Epidemiology and Prevention

of Communicable diseases:
Trachoma; tetanus; leprosy
 TRACHOMA
• Trachoma is a chronic infectious disease of the conjunctiva and
cornea, caused by Chlamydia trachomatis.
• Trachoma inflammation may undergo spontaneous resolution or
may progress to conjunctival scarring
• From the public health point of view, trachoma is classified as
blinding and non-blinding
• blinding trachoma can be recognized by the presence of persons
with lesions
• Non-blinding trachoma often becomes blinding trachoma when
other ocular pathogens interact synergistically
Diagnosis
In epidemiological studies, more stress is now put on the upper tarsal
conjunctiva as a convenient index of trachomatous inflammation in
the eye as a whole. cases must have at least 2 of the following
diagnostic criteria:
a. follicles on the upper tarsal conjunctiva
b. limbal follicles or their sequelae, Herbert's pits
c. typical conjunctival scarring (trichiasis, entropion)
d. vascular pannus, most marked at the superior limbus
Problem statement
• Trachoma is a major preventable cause of blindness in developing
countries.
• In 41 endemic countries about 1. 9 million people suffer from visual
impairment due to trachoma
• 1.2 million are irreversibly blind, and about 190.2 million are at risk of
infection
• The incidence and prevalence of trachoma has shown a significant
decrease in many endemic countries of SEAR during the past few decades
• This decrease has been mainly due to improved sanitation, water and
housing, and implementation of control measures
• trachoma, particularly in its active form, still remains a public health
concern in some parts of the world.
Epidemiological determinants Agent factors
• AGENT : The classical endemic trachoma of developing countries is
caused by C. trachomatis of immune types A, B, or C. The sexually-
transmitted C. trachomatis may also infect, causing an eye disease
difficult to differentiate from endemic trachoma. C. trachomatis,
originally believed to be a virus, is an obligatory intracellular
bacteria, now classified as Chlamydia.
• RESERVOIR : Children with active disease, chronically infected -
older children and adults.
• SOURCE OF INFECTION : Ocular discharges of infected persons
and fomites
• COMMUNICABILITY: Trachoma is a disease of low infectivity.
Host factors
• AGE: In endemic areas, children may show signs of the disease at
the age of only a few months. But typically, children from the age
of two to five years are the most infected
• SEX : Prevalence equal in younger age groups. In older age groups,
females have been found to be affected more than males
• PRE-DISPOSING FACTORS : Direct sunlight, dust, smoke and
irritants such as kajal or surma may predispose to infection.
Environmental factors
• SEASON : Seasonal epidemics are associated with vastly increased
number of eye-seeking flies. In India during April-May and again
during July- September.
• QUALITY OF LIFE : Trachoma is associated with poor quality of life.
• CUSTOMS : The custom of applying kajal or surma to the eyes is a
positive risk factor.
 Mode of transmission
• In communities where trachoma is endemic,
eye-to-eye transmission can be considered
as a rule.
• This may occur by direct or indirect contact
with ocular discharges of infected persons
or fomites
• It has been shown that trachoma is a familial
disease. When one case is detected, others
will almost certainly be found in the family
group.
• Incubation period 5 to 12 days.
 CONTROL OF TRACHOMA
1. Assessment of the problem - The primary objective of a programme
for the control of trachoma is the prevention of blindness. Control
programmes should be focussed on communities with a substantial
prevalence of "blinding trachoma„
2. Chemotherapy - the main activity is chemotherapeutic intervention.
The objective of chemotherapy is to reduce severity, lower the
incidence and in the long run decrease the prevalence of trachoma.
Treatment may be given to the entire community (Mass treatment)
or applied only to persons with active trachoma (selective
treatment).
3. Surgical correction - It has an immediate impact on preventing
blindness.
 CONTROL OF TRACHOMA
4. Surveillance - Once control of blinding trachoma has been achieved,
provision must be made to maintain surveillance, which may be
necessary for several years after active inflammatory trachoma has
been controlled.
5. Health education - In the long run, most of the antibiotic treatment
must be carried out by the affected population itself. To do this, the
population needs to be educated. The final solution would be the
improvement of living conditions and quality of life of the people
6. Evaluation - Lastly evaluation. Trachoma control programme must be
evaluated at frequent intervals. The effect of intervention can be
judged by the changes in the age-specific rates of active trachoma and
in the prevention of trichiasis and entropion.
 TETANUS
An acute disease induced by the exotoxin of Clostridium tetani and
clinically characterized by muscular rigidity which persists throughout
illness punctuated by painful paroxysmal spasms of the voluntary
muscles, especially the masseters (trismus or "lock-jaw"). the facial
muscles (risus sardonicus), the muscles of the back and neck
(opisthotonos), and those of the lower limbs and abdomen. The
mortality tends to be very high, varying from 40 to 80 per cent.
Problem statement
Tetanus is now comparatively rare disease in the developed countries.
Neonatal tetanus (NT) is a killer disease, second only to measles among
the nine target diseases of the EPI. The spores of tetanus are very
resistant and remain in the environment in extremes of temperature for
long periods.
The disease is easily preventable through:
(l) clean delivery and umbilical cord care practices to ensure infection is
not contracted by mother or newborn during the delivery process;
(2) delivery of appropriate doses of TTCV to pregnant women through
antenatal care services and other routine contacts;
(3) vaccination campaigns
(4) strengthening surveillance to identify women at risk
Epidemiological determinants Agent factors
AGENT : tetani is a gram-positive, anaerobic, spore-bearing organism.
The spores are terminal and give the organism a drum-stick
appearance. The spores are highly resistant.
RESERVOIR OF INFECTION : The natural habitat of the organism is soil
and dust
EXOTOXIN : Tetanus bacilli produce a soluble exotoxin. It has an
astounding lethal toxicity, exceeded only by botulinum toxin
PERIOD OF COMMUNICABILITY : None. Not transmitted from person to
person.
Host factors
AGE : Commonly, tetanus is a disease of the active age (5 to 40 years).
Tetanus occurring in the new-born is known as "neonatal tetanus“
SEX: higher incidence is found in males, females are more exposed to
the risk of tetanus, especially during delivery or abortion leading to
"puerperal tetanus„
OCCUPATION : Agricultural workers are at special risk because of their
contact with soil.
RURAL-URBAN DIFFERENCES : The incidence of tetanus is much lower
in urban than in rural areas
IMMUNITY: No age is immune unless protected by previous
immunization.
 Environmental and social factors

Tetanus is a positive environmental hazard (9). Its occurrence depends

upon man's physical and ecological surroundings - the soil, agriculture,
animal husbandry - and not on the presence or absence of infection in
the population. The environmental factors are compounded by social
factors such as unhygienic customs and habits. In the developed
countries, urbanization, industrialization and mechanization of
agriculture have interfered with the normal process of distribution of
Cl. tetani and have reduced the morbidity rate.
Mode of transmission/Incubation period
• Infection is acquired by contamination of wounds with tetanus
spores. The range of injuries and accidents which may lead to
tetanus
• The incubation period is usually
6 to 10 days. However, it may
be as short as one day
or as long as several month
Types of tetanus
1. TRAUMATIC
2. PUERPERAL
3. OTOGENIC
4. IDIOPATHIC
5. TETANUS NEONATORUM
 PREVENTION - Active immunization
Tetanus is best prevented by active immunization with tetanus toxoid. It
stimulates the production of the protective antitoxin. The aim should
be to vaccinate the entire community and ensure a protective level of
antitoxin approximately 0.01 IU/ml serum throughout life. All persons
should be immunized regardless of age.
Two preparations are available for active immunization
a. Combined vaccine - DPT
b. Monovalent vaccines
i) Plain or fluid (formal) toxoid
ii) Tetanus vaccine. adsorbed (PTAP, APT)
 PREVENTION - Passive immunization

Temporary protection against tetanus can be provided by an injection

of human tetanus hyperimmunoglobulin (TIG) or ATS . (i ) HUMAN
TETANUS HYPERIMMUNOGLOBULIN : It is the best prophylactic to use .
The dose for all ages is 250 IU . It does not cause serum reactions. It
gives a longer passive protection up to 30 days or more compared with
7-10 days for horse ATS
 Prevention of neonatal tetanus
Neonatal tetanus is well controlled in some industrialized countries
through clean delivery practices alone. Over the last decade. most
programmes in developing countries have concentrated on training the
traditional birth attendants, providing home delivery kits and educating
pregnant women about the "five cleans“.
Tetanus toxoid will protect both the mother and her child. In
unimmunized pregnant women, two doses of tetanus toxoid should be
given, the first as early as possible during pregnancy and the second at
least a month later and at least 3 weeks before delivery. According to
the National Immunization Schedule, these doses may begiven
between 16-36 weeks of pregnancy, allowing an interval of 1-2 months
between the 2 doses
 leprosy
• Leprosy is a chronic infectious disease caused by a type of bacteria,
Mycobacterium leprae.
• It affects mainly the peripheral nerves.
• also affects the skin, muscles, eyes, bones, testes and internal organs.
• Leprosy has afflicted humanity, left behind a terrifying image in
history and human memory of mutilation, rejection and exclusion
from society.
• Lots of people have suffered its chronic course of incurable
disfigurement and physical disability.
Problem statement
• Leprosy is reported from all the six WHO Regions; the majority of
annual new case detections are from South-East Asia.
• Elimination of leprosy as a public health problem globally was
achieved in 2000 and in most countries by 2010.
• 2019, Brazil, India and Indonesia reported more than 10 000 new
cases, while 13 other countries each reported 1000–10 000 new
cases.
• Forty-five countries reported 0 cases and 99 reported fewer than
1000 new cases.
Epidemiological determinants - Agent factors
• AGENT : Leprosy is caused by M. leprae. They are acid-fast and occur
in the human host both intracellularly and extracellularly.
• SOURCE OF INFECTION : It is generally agreed that multibacillary cases
are the most important source of infection in the community.
• PORTAL OF EXIT : It is widely accepted that the nose is a major portal
of exit
• INFECTIVITY : Leprosy is a highly infectious disease but of low
pathogenicity
• ATTACK RATES : Among household contacts of lepromatous cases, a
varying proportion - 4 .4 per cent to 12 per cent - is expected to show
signs of leprosy within 5 years
Epidemiological determinants - Host factors
• AGE : all ages, from early infancy to very old age. Youngest age are
reported in South India was an infant 2 months old.
• SEX : Both the incidence and prevalence of leprosy appear to be higher in
males than in females in most regions of the world.
• MIGRATION : In India leprosy was considered to be mostly a rural problem.
• THE PREVALENCE POOL: The prevalence pool of leprosy in a population in
general is in a constant flux resulting from inflow and outflow
• IMMUNITY : It is a well-established fact that only a few persons exposed to
infection develop the disease.
• GENETIC FACTORS : There is now evidence that human lymphocyte antigen
(HLA) linked genes influence the type of immune response that develops
 Mode of transmission/Incubation Period
The disease is transmitted through droplets from the nose and
mouth. Prolonged, close contact over months with someone with
untreated leprosy is needed to catch the disease. The disease is not
spread through casual contact with a person who has leprosy like
shaking hands or hugging, sharing meals or sitting next to each other.
Moreover, the patient stops transmitting the disease when they begin
treatment.

Leprosy has a long incubation period, an average of 3 to 5 years or

more for lepromatous cases. The tuberculoid leprosy is thought to have
a shorter incubation period. Symptoms can take as long as 20 years to
appear.
 Classification
These classifications are based on clinical, bacteriological,
immunological and histological status of patients.
The Indian and Madrid classification systems are the most widely used
in field leprosy programmes;
Indian classification Madrid classification
indeterminate type indeterminate
tuberculoid type tuberculoid: flat; raised
borderline type borderline
lepromatous type lepromatous
pure neuritic type
Clinical classification for control programmes

In 1981, the WHO Study Group on Chemotherapy of Leprosy for Control

Programmes classified patients as having multibacillary or
paucibacillary leprosy according to the degree of skin-smear positivity.
On the basis of the information available , patients could be classified
into two groups:
(1) Paucibacillary leprosy (1-5 skin lesions); and
(2) Multibacillary leprosy (more than six skin lesions)
 Clinical feature
1.Skin:
• Variable lesions: Macules, papules, nodules.
• Single / multiple.
• Hypopigmented, sometimes reddish.
• Sensory loss typically (anaesthesia/hypothesia)
2.Nerves:
• Thickened.
• Loss of sensation.
• Muscle weakness.
 Diagnosis
1. CLINICAL EXAMINATION – based on signs and symptoms
2. BACTERIOLOGICAL EXAMINATION (Laboratory) – positive skin
smears/nasal smears/scrapings
3. Bacterial index
4. Morphological index
 LEPROMIN TEST
• Used to determine type of leprosy.
• Injection of a standardized extract of the inactivated bacilli
intradermally in the forearm.
• Positive reaction: 10 mm or more induration after 48 hrs/ or 5 mm or
more nodule after 21 days.
• Negative In lepromatous leprosy because of humoral immunity not
cell mediated.
 LEPROSY CONTROL
A revised strategy of leprosy control has emerged based on multidrug therapy.
The following elements are considered as a minimum requirement for all leprosy
control programmes:

1. Medical measures
2. Social support
3. Programme management
4. Evaluation

The three main goals of leprosy control are:

(a) to interrupt transmission of the infection, thereby reduce the incidence of the
disease so that it no longer constitutes a public health problem
(b) to treat patients in order to achieve their cure and where possible, complete
rehabilitation
 Medical measures
1. Estimation of the problem - define the size of the problem or
disease load in the community by means of epidemiological surveys.
Random sample surveys are good enough to collect baseline data.
2. Early case detection - identify and to register all cases of leprosy as
soon as possible after they become evident.
3. Multidrug therapy:
a. to interrupt transmission of the infection in the community by
sterilizing infectious patients as rapidly as possible with bactericidal
drugs
b. to ensure early detection and treatment of cases to prevent
deformities
c. to prevent drug resistance.
 Medical measures
4. Surveillance - Clinical surveillance of cases after completion of
treatment is an important part of the current recommendations for
multidrug therapy;
5.Immunoprophylaxis - The fact that a scientifically valid tool for
the detection of infection is not yet available which could deepen the
understanding of how leprosy is transmitted and could lead to the
development of an effective vaccine and other interventions. High
BCG coverage remains an important contribution to reducing the
disease burden due to leprosy
6. Chemoprophylaxis
7. Deformities
 Medical measures
8. Rehabilitation - Rehabilitation is, therefore, an integral part of
leprosy control. It must begin as soon as the disease is diagnosed. The
cheapest and surest rehabilitation is to prevent physical deformities
and social and vocational disruption by early diagnosis and adequate
treatment
9. Health education - No anti-leprosy campaign is complete without
health education. Health education aims at helping people develop
attitudes and behaviour by their own actions and efforts and seeking
professional help when needed. Health education should be directed
towards the patient and his family and the general public.
 LEPROSY CONTROL - SOCIAL SUPPORT
Chemotherapy alone is not likely to
solve the whole problem of leprosy.
The economic and social problems of
the patient and his family should be
identified and met. This may include
social assistance and social support
Such care should be provided
through voluntary agencies and
Departments of Social Welfare.
 LEPROSY CONTROL - PROGRAMME
MANAGEMENT
Leprosy control is a long-term activity.
Therefore planning and programme
management are essential ingredients.
It is generally assumed that with
existing tools, we can achieve rapid
control of leprosy, provided the
"operational performance" is stepped
up to the maximum level required
 LEPROSY CONTROL -EVALUATION

An important aspect of leprosy control is to assess the impact of the

control operations on the endemicity of the disease, arid to compare
results between different times and places. Indicators are required for
such an evaluation. It is important that these indicators can be easily
used and satisfy the criteria of repeatability and validity. Ideally they
should be conceived and treated as signals for action by programme
managers.
 TREATMENT
Leprosy is a curable disease. The currently recommended treatment
regimen consists of three drugs: dapsone, rifampicin and clofazimine.
The combination is referred to as multi-drug therapy (MDT). The
duration of treatment is six months for PB and 12 months for MB
cases. MDT kills the pathogen and cures the patient. Early diagnosis
and prompt treatment can help to prevent disabilities. WHO has
been providing MDT free of cost. Free MDT was initially funded by
The Nippon Foundation and since 2000 it is being donated through
an agreement with Novartis.
 WHO response
• WHO provides technical support to Member States on leprosy
prevention and control.
• Every year, WHO collates epidemiological data on leprosy from all its
Member States and publishes a consolidated report. These data are
provided by countries.
• WHO released the
Towards zero leprosy: global leprosy (Hansen’s disease) strategy 2021
–2030
aligned to the neglected tropical diseases road map 2021–2030. The
Strategy calls for a vision of zero leprosy: zero infection and disease,
zero disability, zero stigma and discrimination and the elimination of
leprosy (defined as interruption of transmission) as its goal.