i.Man & Medicine 1. Indian medicine 2. Family & Community medicine papit’s PSM made-easy = 9893180410 drarpltvernia1983@gmail.com Jaiswal Photo Copy Mob. 8989409408 Page fArpit’s PSM made-easy 9993180410 Jaiswa! Photo Copy drarpitverma1983@gmail.com Mob. 8989409408 Mon & Medici tei + Hinde go Medical knowledge harvaveda (one of the four Veda) gradually developed into the science of Celebrated authorities in Ayurvedic medicine were Atreya, Charaka, Susruta & Vaghbhatt Charaka Samhita - based on teaching of Atreya & Charka eva * Indian physi Charaka * court physician to the Buddhist king Kanishka + Charaka mention some 500 drugs Susruta. + father of Indien surgery @ wy in + _who Compiled his surgical knowledge brute 2 Samhita Of significance in Ayurveda is the Tridosha Theory f Dig ease + Doshas or humors are ~Vata(wind), Pigtalgall, *iepte (Mucus) * Disease was explained as disturbance in thévequilibiiughof the three humors + Theory is strikingly similar tothEOry.of fourhimors ine Lows of Manu ay fn ine * code of personal hygient Golden age of Indian medicine- Ayurveda declined during fioghul peti tate support Indian medicine has pl&j UnanigiBbmedicine intt Family Medicine K4 = field off specialization in medicine which is neither disease nor organ oriented = Itis family oriéhted medicine or health care centered on the family as a unit- from first contact to the dhgoing care of chronic problems(from prevention to rehabilitation) — Specialty of family practice is specially designed to deliver primary care ‘Community medicine - itis the successor of what was previously known as public health, community health, preventive & social med — Prevention of disease & promotion of health . — Defined as the specialty which deals with population & comprises those doctors who try to measure the needs of the population , both sick & well, Who plan & administer services to meet those needs & those who are engaged in research & teaching in the field Page 2 a~nm~ 27 & 2 ~ma omvw FS ewe ee ~~ ww Health efinttion of Hea Health isa ste ahysical, mentol & socio! well being & not merely an absence of disease or infirmity s lly productive life) 2- Dimensions of Health CITI cts pnsetncione ontop inte ry th the rest ofthe body 2 ealth has been defined a state of balance between the individual & the surrounding world ~ Mentally healthy person * Free from Internal conflicts + Well adjusted + Knows himself, his needs & goals + Has good self control 3 + Faces problem & tr 3 S's = usr gusty of ania * a t part of the individual whic s. ling c - nS lays a imbate — Physical work is (sty astgek in physical capacity, while goal ignited self esteem © 0-worst performance © 100-best performance + India-65 + Measures the result of social, economic & political policies ° + PQUIsa subjective component of quality of life Arpit's PSM made-easy wae Jalswal Photo Copy 9093100410 4ob. 89894094 drapltverma1983@gmall.com ob. 899409408 Page 21. Define Health 2. Dimensions of health 3. PQLI & HDI 4, Spectrum of health 5. Determinants of health 6. Indicators of health 7. Health care 8. Epidemiological tiiad 9. Web of causation 10.Natural history of disease 11.Iceberg phenomenon 12.Surveillance @ 13.Differencé between Monitorin, 14.Sentinel surveillance 15.Difference between activ 16.Levels of prevention & Mé 17.Rehabilitation 18.Public health 18 €eSurveilla “> Points to remember iswal Photo COPY = , job. 8989409408 page ‘Arpit's PSM made-easy Mi 9893180410 drarpitverma1983@gmail.com -_— a a mewn esssue, organ &: organ system & theit hi ~ Bernat ~ Te Purchasing power ~ Education * Especially female education > Occupation Seer services Immunization of children Provision of safe water Ill, Infant mortality rate IMR = Total infant death x 1000 Total live birth monious fun State of being employed promotes health * tegen of work can couse psychologiGl & social damagé family welfare services toning within the sy a lv. Child mortality rate (CMR = Total death of 1-4 years x 1000 ‘Midyeor population of 1~4 years Arpit’s PSM made-easy 9993180410 rarpitverma1983@gmail.com Jaiswal Photo Copy Mob. 8989409408 Page 4‘Arpit’s PSM made-easy 9893180410 eiopmental inde expected years of schooling Otox culation of each dimension index ; maximum value minimum value eee xi val eee 0 aoe of 3 dimension indices = Wife x 1 (education) x 1 come), ducation) tt erecutote+ 1/3 gross eneolment ato (primary, secondary fe tertiary loves ot Hl India ~0.640- rank 130 of 189 countries Human poverty ind ‘ex (HPI) is complimentary norneecee (HPI) is complimentary to HOt = Top. Australia, Switzerland ~ Medium-tndia aprenon & a process of continuous change BoIht corresponds to positive health ease are known to be of genetic origin e.g. chromosomal anomalies, diabetes Lifestyle — Cultural & behavioral pattern — Personal habits — Developed countries * Obesity, drug addiction — Developing countries * — Lack of sanitation, poor nutrition Jaiswal Photo Copy 409408 pages drarpitverma1983@gmail.com Mob. 898% ge3fe expecta Sjustment for tre HALE is replaced by DALE (Disbillty Adjusted Life Expectancy) QALY- Quality Adjusted Life Years Based on number of years of life that would be added by Intervention DALE: Disability Free tife Expectancy Average number of years an Individual s expected to live free of disability + Sullivan's index © Sullivan's index = life expectancy ~ duration of disability © K/a disability free life expectoncy (OFLE) DALY- Disability Adjusted tife Years eff€tiveness of interdéhtion ay Me x y Itexoresses years ost to premature destiny veors Viel with Urea Averoae lenathof stay Bed turnover ratio — Amount of time beds at hospital are unoccupied until next pa Aeantt Ue pled untll next patients admission following Negative value-Indieates aver 100% occupancy services = Positive valuc- indicates vacant beds, underutlization of services Slight positive vatue- Indicates optimum utilizction of services Scarcity of beds, over utilization of soine Satswal Photo Copy drarpitverma1983@gmallcom Mob, 8989409408 Page 6curring In the under 5 age group years per 1000 population Maternal ( puerperal) mortality rate + Deaths am men of reproductive age group vii, Disease specitic mortality rate Mortality rates computed for specific disease = death from a specific disease x 1000 Midyeor population Proportional mortality rate &. * Measure of estimating the burden ofa disédegtin a commu PMR = deoth from specific disease x 1000 Total deaths % Case fatality rate CFR= Total no. of death due to soli disease Total no. of cases due to that Specific disks Always expressed in percentage 2. Morbidity indi . iv, 3. Disability indicators i. Event type indicators a, Days of restricted activities b. Bed disability days. & Work loss days i. Person type indicators a, Umitation of mobility + Confined to house b, Limitation of activity + Limitation to perform basic activities i's PSM made-easy | 903180410 Jaiswal Photo Copy, |. « drarpitverma1983@gmail.com Mob. 8989409408.feats SaentonesRy / Bs \ — Person that harbors the disease — Genetic makeup, immunity, level of e Environment 6. Soclal agents = Poverty, smoking, alcohol, drug abuse ete. Hostfactor 1, Demographic characteristics = Age, sex, ethnicity 2. Blologleal characteristles = Genetic factors, Immunological factors ete. 3. Soclal characteristics = Socioeconomic status, occupation etc. 4, Lifestyle factors se Nutritional habits, physicel exercise, behavioral patterns etc. ‘Arpit’s PSM made-casy Jaiswal Photo Copy 9us318002) Mob. 8989409408 drarpltverma1983@gmail.com age 8Tindleators of sects! & mental hoatth cide ~ Homicide — _Juverile detinquency = _ Battered baby syndrome S.environmental indicators = Indicators of Noise potlution = Indicators of Air pollution ~ Indicators of Water pollution S.Soclo eccnomlcindicaters (Me FLAGGED) = Housing ~ Family size ~ Mteracy rate = Availability per capita calorie — Growth rate - _unEmployment level = Dependency ratio 10. Health policy indicators Levels of health care Health care services are organized at 3 levels * Primary health care- = 1" level of contact between Individual & health system — Primary health centers, subcentres + Secondary health care — First referral units (FRU’s) — District hospitals, Community health centers * Tertiary health care — Super specialist care — Regional/ central level institutions ‘Arpit’s PSM made-easy i 9093180410 Geer drarpitvermai983@gmail.com 1 wal Photo COPY nn £989409408 page?phlei change asemaybe recone. cei de el dieaismoy improve grospot Istana ry ten tee of pase ~ tary pathogenesis phase phosein chr ~ tatepathoronest pare o bythe ti s y the time signs & symptom appears the disease is already well advanced into the late phase ae, Ea saesencsis Se ase is referred to as presymtomatic phase pee un = Example - PEG} + Submerged portion: ©”. = Represents the hidden mass of disease, je. latent cases, inapparent cases, presymtomatic cases undiagnosed cases &.carrlers in the community + Waterline- = Represents demarcation between apparent & Inopporent disease + Epldemtotogist is concerned with hidden portion of iceberg whereas clinician fs concerned with tip ofthe leeberg + Screening Is done for hidden portion of the iceberg whereas diagnosis is done for tip of iceberg + Used In diseases tke ‘= Hypertension, Diabetes, Anaemia, Malnutrition, Mental liness & Obesity + Iceberg phenomenon fs not shown by = Rabies, Tetanus, Measless& Rubella ’s PSM made-cas} gepnieonio Jaiswal Photo Copy drarpitverma1983@pmall.com Mob. 8989409408 Page 10srof Health & Diseases favironmentat factors action isin constant intera ‘i that which i external to the individual host living or non living with venieh ie Is 1 1, Physical environment Air, water, soil, radiation ete 2. Biological environment = Microbial agents, animals, plants ete 3. Psychological environment = Cultural values, customs, beliefs ete, ‘9- Web of Causation + Suggested by MacMohan & Pugh ‘+ This model is ideally suited in the study of chronic disease , where the, buts the outcome of interaction of multiple factor sease agent is often not known, WEB IORGAUSATIC i sNeARerion l history of disease UP way in which a disease evolves over ath EREESs phase to Its termination as recovery disability or deat ime from the earliest stage th, In the absence of ¢ Is best established by cohart studies p> consist of two phases — Prepathogenesis (i.e. the process in the enviro = Pathogenesis (ie. the process in man) Ament) 1, Prepathogenesis phase — Refers to perlod of preliminary to the onset = Interaction of causative factors of. the community ~ Primary level of prevention Arpit’s PSM made-easy _— 9893180410 Sai drarpltvermal983@gmail.com siswal Photo Co,2.Conceptof Health & Dis Sra uNyeuleN a Nepiaeas e® alsease + Objectives: = Toprovide informatio = Toprovide timelysort + survellance requires professanals SS tatus of a population fat interventions can be mobilized 3 5 ising cases & supplementing notified cases = Epidemioldgital surveillance = Demographitgrveillance = Nutritional surveillance = Sentinel surveillance ‘Actuol target of surveillance is health plonning ‘Arplt’s PSM made-easy “3: 9893180410 drarpitverma1983@gmall.com Jaiswal Photo Copy Mob. 8989409408 Page 12ween Monitor Monitoring + Definition = Continuou! + We have moi «to ensure that they are proceeding according to plan nutritional status oried out by teeicians + Moritering canbe catiedovt OY eis old ot detecting chong In environment 2 itisananslysis of routine measurement + Defintion- = Monitoring of rftepPoccurteg use of eatth practitioners to monitor trends of a disease in a specific population Nbrce hospitals used to collect data on various diseases & their causative agents = _Network¥y + Used when- a high tility data are needed about a particular disease that can not be obtained through 2 passivesystem sites + Sentinel system- deliberately involves only a limited network of carefully selected report +" Sentinel surveillance agencles- could be physicians or institutions interested in selective diseases in certain areas + Data collected- can be used to signal trends, Identifying outbreaks, & monltor the burden of a disease ina ‘community + Donein- = National AIDS Control Program = STD clinies & ANC clinics are sentinel sites + Selected diseases- HIV, Hib etc + True morbidity is measured by sentinel surveitiance Arps PSM made-easy a sevsigo4i0 Jalswal Photo Copy rarpitvermal983@gmail.com Mob. 8989409408 page 122. Concept of Health 15- Difference betw en Active & Passive Surveillance Active Surveillance - Passive Survelliance (Daa is actively collected Data Is passively reported Hith system staff goes tthe patients to gather data | Data Issel reported to health system Mistly used when disease is targeted for eradication or | Mostly used when disease i targeted for control elinination Exmple- health worker goes house to house to detect | Example- patients coming to PHG, CHG, private practitioners fever cases & collect blood slides etc Induces mainly NVBOCP & NLEP Includes most of the national health programmes in India ‘Mire expensive Less expensive ‘Sebcted diseases- poliomyelitis, eprosy, neonatal Selected diseases. Dightheria, Hepatitis 8, mumpsete tetnus ete 16- Levels of prevention & their Mi © 4levels of prevention 1. Primordial prevention- p of the emergen itis primary prevention In purest se Best level of prevention for non com! Mode of intervention- 1. Education Through health care providers, community leaders, decision makers ‘Marriage counseling Is an example of primary prevention = Cancer education Environmental modification = Provision of safe water(portable safe water supply), Installation of sanitary latrines, control of insects(Insectleidal spray) & rodents & improvement of housing © Nutritfonal Intervention ~ Food fortification, nutritional education, child feeding programme = Example- high fibre diet to prevent obesity, dietary salt reduction Ufestyle & foral changes = Changing habits & behaviour of the patlents ~ Control of tobacco, exercise promotion, welght reduction ene Jaiswal Photo Copy drarpitverma1983@gmall.com Mab, 8989409408 page 13x2. Concept of Health & Ni Specific protection enesis phase of. tors + Intervention dane in + Based on elimination of rs + Approaches: Mass strategy- whole population li. High risk strategy- individuals at risk © Examples: © Immuntration/ vaccines ‘Chemoprophylaxis/ Vitarnin A prophyloxts use of condoms/ contraceptives © “Teditation of salt defloridation of water - protection asnfbnscupational azatds & accidents(helmets/ecatbelts) {3 «desks provided withYable top td prevent neck problem © National iron plus initiatives, mosque bed. © Radiation frotectior © Wearing of @ ane welders wr dentdtgarles- fludfidation & dental he 3, Secondary prevention- ‘~ Action taken to halt the p = Aerts to arrest ake process, Seek ol of transmgiey LELbELELELIELELE LEE LEE © Case finding for malorla © Health screening for die © Forly diagnosis & treatment Is the best level of prevention for breast cance = = Mass treatment = + Used in control of - Yaws, Pinta, Trachoma, Filaria = * Used when at least 5 cases of latent infection for each clinical case of active disease in the community = + Variants- total mass treatment, juvenile mass treatment, selective mass treatment re =| . ‘Arpit’s PSM made-easy 9893180410 Mob, 8989409408 drarpltverma1983@gmall.com Page 14 ate TST PTO4 Tettiary prevention Action taker lini the npaliment & ee Aton tka ttn he mpaement debs fates ten seas hs stint bean ey ag vention danein fate pathogeneipsisat dees Modes of Interventions- meseet es 1“ Disability inttion © _Anyebnormal condition of an organism that im; imnem ‘anism that impairs function © fav loss or abnormality of psychological, physiological or anatomical structure or function © Example-loss of foot, defectheision s + Disabinty © (Because of impairment) Any restriction or inal .to perform an activity in yto perform an a arange considered normal for a human b Sea * Handicap i > © ADisadvantagesfor a givehi{auitiddals resulting from an impair that limits/ prev fulfill role considered normal fos + Examples- © Accident. dis © Loss of foot-——-— imp ° > + Prevents transit {@handicap © Example. SS jedical rehabilitation b, — Restoration of function Scational rehabilitation = _ Restoration of capacity to earn livelihood 3. Social rehabilitation = Restoration of family & social relation 4, Psychological rehabilitation “= Restoration of personal dignity & confidence = Bxamples- = _ Establishing schools for blind = Graded exercises in polio = _ Aids for crippled (crutches in potiomyetitis) = Reconstructive surgery in leprosy = Crutches in poliomyelitis Arpit’s PSM made-easy ~ } wal Photo COPY 9893180410 Pas 15, sapwalpheeooeos drarpitverma1983@gmail.come ‘Arpit’s PSM made-easy 2, Concept of Health & ise Betinition ~ Science & art of preventing disuas community efforts Includes. , protonging life & promoting health through organized Sanitation of the environment — Personal hygiene ~ Control of communicable disease Health education to the individuals — _ Early diagnosis & treatment Public health in- ~ Developed country- 1 control of non communicable diseases Developing country- control of communiabte, Definition- a. ~ Refers to the identification & quant ‘mortality & morbidity a — Pattern of disease in a community descr Based on: ~ collection & interpretation of data si Community treatment Improvement of ware indard diagnostic classification for all general epidemiological & many health irposes t's base for use in other health fields also = [eDis revised every 10 years = ICD 10 came in- 1 January 1993 ~ Coding system in 10” revision is olphanumerical Arranged in- © 22 chapters{ICD 10-CM~21 chapters) & 3 volumes ‘+ Volume 1- classification, lists, nomenclature & definitions © Volume 2-instruction manual © Volume 3- alphabetical index = Codes U 00 -U49- new diseases of uncertain etlology = Codes U 50-U99- usedjn research 9893180410 Jaiswal Photo Copy he 8 Bi drarpitvermal963@gmall.com Mob. 898940940823- Otta Sey action areas i 2 Personal skills development 3. Strengthen community ection for health 4 Reorientation of health services 5. Supportive environment for health 6. Public Skilled Action Reorients Environment + Baste strategies 1. Advocate 2. Enable 3. Mediate + Health promotion logo 1. Circle with 3 wines 2. Incorporates § key acti As; SlOgical & cultural determinants of health Perfect fYiet Conceptual cot ATF pends on. ones Objective component- + Standard of living = Income, occupation, housing, nutrition, education & other services collectively " used as an index of standard of living = Subjective component = Quality of fife = Physical, mental & social well being as perceived by happiness, satisfaction & gratification, that is concerned with financial situation, educational ‘opportunities, scone & trust in others ————————————_———————y—y—yy ‘Acpit’s PSM made-easy 2 Photo Copy 9893180410 drarpltverma1983@gmail.com cb. 8599409408 Page 182. Concept of Health & Disease: ~ 3volumes Volume 3- tabulsr list Volume 2- reference guide * Volume 3- alphabetical index — 26chapters with V, x ‘Chapter 6- mentel, behavioral or neurodevelopmentel disorders Chapter 21- symptoms, signs or clinical findings, not elsewhere classified Chapter 26- traditional medicine conditions- module | \V- supplementary section for functioning assessment * _ X- extension codes ~ ICD 11 linkage to other data standards + ICF- international classification of * ICHI- international classification of he: 21- Standard Refers to scale of our expenditure, gootls we con + Includes . ‘= Income & occupation Standards of housing, — Level of provision of health, educatio + Depends on- per capita GNP Housthg- housing material for roof, walls & floors + Assetsradio TV telephone, computer, refrigerator, bike car etc. ‘+ Range of MDPQ|-033%- poverty 3. >50%-severe poverty 4, India 27.5%- poor population anno eee2. Concept of Health Dis mt Scale 3 components 1. Education status of head of fom 2. Occupation status of head of family 3. Income per capite per menth 28 - Disease Control/ Elimination / Eradication + Disease Control ~ Agent is permitted to persist inthe community at a level where it 2.be a publicheolth problem = Aims in reducing- + Duration of the disease + Effects of infection + Financiol burden of the community + Disease Elimination Interruption of tcansmission’Gfuisease = tis a geographical term ie. con be Se@Qualy ford - adie hos eliminated ‘ - Polio, measleP& dracunculiasis are candidate for global eradic — Polio virus 2 declared eradicated on 20 sep 2015 ‘+ New targets of GO! (1 February 2017) = By 2017- elimination of kala azar & filariasis = By 2018- elimination of leprosy = By 2019- reduction of IMR t0 28 = By 2018-2020- reduction of MMR to 100 = By 2020- elimination of measles = By 2025— elimination of tuberculosis, ee Arpit’s PSM made-casy = 9893180410 . Jaiswal Photo Copy drarpitverma1983@gmail.com Mob. 8989409408 — Page 19th & Diseases Points to Remember Ainksaspeciic competition: Competition betwen individuals of o some species interspecies /Interspecitie competition- Competition between indvdusirar ‘two different species © Bitect standardization is used to compare mortalty data of two counties Thisiadane becouse of difference in age distribution durotion of observotion care of a pottent is expected to be 24 hours or more nt recelving care in hospital/ clinie/ at emergency care & where patient is released within 23 hours * Observation status patient- active treatment is required to determine of, hospitalization or discharge the same day Urgent eare patient: patient who requires stabilization due to coergegeyatuation Domiciliary core- personal services rendered by dottors.to patients4n hospital, nursing home & at home * Death certificate 3% = Part. if patient requires immediate cause of death direct underlying na Saisval Photo Copy ‘Arpit’s PSM made-easy 180410 sespevermai9ex@gmallco™ Mob. 8989409403 P#8e203. SCREENING FOR DISEASE . Screening . Difference between screening test & diagnostic test . Lead time |. Uses of screening i. Difference between prescriptive & prospective screening 5. Types / Methods of screening i. Multiphasic screaning ii. High risk / selective screening; G. Criteria for Disease to be screened 7. Screening test criteria Validity of a screening tes! Difference between@yeci: 2x2 tabli . Sensitivity & specificity o' Difference between sensifi 8. Predictivity of a screenil 9. Ideal Screening test 10.Examples of screen 11.Likelihood ratio, § BONE fs PSM mad oosisond Jaiswal Photo Copy drarpitverma1983@gmail.com Mob. 8989409408 a55, Screening for Diseases 1. Screening snviucle Search of unrecognized disease by means of ropidly applied tests In apparently healthy individuals Epidemfotoaical survey of at risks called as screenlag ts done in population who ore not seeking health care Itmay be defined as presumptive Identification of unrecognized disease Pablentson a + Itls the advantage galN@B by screening * Screening test is most useful if applied | on 1" possible point of dic »sis & final critical point * 1 possible point ‘of diagnosis cannot detect a disease before it * Final ritcal point point after which attempted treatment of disease may not yield desirable benefcal effects Le be ‘Arplt’s PSM made-easy Jaiswal Photo Copy 9993180410 , Mob. 89894094 drarpitverma1983@gmail.com 408 Page 2 eeaean EAA BR AAAAARAAA AMANDA ROL1) 2 3) 4) screening tor Diseases 4. Uses of screening Case detection — People are screened for their own benefit (prescriptive screening = Breast cancer, cervical cancer, anemia, diabetes Control of disease ~ People are examined for benefit of thers (prospective screeninal = tuberculosis Research purposes = Fordiseases whose natural history isnot fully known Educational opportunities = For creating public awareness Difference between Prescriptive & Prospective Screening Prescriptive screen, Piprospective screening Tefinition People screened for thel cople screened for others benefit benefit Tarpore Case detection : Requested by None Example neon urine for 1 2) Acceptability 5. Types of s Mass screening = Tests that are discomforting are not likely to be acceptable (P/R or P/V examination) 2) Repeatability/ Precision/ Rellability/ Consistency/ Reproducibilit ‘= Give consistent results when repeated more than once on same individual under same condition — Investigator knowledge is important = Extent of variation of measurement tal ur 3) Validity (accuracy) ‘Arpit’s PSM made-easy = Means close to true or actual value — _Abllity of the diseases to separate those who have the disease from those who don’t = 2components 1. Sensiti Specificity 1: 9893180410 Jaiswal Photo Copy drarpitverma1983@gmall.com Mob. 8989409408 Page3Difference between Precision & Accu Precision Ae ae _ Definition eat career efiition Repeatability, refabliy,conssteney, Degree of doaenezs of manned quant Ti reproducibly of ates true value Test ang af ar fi fest Range chart / R chart ‘Mean chart/ levy Jennings (U) chart, shewhart conto chart 2x2 Table ran Sensitivity = true positive 100 total diseased (i.e. TP + FN) Specificity + Specinety= true * 100 Total norigiseased (i.e. FP + TN) + Abitty of test correctly those who do not have the disease Le, te negot + Interpretation for example if specificty 90% then rPre'90% of the non diseased person will give true negative result, 10% of non diseased person will ive false postive rpit’s PSM made-easy Jaiswal Photo Copy 180410 33 180410 segmallcom fob. 8989409408 Page 43, Screenin 8. Predictivity / Predictive value of screening Predictive value reflects the diagnostic power of the test * Predictive value (i.e. PPV & NPV) depends on + Sensitivity + Specificity + Prevalance ofa disease Positive predictive value + Ability of o screening test to identify correctly all those who have disease, out of all those test positive on a screening test PPV= true positive x 100 total positivei.e. TP + FP) © peVaprevalence of a disease ‘© PPVis most affected by prevalence Folse positive rate =1~specficity Negative predictive value + Ability of a screening test to Identify cf test negative on a screening NPV=truenegative. x 100 total rlegative(TN + FN) fe the disease oe specrefout EBM ideal for s “ ~DMunder NPCDCS Carcinoma cervix under NPCDCS ‘Refractory error under NPCB ‘Arpit’s PSM made-easy sal Photo COPY 9893180410 drarpitverma1983@gmail.com Mob. 8989409408 are ge10. Examples of screening tests Cervical eancer- pep smear, VIA (at PHC) + Endometiat eancer-USG.offce endometrial washing + preast cancer- BSE (best time ~1 week after menses), mammography «prostate cancer: ORE{diital rectal examination), PSA (orstate specific antigen) + Colorectal cancer ~faecal occult blood test + Orateancer= bimanual oral examination + RIVE EUSA, RAPID, SIMPLE + DM-urine for sugar, random blood sugar, + Vitamin D deficiency- 25 hydroxy vitom/ Gere ere er coe rE ees fe ten > cats cate Ess A Pec ee See es ce coo Ss Soe es ‘ sea IU eRe) SA ees cd ee Jaiswal Photo Copy drarpitverma1983@emalLcom Mob. 8989409408, Pages11. Likelihood ratio Provides direct estimat UR of positive result © Tells how much the odds of disease increase when a test is positive LR" = Sensitivity 1- Specificity UR of negative result a © Tells how much the odds of disease decrease when a test is negative U= 1= sensitivity specificity '¢ of how much test result will change the odds of having disease 12. Baye’s theorm + ppve (Sensitivity x Prevalence x (Sensitivity x Prevalence) + (1 - Specificity) x (1 Pret Tests In series ‘Testsin parallel Combined sensitivity Decreases Increases ‘Combined specificity Increases Decreases, ‘Combined PPV Increases Decreases ‘Combined NPV Decreases Increases 15. ROC curve (Receiver Operator Characteristic Curve) + Determining the thresho! nin tive te + Comparison of 2 or more screening tests ‘Arpit's PSM made-easy = a S 9893180410 Mob. 8989409408 drarpitverma1983@gmail.com Page71 Ldeniotony Bien 4. Epidemiology, Disease Transmission & Immunization 4 Altpidemiotogical Methods Epidemiology 3 Prevalance «Relationship between Prevalence & incidence 4-tpidemiotogical Methods s-Descriptive tpidemiology + Epidemic + Types of epidemic + propagated epidemic 6-Analytical Epidemiology + Case Control Stuy + Cohart study meets . 7- Experimental epidemiology + Randomized contro trial 8- Meta: Analysis 9- Bias 10- Blinding 11-Confounding 22- Matching 13- Association & Causation 14- Uses of Epidemiology insmissior tious Di Disease Control/| 2. Source & Reservoir 3. Cases = Primary case = Indexcase 4, DPT vaccine ‘5. Inactivated Polio Vaccine (\PV) 6. Oral Polio Vaccine (OPV) 7. Herd immunity 8. Rota Virus Vaccine 9, Mycobacterium indicus Pranii (MIP) vaccine 30. Cold Chain ‘= Vaccine Vial Monitor (VM) 411. National immunlzation Schedule(NIS) 32. Age limits for delayed immunization in NIS, India . 13. adverse Events Following Immunization (AEFI) 14, Open Vial Policy 45. Mission Indradhanush a a Tpirspanndeo7 gou3i804t ant : seraspeeises@gmalicom 8 Jaiswal Photo COPY page Mob. 8989409408 ‘e' te ah : en te4.1 Epidemiological Methods 1-Epidemiology 2-ncidence 3-Prevalance + Relationship between Prevalence & Incidence 4-Epidemiological Methods 5-Descriptive Epidemiology + Epidemic + Types of epidemic + Propagated epidemic 6-Analytical Epidemiology + Case Control Study , + Cohart study “ pe + Difference between case.control § 7- Experimental epidemiology’ + Randomized control trial 8- Meta- Analysis 9- Bias 10- Blinding 11- Confounding 12- Matching 13- Association & 14- Uses of Epidey Jaiswal Photo Copy sM made-easy a reels Mob. 8989409408 Pee? ararpitvermal9s3@email.com1-Epidemiology Definition. Study of distribution & determinants of health related events in specified populations & thes pplication of this study to the contro of health problems 3 components ~ Frequency of disease- Prevalance rate, incidence rate — Distribution of disease: wrt. Time place & person = Determinants of disease- Identifying the underlying cause or risk factors of disease + inepidemiology- = Unit of study is population = Concerned with disease pattern i the entire population = Interested in relationship between cases & population = Seeks to idemity source of infection , mode of spread & etiologiea = Data from epidemiological studies is symbolizdifiythe form of ta + Measurement of epidemiology = Measurement of distribution of disease — Measurement of needs & — Measurement of demographic variables “Xe — Measurement of morbiclty- In rate, Peyalence rate ete, = “Measurement of mortality- crude death rateXesseQgtality rate, proportionaltwartality rate etc. [Measurements in epidemiology - _ Rate- numerator is a part of denominator & mt = Ratlo- ° Measurement of morbidity Incidence - Number of nt sd\population during a specified period of time fat a given point in time or over a period of time ‘total number of death due to a particular disease x 100 ‘total number of cases due to the same disease Limitation is that timeSaterval is not specified (So it’s o killing power of a disease with no time Interval) + Compliments Survival Rate jotal number of patient alive afterS years x 100 Total number of patients diagnosed /treated CFR ( here CFR is taken in decimals .e. 25% taken as 0.25) + Describes prognosis. + Useful in cancer studies + Assess standards of therapies : * Whenever screening test is performed ~ higher 5 year survival rate is observed, this is_a Potential bias due to earlier diagnosis being made(& not because people live longer] Crt <7 == = aT ‘Arpit’s PSM made-easy 5 9893180410 we le Jaiswal Photo Copy érarpiverma1983@gnaiLcom Mob. 8989409408 Page 34 tpiderioloy 3. Proportional mortality rate MR = number of death from specific disease in a year » 100 Total death from all causes in that year Simplest measure of estimating the burden of a disease in the community PMR is o proportion 2-Incidence + Number of new cases occurring in a defined population during a specified period of time Incidence = number of new cases of specific disease during a given time period x 1000 Population at risk during that period Incldence Is rate, expressed per 1000 Not Influenced by duration of disease Use of incidence is generally restricted to acute condit Incidence can be determined by Cohart study Incidence measures the absolute risk of developing the disease > ilienee e prluler progromme is efflent SrecolIncdencertes ® L___Attock rate + used when population is exposed f + reflects extent of epidemic Attack rate = numbc I inter ime e.g. epidemic of led di during ecified time Interval x 100 Interval thon the rank of the incubation period dis more inf on Index o] se Is alway ber: wnicobil luded both fr imerator & denominator for SAR calculation disea! tT of 1 x 100 tible contacts SAR 30-45% > 80% I numbebot | 86% ‘90% Uses of Incidence rate + For research into aetiology & pathogenesis, distribution of diseases & efficiency of preventive + therapeutic measures + Ifthe incidence rate is increasing it indicate ineffectiveness of the current control programmes + Better indicator of hospital services & hea is + Best measure of disease frequency in etiological studies OO faa center Jalswal Photo Copy drarpitverma1983@gmailcom | —~ Mob. 8989409408 Page 44 tipide 3-Prevalance Refers to all current cases (old + new) existing at a given point in time or over a period of time in a given population Prevalence can be determined by cross sectional study + Prevalence is a proportion & not a ratio. + Always expressed in percentage + Two types- I. Point Prevalence Paint Prevalance = number ofall current cases (old + new) of a specified disease existing ata.given point in time x 100 Estimated population at the same point in time = When term Prevalence rate is used , without any further qualificat tion, itis taken to mean point Peiiod Prevalance Estimated mid interval population at ris + Uses of prevalence &, = Toestimate magnitude of disease Inthe com Example of Incidence & Prevalance dant 0-Ststteh ness - fabian leah AG + Incidence would include - cases-3, 4, 5&8 + Point Prevalance (Jan 1}-cases-1, 2&7 + Point Prevalance (Dec 31)- cases-1, 3, 5&8 + Period Prevalance (Jan -Dec)- cases-1, 2,3,4,5,7&8 ————————— a ‘Arpi’s PSM made-easy ‘9693160810 rw, Jaiswal Photo Copy éragpivermat963@gmallcom Mob. 8989409408 Page 5 ; ae ne ' ;3.1 Relationship between Prevalence & Incidence + Uhthe DISEASE IS MORE FATAL than the duration of disease will decrease & hence the Prevolonce will also decrease imareo Jalswal Photo Cop ‘ drarpitverma1983@gmallcom aye 1" Mob. ssec0g408 Page 64-Epidemiological Methods ‘TWies of Epidemiological Studies | Observational studies 1) Descriptive studies (hypothests formulation) 2) Analytical studies (hypothesis testing) 1. Ecological/ Correlational study (unit of study is population) i. Crossectional/ prevalence survey/ snapshot of population survey (unit of study is individual) Case control (unit of study is individual) iv. Case series study v,_ Nested case control study vi Cohort (unit of study is incu b = Prospective cohart = Retrospective cohart Se . Mined cohart/ combined prospective retrospeciBeohatt thesis confirmation) 1. Experimental studies, nt fees) 1) RCT (unit of study Is, 2) Field trials 3) Community trials (unit of study is cof Clinical trial (unit of study is patients/ based medicine = likelihood ratios & receiver operator characteristic curve ° © Highest importance is given to meta-analysis ‘Most important - Metaonalysis , systematic review & blind trials + Evidence based pyramid = Meta analysis- highest clinical relevance/ gold standard = Invitro / test tube research — lowest clinical relevance —_—_—_— ‘Arpit’s PSM made-easy 9893180410 fi Jalswal Photo Co; 1a1983@gmail.com ae ORY drarpitverm: aitcom Mob. 8989409408 Page 7descriptive studies Defining the population to be studied; Defining the disease under study Deseribin p 5. Formulation of hypothes Time distribution 1 “Arpit’s PSM made-easy 9893180410 drarpitverma1983@gmailcom SJalswal Photo Copy Mob. 8989409408 Page 84. Kpademivlon ji Cantinuous or repeated or multiple exposure epidemics + Sharp rise in number of cases Fall in number of cases is interrupted by secondary waves/peaks + Example- STD-prostitutes, contaminated well in a village, , legionnaire disease outbreak in Philadelphia (2976) ber chart incase of continuous exposure eniderne : : . fa 2 rropagstedepidenie: By Gradual rise & gradual fall ovel Results from person to person tras = Transmission continues till no suscep) infected individuals = Speed of spread depends: nit = Example- HIV, TB, Polio, i ZA (J sesceptte poputation © Sheinleezther LAA ‘monsve portation © Reem” Fa. Cove of ype! pronase! epidemic (Source 8) is ee nn ‘Arpit's PSM made-easy A 9993100410 ; rarpitvermal983@gmailcom seat ot Jaiswal Phota Copy Mob. 8225 205 425 Page “ coy te:|, Periodic fluctuation 1. Seosonal trend * ftis.o seasonal veriation of a dsease occurrence may be related f0 eA conditions + Gatinfection- winter season gir intection = summer season 2 Gyclicaltrend Rubella ~ every 6-9 years *influenza- every 7-10 years ™. Long term or secular trends eter ends changes over along period of time or decades | Bo concer, diabetes - increased in lat few decades Polio, diphtheria, typhoid ~ decreased in ftfew decades 2 Epidemics- unusual occurrence of a disease In a community, Hany in of expected occurrence ‘0 Outbreak small localized epidemic 5 The area declared free of epidemic when no.new case is reported from. of disease since the last case Stoanost the hep © Endem! ‘e constant presence or usual or expected frequt 2. Hyper-endemic— ‘© Constant presence of «affects all age group b. Holo-endemic— "High level ofp = affecting te- ROX Sed BU f secondary case caused by a single case in a Endemic Epidemic i | © Pandemic= (© anepidemic usually affecting large proportion of population over a caren such asentire nation or a continent or world (country to country spread) ‘© pandemic are caused by Influenza A . ‘Arpit’s PSM made-easy ie 9993180410 2 Jalswal Photo Copy drappitvermal963@gmailcom — _*** ‘* ‘Mob. 8989409408 Page 19 AananananoeceeeceaagesnNe Sporadic: Scattered cases, widely separated in space & time & show no connection with each other Occurrence of disease in haphazard or irregular pattern _ No recognizable source af infection or Outbreak ‘ Eedemic - disease that originates outside pfat % Exotic disease- disease Impo Place distribution 1. Local voriation + Spot maps + _Shaded maps LG. ‘Spot map of Aaintie chatera in London 2. Rural-urban variation + Rural- Zoonotic diseases, soil transmitted helminths + Urban- Accidents, CVD 3. National variation + Northern region- goiter ‘+ Southern region — malaria + Central region- lathyrism 4, International variation + Japan- Cancer stomach + India-Cancer in oral cavity <== eee ‘Arpit’s PSM made-easy 9993180410 , Jalswal Photo Copy ale drarpitverma1983@gmailcom Mab. 2989409408 Page 11Peson distribution 1. Age = childhood meastes = Middle age- cancer = Old age ~ atherosclerosis, = Females: hyperthyroidism = Males: lung cancer 3. Marital status = Married females- cancer cervix ‘Mortality rates are lower in married males or females 4. Occupation = Coal mines- pneumoconiosis = Deskjob- CHD S. Social cass = Upper class- non communicable diseases- DM, HTh = tower class- communicable diseases-T8, AIDS 5.1 - Investigation of an€pider + Objective of epidemic investigations ie = Todefine magnitude of the epidemi = Todetermine factors responsible for occurrence = Toidentify source of infection & modes of tr = Tomake recommendations to prevent recut 1. Verification of diagnosis = Lab investigations to confirm the dag = First step in Investigation of an ep} = _ Not necessary to examine al 2. Confirmation of epidemic = Done by comparing t = Epidemic threshold- e from the endemic occurrence 3. Defining the population at ist fallendmarks, roads & location of all dwellings '&. may again be divided into smaller sections. Bases at homeseamily or neighborhood eee MERy cs are caried out everyday tithe area is declared fee of epidemic, this period is usually ‘on period of the occurrence of last case . 5. Data analysis = Analyzed on the b = Time- construct an epidemic curve = Place ~ prepare a spot map = person —analyze data by age, sex, occupation & other risk factors rorrailation of hypothesis To explain possible source, causative agent, modes of spreed & ‘Testing of hypothests- By comparing the attack rates Evaluation of ecological factors infection & modes of transmission = Water &milksupply Relate disease with environmental factors to find reservoir of population a sk: Medical examination, screening test examination ‘of suspected sample & ‘environmental factors 9, Further investigation of biochemical studies 10. Writing the report oe Spould be complete & convincing ould be complete &.COnvincing ca gata, methodology analysts of data & control measures Under following headings- backero ————_—_— nw = = —— Jaiswal Photo Copy Page 12, Frpits PSM made-casy nels Mob. 8989409408 9893180410 drarpitvermai9e3@emallcomNy ee “ woe v 6-Analytical Epidemiology sociation exists between a disease & suspected factor(exposure) + To determine whether or not a statistical ass Aalytical studies (hypothesis testing) 1. Ecological/ Correlational study (unit of stu 2. Crossectional/ prevalence survey/ snapshot of population survey 3. Case control study Case series study Nested case control study Cohort study i. Prospective cohart fi, Retrospective cohart Mixed cohart/ combined prospective ee ry TPRESENT idy is population) [Retrospective stl study/ disease to. Features + Bot & out 1e have pee cd me have ossred before the stort oft + Uses.a control group to support an inference ‘Arplt's PSM made-easy - ‘9893180410 i drarpitverma com a -pitverma1963@gmalls — Jalswal Photo Cory ‘Mob. 8989403408 Page 13aceite acas AU. Selection of cases * Definition of case 4.Fpidenolugy, Disease wansins Diagnostic criteria Eligibility criteria Sources of cases, + Hospitals General population 22 Selection of controls + Sethap mathe 2 inst ta hecasesos posse escape fr he absence of disease sent erauP small choose up to 4 controls per casera) it larger studies 1:1 of cases & controls should be taken Sources of controls- + Hospital (often source of selection bias) , + Relatives nna controls are unsuitable in genetieClodies + Neighborhood 2.Matehing To ensure comparability between Wena < * Types- Group matching- age, i. Matching in pairs '3.Measurement of exposure * Obtained by- interviews, by questifqneitee record) General population ‘occupation, so ne i ag ‘ Exposure rates, + Cases Sha +6 + Controls B/b +d ii Estimaton of risk (strength of association) Cannot provide with inciden is known as odds ratio or cross product ratio is calculated (less accurc estimate) Odds ratio(Cross product ratio) OR=axd bxe Interpretation- Exposed showed a risk of having disease times that of non exposed Indicator of increased risk of disease in predisposed population oa tis Just an estimate of relative risk not the calculation of relative risk + Similar to relative risk ‘Arpit’s PSM made-easy wl Jalswal Photo Copy iver ~ b. 8989409408 He rerma1983@gmail.com Mol Page 14 anna ea eee aaeOR > 1- Positive association * so many times odds that cases were exposed to a risk factor is more to the odds that the controls were exposed + example- OCPs & thromboembolism 2 association + Odds that cases were exposed to a risk factor is same as the odds that the controls were exposed + Example- smoking & HIV/ AIDS + OR<1-Negative association + So many times odds that cases were exposed to risk factor is less than the odds that the control were exposed + Example- regular physical exercise-CHD Uttities of Case Control Study © investigation of rare disease ‘0 study of multiple exposure © investigation of long latent period Advantages of case contro! studies + Rapid & inexpensive ier + Suitable to investigate RARE + Risk factors.can be identified + Noethical problem Disadvantages of case control studies + Selection of appropriate contri + Problem of selection bias + Inciden (Prospective study/ Longi study/ enfebdreto outcome’ fo disease wees 1. Prospective cohart studies = Current cohart studies / Concurrent cohart studies — _ Outcome has not yet occurred when the study has begun, only exposure has occurred , we look {for development of some disease in both exposed & non exposed groups = &x-Framingham heart study — Retrospective cohart studies ‘Arpit’s PSM made-easy 9692200410, - drarpitvermat963@gmailcom =“ passes Phaza Copy Mob. 8989409408 Page 15que nization. viology, Diseas 2. Retrospective cohart studies = Historical cohart studies / Mon-concurrent cohart studies ~ Both exposure as well as outcome have occurred, firs we go back In time & take only exposure into consideration then look for development of same disease in both exposed & non exposed ~ Ex Effect of fetal monitoring on neonatal deaths ~ Example: e cohart of nurses with contro! group is studied for use of 1UD & abdominal pain as side effect, incase control manner 3. Combined Retrospective Prospective cohart studies = Mixed cohart study = First we go back in time & take only exposure into consideration , later cohart is followed prospectively into future for outcome — Ex Court Brown & Doll study on effect of radiation therapy Fetures + Cohorts are identified + Study proce 1m cause to effect ae 1. Selection of study subjects 1. General population g ae Selected groups- doctors, teachers, ers 2. Obtaining data on exposure i. Personal interviews fi, Review of records fi, Medical examination/ t 'v. Environmental surveys SE 9893180410 Photo Co! drarpitverma1983@gmail.com Salswal copy Mob. 8989409408 Page 16,| Incidence rates + Among exposed = 2/ a+ b * Among non exposed = ¢/ c+ d ii. Estimation of isk strength of association) 2) Relative Risk (risk rotio) “RR = incidence of disease among exposed incidence of disease among non exposed + RR measures the strength of association between suspected couse & effect Indicates no association + Ex-smoking & HIV/ AIDS + Interpretation- Chance of disease develo Rk> 1 indicates positive association between exposure & 7 Bee smoking & lung cancer & + Interpretation-RR of indicates that incidence of tisea: group 2s compared with unexposed Rt < 1 negative association between exposure & disease ba, + Ex-vitamin A intake & epithelial cancers > + Interpretation. -Chances of disease deyelopmet ng exposed as compared to;nbn exposed ‘hy ers n exposed 95 compared Ro inexposed pment is same among exposed as compared to non exposed isease Ex. RR of 0.25 indicates 75 % reductidUajncidenc tr (© Testing multiplegetfects © Measurement of¥{mie relationship ‘© Direct incidence measurement Advantages of cohart study = Incidence & Relative risk can be calculated = No recall bias = Natural history of disease is best studied by cohart study = Done for RARE CAUSE Useful for CHRONIC DISEASES Disadvantages of cohart study = Unsultable for RARE DISEASES = Expensive & time consuming = Loss to follow up ee SSS SSS Tries PSN made-easy ; 9983100410 unselé Jalswal Photo COPY alii cao Mob. 8989409408 Page 17ission & 100 ology. Disease teat +} Framingham Heart Study * Cohort study + 1988 by US pubic heath services at Framingham ‘+ To study relationship of risk factors (serum cholesterol, blood pressure, weight & smoking) & evelopment of cardiovascular disease ‘Age-troup ~ 30.62 years Sample sine: 5127 Multiple exposure were studied by using multivariate methods Follow up: study population was examined every 2 years for 20 years Findings of study © Increasing risk of CHO with increasing age & more in males Hypertensive have a greater risk of CHD Elevated blood cholesterol associated with Gp, Tobacco smoking & habitual use of alcohol ineBdses risk a Increase body weight predisposes CHD DM increases risk of CHD Increased physical activity decreases ED devefopment eccc00 Differences fee ee & Cohart study: as Vv ctional Study Identity exposure status tnd ai Prevalence survey Exposure as well as outcome may coexist at the sam “+ Sased on single examination of a cross-section of population, at one polnt of time, result of sample ore to whole population Simplest form of observational epidemiological study + Least time consuming study ‘Arplt's PSM made-easy 9093160410 wnat Jalswal Photo Copy drarpitverma1903@ gmaiLcom Mob 2989409808 Page 18 VANIER ONAN AN MAN ANA IN AAA AR AAA Re VA oa4 sony, Disease Advantages. Gives a snapshot of @ population lence of a disease cful for chronic diseases Show pattern of disease * Disadvantages ~ Tells cbout distribution of disease rather than its ETIOLOGY ~ Cannot establish causality as does not establish time sequence 6.5- Nested Case Control Study Hybrid design where a co ud Predominantly a type of cohart study due to forwag Only exposure has occurred when the ‘Study design = Apopulation is identified & a base Population is than followed up, 6.6- Ecological study lonal study Provides least satisfactory type of evidence on causality Least preferable observational /analytical study desien Unit of study is population Uses data that is already available ‘Advantage~ Provides group's characteristics Disadvantage: Socio economic confounding + Ecological fatlacy- An ertor of interpretation in an ecological study , whereby characteristics are ascribed toa group of people which they may not possess as individual + fxomples of ecelogicel study. tn UK it was found that there were more desths from asthma than the sale of entlosthma drugs —_ “aepit's PSM made-easy ‘gevaiwo410 - Jalswal Photo Copy Arar putvermat983@gmaitcom atswatongaoscosPage9 - a 7= goth 6.7- Case Series Study {,fothoucome as wells esosie hove ected en the sy as beg itt we take outcome into consideration & then go back in time taking exposure Into consideration + There is no comparison with non diseased or controls hig exposure io conde + Example ~ potients of glaucoma imple - patients of glaucoma are identified & surveyed by patient interviews regarding family history of glaucoma 7 - Experimental i Experimental studies (hypothesis testing) " Sane 1. RCT (unit of study Is patients) 2 feldtnt 5 imu a a ea imental trials ty depends on the hypothesis type of stu + The dropouts from@he,trial are not excluded from the stus + Intention to retreat ndlysis is done in Bt ‘Steps of RCT 1. Drawing up a protocol ‘+ Specifies the alms & objectives of the study + Size of the sample + Treatment to be applied- when, where & to whom Selecting reference & experimental population 2 I. Reference or target population oor is the population to which the findings of the tral, iffound successful, are expected to be: applicable . — May be geographically limited or limited to persons in specific age, Sex, occupational or social groups PSM made-casy ‘ apie0i0 Une Jalswal Photo COPY 5. 94 Mob. 8989409408 drarpitvermal983@emailcom4. Fpcomioloyy, Disease transnutsston & Lnannict Experimental or study population — Derived fram the reference population = Actual population that participates in the study = Itshould be randomly chasen from the reference population + purpose of control group in-an experimental study is that it helps to eliminate alternative explanations for the results of the study 3. Randomization Statistical procedure by which the participants are allocated into groups called study & control groups to receive or not to receive the intervention «Randomization Is done while dividing patients into experimental group & reference group + Randomization is the heort of trial + Best done by using a table of randomgjumbers Purpose of randomization 5, Follow-up; + Examifgtign of the experimental & control group subjects at defined intervals of time with equal intgjity, under the same given circumstances + Attrition-Some losses to follow up are inevitable due to factors , such as death, migration & loss of interest Assessment of outcome + Positive results — Reduced incidence or severity of disease + Negative results = Frequency of fe effects & complications es ‘Arpit's PSM made-easy 9893180410 nantes drarpitvermal983@gmailcom Jaiswal Photo Copy Mob. 8989409408 Page 21Sudy design 1. Concurrent parallel study designs “© Comparison is made between 2 random groups 2 one group exposed ta specific treatment (experiment group) & the other 2r0u {reference group) 1+ Patient remains in the same group throughout the study duration 2. Crossover type of study designs © Each patient serves as his own control ‘study group receives the treatment & control group receives the placebs or placebo to al wp nat exposed low elimination of 2 patient in each group are taken off from their treatment carry over effects «the two groups are now switched «Those who received treatment will rt receive the treatment Jjacebo & t}fSep retelved placebo will now + Both groups . «© Coses acts as their own controls 3 aay Helps in removing ethical concer Intention to treat trial - result of RCT aeeggsene? follow up or changeover of stidy subjects from st ‘one group to another aluating therSpeutic agents , mainly drugs n cardiovascular mortality jed Gut before any new therapy Is introduced ‘rials of primary preventive measures gx trials of vaccines or chemoprophylactic drugs © Risk fae{ghtrials {fMcstigator interrupts the usual sequence in the development of individuals who have risk factors of disease Eg. multiple risk factor intervention tril (MRFIT) in USA ase for those © Cessation experiments ‘+ Attempt is made to evaluate the reduction of disease «Trial of aetiological agents «Aims to confirm or refuse an aetiological hypothesis 2 Egetrial for retrolental fibroplasia as a cause of blindness ‘© Evaluation of health services + Toassess the effectiveness & efficiency of health services ‘Also called health services research studies effect termination of habit or removal of agent & : Jaiswal Photo Copy Sopli’s PSM made-easy ne (993180410 af" Mob. 8989409408 Page 22 drarpitverma1983@emacom ~anA nr KAHAN OHOSHKLEAAAARE7.2- Clinical Trials Does not have true control group- patients acts as their own control 7, Each patient has pre-test score followed by a post Clnical phase Phase Units Tarps Preclinical phase _ _ | Lab experiments Animals pretesting. a I phase Phase 0 Healthy humans volunteers | Micro-dosing Phose1 Healthy humans volunteers | Safety & non toxicity profile Phase I Patients Efficacy Phase It Patients q $04 'Comparison with existing drug Phase Iv Patients", GIDL Long term & rare side effects Phase 1: makimum tolerated dese afadiua is aven & 50 eValuated in iB phase + Phase il. maximum drug failure reported + Phase I © Its an RCT as comparison of new drug is age © New drug is launched in market + Phase wy © Longest phase of a trial © Post marketing surveillance ¢ Scribe distributton of effect size (Ba posion of the equate ex point estimate 7 araiaes axgtnwortasi@on m4 Bemtternac remo | reimanaingeey af Beaton eats | Shes time 1997 ——a rea oon a eset rome te ceed ete rst (5609 eS Bae ee SRENGiisceee Sf | ‘The ier wally the O84 Ra (OR {aly eca latin ele “The veal line reeset an OR of 1. “aoe ‘Arplt’s PSM made-easy i 9893160410 te dranpitverma198%@pmaltcom Jalswal Photo Copy Mob. 8989409408 Page 23© Funnel plot- To check publication bias u z ‘ No Publication Bias Publication Bias + Strength- © Provide point estimate of effect size ‘© Report confidence interval around effect size © Identify gaps in a particular field + Limitation © Garbage in Garbage out (GIGO}- result can only be ‘© Apple & oranges effect- tendency to mash together di © File drawer effect- publication bias, Blas + Anysystemati erorin an epidemiological study, ce interpretation + Arise from human errors of assessment of the outc¢ 1. Subject bias = ror introduced by tu ff * participants who may subject they were receiving a new treatment. Xposure than controls ve study that can be eliminated by a ‘Occurs during recrultment © BerkiBhian bias « [tise type of selection bios + ftisdue to different rates of admission to hospital due to different diseases 3. Analyzer bias- Introduced by analyzer 4. Interviewer bios- Interviewer devotes more time with cases as compared to controls 5. Lead time bias/ zero time shift bias- Bias of over estim: of survival time due to backward shift of starting point 6. Neyman/ Prevalance-ncidence duration cases from the study 7. Bias in evaluation- investigator may subconsciously give a favorable report of the outcome of the trial “Blinding, Randomization & Matching help to reduce bias. Bias due to missing of fetal cases. Mild/ silent cases & short Tes PSM made-easy nt 3073100410 nels Jaiswal Photo Copy drarpitverms1983@gmailcom Mob. 8989409408 Page 24ee, _4. Epidemiology, 10- Blinding Done in 3 ways 1. Single blinding + Participant wore whether he belongs to study group or control group + Minimizes subject bias 2. Double blinding + Neither the Investigator nor the participant is aware of the group allocation &the treatment received + Minimizes subject bias & investigator bias + Most frequently used method is double blinding 3. Triple blinding + Participant, investigator & the person analyzing the data areal unaware of the two groups + Minimizes subject bias, investigator bf@s'&, analyzer bia + Ideally triple blinding should be used 1fBign independent ee jon of outcome came ‘of bias is interpretation ‘Methods used to control confoundint © Randomization- most © Matching- mostly us © Restriction © Stratification ° Statistical = Age standardization removes confounding effect of different age structures, = _ standardization is carried out by using standard population = _ Standard population ‘© population where age & sex group are known © national 2n need not always be taken as standard populati ‘© used in occupational studies & for occurrence of diseases Types of standardized death rates © Direct Stndardization * Age specific death rates (ASDR) © Indirect Standardization ‘+ Standardized mortality ratio (SMR) —_—_—_—_—_—_—_—_— ‘pits PSM made-easy - 999318041 ane =o Jaiswal Photo Copy drarpitverma1983@gmailcom Mob, 8989409408 Page 25et Epidemiology, Disease transmission & fname nuzatinn served death x 100 Expected death ‘SMR is best to make a comparison between health status of 2 population The rate adjusted to allow for the age distribution of the population is known as age standardized mortality. rate + Standardized mortality rate is standardized for age © ‘Specific death rates * Specific for oge & sex + Identify at risk for preventive action 12- Matchit + Process of selecting controls in a such a way that they af + Matching is done to remove known confoundir ‘+ Matching eliminates confounding as it distributes known con + Types (© Caliper matching- Matching of two group: within 2 years) (© Frequency matching- Similar Fre vari (© Category matching- Matching study & co occupation) ‘© Individual matching- Identifying ‘matched variable © Pair matching- Pair of study & selection bias, known confounding & nding & blinding removes bias only Consistency of association- results are replicable indifferent settings Biological plausibility- Credibility of association by anatomical/physiological justification Coherence of association. association is supported with relevant facts & studies Dose response relationship- increase in dose cause increase in incidence of effect ‘Reversibility: removal of cause reduces risk of disease ‘© Exomple- current si re at higher risk of developing luna cancer as compared to ex smoker + RCTare best studies for establishing cousation + Ecological study is the weakest study to test the association between risk factor & disease indirect association ~ example- association of high altitude areas with aoitre it’s PSM made-easy at 373180410 unas Jalswal Photo Copy drarpitverma1983@gnaltcom Mob. 8989409408 Page 264. Epidemiology, Disease transi 14- Uses of Epidemiology 4. To study rise & fall ofthe disease + Study of disease profiles & time trends in human population 2. Community diagnosis *+ Identification & quantification of health problems in @ community in terms of mortality & mor bidity rates & ratios : 3. Planning & evaluation of health services + Epidemiological information about the distribution of health problems over time & place provides the fundamental basis for planning & developing the health services & for assessing the impact of these services 4. Evaluation of individual risks - + Epidemiologist calculate relate risk & attributable risk fora factorgelated to be a cause of the disease fee, 5. Syndrome identification + Media syndromes ar idetied by observing eq assoc G. Completing the natural history of disease + Epidemiologists by studying disease patte environmental factors isin a bettenposition 7. searcingtoreawesarsktacors SG) + Epidemiology , by relating disease to inter the causes of disease Yes main underlying cause) t related to condition causing it as essence of death certificate Example 2 © Une smorrhage ‘© Line i.b- ruptured metastatic deposits in liver + Line Lc- metastatic deposits in liver Line I.d- primary adenocarcinoma of ascending colon ‘+ Une Il- hypertension. Sees ‘Arplt’s PSM made-easy 9053180410 - demptvernat983@gnaicon Jalswal Photo Copy Mob. 8989409408 Page 271 Lyndemiolopy. 4.2 Disease Transmission in Infectious Diseases e Disease Control/ Elimination / Eradication Source & Reservoir Cases | Primary case * Index case | ‘© Serial interval | J \ 7? 4. Carriers * Convalescent carriers 5. Disease Transmission 6. Incubation period © Generation time 7. Isolation 8. Quarantine 9. Emporiatrics we | 1 photo Copy ie 75m madly sais 8969409408 Page 28 ! 98931! drarpltverma19e3@gmallcom !1- Disease Control/ Elimination / Eradication + Disease Control = Agent is permitted to persist in the co problem = Aims in reducing- + Incidence of disease + Duration of the disease + Effects of infection + Financial burden of the community + Disease Elimination = Interruption of transmission of disease . = But the causative organism may be persisting in.environment = India has eliminated 4 disease tll date + Guinea worm (dracunculiasis) + Leprosy + Yaws + Maternal & neonatal tetanus = Next disease likely to be eliminatgdffom Ini + Disease Eradication ‘= Termination ofall transmission of infection by = Tearing out by roots of a disease = Exhibits all or none phenomenon t's a global term ie. can only be, smmunity at a level where it ceases to be a public health fectious agent passes or is disseminated to the host hie a part of reservoir Siffected person or animal that harbors a specific agent in the absence of clinical Blsease & serves as a potential source of infection + _ Carriers are ess infectious than cases but are more dangerous epidemialogi . n pidemiologically Polio & solmonella typhi does not have human reservoir. 2. Animal reservoir © Senin rabies, influenza, yellow fever etc. 3. Reservoir in non living things . © Sollfor tetanus, anthrax, rat Examples of sources & reservoir es Source Reservoir Hookworm Soll Pe Tetanus Soil hold i = Tye Feces/ urine/ water Cases/carriers 4 ‘Arpt’s PSM made-easy 9893180410 wane drarpitverma1983@gmailcom =~ Jalswal Photo Copy Mob, 8989409408 Page 29won & IL nization 4 Epidemiology, Disease transmission & Mua cauizat 3- Cases = Person inthe population identified as having a disease or health disorder Variation inthe manifestation of disease are referred to as spectrum of disease or gradient of infection = Ginicatitness il cases may be more important sources o abundant Subclinical ilness * Referred to as inapparent, covert, missed or abortive cases + aya dominant roe in maintaining Endemicity in the community * Subclinical infection occurs mostly in * Eg. polio, influenza etc. ib fection than severe cases because they are symptoms + Eg.herpes simplex Primary case * First case of a communicable disease introdui + Always excluded from both numerator Index case- First case to come to the attention of t Secondary case- Those developing from con Serial interval + Time gap in between the onstet + By collecting information 8 Incubation period of, Suspect case- Individuals wh ooe * ect measles mumps polio, Pertusis influenza, , hepatitis B, diphtheria 2 Convalescent carrlers + Continue to shed the disease a healing after illness) {o.cinlcal recovery does not coincide with bacteriological recovery * Eg. Typhoid fever, bacillary/ a c smoebic dysentery, cholera, , Pertusis, diphtheria Healthy carriers ‘+ Victims of subclinical infectio from overt disease Eg. polio, Salmonellosis, meningococcal mentnaitis, diphtheria, cholere, typhoid gent during the period of convalescerice (gradual n who have developed carrer state without suffering ‘ples PSM made-easy bp iabehtid st Jalswal Photo Copy drarptverms1983@gmailcom Mob. 8989409408 Page 30pidemiology, Disease transmission & hmmunization Hi. Duration 1. Temporary carriers ‘+ Shed the infectious agent for short periods of time ‘© Includes incubatory, convalescent & healthy carriers 2. Chronic carriers * Excretes infectious agent for indefinite periods + Eg. typhoid , gonorrhoeae, hepatitis B, malaria ic carriers are known to reintroduce disease into areas which are otherwise + Carriers of avirulent organisms are called pseudo-carriers IL Portal of exit © Urinary carriers - typhoid ‘© Intestinal carriers - typhoid, cholera, 4 Intyphoid fever, Urinary carriers is © Respiratory carriers Nasal carriers- diphtheria + Communicability- ability of a disease to spread fro + Period of communicability © Time during which an infectious ag animal, including arthropods ‘© Important measure of commut EID , AIDS, Leprosy = “Wiost common route of Nosocomial / hospital acquired Infection is through direct contact . “Hospital acquired infection of surgical wound is mostly by instrument + Nosocomial infection- develops after 48 hours of hospitalization fi, Droplet infection = Direct projection of spray of droplets of saliva & nasopharyngeal secretions d coughing, sneezing etc. = Pertusis (Whooping cough), tuberculosis ii, Contact with soll Hookworm, tetanus iv, Inoculation into skin or mucosa- Rabies virus by dog bite, Hepatitis B Vv. _ Transplacental (vertical)- TORCH agents (Toxoplasma, gondi, Rubella virus, Cytomegalovirus ‘& Herpes virus) _ ‘Arpits PSM made-easy 9993180410 can ele Jaiswal Photo Copy drarpitverma1983@gmailcom ‘Mob. 8989409408 Page 31Disease wansmission & Immunization transmis © Traditional 5's- files, fingers, fomites, food & fluid i. Vehicle borne = Transmission of infectious agent through the agency of water, fo0d, blood , tissue & organs — Disease transmitted by water & food- typhoid fever, cholera & hepatitis A = Transmitted by blood include- hepatitis 8 , malaria & syphilis = Organ transplantation- cytomegalovirus in kidney transplants i, Vector borne a. -ByVector L Invertebrate type + arthropod vectors falls into 9d — man (malaria) non vertebrate host jpod- man (plague) te hosts By methods in which vectors are involved in the transmission & propagation rasites ‘Types of transmissions in arthropod borne diseases Direct contact- ‘+ Transferred from man to man close contact. + Scabies 2. Mechanical transmission- + Agentis transferred mechanically by the arthropod * typhoid / trachoma by housefly 3. Biological transmission + When disease agent multiplies or undergoes some developmental ‘change with or without multiplication in arthropod host itis called biological transmission Ot —— “Arpit’s PSM made-easy 9893 180410 were Jalswal Photo Copy drarpitverma1983@gmailcom Mob. 8989409408 = Page 32i. Cyclo-developmental — Disease agent undergoes cyclical chanaes but does not multiply in the body of the arthropod = Example. guineeworm embryo in Cyclops & filorio! parasite in Culex mosquito ii Propagative eee oisease agent multiplies in the body of vector but does not undergo any cyclical chances — Example ~ plague bacilli in rot fleas & yellow fever virus, in Aedes mosquito ‘i, yclo- Propagative = Disease agent undergoes cyclical changes & multiplies in the ti, Al-borne a © TB, inf lied during fading . couthing or sneezing settle down on the floor iding & becorre part of the dust making the dust is released into the air & ‘© Mons dead end for tetanus & rabies & Zoonosis + Anthroporoonosis Infections transmitted from antmal{zo0} to man (anthro) = Rables, plague, anthrax, hydrated cyst, trichinosis, + Zooanthroposis ~ Infections transmitted from man (anthro) to animals (z00) = Human TBin cattle + Amphixenosis ~ Infections transmitted in either direction between animals & man = _ Trypanosoma cruzi, Shistosoma japonicum: ‘Arplt’s PSM made-easy ‘9893 180410 drarpitverma}983@gmailcom Mob. 8989409408 Page 33etna rigattiol _4.Fpidermology, Disease transi pura nigel 6- Incubation period + incubation period © Time Interval between invasion by en infectious agent & appeorance of the first sian or symptom of the disease * During incubation period agent undergoes multiplication in the host, when sufficient density of the agent is built up in the host, health equilibrium i disturbed & the disease becomes overt + Uses of incubation period 1. Tracing the source of infection & contacts ‘Follow the tral of spread of infections 2. Determining the Period of surveillance ‘Usually equal to maximum incubation period . 3. Applying Immunization principles © Knowledge of incubation period help: immunizations 4, Identification of point source or propagated epidem! + Point source epidemic all the ca * Propagated epidemic- cases occ S. Estimating prognosis ‘© prognosis is poor in diseasesteg. t ‘© Incubation depends upon + Infective dose + portal of entry + individual susceptibitity RG equivalent of incubation period in infectious diseases disease initiation to disease detection + Defined as perl sures for incubation period in diseas Latent period, eral Interval, Generation time ‘Diseases communicable nor highly transmitted during later part of incubation period + Measles, Pertusis (whoopir ih), hepatitis A ‘Diseases with Incubation period < 10 days - Cholera, influenza, pla + Disease infectious before & after onset of ms ore- Measles, mumps, hepatitis B ‘pts PSM madeeasy Se 9993180410 unael¢ Jalswal Photo Copy drarpitverma1963@gmaiLcom Mob. 8989409408 Page 347- Isolation Isolation v= Separation from the period of communicabitity of infected persons from others to prevent transmission of the infectious agent from infected to susceptible + Types of isolations = Standard isolation = Strict isolation = Protective isolation = High security isolation + Hospital isolation is better than home isolation + Isolation may also be achieved by ring Immunization “= Encircling the infected persons with a barrier of spread — Method was applied to eradicate small pox = Applied for control & eradication of measles in Nort «Isolation has failed in control of disease such as TB, leprosy & STD: isolation, chemical isolation (.e. rapid treatment ofases in gheir own homes as quickly as possible nf day isolation is recommended only wheh@e risk of legion Is exceptionally serio Polio- 2weeks (adults) & ‘TB- until 3 weeks of etemot Huarantineg defined above Fed quarantine- selective partial limitation of freedom of movement, such as exclusion ES oaration of some part of group of persons from the others to facilitate control of ‘Smmunicable diseases e.g. removal of susceptible children to homes of immune persons + Quarantine as a method of disease control has become outdated & has been replaced by active surveillance nS ‘Arpit's PSM made-easy 9893180410 ) Sormenstsemeicie® Te Jalswal Photo Copy Mob. 8989409408 Page 359- Emporiatrics Enporiatrics + Term coined to describe science of health of travelers International travelers may subject to resistance to disease due to crowding, disruption of eating habits, change in climate ete. ‘Secondly In developing countries they are exposed to disease which are not covered by international health regulations e.g. malaria dengue, STO, AIDS, typhoid, hepatitis ete. + There risk can be minimized by immunization & chemoprophylaxis Some recommendations 1. Avold bath in polluted water 2. Measures for prevention of insect bites 3. Diarrhoeal diseases + Use boiled water or bottled mineral water + Oral rehydration fluids 4, Malaria- Prophylaxis begin at the day of arrival in the malariBdS areas, 1gtA.weeks after leaving the area S. Hepatitis A- Immunoglobulin- 0.05 mgfkg every: 6. Hepatitis E- Avoidance of contaminat 7. Hepatitis B © 3doses of vaccines ‘First two doses are given 1 month apa 8. STDRHIV Disinfection- Physical (t (except bacterial spore: + Sterlle- state of beihgtige from all living organisms _Asepsis- prevention digpntact with microorganisms {deal disinfectant- Broad spectrum, Fast acting, Nontoxic, Odorless, Types of disinfection 1. Concurrent disinfection- * application of disincentive measure as soon as possible after soiling of articles with infectious discharge © example disinfection of urine 2, Terminal disinfection- * application of disincentive measures after the patient has been removed from the hospital due to death or is discharged 3. Precurrent/ prophylactic disinfection: ‘* Disinfection n of water (chlorination), pasteurization of milk hand washing etc. ‘Arpit’s PSM made-easy 9893180410 male Jalswal Photo Copy drarpitverma1983@gmailcom Mob. 8989409408 Page 36 Economical & have Residual effects etc. A 8 BR DRAW AAADADRADODOAAA CO eC eeCeCeCACANo 4. Epidemiology. Disease wansmnssion & muni © Dhinfecting agents + Natural agents- Sunlight, ir + Physical agents: Burning, Hot air, Boiling, Autoctaving, Radiation + Chemical agents 1. Phenol related compounds- phenol, cresol, dettol ‘Geesol has no sporkcidal effect 2. Quaternary ammonia compounds- cetrimide, savion “Sovlon contains. Chlorhexidine-{ Cetovlon) & Cetrimide-(Hibitane| > 3. Halogens & thelr compounds 1. Chlorine compounds . 2. Bleaching powder- Chlorinated ime (Ca0C) : + Contain 33% of avaliable chlorine b frites (it Ison ontivial + Liquid: godium hypochlorite + Solid—calcium hYegehlorte vu . © chlorine tablets &. + Holorone tablets > : sodium did A ous aig & chlorine 7 + Goodin disinfect > 4," Aleohots- ethyl alcohol, methylatedspirit 5. Formaldehyde- formalin 7 6 Onidizing agents- ; + Potassium permanganate- aqua ) + Rydrogen peroxd + Paraceticacid 7. Metals silver ’ . ideo! woker coefficient /Carbolle acid coefficlent: + Represents germicidal, a disinfectont * Stondé fon. West + RWC= 10 means disinfectant i 10 times more potent than pheno! + Organism used for testing- salmonella typhi ¢ teorothermophils 2 stelirotion of an avtoclove ‘Gloss can be sterilized by. hot oir oven 160 degrees Celsius for 30-60 minutes © Sterlizotion © By dry heot- floming, hot air oven & incineration tolroven 7 powders heen heat pasteurzation, boing, steam seller, outolving,tyndalisation e ode TRESS dy 9893180410 fanle drarpitverma1963@gmailcom =~ Jalswal Photo COPY 5. 37 Mob. 89894094084.3 Immunization & Cold Chain Vaccine BCG vaccine Measles Vaccine DPT vaccine Inactivated Polio Vaccine (PV) Oral Polio Vaccine (OPV) . Herd immunity ge. . Rota Virus Vaccine b |. Mycobacterium Indicus Pranii (MIP) > e 10. Cold Chain fF ‘* Vaccine Vial Monitor (VM! 11. National immunization Set eins 12. Age limits for delayed immunization dia 13. Adverse Events Following Immun(ation (Al 14. Open Vial Policy NO 15. Mission RS) pexnaw een ‘Arplt’s PSM made-easy 7 9893180410 a Jaiswal Photo Ca) mot nakayama strain, $4-14-14-2 (cell culture der © Adult JE vaccine campaign co ‘* Swine flu (killed)-7/ California /2003 © Vaccine administered os nos®tirops- IN S Fitelent inttuensa vaccine. Wafuenca Ati © Hib conjugate vaccine- PRP with carrier Typhold - Ty 21 A (For typhoid. best va 3 Malaria- SPF 66 (iytic cocktail) & RTS,S/ASO1 (mB © Checker KA * Bev vaccine-blvalent(Cervarix. HAUEAE Da ucd ATER (Gardasil 9 — HPV 6, 11, 16, 18,4153 5 * Cholera vaccine- Dukoral, San Vaccine strain which chang colostrum is known ongenital passive Yarmtihity ‘Most common cause¥p> Bb the baby found iit polio, mumps, measles ete gccine foilure — maternally derived antibodies *econdary booster in cBliparison to primary response ne © Shorter lot&W Period © Antibody is mBximum Hon tod response is maintalried ot higher levels for a to of tin Premunition- © Stat muni © Protects @ individual © qinialty denends on the presence of an Inactive infection with the same © Species specificity present intesera is obtained from horse 11,16,18) & 9 valent 2s i it’s PSM made-casy ne eoaten4i0 y drarpitverma1983@gmailcom ’ Jaiswal Photo Copy = Mob. 8989409408 Page 402- BCG vaccine © Bacilli Calmette Guerin © Live attenuated © Liquid fresh type © Ereezed dried (lyophilized) vaccine (more stable & used currently) DANISH 1331 strain (WHO recommended) © Derived from mycobacterium bovis © BCG laboratory, guindy, Chennai in India © Reconstituted with normal saline (NaCI)Must be used within 4 hours of reconstitution '* 0.05mi Intra dermally at birth on skin over left deltoid (0.1 ml = 0.1 mg) © 0.05 mi- birth - 28 days © O.ml> 28 days © Tuberculn syringe (omega microstat syringe, Gree, 26 gaufSpeeiie) © Site of the vaccine must not be cleaned with spirit © Age for vaccination (© Direct BCG- upto 1 year - without Mantouxtest ‘© Indirect BCG- beyond 1 year ~ after prior x © Phenomenon after vaccination © 2-3 weeks- papule formation © 6-8 weeks- break into shallow ulcer covered with ci © 6-12 week- permanent tiny round scar © 8-14 weeks- Mantoux test become positive © Protective efficacy for ‘© pulmonary tuberculosis 0% (© Severe form of TB- 0-80% (medi © leprosy- 20-40% protective for 20 years complications- suppurati 0.5 mis/Cin righteany 2 doses 5 © 1% doseas Mi (Can be lowered to 6-9 months In epidemic & malnutrition) 24 month 0 If child misses theStheduled dose MR can be given till S years Stabilizers- sorbitol, hydrolysed gelatin Diluent- distilled water or sterile water- Use within 4 hours ofter reconstitution with dilvent Preservative-neomycin & erythromycin ‘Stored at- +2 to +8°C Protective efficacy- > 90% (with one dose) & > 99% with 2 doses Lifelong protection IP of vaccine Induced measles ~7 days ide effect- Toxie shock syndrome! C/i= pregnancy ‘Dose of rubella immunoglobulin = 20m! (MMR vaccine Is given at 15-18 months Boe eeeveces ‘Arpit's PSM made-easy 9893 180410 aint Jaiswal Photo Copy drarpitverma1983@gmailcom Mob. 8989409408 Page 414. pidemiolony. Disea 4- DPT vaccine © biphtheria & Tetanus are toxoids and Pertusis is killed acellular bocili aa > Addition of killed bordetella Pertusis microorganisms to diphtheria toxoid enhances thee antibody response of the latter because of additive action of two antigen = 0.5mi /M at anterolateral aspect of mid thigh (middle 1/3) 4 © intiis 1" , 2°48 3"doses given with Pentavalent vaccine at Gweeek , 10 week & 14 week respectively an than 2 boosters of DPT at 16-24 week & 5 year 6 week Pentavatentt 30 week Pentavaient2 14 week Pentavalent3 36-24 month | DPT booster Syear DPT booster Gh, | ‘ ‘Recommended interval between 3 successive doses- 1 mai © Adjuvant (increases. enicity of vaccine) - aluminium pRosphate’ghaluminium hydroxide + Preservotive-thiomersal © Composition iso pr Laffer, 71, erie SDA 20000 ition, anu Bhesphate-2 me thoneral Gi SG) ofa Gc O30 offer, 77 200 phosphate 3m, homers 01% 12 10s8°c(e. nah gets ore cident the Contandcaton 0" sevee hypertensive reaction lular bacil-32000 millianPatimunium te) Absiec [Farie- 0.5 mn ARR ° © Poliovirus type % © Poliovirus type 35 * Advantages 7 © _ safe in- immunodeficiency disorders, patient on radiation ic i oer tama Pe radiation or corticosteroid therapy & pregnancy © Disadvantages © Unsuitable for epidemics * Asimmunity is not rapidly achieved (> 1 doses required) * Injection can precipitate paralysis during epidemics antigen units 2D antigen units ‘Fplts PSM made-easy ay, Jaiswal Photo Copy P 9993180410 7 drarpitverma1983@gmail.com Mob. 8989409403 Page 426- Oral Polio Vaccine (OPV) + Live attenvated + Bivatent * Composition © Poliovirus type 1- 10° CCID © Poliovirus type 2—105* CCID * Mechanism © Primary multiptication- Intestinal epithelial cells © Secondary multiplication- Peyer's patches (leads to viraemia) + Includes both systemic os well a local immunity / + 2 drops orally (equivalent to 0.1 ml) (OPVO- at birth OPV1- 6 weeks OPv2- 10Weeks ‘OPV3- 14weeks OPV booster- 16-24 months ‘Stabilizer used- Ma2sion ‘Thermolabile vaccine during transport kept in-di For long term storage -15 to ~ 25°C (at district lev ‘OPVis a live vaccine where single dose i development of immunity) “ SUttnintimm 5 doses are required for © Advantages (© Easy to administer Includes both hugp © Vaccine Derived Po PV) = Very rare strain of polio virus , genetically changed from strain in OPV vaccine j + Most commonly caused by polio virus type 2 (CVOPV type] "Under very rare occasions under certain conditions may cause paralysis, + Bigswitch © 25 April 2016 © National Validation day -9 nay 2016 (India declared free of tOPV) © Switch from trivalent OPV (tOPV) to bivalent OPV (bOPV) © Removing type 2 component ie ‘Arplt’s PSM made-easy ‘Sena 180410 ana le Jalswal Photo Copy drarpitvermal983@gmail.com Mob. 8989409408 Page 434 #pidemiology, Disease tasinission 2 1 = 7- Herd immunity Heed immunity + itis thes Lof resistance of a cor mmunity to a particular disease Herd immuni implies group protection ; it ftlts fo aroup protection Beyond what i afforded by the brotection of immunized individuals brevis an immunological barir to the spread of eee the human herd rer erample, when an infectious diseaseis introduced iment Yery low or no immunity the attack & case fatality rotec te Epidemic wave declines with the build up of herd immunity Elements which contribute to herd immunity — (Pecurrence of clinical & subctinial infection in the herd Immunization of the herd, — Herd structure * Includes not only the hosts populat hosts & insect vectors as well as envir spread of infection I the herd immunity i suficently high the ocefftence g If that immunity i maintained & stepped up to Hey ‘mall proportion, it may lead to elimi Rotarix Monovalent human strain Live attenuated Oral vaccine 2 doses- at 2 months, Mus then first dose given after 12 weeks AU Egided in catch-up campaigns where exact age is difficult to ascertain 9- Mycobacterium Indicus Pranii (MIP) vaccine Made in india leprosy vaccine Preventive measure to people lvingin el ‘To be given along with a dose of Refamp Developed by GP Talwar, founder & director of ‘ational institut Approved by drug controller general of India & the FDA in the: (Cases can be brought down by 60% in 3 years te of immunology Delhi Us. Arpit’s PSM made-easy 9893180410 drarpitverma1983@gmailcom Jalswal Photo Copy Mob. 8989499403 Page 44 aecaccaeansnaanan Akuma le4 Epidesiology, Di 10- Cold Chain Cad chain. + system of storage & transport of vaccine at low temperature from the manufacturer to the actus! vaccination site ‘Reverse cold chain is seen in stool specimen of polio send for testin ‘© G Rights of supply chain- - Right Vaccine in the Right Quantity at the Right Place at Right Time in the Right Condition & at the Right Cost ‘Vaxcine sensitive to light- 8CG, measles, MR. \Vaxcine sensitivity to heat & freezing ‘Vaccine are grouped into 6 categories-A, 8, C,D, E, F (most heat sensitive to~—Pleast heat sensitive) + Most heat sensitive are in group A & least heat sensitive (i.e. freeze sensitive) are in group F + Group A-OPV, BCG + Group B- influenza Group C-IPV, JE, MR Group D- Pentavalent , Rota, Group E- Td + Group F-Hep B Vaccine storage + 420 481s K/A cold chain temperature of vaccines’ + Most vaccines can be stored up to S weeks a + oPv (© Routine storage- +2 to +8 deg © Amonth of ot (© Minimum levElf vaccine storage (focal point) in cotd chain in india is PHC, below it vaccines are transported to subcentres & Anganwadi centres during vaccination session through vaccine carrlers & day cartiers + Sub-centre level (© Vaccine carrer & Day carrier © 48-72 hours (2-3 days) of storage © Maximum chance of cold chain foiture in I centre) + Session level (Anganwadl centre) © Fully frozen icepack © 1-3hours ofstorage is ot subcentre level: level ams eps PSM madecasy ‘9893 180410 sale dranpitverma1983@gmallcom Jaiswal Photo COPY page 45 Mob, 8989409408sion & Immunization, ‘Cay Chain Equipments (CCE) 2. Walkin freezer(wir) + -18to-25degc Bulk storage of OPV & for preparation of frozen ice packs 2. Walkin cold rooms (WiC) + 42t04Bdegc + Storage of large quantities of vaccines Government medical store depot, state, B. Deep freezers + -15t0-25 degree c + Icepacks 4. Ice Lined Refrigerator (ILR) ‘+ Most important component of cold chain in india + Temperature monitoring is done twice daily by dial + Capacity * District hospital ~ 300/240 litres + PHC 140 litres + Must be kept on a horizontal leveled suyface , § Can maintain temperature of vaccin + Vaccines * Kept at bottom/ Freezer compartment (te = OPV, BCG, Measles, JE & regional vaccine stores 6. rn Day carters, G8 vials + 2icepacks 9. Kee packs Prepared by keeping in deep freezer Mahia enpeie dee era ng ersoratonacne Capacity- 320 - 340 mt ‘ forconal mre ) & immunization session ‘Ampit’s PSM made-easy 9893180410 nals Jalswal Ph drarpitverma1983@gmailcom Wal Mf AGAAAAAAARAAA APP PPPPPPPPLDPLLLLLAA4 Dial thermometer Used to monitor temperature of cold choin ot PHC © Kept in tk Twice daily temperature recording is done © Based on principle of thermocouple Cold storage means 8-15°C Test to identify frozen vaccine- Shi Vaccine Vial Monitor (vvM) + Heat sensitive material placed on vaccine vial to register cumulative heat exposure over a period of time Marker of potency of vaccine & efficiency of cold chain maintenance WM status helps the user to decide which vaccine should be used first oe gi WM records its cumulative heat exposure through a gradudighange i s remain blue + Stages / Grades of WWM STAGE 1- Inner square lighter (w STAGE 2- Inner Square still lighter (light bf Gea Pontmndecsay SBsteoe10 - Jalswal Photo Copy rma963@gmailcom ; aoe ‘Mob. s9so409408 "2°47Yo Leltupperarm yar _Antero tera side of id thigh Oral Oral oni: Orel YM: Antero lateral side of mid thigh{Left) yp Rightupper arm : Oral Oval, | AIM nie teal side of id hig) Fepies PSM made-casy 9893180410 at te drarpitvermal983@gmailcom Jaiswal Photo Copy Mob. 8989409403 Page 4gpoe 2 Eputemion Tein Pregnancy + Primigravida. © 2 doses 1 month apa, as soon as possibte © Duration ot protection with 2 doses: al pre + Muttigraviea © Completely immunized in last 3 years- sRNancies In Next 3 years (so just a booster Hs required) 1 booster dose © Partially immunized in last 3 years- 2 doses, 1 month apart © Unimmunized in tast 3 years- 2 doses, 1 month apart © Completely immunized but more than 3 years ago- 2 doses, 1 month apa Fe for delayed immunization of Td in pregnancy © Give 2 doses of T41 month apart, anytime in roa irespee(fSBr ume of delivery (to provide protection for next 3 years) ition in NisHindiay » (1saal takk. vari BB] 0000... calle (2° & 2” year me......7.. DePartmenTs} 12. Age limits for delayed immuni Upto 24 hours- Hepatitis 8 birth dose Upto 15 days- BOPV 0 dose Upto 1 year- Rota, PY, PCY, Pentavalent, BCG Upto 5 year- bOPV1/2/3 , Vitamin A, MR Upto 7 year- DPT booster 1&2 : Upto 45 year-J Upto 36 year-TT Cases of delayed immunization © BCG (direct) © OPV-1+Pentavalent Pote-1+flpv-i+ Pcv-t MR-1+JE-1 +Vitah . Acompletely unimmunizedtchild of 4 years of age should receive © BCG (indirect i.e. after Mantoux test } © OPV-1+ DPT-1 © MR-1-44E-1+ Vitamin A (2 Lk IU) Fully immunized child- taken all vaccines till 1 year of age Completely immunized child- taken all vaccines till 2 year of age oe Vaccine Multiplication Factor - BCG-2 - Measles- 1.33 - Allother vaccines- 1.11 Tepe ed Smaieono ae Jalswal Photo Copy drarpitverma1983@gmailcom ~~ Mob. 8989409408 Page 49e ssamission 8 HAT Zale 1 Epademiology, Diseas 13- Adverse Events Following Immunization (AEFI) incident that takes place after immunization causes concern & is believed to be caused Py Patt pedi jnmurization (Cassification of AEFI Cc cto me reaction: Event caused by inherent properties of vaccine Fact rea error. Evert caused by an error in vaccine preparation, handling of administration ‘ 3 Coincidental- Events that happens after immunization but not caused by the vaccine © . Association is Just by chance c 4. Injection reaction- Event from anxiety or pain from injection itself rather than the vaccine f Ghanown «Event cause cannot be determined - Vaccine reactions | oe ges: iymphadenits ‘ 2 Hepatitis - anaphylaxis F Mensles- thrombocytopenia t [Ove voccine associated paralytic poliomyelitis 2 Tetanus: brachial neu c + Pertussis- hypotonic hypo responsive epi code Investigation of AEFI G Step1- Confirm Report- patients me fe ‘Step2- Investigate about the patient & about the. Cc + immunization history + Previous medical history c +Family history + Conditions under which vat Sshippe! sored C ‘Step3- Assess the service vaccine storage c + Diluent storage i Reconstitution HB c + immunizaticheey st othesis- I Stept ‘corrective action & recommend further action C [Basen of rt oN Z oN Y™ « J att eases, we . 1 simitae — RAT Ba See“ tome \ ng / tian ne [Paar « “iotiwed 2 Nort 4 emeton? ON. Siete < NO 4 r yek ves 7 « [Coincidental event Aon a piesoinl sient) c Immunization error ‘Simiter ~ = 7 gemeot es ae memunienterrane’ [No _inestin, 3, reaction wathyn No, Teumuntzation srr (‘Sasa tee 2 EEE So SRS | i 4 » ; ‘arpit’s PSM made-easy u Jalswal Photo Copy 180410 y 9893 Mob. 8989409403, 7 ararpitvermal903@gmaiLeom Page of