by DGHS prepare the list
Prescription audit: An objective and systemic way of evaluating the prescription given to the
patients by health care personnel. This is rarely done in our country.
Quality control: sample of dug are taken by drug controller & tested & certified as
satisfactory or non-satisfactory.

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RATIONALE USE OF DRUGS

The rationale use of drugs includes not only that appropriate drug be prescribed but
that it is available when needed & at a price people can afford, that if be taken in the right
dose, at right intervals and for right length of time and that it be effective of acceptable
quality and safe.
SANE criteria: safety, affordability, need & efficacy
Rule of right: right drug given to right patient, at right time, with right dosage at right
intervals & right length of time.
Objectives of rationale use of drugs
1. To identify the magnitude and nature of inappropriate drug utilization
2. To describe factors which influences the decision making process
3. To identify factors which influence the behavior of the prescriber.
4. To relate issues to specific drug use problem
5. To assess which prescriber and patient factors might be addressed in a progress to
decrease irrational use of drug.
Guidelines for rationale use of drugs
 Choosing drugs which are effective ex; malaria – chloroquine, ACT
 Using first line drugs as far as possible – ex: TB, HIV
 Use simple ingredient drug – avoid unnecessary combination
 Using drugs indicated for specific infections carefully – streptomycin – TB,
chloromphenicol- typhoid (not for other infections even though broad spectrum)
 Choosing drugs which are relatively safe.- paracetamol – aspirin
Factors for irrational use of drugs
 Patients:
 Lack of proper drug information
 Patients demand/ expectation
 Easy to purchase any drug from the drug store without prescription
 Wrong way of taking medicines – reduce dose to make treatment long lasting,
increase dose for quick action.
 Doctor shopping
Prescriber:
 Wrong diagnosis – overdiagnosis
 Heavy patient load
 Prescribe from their own clinical experience
 Trying to retain patients good will- patients need immediate symptomatic relief
 Influence of drug companies
Dispensaries: irrational dispensing is done by
 Wrong interpretation of prescription
 Supply wrong drigs from stock
 Wrong dosage
 Inaccurate compounding
Impact of irrational use of drugs

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 Reduction in the quality of drug therapy – increased morbidity & mortality

 Wastage of limited financial resources
 Increased unwanted affects such as adverse drug reaction & the emergence of drug
resistance
 Psychological impact:
Approaches to tackle;
1. Educational
2. Managerial
3. Regulatory
4. Prevention of irrational prescribing
a. Making correct diagnosis
b. Limiting the number of drugs
c. Encouraging the availability of essential drugs
d. Providing adequate training, drug information & standard treatment guideline
to the prescriber, CME
e. Teaching the rational prescribing into curriculum of medicine, pharmacy,
dentistry and nursing
f. Evidence based medicine

HEALTH FORECASTING
A forecast is a prediction about the future that accounts for complex events and
interactions by modelling characteristics and behaviour while taking dynamic variable into
consideration. Forecasting provides a useful framework that mitigates, to some extent, the
uncertainty of the future.
Health forecasting is a new healthcare discipline. Identifying who is at risk and forecasting
when and where they are at risk and using this information to trigger anticipatory care to
help keep people well. It is currently the subject of an innovative project in the United
Kingdom.
The natural environment affects human health. There are many cases in which the weather
has a direct or indirect affect on the health of an individual. These include:
 Heat that causes up to a 30% increase in mortality amongst the elderly and very
young. Prevention can save lives.
 Cold is still a big killer in the UK. Prevention consists of keeping active, eating well,
dressing up appropriately especially hat gloves and coat when outside and keeeping
the indoor temperature at 21C.
 Thunderstorms can cause asthma epidemics if they occur during high levels of either
pollen or fungal spores in the summer.
 Low boundary layer may increase the way viruses are transmitted by increasing the
amount of stagnant air.

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Health forecasts help professionals and patients know when and where there is a risk of
illness. Through this understanding, preventative action can be taken and healthcare capacity
(ie hospitals and doctors) managed to reduce illness and death.
The main strand of the Health Forecasting project is forecasting the risk of exacerbation of
chronic obstructive pulmonary disease (COPD). COPD Health Forecasts are used to drive the
provision of anticipatory care to COPD patients, helping to ensure patients with these long-
term conditions achieve their potential for independence and wellbeing.
A fall in outdoor or bedroom temperature is associated with increased frequency of
exacerbation and decline in lung function for people with COPD. Suppression of immune
responses by stress hormones during cold exposure is likely to reduce resistance to
respiratory infection, as will direct effects of cold on the respiratory tract.
Stages of Forecasting
 Formulate Problem
 Obtain Information
 Select Method
 Implement and Evaluate Method
 Use Forecast Results

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