DYNAMICS OF DISEASE TRANSMISSION

Communicable diseases are transmitted from

reservoir/source of infection to susceptible host
 DISEASE CONTROL
A. CONTROLLING THE RESERVOIR/ SOURCE
5

RESERVOIR:

It is the natural habitat in which the organism metabolizes and

replicates

It can be a person, animal, arthropod, soil or plant on which

organism depends primarily for survival

SOURCE: It is defined as person ,animal or object from which

an infectious agent passes or is disseminated to the host
 cases
 carriers
 B. INTERRUPTION6OF TRANSMISSION
 Breaking the chain of transmission or interruption of
transmission
Water-Borne Diseases:
Typhoid,
dysentery,
Hepatitis A, Cholera,
Gastroenteritis.
Water treatment
 Food-Borne diseases: Clean practices like hand washing, adequate
cooking, prompt refrigeration of prepared foods, withdrawal of
contaminated foods.
 7

 Vector-Borne Diseases: control of vector.

 Droplet Infections or droplet nuclei: difficult to
control. Early diagnosis and treatment, personal
hygiene, proper handling of secretions.
 To bring about an adjusted equilibrium between
host and environment
 C. THE SUSCEPTIBLE HOST
8

1. Active immunization
2. Passive immunization
3. Combined active and passive immunization
4. Chemoprophylaxis
5. Non-specific measures
HEALTH EDUCATION - BEHAVIOUR CHANGE
9

A major obstacle to disease control is Human

Behavior.
Medical technology is often ineffective in changing
behavior.
 Health Education remains the only approach to
enlist public co-operation and to induce relevant
changes in the behavior and life style of people.
powerful methods of disease control.
 IMMUNITY
10

DEFINITION
Body defense against exogenous (microbes) and endogenous
( tumor cells) agents.
TYPES OF IMMUNITY
1- Innate (natural, born, non-adaptive, or nonspecific) immunity.
2- Adaptive (active,acquired, or specific) immunity. Occurs after
exposure to antigen. It is mediated by either antibodies (Humoral
immunity) or lymphoid cells (Cellular immunity). It can be:
A- Passive (borrowed, short time)
B- Active (produced)
 HOST DEFENSES
11

Can be
 Local- as manifested by an organ or a tissue as a whole or in
part
 Systemic- as manifested by the body, provides enhanced long
lasting systemic immunity to secondary infection by pathogens
 Non-specific
 Specific
 Humoral
 Cellular
 SPECIFIC DEFENSES They come into play when local
defenses are breached by micro-organisms
12

ACTIVE IMMUNITY PASSIVE IMMUNITY

 Humoral immunity  Normal human Ig

 Cellular immunity  Specific human Ig

 Combination of the  Animal antitoxins or

above anti-sera
 ACTIVE IMMUNITY
16

Acquired in three
ways :-

Following clinical infection e.g chickenpox, rubella

and measles

Following subclinical or in-apparent infection e.g polio

and diptheria

Following immunization with an antigen which may be

a killed vaccine , a live attenuated vaccine or toxoid
 IMMUNE RESPONSE
 PRIMARY RESPONSE
17

 Human or animal first time exposure

 Latent period 3-10 days

 Antibodies appear

 First antibody to appear is IgM. The titre rises steadily during next 2-3 days

reaches peak and declines

 IgG antibody appears and reaches peak in 7 -10 days and then falls in a

period of weeks or months

 Secondary booster response
19
 Short latent period

 Production of antibody more rapid

 Antibody more abundant

 Antibody response maintained at higher levels for a longer

period of time
 Antibody has greater capacity to bind to the antigen

 IgG and IgM antibodies are produced

 Brief production of IgM and prolonged production of IgG

 Humoral immunity
20
 Comes from B cells( bone marrow derived lymphocytes)

 Proliferate and manufacture specific antibodies after antigen

presentation by macrophages
 The antibodies are localized in the immunoglobulin fraction of

serum
 Immunoglobulins are divided into 5 main classes IgM, IgG, IgA,

IgD, and IgE

 Each class representing a different functional group

 Antibodies are specific , they react with the same antigen which

provoked their production (specificity)

 Cellular immunity
 Mediated by T- cells 21

 Responsible for recognition of antigen

 On contact with antigen T-cells initiate a chain of

responses:-
 Activation of macrophages

 Release of cytotoxic factors

 Mononuclear inflammatory reactions

 Delayed hypersensitivity reactions

 Secretion of immunological mediators

 ( e.g.,rejection of skin grafts)
 Combination of the above
22

B and T lymphoid cells very often cooperate with one

another and with certain accessory cells
Macrophages
Human K (killer) cells
Subsets of T cells – helper T cells, suppressor T cells
may combine with
Natural killer cells ( NK)
Cell mediated (K) cytotoxic cells
 PASSIVE IMMUNITY
23
Antibodies produced in one body (human or animal) are transferred to

another in order to induce protection against disease

Body does not produce its own antibody but depends upon ready- made

antibodies

Passive immunity may be induced :-

 By administration of an antibody- containing preparation (Ig or

antiserum)

 By transfer of maternal antibodies across the placenta, human milk (IgA)

 BIOLOGICAL SHIELD
24

 Passive immunity transmitted to the baby from

mother across the placenta
 Infant remains immune for 3 to 6 months
 Presence of immunoglobulin IgM and IgG in cord
blood and plasma of infants born of immune
mothers
 Active versus passive
25

 Active immunity is superior than passive immunity

 Duration of protection is long lasting

 Severe reactions are rare

 Protective efficacy of active immunization exceeds that of

passive immunization sometimes approaches 100%

 Less expensive
 Herd immunity
26

It is the level of resistance of a community or group of

people to a particular disease (group protection) when
the majority of population develops immunity
It provides an immunological barrier to the spread/
transmission of disease in the human herd.

Elements which contribute:

Occurrence of clinical, and subclinical infection in herd
Immunization of herd
Herd structure
 Herd Immunity: Mechanism

.
 Immunization

Immunization is the process whereby a person is

made immune or resistant to an infectious disease,
typically by the administration of a vaccine
 Vaccination

Introduction of a killed or weakened form of the

actual antigen or toxin that causes the disease
into our bodies through an injection

This gives rise to a process of developing

immunity against that particular antigen or toxin
 Immunizing Agents
31

 Vaccines

 Immunoglobulins

 Anti-sera
 Immunization Agents
32

Vaccines- latin word from

VACCINUS---pertaining to cow, so named from –the
cowpox virus inocculation for immunization against smallpox

 immuno-biological substances designed to produce specific protection

against a given disease

 Stimulate the production of protective antibody

 Vaccines can be live, killed or inactivated , extracted cellular fraction or

toxoids or combination of these

 Live vaccines
33

 Prepared from live attenuated organism ( immunogenicity is

maintained, but not the capability to produce disease)

 Live attenuated vaccine Bacterial --BCG, typhoid (oral)

Viral- Oral polio, yellow fever, measles, rubella, mumps,

chicken pox, influenza Rickettsial -- Typhus

 Live vaccines
 34
Should not be administrated to persons with

Immune
 deficiency disease AIDS

suppressed
 immune response  because of leukemia, lymphoma or malignancy or

because of therapy with corticosteroids, alkylation agents, anti- metabolic agents or radiation

Pregnancy (until the risk of infection exceeds the risk of harm to the foetus )


Two
 live vaccines if have to be administered simultaneously, should be given at different sites or

at interval of 3 weeks

Immunity
 is achieved generally in single dose(except OPV)
 Inactivated or killed vaccine
35
 Organisms are killed by heat or chemicals

 Produce active immunity

 Requires 2 or 3 doses, to produce adequate antibody

response(booster dose required in most cases)

 Killed vaccines

 Bacterial- ( typhoid(inj), cholera, pertussis, meningitis,

plague)
 Viral- ( rabies, polio-salk, influenza, hepatitis B, A,

Japanese encephalitis )
 Comparison of Characteristics
Characteristics Killed vaccine
36 Live vaccine

Number of doses Multiple Single

Need for adjuvant Yes No

Duration of immunity Shorter Longer

Effectiveness of protection Lower Greater

Immunoglobulin produced IgG IgA and IgG

Mucosal immunity produced Poor Yes

Cell mediated immunity Poor Yes

produced
Stability at room temperature High Low
 Cellular fractions
37
 SUBUNIT VACCINES
- TOXOIDS
-PROTEIN VACCINES – pertussis, influenza
-RECOMBINANT PROTEIN VACCINES – hep B(polypeptide vaccine)

-POLYSACCHARIDE BASED VACCINES –hib, typhoid ( Meningococcal

vaccine from polysaccharide antigen of cell wall,Pneumococcal vaccine

from polysaccharide contained in the capsule of the organism)

-CONJUGATED VACCINES

 COMBINATIONS
 Toxoids
38

 Certain organisms produce exotoxins (diptheria and

tetanus bacilli, pertussis )

 Toxins are detoxicated and used in preparation of vaccine

 Antibodies produced neutralize the toxin moiety produced

during infection (does not act on organism)

 Combinations
39
 More than one kind of immunizing agent is included in vaccine

 AIM
 To simplify administration , Reduce costs, Minimize the number of
contacts of the patient with health system
(DPT, DT,DP, DPT and typhoid vaccine, MMR, hepatitis A and B)
 Polyvalent:- prepared from two or more strains of the same species
 Autogenous :- when the organism in the vaccine is obtained from the
same patient
 Adjuvant vaccine:- adjuvants are substances that are added to
vaccines with the intent of potentiating the immune response, so that
the greater amount of antibody is produced, lesser quantity of antigen
is required and fewer doses to be given ( aluminium phosphate,
aluminium hydroxide, water-in-oil)
 40

 Antibiotics- used during manufacturing phase to

prevent bacterial contamination of tissue culture
cells in which the viruses are grown
 Preservatives- thiomersal, formaldehyde
 Stabilizers- K or Na salts,lactose, gelatine

Plain vaccines
Freeze-dried preparations
 Types of Vaccines

.
 IMMUNOGLOBULINS
42

 Composed of 5 major classes(IgG, IgA IgM, IgD, and IgE)

and sub classes within them . They represent different

functional groups

 All antibodies are immunoglobulin but all immunoglobulins

are not antibodies

 Immunoglobulins
43
IgM

 Comprising 6 % of total serum immunoglobulins

 Promptly formed with exposure to antigen

 Its presence is indicative of recent infection

 Half life of 7 days

• IgG
 Comprising 80 % of total serum immunoglobulins

 Smaller molecular weight - diffuse into interstitial fluid

 Can be transported through placenta

 Antiviral, antibacterial and antitoxic activity

 Half life of 21 days

 44
IgA
 Comprising 13 % of total serum immunoglobulins
 Antiviral and antibacterial activity
 Found in large quantities in body secretions e;g saliva, milk,
colostrum, tears, bronchial secretions, nasal mucosa, prostatic
fluid, vaginal secretions and mucus secretions of the small
intestine
 Provides primary defense mechanism at mucosal membrane
against local infection
 Half life of 6 -8 days
• IgD
 Present in trace amount < o.oo3 mg/ ml
 Main function not known, act as an antigen receptor when present
on surface of certain B lymphocytes, half life is 2 days
 45

IgE
 Serum level is < o.ooo5 mg/ ml
 Half life 2 days
 Concentrated in sub-mucous tissue
 Antibody responsible for immediate
allergic anaphylactic reactions
May appear in external secretions
Inc in helminth infestation
 IMUNOGLOBULIN PREPARATIONS
46

 NORMAL HUMAN IMMUNOGLOBULINS

 SPECIFIC (HYPER IMMUNE) HUMAN

IMMUNOGLOBULINS
 NORMAL HUMAN IMMUNOGLOBULINS
 Antibody rich fraction, obtained from pool of at least 1000
47
donors
 Live vaccine should not be given for 12 weeks after normal
immunoglobulin
 WHO –STANDARDS
 Preparation should contain at least 90 % intact IgG
 Free as possible from IgG aggregates
 All IgG sub-classes should be present
 low IgA conc.

Examples:-
 Used to prevent measles in highly susceptible individuals
 Provide temporary protection( upto 12 weeks) against
hepatitis A for travellers to endemic areas and to control
institutional & household outbreaks of hepatitis infection
 SPECIFIC (HYPER IMMUNE) HUMAN
IMMUNOGLOBULINS
 Contains 5 times the antibody
48 potential of the standard
preparation per unit volume
 Made from plasma of patients who have recently recovered

from infection or obtained from individual immunized

against specific infection ( high antibody content)
 Example:-

 Used against chickenpox prophylaxis of highly susceptible

individuals
 Post exposure prophylaxis of hepatitis B and rabies

 Tetanus prophylaxis in the wounded

 ANTI SERA OR ANTITOXINS
49

Materials prepared in animals (horses)

Are used against tetanus, diphtheria, botulism, gas

gangrene and snake bite

 Contraindications

Live attenuated vaccines:

Immuno deficient
Immunocompromised:
Leukemias, lymphomas
Drugs: Corticosteroids
Radiotherapy
Pregnancy
Previous allergic reaction
 Cold Chain

.
 Cold Chain

.
53
 COLD CHAIN
 It is a system of storage and transport of vaccines at low
temperature from the manufacture
54 to the actual vaccination
site
 ELECTRICAL COLD CHAIN EQUIPMENT :-
 Walk in freezer (WIF):- is a pre-fabricated modular
polyurethane foam (PUF) insulated panel assembled cold
room with two identical refrigeration units and a standby
generator set to provide uninterruprted power supply. The
generator set starts automatically as soon as the power cuts
off.
 It maintains a temperature between - 15°C to - 25°C.
 WIF are usually installed at national, state and regional
vaccine stores.
 It is used for bulk storage of OPV and for preparation of
frozen ice packs for vaccine transportation.
 55

 Walk in cold rooms (WIC):- Walk-in-coolers

(WIC) is a pre-fabricated modular polyurethane
(PUF) insulated panel assembled cold room.
 They maintain a temperature of +2°C to +8°C.
BCG, hepatitis B, DPT, pentavalent, IPV, and
TT. WIC and WIF come with continuous
temperature recorder and alarm system. Once the
temperature of WIC/ WIF exceeds the recommended
storage temperature the alarm system gives alarm
loudly.
 56

 Deep freezer and Ice Lined Refrigerator(ILR) :-

supplied to all districts and the WIC location to
store vaccines. Deep freezers are used for making
ice packs and to store OPV and measles vaccines,
temp maintained at -15 to-25 C for DF, 2-8 C for ILR
 Small deep freezers and ILR:- provided to PHCs,
urban family planning center, postpartum
center.deep freezers are used to prepare frozen ice
packs which are used in cold boxes, vaccine
carriers, for transportation of vaccine
 57

 Domestic refrigerator (front load):-Domestic

refrigerators can also maintain the cabinet
temperature between +2°C to +8°C, but the hold-
over time and capacity to store vaccines/freeze
icepacks is limited. They can be used for storage of
vaccine at private clinics and nursing homes,
provided continuous power supply is ensured.
 58

Vaccine refrigerator/freezer : It is a refrigerator

cum freezer having basket for storing of vaccine and
freezing of ice-packs. It has two separate
compartments :
 1. Vaccine storage compartment maintains
temperature range of + 2°C to + 8°C.
2. Freezer compartment is for storing frozen ice-
pack maintaining temperature upto -7°C.

OPEN VIAL POLICY

 COLD CHAIN
59
 Cold boxes:-Peripheral centers, mainly for
transportation of the vaccine
 Vaccine carrier:- small quantities of vaccine (16-
20 vials) for out reach sessions
 Day carries:- small quantities of vaccine (6-8
vials) to a nearby sessions
 Ice pack:-
 60

Vaccine Vial Monitor (VVM) : A label

containing a heat-sensitive material which is
placed on a vaccine vial to register
cumulative heat exposure over time, inner
square should be lighter than the outer circle.
Thermochromic label- heat sensitive square
within a circle.
It gives a visual indication of whether the
vaccine has been kept at a temperature which
preserves its potency.
61
 62

Freezer compartment: P-polio, M-

measles

Cold part:
T series, DPT, DT, TT,
B ( Hep B, BCG, diluents, Hib )
63
The expanded Programme on Immunization (EPI)
64

Is a disease prevention activity aiming at reducing

illness, disability and mortality from childhood

diseases preventable by immunization

 The expanded Programme on Immunization (EPI)
65

These diseases are referred as 12 EPI target diseases and cause millions of
ailments, disabilities & deaths each year
Poliomyelitis
Neonatal Tetanus
Measles
Diphtheria
Pertussis (Whooping Cough)
Hepatitis-B
Hib Pneumonia
Meningitis
Childhood Tuberculosis
Diarrhoea
Typhoid
Rubella
 The expanded Programme on Immunization (EPI)
66

WHO initiated this program in 1974

1984 WHO established a standardized vaccination

schedule

EPI was launched in Pakistan 1978

 Components of EPI

67

 Routine Immunization

 Children 0-23 months

 Pregnant ladies by TT
 Supplemental Immunization Activities

 Routine immunization does not ensure 100% coverage of the mobile

population i.e. nomads, hard to reach areas / missed areas. So SIAs are
scheduled to ensure coverage of this population / areas.
 NIDs / SNIDs: children < 5 years receive polio drops (3-days campaign)
(national/ subnational)
IMMUNIZATION SCHEDULE
68
 AGE Vaccine Disease Dose Route Site

At Birth
IMMUNIZATION SCHEDULE
•BCG
•OPV (Zero dose )
Childhood
tuberculosis and
0.01 ml
2 Drops
I/D
Oral
Orally
deltoid
•Hep B Polio
6 Weeks OPV -1 Polio, Diptheria, 692 Drops Oral Orally
Pentavalent -1 pertusis, tetanus, 0.5ml I/M Antero-lat
PCV10 -1 Hepatitis B 0.5ml I/M
ROTA 1 meningitis&
aspect of right
pneumonia thigh
Antero-lat
aspect of left
thigh
10 Weeks OPV -2 Polio, Diptheria, 2 Drops Oral Orally
Pentavalent -2 pertusis, tetanus, 0.5ml I/M Antero-lat aspect of
PCV10 -2 Hepatitis B 0.5ml I/M right thigh
ROTA 2 meningitis& Antero-lat aspect of
pneumonia left thigh

14 Weeks OPV -3 Polio, Diptheria, 2 Drops Oral Orally

Pentavalent -3 pertusis, tetanus, 0.5ml I/M Antero-lat aspect of
PCV10 -3 Hepatitis B 0.5 ml I/M right thigh
IPV 1 meningitis& Antero-lat aspect of
pneumonia left thigh

9 Months Measels Rubella-1 Measles 0.5 ml Subcutaneous Lt.Deltoid

IPV 2 Polio
TYPHOID (TCV) Typhoid 0.5 ml I/M

15 Months Measles 0.5 ml Subcutaneous

MR 2
 Pregnant
70
Women

 IN UNIMMUNIZED – 2 doses of TT between

16-36 weeks of pregnancy with an interval of 4-6 weeks

 IF PREVIOUSLY IMMUNIZED( within 2Years) – A Booster Dose is

sufficient
IMMUNIZATION SHEDULE FOR CHILD-BEARING AGE
WOMEN(15-49 yrs)
71

Dose of tetanus When to give Expected duration of

protection

TT1 At first contact or as early as None

possible in pregnancy

TT2 At least 4 weeks TT1 1-3 years

TT3 At least 6 months after TT2 5years

TT4 At least 1 year after TT3 10 years

TT5 At least 1 year after TT4 For all childbearing age

years and possibly longer
 World Immunization Week by WHO
Celebrated in the last week of April (24 to 30
April)

Campaign focuses on how vaccines

and the people who develop, deliver
and receive them –
are heroes by working to protect the
health of everyone, everywhere
 HELP TO MAKE EPI WORK
73

 CONTRAINDICATIONS
 No contraindication EXCEPT
 child is very ill and requires admission in hospital
 Child has previous experience of hypersensitivity reaction
 Known case of AIDS

 MONITORING AND EVALUATION

 Keeping records of children being immunized
 Records are available at each health facility (daily registers/permanent
registers)
 Analysis of data from these records helps in monitoring the
implementation of program and to evaluate the achievements