Essentia s of

lclne
 Contents

Essentials of Community Medicine

A Practical Approach
 Essentials of Community Medicine
A Practical Approach

SECOND EDITION

Lalita D Hiremath MD
Professor
Department of Community
Medicine S Nijalingappa Medical
College Bagalkot, Karnataka, India

Dhananjaya A Hiremath MD
Professor
Department of Anesthesia
S Nijalingappa Medical College
Bagalkot, Karnataka, India

Foreword
SJ Nagalotimath

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Essentials of Community Medicine—A Practical Approach

First Edition: 2004

Reprint: 2006
Second Edition: 2012

ISBN: 978-93-5025-044-0

Printed at
 Foreword

There was a time when medical students used to consider

community medicine as a less important subject. The result sheet
used to show passing percentage over 95 percent. But the subject
has gained importance steadily. Today it is one of the important
subjects. Not only the theory but the practicals are also
important.
Students need a manual to complete the practicals. However, a
useful practical manual was not available. This lacunae is being
fulfilled herewith by Dr Dhananjaya A Hiremath and Dr Smt
Lalita D Hiremath. This is a gift from the authors to all the
students. They have covered in this book all topics required by
the medical students. The explanation and descriptions are so
detailed that even the postgraduates can refer.
The book is quite useful to dental, nursing and paramedical
students and public health consultants.
I wish all the best to the authors and they should produce such
useful books for the students in future.

SJ Nagalotimath MD
Medical Director
S Nijalingappa Medical
College Bagalkot, Karnataka,
India
 Preface to the Second Edition

The community medicine subject undergoes frequent changes

according to the needs of the community and to match its
dynamic growth, the updating of the subject is essential. It gives
us a great pleasure to present this revised second edition.
Considering mainly the interests of the postgraduate students, the
following topics are updated, viz. Economics, Reproductive and
Child Health, Contraceptive Methods, Immunization, Nutrition, and
Hospital Waste Management.
Newer topics, viz. Integrated Disease Surveillance Project,
Integrated Management of Neonatal and Childhood Illness,
National Rural Health Mission, Community-based Rehabilitation,
Indian Systems of Medicine, Hospital Statistics, and Social
Security, are added.

Lalita D Hiremath
Dhananjaya A Hiremath
 Preface to the First Edition

We are living in a world different from that of previous

generation. The “information superhighway” is a reality and has
become a tool for instant sharing of vast amounts of information.
This book is written to serve both the undergraduates and
postgraduates to face the practical and viva voce confidently and
derive the maximum benefit from their honest endeavor.
It is generally observed that students face acute difficulties in
accurately answering questions raised in viva voce. The practical
portion has been written in a systemic and lucid manner so as to
enable the students to grasp the subject easily and quickly answer
any question to the complete satisfaction of the honorable
examiners.
The book also serves the needs of the dental, nursing and
paramedical students. It is a good tool for the personnel working
in the department of health and family welfare services and
public health administrators and consultants.

Dhananjaya A Hiremath
Lalita D Hiremath
 Acknowledgments

We express our deep sense of gratitude to Dr Ashok S Mallapur,

Principal, S Nijalingappa Medical College and HSK Hospital and
Research Centre, Bagalkot, Karnataka, India, for his incessant
inspiration and encouragement. We convey our sincere thanks to
Dr TM Chandrashekhar, Dean, HSK Hospital, Bagalkot, Karnataka,
India.
We are thankful to Shri Veeranna Charantimath, the Chairman
of BVV Sangh, who is the visionary and founder of many
educational institutions. We are also thankful to Shri Siddanna
Shettar, Chairman, Governing Council of S Nijalingappa Medical
College and HSK Hospital and Research Centre, Bagalkot,
Karnataka, India, who is an eminent educationist and able
administrator.
We convey our sincere thanks to Dr CH Ghattargi, Professor
and Head, and all members of the Department of Community
Medicine, S Nijalingappa Medical College, Bagalkot, Karnataka,
India. We are grateful to all the students and teaching faculty, who
have encouraged us to bring the revised second edition. We also
express sincere thanks to Smt Kalpana Kulkarni, who contributed
chapters on Biostatistics. The critical appraisal of the book by
readers is always welcome. We are thankful to M/s Jaypee
Brothers Medical Publishers (P) Ltd, New Delhi, India.
 Contents

1. Present Health Status 1-6

• Disease Burden 1
• Reasons for High Disease Burden 1
• Communicable Diseases 2
• Chronic Noncommunicable Diseases and Conditions 2
 Nutritional Deficiencies 2
• Maternal and Child Health 3
 Burden of Occupational Diseases and Injuries 3
 Clinical Diagnosis and Community Diagnosis 5
• Notifiable Diseases 5
2. Family 7-9
• Family 7
 Definition 7
 Types of Family 7
 Special Objectives 8
 Method of Study 8
 Family—A Dynamic Unit 8
• General Information for Students 9
3. Economics 10-15
• Poverty Line 10
• Per Capita Income 10
• Overcrowding 10
 Accepted Standards 11
 Sex Separation 11
 Housing 11
 Social Classification 11
4. Communicable Diseases 16-75
• Communicable Disease 16
 Definition 16
• Tuberculosis 18
 Sites Affected 18
 Economic Burden of Tuberculosis 18
 Epidemiological Indices 19
 Communicability 19
 Case Finding 20
 Chemoprophylaxis 21
 Treatment 21
 Important Definitions 23
xiv Essentials of Community Medicine—A Practical Approach
• Pediatric Tuberculosis 25
 Pediatrics DOTS 25
 Directly Observed Therapy Short-course (DOTS) 27
 Structure of the RNTCP 28
 Reasons for Dropout of the Treatment 29
 National TB Control Program 29
 Objectives of NTCP (1962) 30
 Disinfection of Sputum 30
 DOTS-Plus Strategy 30
 Green Light Committee Initiative 32
 HIV Infection and Risk of Tuberculosis 32
• Leprosy 33
 History 33
 Burden of Leprosy 33
 Essential Indicators for Leprosy 34
 Epidemiology 35
 Lepromatous Leprosy 37
 Diagnosis 38
 Bacteriological Examination 40
 Treatment of Reversal Reaction 44
 Treatment of ENL Reaction 46
 Completion of Treatment and Cure 46
• Leprosy Control 47
 Leprosy Control Programs 47
 Health Education 48
 Rehabilitation 49
 Leprosy Organizations in India 49
 National Leprosy Eradication Program (NLEP) 50
 Modified Leprosy Elimination Campaigns 50
 Special Action Projects for the Elimination of Leprosy 51
 Global Leprosy Elimination Program 51
• Filariasis 52
 Burden of Disease 52
 Epidemiology 52
 Clinical Manifestations 53
 Control Measures 53
 National Filaria Control Program 54
• Diarrhea and Dysentery 54
 Definition 54
 Dysentery 55
 Problem of Diarrheal Disease 55
• Cholera 56
 Epidemiology 56
 Disinfection 62
 Diarrheal Diseases Control Program 63
 Cont xv
• Scabies 66
 Epidemiology 66
 Clinical Features 67
 Complications 67
 Variants 68
 Control of Scabies 68
• Sexually Transmitted Diseases 68
 What are Sexually Transmitted Diseases? 68
 Why is STD Control an Important Component of
HIV/AIDS Prevention? 68
 What are the Symptoms of STDs? 69
 How can One Protect Oneself from STDs? 69
 How can Reinfection of STDs be prevented? 69
 What are the Approaches to STD Management? 70
 What is the Syndrome Approach? 70
 The Steps Involved in Adopting a Syndromic Approach 71
 Syndromic Case Management necessitates Clinical
Examination of the Patient 71
 Syndromic Case Management 72
 Advantages of the Syndromic Case Management 72
 Treatment for the Most Common STD Associated Syndromes 73
 National STD Control Program 74

5. Noncommunicable Diseases 76-100

• Coronary Heart Disease 76
 Definition 76
 Measurement the Burden of Disease 77
 Epidemiology 77
 Risk Factors for CHD 77
 Medical Treatment 78
 Prevention and Control 79
 Population Strategy 79
• Hypertension 80
 Prevalence 80
 Risk Stratification 80
 Pharmacologic Treatment Initiation 81
• Obesity 82
 Prevalence 82
 Assessment of Obesity 83
 Clinical Features of Obesity 85
 Complications 85
 Treatment 85
 Prevention and Control 86
• Rheumatic Heart Disease 86
 Prevalence 87
 Clinical Features 87
 xvi Essentials of Community Medicine—A Practical Approach
 Diagnosis 87
 Prevention and Control 88
• Mental Health 88
 Prevalence 88
 Classification 89
 Etiology 89
 Organic Conditions 89
 Social Pathological Causes 90
 Environmental Factors 90
 Warning Signals of Poor Mental Health 90
 Prevention and Control 90
 National Mental Health Program 91
 Aims 91
 Objectives 91
 Strategies 91
• Diabetes Mellitus 92
 Latent Diabetic 92
 Black Zone 92
 Clinical Classification of Diabetes Mellitus as Adopted by WHO
92
 Epidemiology 93
 Environmental Factors 93
 Social Factors 93
 Clinical Features 93
 Complications 93
 Investigations 94
 Prevention and Care 94
 National Diabetes Control Program 95
 Objectives 95
• Cancer 96
 Prevalence 96
• Causes of Cancer 98
 Environment 98
 Genetic 98
 Primary Prevention 98
 Health Education Regarding “Danger Signals” 99
 Secondary Prevention 99
 Treatment for Cancer 99
• National Cancer Control Program (NCCP) 99
 Basic Steps 99
 Goals of NCCP 99
 District Cancer Control Program 99
 Carcinoma of Breast 99
 Carcinoma of Lung 100
6. Maternity and Child Health 101-133
 In Developing Countries 101
 Causes of Maternal Death 101
 Cont xvi
 Conceptual Framework of Safe Motherhood 102
 Risk Approach 102
• Reproductive and Child Health Program 103
 Definition of RCH 103
• Major Elements of RCH Program 104
 Reproductive Health Elements 104
 Child Survival Elements 104
 State Committee on Voluntary Action 105
 Contents of Kits Supplied to Subcenter and First
Referral Unit (FRU) 105
 Under RCH Program 106
 Methods to Estimate Requirements for MCH Services 107
• Antenatal Care 107
 Objectives of Antenatal Visit 107
 Specific Protection 108
• Maternal and Child Health 108
 RCH-II and Family Planning 108
 Program Implementation Plan (PIP) 109
 Janani Suraksha Yojana 109
 Mamta Scheme—An Example of Public Private
Partnership in Health Care 111
 Health Care Services for the Beneficiaries under the Scheme
112
 Eligibility Criteria for Beneficiaries under the Scheme 112
 Registration of Beneficiaries under the Scheme 112
 Prevention of Patient to Child Transmission (PPTCT) 112
 Role of Maternal and Child Health Services in the
Prevention of HIV Infection in Infants and Young
Children Program. 113
 Integration of PPTCT within Postnatal MCH Services 114
 Key Points 114
 Infant Feeding Formula 115
• Intranatal Care 116
 Care at Birth 116
• Postnatal Care 116
 Objectives of Postnatal Care 116
 Warm Chain 117
 High-Risk Infants 117
• Malnutrition 117
 Definition 117
 Classification 117
 Nutritional Problems 118
 Epidemiology 118
• Protein-Energy Malnutrition 119
 Definition 119
 Types of PEM 119
 Clinical Features 119
 Clinical Features 120
 Signs 120
 xviii Essentials of Community Medicine—A Practical Approach

 Classification of PEM 120

 Epidemiology of Malnutrition 122
 Examination of the Case 124
 Weighing Procedure 124
 Height or Length 126
 Midarm Circumference 128
 Head and Chest Circumference 129
 General Procedures for Treatment of Severe PEM 129
 Calculation of Expected Weight of the Child 131
 Calculation of Expected Height of the Child 132
 Surface Area According to Weight 132
 Calculation of Pediatrics Doses 132
• Breastfeeding 132
 A to Z Benefits for Baby 132
 Advantages to Mother 132

7. Reproductive and Child Health 134-154

 Qualities of Good Contraceptives 134
 Methods of Family Planning 136
 Emerging Oral Contraception 142
 Give Specific Instructions 143
 Important 144
 Give Advice on Common Problems 144
 Explain Specific Reasons to Return to the Health Care Provider
144
 Introduction to Injectable Contraceptives 145
 Mechanism of Action 145
 Advantages and Disadvantages of Injectable Contraceptives
145
• Subcutaneous DMPA and Home Injection 147
 Centchroman 147
 Family Planning Insurance Scheme 148
 Medical Methods of Abortion 149
 Mifepristone and Misoprostol 149
 Future Fertility 150
• Manual Vacuum Aspiration (MVA)
150
 Methods of Uterine Evacuation 150
• Calculation of the Effective Couple Protection Rate (ECPR) 152
 Effective Protection 152
 Pearl Index 153
 Important Facts about Contraceptives 153

8. Immunization 155-187
• National Immunization Schedule 155
 Immunization of Pregnant Woman 155
 Determine Needs and Requirement 156
 Difference between EPI and UIP 157
 National Immunization Schedule 157
 Estimation of Requirements of Syringes and Needles 158
 Cont x
 Estimation of Requirements of Sterilization Equipment 159
 Estimation of Vaccine Needs 159
 Estimation of Cold Chain Requirements 160
 Determine Training Needs 161
 Estimation of Requirements of Immunization Cards 162
 Estimation of Vaccine Requirements 162
 Maintain Vaccines 164
 Maintain Equipment 165
 Vaccine 166
 Oral Polio 168
 National Immunization Schedule 168
 Development of Immunity 168
 Strategies for Polio Eradication 170
 Current Four Basic Strategies to Eradicate Polio 170
 National Immunization Days 171
 Intensive Pulse Polio Immunization (IPPI) 175
 Vaccine Vial Monitoring 176
 Measles Vaccine 176
 Adverse Effects of Vaccine 177
 Combined Vaccine 178
 Urban Measles Campaign 178
 Diphtheria Immunization 178
 Composition of DPT Vaccines 179
 Tetanus Toxoid 180
 Active and Passive Immunization 182
 Elimination of Neonatal Tetanus 182
 Anti-Rabies Vaccine 182
 Anti-Snake Venom 184
 Newer Vaccines 185
9. Nutrition 188-214
 Dietetics 188
 Balanced Diet 188
 Assessment of Nutritional Status 190
 Assessment of the Energy Requirement for Family 191
 Cereals and Millets 191
 Pulses (Legumes) 192
 Fruits 194
 Nuts and Oil Seeds 195
 Nutrient Requirements during Pregnancy 196
 Rich Sources of Essential Nutrients 199
 Protein Requirements 200
 Principles in Calculating Balanced Diet 200
• Balanced Diets 200
 Balanced Diet for Children 201
 Average Weight of Vegetables 204
xx Essentials of Community Medicine—A Practical Approach
 Approximate Weight of Foods Equal to 1 Level Katori
(Bowl) of 150 ml Volume 205
 Average Weight of Nuts and Spices 205
10. Medical Entomology and Worm Infestations 215-227
• Arthropods 215
 Arthropods of Medical Importance 215
 Mosquito 217
 Mosquito-borne Diseases 217
 Mosquito Control Measures 220
 Ticks 220
 Houseflies 221
• Public Health Importance of Worm Infestation 224
 Ascariasis 224
 Enterobius vermicularis 225
 Trichuris trichiura 225

11. Disinfection 228-233

• Definitions (Disinfectant or Germicide) 228
 Disinfectant 228
 Antiseptic 228
 Deodorant 228
 Detergent 228
 Sterilization 228
 Disinfection 228
 Types of Disinfection 229
 Disinfecting Agents 229
 Natural Agents 230
 Physical Agents 230
 Chemical Disinfectants 231

12. Insecticides and Rodenticides 234-237

• Insecticides and Pesticides 234
 Classification 235
 DDT (Dichloro-diphenyl-trichloroethane) 235
 HCH (BHC) Hexachlorocyclohexane 236
 Malathion 236
 Mineral Oil 236
 Paris Green (Copper aceto-arsenite) 237

13. Environmental Models 238-245

• Chloroscope/Chlorinometer 238
 Procedure 238
• Dry and Wet Bulb Thermometer (Hygrometer) 238
 Procedure 239
• Maximum and Minimum Thermometer 239
 Procedure 239
• Kata Thermometer 240
 Cont x
 Used for Measuring 240
 Procedure 240
• Globe Thermometer 240
 Procedure 240
 Sling Psychrometer 241
 Procedure 241
 Gully Trap 242
• Soak Pit 242
• Slow Sand Filter 244
 Rapid Sand Filter 245

14. Water Analysis 246-252

• Determination of Total Hardness 246
 Theory 246
 Procedure 246
• Bacteriology of Water 247
 Bacteriological Examination of Water 247
• Steps in Well Disinfection 250
 Find the Volume of Water in a Well 250
 Find the Amount of Bleaching Powder
Required for Disinfection 250
 Procedure 251
 Dissolve Bleaching Powder in Water 251
 Delivery of Chlorine Solution into the Well 251
 Contact Period 251
 Orthotolidine Arsenite Test 252

15. Bacteriology of Milk 253-254

• Bacteria in Milk 253
 Types of Bacteria in Milk 253
 Bacteriological Examination 253

16. Staining, Culture Media and Microscopy of Slides

255-263
of Public Health Importance
• Gram Stain 255
 Aim 255
 Requirement 255
 Procedure 255
 Result 255
• Ziehl-Neelsen Stain 256
 Aim 256
 Procedure 256
 Result 256
• Albert Stain 256
 Aim 256
 Requirement 256
 Procedure 257
 Result 257
 xxii Essentials of Community Medicine—A Practical Approach
• Culture Media 257
 Types of Media 257
• Microscopic Slides
258
 Mycobacterium tuberculosis 259
 Mycobacterium leprae 259
 Treponema pallidum 259
 Neisseria meningitidis 260
 Corynebacterium diphtheriae 261
 Neisseria gonorrhoeae 261
 Clostridium tetani 261
 Leptospira 262
17. Hospital Waste Management 264-279
 Type of Hospital Waste 265
 Hazards and Risks from Hospital Waste Exposure 266
• Hospital Waste Disposal 266
 Categories of Biomedical Waste 267
 Objectives of Plan 268
• Planning and Organization 268
 Organization 269
 Staff Appraisal on Hospital Waste Management 269
 Waste Disposal Strategy 270
• Incinerators 272
 Site for Incinerator 272
 Standards for Incinerators 272
 Inertization 276
 Legislative Framework 276
 Summary of Biomedical Waste Rules 276
 What You should Know and Do 277
18. National Rural Health Mission (2005-2012) 280-296
• Goals 281
• Strategies 281
 Core Strategies 281
 Supplementary Strategies 282
• Plan of Action 282
 Component (A): Accredited Social Health Activists 282
 Component (B): Strengthening Sub-Centers 283
 Component (C): Strengthening Primary Health Centers 283
 Component (D): Strengthening CHCs for First Referral Care
284
 Component (E): District Health Plan 284
 Component (F): Converging Sanitation and Hygiene
under NRHM 284
 Component (G): Strengthening Disease Control Programs 285
 Component (H): Public-Private Partnership for Public
Health Goals, including Regulation of Private Sector
285
 Component (I): New Health Financing Mechanisms 285
 Component (J): Reorienting Health/Medical
Education to support Rural Health Issues 286
 Cont x
• Institutional Mechanisms 286
• Technical Support 287
 Program Management Support Center 287
 Health Trust of India 287
• Role of State Governments Under NRHM 288
• Focus on the North-Eastern States 288
• Role of Panchayati Raj Institutions 288
• Role of NGOs in the Mission 289
• Mainstreaming Ayush 289
• Funding Arrangements 289
• Timelines (for Major Components) 290
• Outcomes 290
• National Level 290
 Community Level 291
• Monitoring and Evaluation 291
 Is NRHM a New Program of the Government of India? 292
 What is the Institutional Setup at National, State and
District Levels? 292
• National Urban Health Mission 292
 Goal 293
 Core Strategies 293
 Components of Urban Health Mission (UHM) 293
 Targets 294
 Urban Health Delivery Model 294
 At Community Level (Urban Social Health Activist, USHA) 294
 Essential Service to be Rendered by the USHA 294
 Primary Urban Health Center 295
19. Sanitation of Camps 297-301
• Camp Site 297
• Accommodation and Equipment 298
 Water 298
• Food and Cooking Arrangements 298
• Disposal of Refuse and Excreta 299
 Dry Camp and Kitchen Refuse 299
 Liquid Waste 299
 Disposal of Feces 300
• Disposal of Stable Litter 301
20. Indian Systems of Medicine 302-307
• Ayurveda System of Medicine 302
• Siddha System of Medicine 303
 Introduction and Origin 303
 Basic Concepts 303
 Diagnosis and Treatment 303
• Unani System of Medicine 304
 Origin and Development 304
 Fundamental Principles 304
• Diagnosis and Treatment 304
• Homeopathy 305
xxiv Essentials of Community Medicine—A Practical Approach
• Yoga 306
• Naturopathy 307
• Allopathy 307
 Methods 307

21. Adolescent Health 308-315

 Population Profile: Ages 10 to 24 Years in India 308
 Characteristics 308
• Physical Changes during Adolescent 309
• Puberty Changes in Adolescent 310
 Puberty in Girls 310
 Psychological and Behavioral Changes 310
 Impact of Adolescence 310
 Adolescent Health Problems 311
• Emotional Problems 311
• Educational Problems 311
 Reasons for Adolescent Reluctant to seek Help 312
 Prevention 312
 Syllabus for Adolescent Health Education 312
 Life Skills 312
 Adolescent Friendly Health Center Services 313
 Criteria for Adolescent Friendly Health Worker 313
 Criteria for Adolescent Friendly Health Center 313
 Adolescent Girls Scheme 314
• Beneficiaries 314
 Scheme I: Girl-to-Girl Approach 314
 Scheme II: Balika Mandal 314
 Interventions 315
 Training 315

22. Integrated Disease Surveillance Project 2004-2009

316-334
• Project Objectives 316
• Specific Objectives 316
• Phasing of IDSP Covering the States of India 316
 Project Activities 317
• Sentinal Surveillance under IDSP 317
• Regular Periodic Survey 317
• National Surveillance Unit 318
• State Surveillance Unit 318
• District Level Unit 318
• District Surveillance Unit 318
 Functions of the District Surveillance Unit 318
• District Epidemiological Cell 320
• Levels of Response to Different Triggers 321
 Malaria Triggers 322
 Cholera Triggers 322
 Typhoid Fever Triggers 322
 Cont x
Polio Trigger 322
Plague Triggers 323
Japanese Encephalitis Triggers
323 Dengue Triggers 323
Triggers for Syndromic Surveillance 323
• Surveillance of Noncommunicable Diseases 332
 Aims 332
 NCD Risk Factors 332
 Program for Control and
Treatment of Occupational
Diseases 332
 List 332
 Etiological Classification of Occupational Disorders 332
 Proposed Projects for Occupational Diseases under
National Program for Control and Treatment of
Occupational Diseases 333
 Global Strategy of Occupational Health 333
 Monitoring and Evaluation 334
23. Integrated Management of Neonatal and Childhood Illnesses
335-338
• Components of IMNCI in India 335
• IMNCI Strategy in India 335
 Timeline of IMNCI 337
 The IMNCI-PLUS 338

24. Community-Based Rehabilitation 339-345

• Hard Facts 339
• Need of Rehabilitation Service 340
 Seven National Levels Institutes 340
 Government Rehabilitation Services 340
 Objectives 340
 District Rehabilitation Center (DRC) Project 340
 Regional Rehabilitation Training Center (RRTC) 341
 National Information Center on Disability and
Rehabilitation (NICDR) 341
 Role of Primary Health Centers for Disability Rehabilitation 342
 Model Method of Implementation of CBR Using Primary
Health Centers 343
 Orientation of Medical Officers Working in Primary
Health Centers to Disability Management 344
 Expected Benefits of the Program 345

25. Social Security 346-349

• Workforce in India 346
 Organized and Unorganized Sectors 346
• Functions of Social Security Division 347
 List of Subjects 347
 New Initiative in Social Security 349
xxvi Essentials of Community Medicine—A Practical Approach
26. Swine Flu 350-352
• Transmission 350
• Signs and Symptoms 351
 Cause of Death 351
 Facility Management 351
 Herd Management 351

27. Hospital Statistics 353-355

• Daily Analysis 353
• Monthly Reports 353
• Census 353
• Death Rate 353
28. Biostatistics 356-377
 Definitions of Statistics 356
 Use of Biostatistics 357
• Collection and Presentation of Data 357
 Frequency Table 358
• Graphical Representation of Data 358
 Graphs 358
 Bar Diagram 358
 Histogram 359
 Frequency Polygon 360
 Pie Diagram 360
 The Ogive 360
• Centering Constants (Measures of Central Tendency) 361
 Arithmetic Mean 361
 Median 362
 Mode 362
• Measures of Variation 362
 Range 362
 Mean Deviation (MD) 363
 Standard Deviation (SD) 363
 Coefficient of Variation (CV) 363
 Quartile Deviation (QD) 363
 Percentile 364
 Tests of Statistical Comparison of Two Groups 364
 Test of Significance (for Large Size) 364
 Test of Significance (for Small Sample Size) 366
 t-tests for Unpaired Data 366
 t-tests for Paired Data 367
 Steps for Paired t-test 367
 Standard Error of Proportion (Large Sample Size) 367
 Standard Error of Difference between Two Proportions
(Large Sample) 368
 Probability of a Larger Value of ‘t’ 369
 Normal Distribution 370
 Cont x
 Table of the Unit Normal Distribution 371
 Chi-square Test (-Test) 372
 Table of Chi-square 372
 Formula 373
 Fallacies in Biostatistics 373
 Vital Statistics 374
 Geometrical Progression Method 374
 Measures of Vital Statistics 374
• International Death Certificate—Cause of Death 377
29. Problems 378-407
• Environmental Problems 378
 Problems 378
• Biostatistics 381
 Limitations of the Mean 384
• Correlation and Regression 387
 Problems 389
• Demography 392
• Epidemiological and Nutritional Exercises 399
 Miscellaneous Problems 404
30. Visits 408-434
• Integrated Counseling and Testing Center (ICTC) 408
• Visit to Blind School 409
 Admission Criteria 409
 Government Authority 409
 National and International Agencies 410
• A Visit to Deaf and Dumb School 410
 Staffing Pattern 411
 Rules and Regulations 411
• Visit to District Health Laboratory 411
 Staffing Pattern 411
 Functions 411
• Visit to Primary Health Center (PHC) 412
 Functions of the PHC 412
 Staffing Pattern 412
• Postpartum Center 413
 Functions of Postpartum Unit 414
 Department of Obstetrics and Gynecology 415
 Monitoring and Evaluation Aspects 415
 Broad Functions 416
• Delivery of Integrated Services for Maternal and Child
Health, Family Planning, Nutrition and Immunization 416
• The Baby Friendly Hospital Initiative 417
 What is BFHI? 417
 Why this Program? 417
 What is New About it? 417
xxviii Essentials of Community Medicine—A Practical Approach
What is this Program All About? Can it be

Simply Described in a Few Words? 418
 What are the Benefits of Making My Hospital Baby Friendly?
418
 What are the Investments Needed and What is
the Cost Involved? 419
 What should I do to get My Hospital
Recognized as Baby Friendly Hospital? 419
• World Breastfeeding Week 419
 What are Our Problems? 419
• Anganwadi 421
• Integrated Child Development Scheme 421
 Objectives 422
 Organizational Set-up 422
• Visit to District Tuberculosis Center 425
 National Tuberculosis Program (NTP) 425
• Visit to District Rehabilitation Center 426
 Services Provided 426
 National Program for Rehabilitation of
Persons with Disabilities 427
• Visit to Places of Natural Calamities 427
 Disasters 427
• School Health Service 430
 Benefits of School Health Programs 430
 Objectives of School Health Service 431
 School Health Program in India 431
 Aspects of School Health Service 431
• Visit to District Leprosy Center 432
 District Infrastructure 432
 Goal of National Health Policy 2002—
Elimination of Leprosy by 2005 433
Appendix...........................................................................435
Index.................................................................................447
 Introduction

COMMUNITY MEDICINE
Community medicine is comparatively a newcomer among
academic disciplines of medicine. Previously it was taught to
medical students as hygiene and public health. This name was
later changed to preventive and social medicine when it was
realized that the subject encompassed much more than merely
the principles of hygiene and sanitation and public health
engineering. The name preventive and social medicine
emphasizes the role of: (a) disease prevention in general through
immunization, adequate nutrition, etc. in addition to the routine
hygiene measures and (b) social factors in health and disease.
The modern day message is that the discipline variously labeled
in the past as public health or preventive and social medicine
cannot be divorced from health care, including clinical care of the
community. It is in recognition of this wider role that the Medical
Council of India has recently decided to label the discipline as
Community Medicine in place of Preventive and Social Medicine.

CHALLENGES OF 21ST CENTURY

Challenges of 21st century are not only to combat diseases
producing microbes but also to recognize that many of the causes
of ill health are increasingly related to lifestyle, man-made
changes in environment, and disparity and inequality in resources
distribution within country and between the countries. Developed
world is facing epidemiological transition that is transition from
infectious diseases as measles, diphtheria, and pneumonia to
chronic diseases as heart diseases, cancer, stroke and diabetes,
which consisted 9 out of 10 leading causes of deaths. This
transition is mainly due to improved water supply, sewerage, and
less crowded living environment, application of the preventive
health services, such as immunization, preventive health check-
ups, specific food interventions and use of highly developed
curative
technology.
Now, developing countries are experiencing the double burden of
diseases,
i.e. one which is caused by poverty, poor water supply and
sanitation and low standard of livings and other which is due to
adopting similar lifestyles as of developed world.
Another important concern is the world population that has
increased three- fold in last century whereas India has increased
almost five times in the same duration. The number of persons
living in urban areas increased globally from 32 percent of world
population in 1955 to 38 percent in 1975, and to 45 percent in
1995. It is expected to reach 54 percent by 2015 (World Health
Report 1998).
xxx Essentials of Community Medicine—A Practical Approach

In India, the urban population during 1911-1931 was 11-12

percent only and in 1951 was 17.3 percent only, however, in
1991 it reached to 25.7 percent and it is estimated 31 percent in
1996-97 and it was going to be 38 percent in 2006-07.
 Chapter
1 Present Health Status

Chapter Outline
DISEASE BURDEN REASONS FOR HIGH DISEASE BURDEN IN INDIA
COMMUNICABLE DISEASES CHRONIC NONCOMMUNICABLE DISEASES AND CONDITIONS
MATERNAL AND CHILD HEALTH  NOTIFIABLE DISEASES

DISEASE BURDEN
It has been estimated that the disease burden of the people of
India is one of the highest in the world (Table 1.1). We have a
triple burden of infectious diseases. Firstly, we have those
infectious diseases that are prevalent worldwide and for which
specific preventive measures are yet not available. Secondly,
we have infectious diseases that are prevalent because of
insufficient public health measures. Thirdly, we have infectious
diseases perpetuated by the prevalence of vectors
(hematophagous arthropods) as well as vertebrate fauna, the
ecological determinants of which are given due to our
geoclimatic features.
REASONS FOR HIGH DISEASE BURDEN
1. Poor economy of the country
2. Maldistribution of country resources
3. Poor governance and management to utilize resources
appropriately
4. Poor people participation.
Table 1.1: Ten leading causes of burden of disease,world, 2004 and 2030
2004 As % of Rank Rank As % of 2030
Disease or injury total total Disease or injury
DALYs DALYs
Lower respiratory infection 6.2 1 1 6.2 Unipolar depressive disorders
Diarrheal diseases 4.8 2 2 5.5 Ischemic heart disease
Unipolar depressive disorders 4.3 3 3 4.9 Road traffic accidents
Ischemic heart disease 4.1 4 4 4.3 Cerebrovascular disease
HIV/AIDS 3.8 5 5 3.8 COPD
Cerebrovascular disease 3.1 6 6 3.2 Lower respiratory infections
Prematurity and low birth weight 2.9 7 7 2.9 Hearing loss, adult onset
Birth asphyxia and birth trauma 2.7 8 8 2.7 Refractive errors
Road traffic accidents 2.7 9 9 2.5 HIV/AIDS
Neonatal infections and other* 2.7 10 10 2.3 Diabetes mellitus
COPD 2.0 13 11 1.9 Neonatal infections and other
Refractive errors 1.8 14 12 1.9 Prematurity and low birth weight
Hearing loss, adults onset 1.8 15 15 1.9 Birth asphyxia and birth trauma
Diabetes mellitus 1.3 19 18 1.6 Diarrheal diseases
COPD, chronic obstructive pulmonary disease
*This category also includes other noninfectious causes arising in the perinatal period apart from
prematurity, low birth weight, birth trauma and asphyxia. These noninfectious causes are responsible for
about 20% of DALYs shown in this category.
 2 Essentials of Community Medicine—A Practical Approach
5. Poor level of literacy of the people
6. Geographical characteristics of the country for certain
diseases like malaria, filaria, etc.
7. Poor political commitment
8. Poor policy
9. Poor scientific development
10. Religious belief system and cultural practices of the
population.

COMMUNICABLE DISEASES
About 17 percent of all deaths and about 21 percent of all
illnesses are due to communicable diseases. The major
problems continue to be tuberculosis, filariasis, leprosy,
malaria, diarrheal diseases and malnutrition.
Among viral diseases smallpox was eradicated in 1980.
Measles continues to be rife frequency in occurrence, and so
is viral hepatitis. Since 1973, the country has been
experiencing large scale outbreaks of Japanese encephalitis.
Dengue fever is also emerging as another health problem.
Among bacterial diseases meningococcal meningitis has
shown a substantial increase. Cholera has significantly
declined, but the other waterborne diseases (e.g. acute
diarrheas, dysentery and enteric fever) have not abated. Half
the world’s tuberculosis patients are in India accounting for
14 million cases of which in the world, estimated to be
0.6 million. Tetanus and Diphtheria are not yet under control.
The country has one-third of leprosy cases. Among parasitic
diseases, Malaria and Kala-azar have staged a comeback.
During 1995, 3 million cases of malaria and 22,000 cases of
Kala-azar were reported. About 420 million people are
estimated to be living in known endemic areas of Filariasis.
Intestinal parasites such as ascariasis, hookworms,
giardiasis and amoebiasis are widely prevalent. STDs are on
the increase.

CHRONIC NONCOMMUNICABLE DISEASES AND CONDITIONS

Noncommunicable diseases such as hypertension, diabetes,
cancer, road accidents, alcohol drug abuse and mental health
problems are slowly emerging as health problems. One reason
for this appears to be changes in lifestyle and growing
stresses of urban life.
The Table 1.2 shows the percentage (approximately) of
major causes of all deaths in developing countries.

Nutritional Deficiencies
Nutritional deficiencies are widespread and include protein
energy malnutrition, vitamin deficiency, vitamin B complex
deficiency, nutritional anemia and iodine-deficiency disorders.
Undernutrition affects millions
 Present Health
of people. In 1992, about 30 percent of babies were born with
birth weight of less than 2.5 kg.
Table 1.2: The percentage (approximately) of major causes
of all deaths in developing countries
Case Years
1985 2000
Infections 35 25
Neoplasm 7 10
Circulatory diseases 20 30
Injuries 8 6

Recent trends with regard to nutritional status of women

and children in India have been positive and modest. The
improvement has been marked with respect to the prevalence
of ‘severe malnutrition’. Even with respect to moderate
undernutrition modest improvements in anthropometry and
birth weight have been noticeable even amongst the poor.

MATERNAL AND CHILD HEALTH

By virtue of the large group (Women 22% Children 38%
together constitute 60%) of total population and also
vulnerable or special risk group mother and children are the
major consumer of health services.
Tables 1.3 and 1.4 show the poor status of MCH (Maternal
and Child Health).

Burden of Occupational Diseases and Injuries

There are 100 million occupational injuries causing 0.1 million
deaths in the world according to WHO (Leigh et al 1999). It is
also estimated that in India 17 million occupational nonfatal
injuries (17% of the world) and 45,000 fatal injuries (45% of
the total deaths due to occupational injuries in world) occurs
each year. Out of 11 million cases of occupational diseases in
the world 1.9 million cases (17%) are contributed by India and
out of 0.7 million deaths in the world 0.12 (17%) is
contributed by India.
Table 1.3: Health facilities in India
India
Population 2001 [Million] 1028.61
Projected population 2010 [Million] 1176.71
Health care infrastructure
Community health centers 42762
Primary health centers 234582
Subcenters 1460362
Total FRUs 18132
Contd...
 4 Essentials of Community Medicine—A Practical Approach
Contd...
India
CHCs owned building 38822
PHCs owned building 197062
SCs owned building 788032
Manpower status
Total allopathic doctors 7251903
Total allopathic doctors in Govt 848523
Total dentist 730573
Total dentist in govt sector 32333
Total ayurvedic doctors 4584183
Total registered ANMs 5492923
Total ANMs in govt 1535682
Total registered GNMs 9715743
Total registered LHVs 514973
Total specialist at CHCs 42792
MBBs doctors at PHCs 243752
Health care indicators
Doctor population ratio [per 1000] 0.633
Doctor nurse ratio 0.463
Nurse population ratio [per 1000] 1.373
Bed population ratio 0.874
Population per subcenter ratio 78382
Population per PHC 487992
1
Census of India 2
RHS-08 3
NPH-08 4
CBHI

Table 1.4: Health status in India

Infants mortality rate 532
Maternal mortality ratio 2542
Total fertility rate 2.72
Crude birth rate 22.82
Crude death rate 7.42
Life expectancy 66.91
Under 5 mortality rate 74.33
Total fertility rate 2.63
ANC-3 check ups (%) 523
I and FA Tab. received for 90 days % 233
Two TT Inj. received in last preg % 723
Birth in medical institutions (%) 493
BCG (%) 783
Polio 3 doses (%) 783
DPT3 (%) 553
Measles (%) 593
1
Census of India 2
NHP-08 3
SRS-08
 Present Health
Clinical Diagnosis and Community Diagnosis (Table 1.5)
Table 1.5: Comparative model of clinical diagnosis and community diagnosis

Clinical diagnosis Community diagnosis

• Sick patient Sick community
• Patient decides to consult doctor Community feels the need for
consulting
professionals
• Visits doctor Professions and community interaction
• Doctor takes history and symptomology Studies community history, hospital
record, birth,death, notification
analysis
• Provisional diagnosis Community provisional diagnosis,
(Identify community problems)
• Decides which system to examine and Decides what type of exploration or
what type of investigations to be performed studies to be conducted in the
community
• Carry out clinical examination Carry health surveys,screening
for and investigations diseases surveillance
• Scrutiny, analysis and interpretation Scrutiny, analysis and
clinical examination and laboratory results interpretation of data
• Arrives at clinical diagnosis Makes community diagnosis
• Decides treatment and advice Decide on community treatment or
community action on priorities.
• Administers the treatment and Plans and implements community
give advices service and program
• Monitor of follow-up of the patient Monitor community change, reduction
in (Symptomatic improvement, etc) morbidity, mortality, etc. (Evaluation)
• If no improvement change the If no improvement, change or
treatment regimen modify plan of action

NOTIFIABLE DISEASES
A disease that, by statutory requirements, must be reported to
the public health authority in the pertinent jurisdiction when
the diagnosis is made. Following are the notifiable diseases:
1. Lead poisoning or its sequelae.
2. Lead tetraethyl poisoning to its sequelae.
3.Phosphorus poisoning or its sequelae.
4. Mercury poisoning or its sequelae.
5. Manganese poisoning or its sequelae.
6. Arsenic poisoning or its sequelae.
7.Poisoning by nitrous fumes.
8. Carbon bisulfite poisoning.
9. Benzene and its derivatives poisoning or its sequelae.
10. Chrome ulceration or its sequelae.
11. Anthrax.
12. Silicosis.
13. Poisoning by halogens or its derivatives of hydrocarbons.
14. Pathological manifestation due to radium, radioactive
substances, or X-rays.
15. Primary epitheliomatous cancer of the skin.
 6 Essentials of Community Medicine—A Practical Approach
16. Toxic anemia.
17. Toxic jaundice due to poisonous substances.
18. Oil acne or dermatitis due to mineral oil or its derivatives in any
form.
19. Byssinosis.
20. Asbestosis.
21. Occupational or contact dermatitis caused by direct
contact with chemical or paints. It could be primary
irritants or allergic sensitizers.
22. Noise induced hearing loss.
23. Beryllium poisoning.
24. Carbon monoxide.
25. Coal miner’s pneumoconiosis.
26. Phosgene poisoning.
27. Occupational cancers.
28. Isocyanates poisoning.
29. Toxic nephritis.
 Chapter
2 Family

Chapter Outline
FAMILY
GENERAL INFORMATION FOR STUDENTS

FAMILY
Each student will be assigned families in the village. The
objective of this program is to provide opportunities to the
medical student to learn that the family is the basic unit for
epidemiological studies and obtain practical experience in the
health promotion, early diagnosis and treatment, disability
limitation and rehabilitation.

Definition
Family is a group of individuals, who are related by blood or
marriage, live under same shelter and share common kitchen.

Types of Family
There are four basic types of families:

Nuclear Family
When the family unit consists of husband, wife and children it
is called nuclear family. Relationships of married couple in
this type of family are more intimate than in other types of
families. Nuclear family is mostly male dominated.
Polygamous type of nuclear family: It is made up of a husband,
two or more co-wives and the children.
Polyandrous type: In some communities polyandrous type of
families exists. This consists of wife, two or more co-husbands
and the children. All family members either live in one house
or each co-wife/co-husband occupies separate house. These
houses (or huts) are usually within family compound or
homestead. In most societies polygyny is socially permitted.

Extended Family
This type of family can be considered as a vertical extension of
nuclear family. Thus, a small extended family consists of the
old man, his wife,
 8 Essentials of Community Medicine—A Practical Approach
their sons, the son’s wife and the son’s children. Here the
married son is a member of two nuclear families, his father’s
and his own. A large extended family, for example, may
consist of, the old man, his wives, their unmarried children,
married sons, son’s wives (each son having one or more wives)
along with their unmarried children.

Joint Family
This family can be considered as lateral extension of nuclear
family. It consists of nuclear families of siblings (brothers in
patrilocal system and sisters in matrilocal system), eldest
brother/sister has the position of authority.

Three Generation Family

This is similar to joint family, but the reason for married son
living with the parents is economical and not social.

Special Objectives
1. To study the family composition.
2. To study and observe environmental factors having their
influence on the health and disease of the family members.
3. To study and observe social and economic factors
associated with health and disease.
4. To observe the growth and development of the family.
5. To study the health status of the family members.
6. To study and follow—the morbidity encountered in the
family and to learn the importance of observing the patient
in his natural surroundings.
7. To learn the multiple factors associated with the cause of
disease and in getting the treatment.
8. To study the mortality in the family.
9. To study the attitudes and practices of people towards health.

Method of Study
a. Observation
b. Questioning
c. Clinical examination
d. Investigation at field level.

Family—a Dynamic Unit

Family Cycle
Family is not a static unit. It is a dynamic unit. Four stages are
described in family cycle.
 Family 9

Stage of formation: This stage begins with marriage.

Stage of growth: In this stage, the family grows due to procreation.
Stage of retraction: In this stage, there is reduction in the size
of family. This is due to members leaving family due to
marriage or due to death. It may also be due to married
children forming a separate family.
Stage of disintegration: The original family looses its existence
due to death of the couple which formed the original family.
All these stages may not follow the above sequence. Some
may occur simultaneously. In joint and extended family the
stage of retraction does not exist.

GENERAL INFORMATION FOR STUDENTS

1. In the family record, the details of the following done
should be recorded namely immunization, environment,
socioeconomic survey, diet survey, health check-up and
annual family morbidity, etc.
2. In family record dead members (in last one year only) in
household should also be recorded at the end with
appropriate heading in the first column of living family
members. The cause of death should be recorded in the
“Remarks’’ Column. Any members dying during our care
should be recorded.
3. A child under 1 year is not taken into account of while
calculating for overcrowding, a child above 1 year but
under 10 years is reckoned as a half unit.
4. Economic status should be enquired only when you have
gained the confidence of the family.
5. In recording diet, note down seven days typical diet of the
family. Weigh it and calculate the calories, proximate
principles, vitamins and trace elements, etc.
6. Health knowledge should be assessed for common
communicable diseases, diet, infant feeding, contraception,
family planning, etc.
7. Past illness should be enquired for all infectious diseases.
8. While doing general physical examination look for the early
signs of chronic diseases, common deficiency, skin
infections, diseases prevalent in the family and treat them
under the guidance of the staff.
9. For antenatal examination of the pregnant lady and
examination of infants make an appointment in
consultation with Public Health Nurse.
10. You will present your family study to the class, bringing
out all the important features of environment, the growth
and development of children in the family, common
diseases in the family members, their problems and how
you have helped them. The outlines for guidance are also
provided.
 Chapter
3 Economics

Chapter Outline
POVERTY LINE PER CAPITA INCOME
OVERCROWDING

POVERTY LINE
Poverty line is generally defined in terms of minimum per capita
consumption level of the people. As per the definition given by the
Planning Commission, this level is the caloric intake of people.
Thus, poverty line refers to the cut off point of income below
which people are not able to purchase food sufficient to
provide 2400 kcal per head per day. This income level has
been fixed by the Planning Commission at Rs 356.35 per
head in rural areas and Rs 538.60 (January 2010) in urban
areas at 1987-88 prices. Definitions and methodologies used
for estimating poverty line differ from one source to other.
According to the sixth five-year plan document, “A family
having five members, whose annual income is less than Rs
3500 is said to be living below poverty line.” This income limit
was increased to Rs 6400 in the seventh plan. It was further
raised to Rs 7200
as per the eighth plan document.
PER CAPITA INCOME
It is the per head income of the people of a country. It is
calculated by dividing the national income of a country by its
population.
Per capita income = National Income/Total population
Increase in the national income may not necessarily lead to
an increase in the per capita income if there is a corresponding
increase in population. The per capita income is the best
indicator of measuring the standard of living of the people of a
country. It provides an index of economic welfare.
Per capita income (1997-1998) Rs. 13,193
Per capita income (2001-2002) Rs. 15,746
Per capita income (2002-2003) Rs. 16,123
OVERCROWDING
Degree of overcrowding can be best expressed as the number
of persons per room, i.e.
Number of persons in household
=
Number of rooms in the dwelling
 Economics
Accepted Standards
1 Room — 2 persons
2 Rooms — 3 persons
3 Rooms — 5 persons
4 Rooms — 7
persons 5 Rooms or more
— 10 persons
(Additional 2 persons for each further room)

Floor Space Accepted Standard

110 sq ft — 2 persons
90-100 sqft — 1½
persons 70-90 sq ft — 1
person
50-70 sq ft — ½
person Under 50 sq ft —
Nil
(A baby under 12 months is not counted—children between
1-10 years counted as half a unit)

Sex Separation
Overcrowding is considered to exist if two persons over nine
years of age, (not husband and wife) of opposite sexes are
obliged to sleep in same room.
Housing

Housing Standards
Floor: The floors should be damp proof and free from cracks.
The height of the plinth should be 2 to 3 feet.
Roof: The height of the roof should be minimum of 10 feet
from the surface of floor.
Windows: Should be placed at a height of 3 feet above the ground
level.
• Window area should be 1/5th of the floor area.
• Doors and windows combined should have 2/5th the floor area.
Lighting: The day light factor should exceed one percent of
the floor area.
Cubic space: The height of the room should be such as to give
an air space of at least 500 cft. per capita, preferably 1000 cft.
Living rooms: At least two rooms, one of which can be closed for
security.

Social Classification
Methods of Social Classification
Prasad’s method: This method is proposed by BG Prasad and
is based on per capita income of family. It is useful for social
classification of family
 12 Essentials of Community Medicine—A Practical Approach
and not for individuals. While using this classification it is
necessary to update the value of rupee by applying
appropriate correction factor.
Correction factor is obtained by multiplying AICPI by 4.93
percent (i.e. 0.0493) as suggested by Kumar 3. This is
preferred for rural areas. This is modified BG Prasad’s social
classification (Table 3.1).
= Per capita family monthly income of
1961 (as suggested by BG prasad) ×
correction factor (CF)
Total monthly income of the
Where, per capita monthly income =
family
Total members of the family

CF = Value AICPI, (Which is variable and it was Rs 741 in

July 2009) multiplied by 0.0493, which is a finite
number/multiplier (linking factor).
Therefore, CF during July 2009 was 741× 0.0493 = 36.53
Table 3.1: Assessment of socioeconomic status by modified BG Prasad’s classification
BGP classification 1961 Modified BGP Socioeconomic class
based on per capita classification for the status
monthly income × CF Year 2009 (July)
Rs 100 and above × 36.53 Rs 3653 and below I
Rs 99 to 50 × 36.53 Rs 3652 to 1826 II
Rs 49 to 30 × 36.53 Rs 1825 to 1096 III
Rs 29 to 15 × 36.53 Rs 1095 to 548 IV
Rs 14 and below Rs 547 and below V

Note:
i. Rs 100 during 1961 is equivalent to Rs 3653 during July 2009.
ii. Per capita family monthly income of today (as assessed by
the above formula) has to be fitted in the second column
and assessed accordingly.
iii. All India consumer’s price Index (AICPI) is variable.
Thus, classification can be derived for any period by referring
AICPI of that period.
Kuppuswamy’s method: Kuppuswamy’s socioeconomic status
is an important tool in hospital and community based research
in India. It was proposed in 1976.1 This scale takes account of
education, occupation and income of the family to classify
study groups into high, middle and low socioeconomic status.
As pointed out rightly by Mishra and Singh2 from Rewa, “An
income scale usually has relevance only for the period under
study. Due to the steady inflation and consequent fall in the
value of the rupee, the income criteria in the scale lose their
relevance.” Mishra, therefore, undertook important task of
revision of family income per month (in Rs.) for 1976 when the
price index was 296 according to base year 1960=100 (Table
3.2). He however revised it for 1998 using base year
1982=100. The base year has been changed from 2001.”
 Economics
Table 3.2: Reference index
Year Reference index
1960 100 (base)
1976 296
1982 490 – 100 (new base)
1998 405
2001 458 – 100 (new base)
2007 April 128
We have attempted the same exercise using the new base
year of 2001 for CPI-IW (All India average consumer price
index for industrial workers).
Price index for 2001 by old base (1982=100) was 458. One
needs to divide given years price index by price index of the
base years. For example, Kuppuswamy’s price index for 1976
was based on 1960 as 100. In other words means that any
thing which cost Rs 100 in 1960 would cost Rs 296 in 1976.
The criteria were, however, changed in 1982 to 100 (called as
new base). As per criteria of 1960 (old base), the price index
for 1982 was 490. Therefore, we get price index of 1976
converted to new base:
Price index by old base for 1982 =
490 Price index by new base for
1982=100 Price index by old base
for 1976 was 296.
Conversion factor for 1976 by new base was calculated as
follows: 100/490 × 296 = 60.04.
To know the price increase in 1998, price index by then new
base (1982) was divided by conversion factor. Mishra, thus
determined new income criteria for 1998 by multiplying old
income ranges of 1976 by 6.745 (obtained by dividing price
index of 1998 by 60.04 (405/60.04=6.745) on the basis of base
year of 1982.
Now in view of new base for 2001 updating for current year
is attempted hereby to help researchers in formulating their
ranges of income for upcoming research. Conversion factor
for 1982 base year has changed with considering 2001 as base
year. To get updated conversion factor same exercise is
adopted as follows:
Price index by old base for
2001=458 Price index by base for
2001 =100
Price index by old base for 1998 was 405
Price index by new base for 1998=100/458 × 405=88.42
To calculate conversion factor for the year 2007, we have to
divide price index by 88.428. All-India average consumer price
index numbers for industrial workers (Base 2001=100) shows
general index as 128 on April 2007.
A conversion factor can be obtained by calculating from
1976 index also, and it comes as 9.764, which implies 9.764
times price increased as compared to 1976. Multiplying 1976
income by the factor of 9.764 would also provide scale for
2007.
 14 Essentials of Community Medicine—A Practical Approach
Now the prices from 1982 levels have increased, and that
increase can be obtained by multiplying prices of that time by
the factor obtained as follows: 128/88.428 = 1.45.
Revised table (Table 3.3) for scales in 2007 to define
socioeconomic status has thus obtained as follows (by
multiplying 1998 income ranges by the factor 1.45): This
revised prices scale for different socioeconomic status has
shortcomings as educational and occupational factors also
need to be revised by large scale survey. Another lacuna is
also the same as were in modification for the year 1998.2
However, this exercise will provide some clue for setting
income group in researches as per current inflation rate.

Table 3.3: Kuppuswamy’s socioeconomic status scale

A. Education score
1. Profession or Honours 7
2. Graduate or postgraduate 6
3. Intermediate or post high school diploma 5
4. High school certificate 4
5. Middle school certificate 3
6. Primary school certificate 2
7. Illiterate 1
B. Occupation score
1. Profession 10
2. Semi-profession 6
3. Clerical, Shop-owner, Farmer 5
4. Skilled worker 4
5. Semi-skilled worker 3
6. Unskilled worker 2
7. Unemployed 1
C. Family income per Score Modified
Modified month (in Rs) original for
1982 for 2007 1. 2000 12
13500 19575
2. 1000-1999 10 6750-13499 9788-19574
3. 750-999 6 5050-6749 7323-9787
4. 500-749 4 3375-5049 4894-7322
5. 300-499 3 2025-3374 2936-4893
6. 101-299 2 676-2024 980-2935
7. 100 1 675 979
Total score Socioeconomic class
26-29 Upper (I)
16-25 Upper middle (II)
11-15 Middle lower middle (III)
5-10 Lower upper lower (IV)
<5 Lower (V)
 Economics
REFERENCES
1. Kuppuswamy B. Manual of socioeconomic status (Urban),
Manasayan, Delhi, 1981.
2. Mishra D, Singh HP. Kuppuswamy’s socioeconomic status
scale— a revision. Indian J Pediatr 2003;70(3):273-74.
3. Kumar P. Indian Journal of Community Medicine 1993;18:2.
 16 Essentials of Community Medicine—A
Chapter
4 Communicable Diseases

Chapter Outline
COMMUNICABLE DISEASE TUBERCULOSIS
PEDIATRIC TUBERCULOSIS LEPROSY
LEPROSY CONTROL FILARIASIS
DIARRHEA AND DYSENTERY  CHOLERA
SCABIES SEXUALLY TRANSMITTED DISEASES

COMMUNICABLE DISEASE

Definition
An illness due to a specific infectious agent or its toxic
products capable of being directly or indirectly transmitted
from man to man, animal to animal or from the environment
(through air, dust, soil, water, food, etc.) to man or animal.
Definition of Infection
The entry and development or multiplication of an infectious
agent in the body of man and animals.
Infectious disease: A clinically manifest disease of man or
animal resulting from an infection.
Contamination: The presence of an infectious agent on a body
surface; also on or in clothes, beddings, toys, surgical
instruments or dressings or other inanimate articles.
Contagious disease: A disease that is transmitted through
contact, e.g. scabies trachoma infestation.
Containment: The concept of regional eradication of communicable
disease.
Infestation: For persons or animals the lodgment,
development and reproduction of arthropods on the surface of
the body or in the clothing,
e.g. lice, itchmite.
Host: A person or other animal including birds and arthropods
that affords subsistence or lodgment to an infectious agent
under natural condition.
1.Obligate host — Means the only host
2.Definitive host — Parasite passes its sexual stage in host
3.Intermediate host — Parasite passes its a sexual stage in host
4.Transport host (carrier) — Organism remains alive but do
not
undergo development
 Communicable
Case
Case is defined as “a person in the population or study group
identified as having the particular disease, health disorder or
condition under investigation”.
Primary case: Refers to the first case of communicable disease
introduced into the population unit being studied.
Index case: Refers to the first case to come to the attention of the
investigator.
Secondary case: Secondary case are those developing from
contact with primary case.

Epidemic (Epi—upon, demos—people)

The “unusual” occurrence in a community or region, of
disease, specific health-related behavior (e.g. smoking) or
other health related events (e.g. traffic accidents) clearly in
excess of “ expected occurrence”.

Endemic (En—in, demos—people)

It refers to the constant presence of a disease or infectious
agent within a given geographic area or population group,
without importation from outside may also refer to the “usual”
or expected frequency of the disease within such area or
population group.
Sporadic
The cases are so few and separated widely in space and time
that they show little or no connection with each other, nor a
recognizable common source of infection, e.g. polio, tetanus.

Pandemic
An epidemic usually affecting a large proportion of the
population occuring over a wide geographic area such as a
section of a nation, the entire nation, a continent or the world,
e.g. influenza pandemics of 1918 and 1957.

Disease
Disease is a condition of the body or some part or organ of the
body in which its functions are disrupted or deranged; in
simple terms it is the physiological or psychological
dysfunction.

Illness
Illness is a subjective state of the person who feels aware of
not being well.

Sickness
Sickness is a state of social dysfunction, i.e. a role that the
individual assumes when ill. It is quite difficult to assess the
illness and sickness,
 18 Essentials of Community Medicine—A Practical Approach
however, disease can be measured directly or indirectly in terms
of clinical state, disability, and death.

TUBERCULOSIS
It is a chronic bacterial infectious disease caused by
Mycobacterium tuberculosis and is characterized by formation
of granuloma in infected tissue and by cell-mediated
hypersensitivity (Table 4.1). Dr Robert Koch discovered TB
bacillus on 24th March 1882.

Sites Affected
Lungs, intestine, meninges, bones, lymph nodes and skin.
It has been reported as one of most important public health
problem by all regions of WHO.
It affects the cream of population, i.e. adults in age group of
21 to 40 years.
Table 4.1: Important rates in relation to burden of tuberculosis
Prevalence of TB infection 30%
Incidence of TB infection (ARI) 1.4% in 0-4 years, 2.1% in 0-14
years, 1.7% is average ARI
Incidence of active TB 168/100,000/year
Incidence of sputum positive 075/100,000/year
Prevalence of sputum positive 0.4%
Primary drug resistance 3-13.3%
Primary resistance to INH 10.6-21.83%
Primary resistance to rifampicin 0-11.9%
Acquired resistance to INH 34.5%-76%
Acquired resistance to rifampicin 0.53.26%
Ethmbutol resistance 0-20.6%(0.5%)
Streptomycin resistance 0/35.8%(2.4%)
Any one drug resistance (means 10.7%)
Multidrug resistant TB 3.5-42.3%
Resistance to 4 drugs 0%-14.1%
In new cases (mean 1.0%)
(Source: Paramasivan, 1998, Jain, et al. 1992, Pablos-Mendez, et al. 1998, Espinal, et al.
2001, 2004; Negi, et al. 2003; WHO Report 2005).

Economic Burden of Tuberculosis

1. TB kills more people in India than HIV, STD, malaria,
leprosy and tropical diseases combined.
2. Every year 30,000 children are forced to leave school
because their parents have tuberculosis, and 1,00,000
women lose their status as mothers and wives because of
social stigma.
 Communicable
3. Every year, more than 17 crores more days are lost to the
National Economy on account of tuberculosis at a cost of Rs
700 crore.

Epidemiological Indices
1. Prevalence of infection
2. Prevalence of disease or case rate
3. Incidence of infection
4. Incidence of new cases
5. Prevalence of suspected cases
6. Prevalence of drug resistance cases
7. Mortality rate.

Epidemiology
Agent: Mycobacterium tuberculosis which is commonly known
as “Koch” bacillus or tubercle bacilli or acid fast bacillus
(AFB).
Sources
1. Human:
a.Rapid multiplier
b.Slow multiplier
2. Bovine—Infected milk
3. Atypical Mycobacterium.
Communicability
Patients are infective as long as they remain untreated.

Host Factors
• Age: Prevalence increases with age up to the age of 45 to 54 in
males.
• Sex: In female the peak of tuberculosis prevalence is below 35
years.
• One percent prevalence: In under 5 years of age.
• Thirty percent prevalence: At the age of 15 years.
• Common in elderly.
Environmental Factors
Housing factors
1. Darkness
2. Illventilated
3. Overcrowded.
Social factors
1. Poor quality of life
2. Poor housing
3. Overcrowding.
 20 Essentials of Community Medicine—A Practical Approach
4. Population explosion
5. Under nutrition
6. Lack of education
7. Large families
8. Early marriages
9. Lack of awareness regarding cause of illness
10. Poor sanitation
11. Air pollution
12. Spitting indiscriminately
13. Sharing of Hukka and smoke
14. Purdha system.
Incubation period: Three to six weeks
Mode of transmissions
1. Inhalation
2. Ingestion
3. Surface implantation.
Case Finding
Based on four cardinal symptoms:
1. Continuous, irregular, intermittent and low grade fever for
more than two weeks
2. Cough with expectoration for more than two weeks
3. Chest pain (plural involvement)
4. Hemoptysis.

Definitions

(According to WHO)
Case: Patient whose sputum is positive for tubercular bacilli.
Suspected case: Patient whose sputum is negative for
tubercular bacilli and X-ray suggestive of shadow.

Case Finding Tools (Table 4.2 to 4.7)

1. Sputum examination.
2. Mass miniature radiography (MMR)
3. Tuberculin test.
4. Other tests:
a. Polymarase chain reaction (PCR)
b. CT scan
c. Magnetic resonance imaging (MRI).
 Communicable
Sputum Examination
Two samples are to be collected:
1. Over night sputum
2. Spot sputum.

Chemoprophylaxis

Primary
When drug is given to person not infected so far (Tuberculin
negative) and who has been exposed to open case.

Secondary
INH is given to person already infected (Tuberculin positive)
in order to prevent development of disease.

Treatment

Drug Regimens Currently used in India

• Standard regimens/Conventional regimens (Table 4.2)
• Short-course chemotherapy regimens (Table 4.3).

Conventional Regimens
Two types:
1. Daily regimens
2. Bi-weekly regimens.

Table 4.2: Standard regimens/conventional regimens

Regimen Regimen with drugs and Duration Mode and rhythm Instructions
code dosage (Months) of administration
2 STH/10TH Inj. S (IM) adminis- Inj.
a. Intensive phase tered daily. Other adminis-
(2 months) two drugs orally tered DTC/
S = 0.75 g daily in a single PHI/other
H = 300 mg dose, self-adminis- health
R1 T = 150 mg 12 tered at home facilities
b. Continuation phase Oral drugs
(10 months) issued on
H = 300 mg monthly
T = 150 mg basis by
DTC/PHI
R2 12TH 12 Both drugs orally Issued on
H = 300 mg daily at home in monthly
T = 150 mg a single dose basis by
DTC/PHI
 22 Essentials of Community Medicine—A Practical Approach
Table 4.3: Short-course chemotherapy regimens (SCC)
Regimen Regimen with drugs and Mode and rhythm Instructions
code Duration dosage (Months) of administration
2 EHRZ/6TH
a. Intensive All drugs daily at Issued on
phase (2 the same time, self- fortnightly
months) administered at home basis
E = 800 mg, H = 300 mg 8 Both drugs orally Issued on
RA R = 450 mg, Z = 1.5 gm daily, self-adminis- monthly
b. Continuation phase tered at home basis by
(6 months) DTC/PHI
H = 300 mg, T = 150 mg
RB 2 SHRZ/4 S2H2R2
a. Intensive phase (2 months) Inj. S (IM) admini- All drugs
nistered daily. Other adminis-
S = 0.75g, H = 300 mg 3 drugs orally daily tered under
in a single dose, supervision
R = 450 mg, Z = 1.5 g 6 under supervision at DTC/PHI
Twice weekly; all
b. Continuation phase drugs together All drugs
(4 months) administered
S = 0.75 g, H = 600 mg under
R = 600 mg supervision
at DTC/PHI
S = Streptomycin, R = Rifampicin, T = Thioacetazone, H = Isoniazid
Z = Pyrazinamide, E = Ethambutol

Table 4.4: Category of patients for treatment

Regimen code Category
R1 a. Smear negative patients with extensive radiological evidence of
disease/ cavity/toxemia
b. New smear positive cases where SCC is not available or a patient is
unable to continue SCC
c. Extra- pulmonary patients in general (e.g. tubercular lymphadenitis)
d. Cases, sputum positive after treatment completion with RA who are
unable to attend DTC or other specialized centers on referral for further
treatment
R2 a. Smear negative patients with X-ray evidence of tuberculosis other than
those in (R1 a)
b. Lost patients, smear negative on reporting back, irrespective of
previous history of treatment
c. Highly irregular patients (e.g. with cumulative default of more than a
month in the intensive phase of any of the regimens or in continuation
phase of RB) irrespective of the smear result
RA New cases
a. All smear positive cases newly indexed under DTP, irrespective of age
and previous treatment outside the program
b. Serious forms of extrapulmonary tuberculosis (e.g. meningeal, spinal)
RB Retreatment cases
a. Patients remaining smear positive on completion of treatment with R1,
R2 and RA or on return after lost
b. Cured patients returning with smear positive result
Note: Patients requiring retreatment should be referred to DTC for initiation of treatment and
sent back to the concerned PHIs for continuation of prescribed regimen.
 Communicable
Table 4.5: Doses of antitubercular drugs for adult and children
Medication Adult Children
Dose thrice Number of pills Daily dose Thrice a
a week in combipack week
Isoniazid 600 mg 2 5 mg/kg 10-15 mg/kg
Rifampicin 450 mg* 1 10 mg/kg 10 mg/kg
Pyrazinamide 1500 mg 3 25 mg/kg 35 mg/kg
Streptomycin** 0.75 mg – 15 mg/kg 15 mg/kg
Ethambutol# 1200 mg 3 15 mg/kg 30 mg/kg
* Patient who weigh 60 kg or more are given an extra 150 mg dose.
** Patient over 50 years of age are given 0.5 gm of streptomycin.
# Ethambutol should not be given in children below 6 years of age.

Table 4.6: Important regimens in relation to burden of tuberculosis

Adult Children
Medication Drug action Daily Dose No.of Daily Thrice a
dose thrice pills in dose week
regimen a week combipack
Isoniazid Bactericidal 300 mg 600 mg 2 5 mg/Kg 10-15 mg/Kg
Rifampicin Bactericidal 450-600 mg 450 mg* 1 10 mg/Kg 10 mg/Kg
Pyrazinamide Bactericidal 1-1.5 gm 1.5 gm 2-3 25 mg/Kg 35 mg/Kg
Streptomycin** Bactericidal 0.75-0.5 gm 0.75 gm – 15 mg/Kg 15 mg?Kg
Ethambutol# Bacteriostatic 800 mg 1200 mg 2-3 2.5 mg/Kg 30 mg/Kg
Thiacetazone Bacteriostatic 150 mg Not applied – Not applied
Ofloxacine/Cipro Bactericidal 200/400 mg
Kanamycine Bactericidal 1gm
Ethionamide Bactericidal 250-1 gm
Cycloserine Bacteriostatic 250 mg
* Patient who weigh 60 kg. or more are given an extra 150 mg. dose
** Patient over 50 years of age are given 0.5 gm of streptomycin
# Ethambutol should not be given in children below 6 years of age

Important Definitions

Smear +ve TB
At least 2 initial sputum smear +ve for AFB or 1AFB +ve
smear and 1+ve culture.
Smear –ve TB
At least 3 –ve smears, but tuberculosis suggestive symptoms and X-
ray. Abnormalities or +ve culture (Fig. 4.1).
Adherence
Persons take appropriate drug regimen for required time (also known
as compliance).
New Cases
A Patient with sputum +ve pulmonary tuberculosis who have never
had treatment for TB or has taken anti-TB drugs for less than four
weeks.
 24 Essentials of Community Medicine—A Practical Approach
Table 4.7: Classification of categories, types of patients,
regimens adopted under RNTCP

Category Type of patient Regimens’ in months Duration Color of

the box
Category New sputum smear 2(HRZE)3@4(HR)3 6 Red
I Positive seriously ill
sputum negative
Seriously ill extra-
pulmonary**
Category Sputum positive 2(HRZES)3 1(HRZE)3# 8 Blue
II relapse*** 5(HRE)3
Sputum positive
failure***
Sputum positive
treatment after
default
Category Sputum negative 2(HRZ)3 4(HR)3 6 Green
III extrapulmonary
not seriously ill
Category MDR-TB cases# # [6(9)Km Ofx eto Cs 24-27
IV ZE/18 Ofx eto Cs E]

All the drugs are administered thrice weekly. The number before the letters refers to the
number of months of treatment. The abbreviations are as follow: R-Rifampicin,
E-Ethambutol, H-INH, S-Streptomycin, and Z-Pyrazinamide, K-Kanamycin, O-Oflaxacin,
Et-Ethionamide, C-Cycloserine.
**Examples of seriously ill extrapulmonary TB cases are meningitis, disseminated TB,
TB pericarditis,Tuberculous peritonitis, bilateral or extensive pleurisy, spinal involvement
with neurological complications; smear negative pulmonary TB with extensive parenchymal
involvement and intestinal and genitourinary TB.
If sputum smear is positive after two months of the start of treatment then same treatment
regimen (Intensive phase) should be continued for another one month. Thereafter
continuation phase should be started irrespective of sputum report at three months. If patient
is sputum positive at five months also then he/she should be labeled as “failure” and category
II treatment should be started from the beginning.
***In rare and exceptional cases, patients who are sputum smear-negative or who have
extrapulmonary disease can have relapse or failure. This diagnosis in all such cases
should always be made by a medical officer and should be supported by culture or
histological evidence of current active tuberculosis. In these cases, the patient should be
categorized “other” and given category II treatment.
# If the Sputum smear is positive even after three months of the start of treatment in category
II patients then four drugs (HRZE), excluding streptomycin, should be extended for one
more month.
# # Smear examination should be conducted monthly during intensive phase and at least
quarterly during continuous phase. Culture examination should be done at least at
4,6,12,18 and 24 months of treatment.
 Communicable

Fig. 4.1: Diagnosis of tuberculosis

Relapse
A patient who returns smear +ve having previously been
treated for TB and declared cured after the completion of his
treatment.
PEDIATRIC TUBERCULOSIS
Tuberculosis is a major cause of childhood morbidity and
mortality. It is estimated that about six to eight percent of all
new TB cases are in the pediatric age group and majority is in
one to four years. Childhood TB is a reflection of the
prevalence of sputum positive pulmonary tuberculosis in the
community and the extent of transmission of infection in the
community. Children suffer from severe forms of TB because of
their poor immunity.
Pediatrics DOTS
Weight Box color Regimen
11-17 kg 1 Orange 2(HRZE)34 (HR)3
6-10 kg 1 Yellow 2(HRZE)34 (HR)3
18-25 kg 1 Orange + 1 Yellow 2(HRZE)34 (HR)3
26-30 kg 2 Orange 2(HRZE)34 (HR)3
 26 Essentials of Community Medicine—A Practical Approach
Orange box Yellow

24 strips 24 strips
H = 150 mg H = 75 mg
R = 150 mg R = 75 mg
Z = 500 mg Z = 250 mg
E = 400 mg E = 200 mg
18 strips
H = 150 mg H = 75 mg
R = 150 mg R = 75
Pediatric TB do not accord high priority as it is less infectious.
But because of serious forms of TB that occurs in children
they are more likely to die if not treated properly.

Failure Case
A patient who was initially smear +ve , who began treatment
and who remained or became smear +ve again at five months
or later during the course of treatment.
Return after Default
A patient who returns sputum smear +ve, after having left
treatment for at least two months.

Transfer In
A patient recorded in another administrative area register and
transferred into another area to continue the treatment.

Transfer Out
A patient who has been transferred to another area register.

Cured
Initially smear +ve patient who completed treatment and had
–ve smear result on at least two occasions (one at treatment
completion).

Treatment Completed
Initially smear –ve patient who received full course of treatment, or
smear
+ve who completed treatment with –ve smear at the end of
initial phase, but no or only one –ve smear during continuation
phase and none at the end of the treatment.
Died
Patient who died during treatment regardless of cause.
 Communicable
Directly Observed Therapy Short-course (DOTS)
• 1993—DOT Pilots
• 1998—DOTS scale-up begins
• 2000—More than 30 percent of country covered by DOTS.
Principles
1. Case detection primarily by microscopic examination of
sputum of patient presenting to health facilities.
2. Adequate drug supply.
3. Short-course chemotherapy given under direct observation.
4. Systematic monitoring and accountability for every patient
diagnosed.
5. Political will.

Follow-up
Response to treatment
• Symptomatic and general well being usually within 10 to 15 days.
• Fever subsides by two weeks , occasionally may take up to one
month
• Respiratory symptoms decrease by second month and may
subside by third or fourth month.

Sputum Examination
In category I and III—Repeat sputum smear examination at
the end of 2nd, 4th , and 6th month (Flow chart 4.1).
Flow chart 4.1: Category—I and III
 28 Essentials of Community Medicine—A Practical Approach
In category II—Repeat sputum smear examination at the
end of 3rd, 5th and 8th month (Flow chart 4.2).
Flow chart 4.2: Category—II

Structure of the RNTCP

National Level (Deputy Director General—TB)

• National Institutes
(NTI Bangalore, TRC Madras)

State Level (State Tuberculosis Officer)

• State TB Training and Demonstration Center (Director)

District Level (District Tuberculosis Officer)

Sub-district Level (Tuberculosis Unit)
• Medical officer—TB control (MOTC)
• Senior treatment supervisor (STS)
• Senior TB laboratory supervisor (STLS).

Peripheral Health Level

• Microscopy centers
• Treatment centers
• DOTs Providers.
 Communicable
Difference in National Tuberculosis Program and
Revised NTCP (Table 4.8)

Table 4.8: Difference in National Tuberculosis Program and Revised NTCP

NTP RNTCP
Objective Early diagnosis and treatment Breaking the chain of transmission
Operational 1. Not defined 1. Cure rate 85%
2. Case finding 70% of estimated
cases
Strategy 1. Short-course chemotherapy 1. DOTs (Directly observed
(SCC) unsupervised treatment short-course)
2. Conventional 2. Uninterrupted drug supply
Diagnosis 1. More emphasis on X-ray 1. Mainly sputum microscopy
2. Two sputum smears 2. Three sputum smears
3. One sputum +ve is 3. One +ve is not a case
considered a case
Reasons for Dropout of the Treatment
1.Long distance from PHI/DTC
2.Transport facilities to PHI/DTC
3. Costing time
4.Affordability (economic status for travelling)
5.Unpleasant side effects
6.Uncooperative staff
7.Communication gap
8.Personal inconvenience
9.Discontinuous/improper treatment
10. Demoralization
11. Stigma
12. Ignorance
13. Sex bias
14. Views expressed by doctor, uncooperative staff,
shortage of staff, shortage of drug
15. Interest in hospital admission
16. Belief in other systems of medicines.

National TB Control Program

Program has been in operation since 1962 in
India. Its objectives are:
1.Long-term
2.Short-term.
 30 Essentials of Community Medicine—A Practical Approach
Objectives of NTCP (1962)

Long-term Objectives
To reduce tuberculosis in the community to that level when it
ceases to be a public health problem, i.e.
a. One case infects less than one new person annually.
b. The prevalence of infection in age group below 14 years is
brought down to less than 1 percent, against about 30
percent, as at present.
Short-term Objectives
a. To detect maximum number of TB cases among the outpatient
attending any health institution with symptoms suggestive of
TB and treat them effectively.
b. To vaccinate newborns and infants with BCG.
c. To undertake the above objectives in an integrated manner
through all the existing health institutions in the country.
Disinfection of Sputum
1. Cheap handkerchiefs, cotton tissue towels and paper box,
etc. used to receive the sputum and nasal discharge of the
patient, should be burnt.
2. Sputum cups containing 50 percent carbolic lotion.
3. Disposal of sputum should be done by burying.
4. Safe, cheap and practical method is to receive sputum in
small tin can and put boiling water in it, within a minute
bacilli will be killed.
5. Cups and utensils should be disinfected by boiling.
6. Beds and beddings should be exposed to sunlight.
7. Wet mopping of floors.
8. Fly sitting on sputum and other discharges should be prevented.
DOTS-Plus Strategy
DOTS-Plus for MDR-TB is a comprehensive management
initiative under development that is built upon the five
elements of the DOTS strategy DOTS-Plus takes into account
specific issues, such as the use of second- line anti-TB drugs,
that need to be addressed in areas where there are significant
levels of MDR-TB. The goal of DOTS-Plus is to prevent the
further development and spread of MDR-TB. DOTS-Plus is not
intended as a universal option and is not required in all
settings. DOTS-Plus should be implemented in selected areas in
order to combat an emerging epidemic. The underlying principle
is that proper implementation of DOTS will prevent the
emergence of drug resistance and should be the first step in
fighting MDR-TB. It is not possible to conduct DOTS-Plus in an
area without having an effective DOTS-based TB control
program in place. The Working Group has identified access to
second-line anti-TB drugs as one of the major obstacles to the
implementation of DOTS Plus pilot projects. While access to
second-line anti-TB drugs must increase, these
 Communicable
drugs should only be used in DOTS-Plus pilot projects that
meet the standards set forth by the Scientific Panel of the
Working Group in the Guidelines for the Establishment of DOTS-
Plus Pilot Projects for the Management of MDR-TB (the
Guidelines). Adherence to the Guidelines results in proper
management of existing cases of MDR-TB while preventing
the rapid development of resistance to second-line anti-TB
drugs. The Guidelines are based on the recommendations of
the Scientific Panel of the Working Group and will be further
developed based on evidence provided by DOTS-Plus pilot
projects. In addition to explaining the DOTS-Plus concept, the
Guidelines define the minimum requirements necessary to
establish and maintain DOTS-Plus pilot projects. Sample
protocols are available to design standardized or
individualized treatment regimens with second- line anti-TB
drugs to be used in DOTS-Plus pilot projects.
Components
DOTS-Plus refers to DOTS programs that add components for
MDR-TB diagnosis, management and treatment. The DOTS-
Plus strategy promotes full integration of DOTS and DOTS-
Plus activities under the RNTCP, so that patients with MDR- TB
are both correctly identified properly managed DOTS Plus is
having five components:
1.Sustained government commitment.
2.Accurate, timely diagnosis through quality assured culture
and drug susceptibility assured culture and drug
susceptibility testing (DST).
3.Appropriate treatment utilizing second-line drugs under
strict supervision.
4.Uninterrupted supply of quality assured anti-TB drugs: and
5.Standardized recoding and reporting system.

Strategy and Focus

1.DOTS reveals the emergence of drug-resistant TB and
MDR-TB by ensuring that patient to the full course of
treatment.
2.DOTS-Plus is designed to cure MDR-TB using second line
anti-TB drugs.
3.DOTS-Plus is needed in areas where MDR-TB has emerged
due to previous inadequate programs.
4.DOTS-Plus pilot project are only recommended in setting
where the DOTS strategy place to protect against the
creation of further drug resistance.
5.It is vital that DOTS-Plus pilot project are implemented
following the recommendation. Stop TB working group on
MDR-TB in order to minimize the risk of creating resistant
second line anti-TB drugs.
6.Before launching DOTS-Plus pilot project, WHO member
states are strongly recommended to consult WHO.
 32 Essentials of Community Medicine—A Practical Approach
7.With the coordination of the working group on DOTS-Plus
for MDR-TB and a partnership industry, the price of
second line anti-TB drugs have fallen considerable, making
these more accessible to the poor.

Green Light Committee Initiative

Component two of the stop TB strategy calls for the control and
prevention of multidrug-resistant tuberculosis (MDR-TB)
through: (i) increased access to quality-assured second-line
anti-TB drugs; and (ii) prevention of development of resistance
to anti-TB drugs.
The Green Light Committee (GLC) initiative, together with the
working group on MDR-TB, promotes implementation of this
strategy in accordance with the global plan to stop TB (2006–
2015) and the global MDR/XDR-TB response plan (2007–
2008).
Established in 2000, the GLC initiative is the mechanism
that enables access to affordable, high-quality, second-line
anti-TB drugs for the treatment of MDR-TB. Its objectives are:
• Ensuring effective treatment of patients with MDR-TB in
accordance with guidelines published by the World Health
Organization (WHO) on the programmatic management of
MDR-TB;
• Increasing access to technical assistance to facilitate rapid
scale-up of MDR-TB management;
• Increasing access to high-quality, low-cost, second-line
anti-TB drugs for the treatment of MDR-TB among well-
performing programs; preventing the development of
resistance to second-line anti-TB drugs by ensuring rational
drug use;
• Advising WHO on policy-related matters to effectively
prevent and control MDR-TB based on the best available
scientific evidence.
The GLC initiative therefore contributes to reducing
transmission of TB, preventing further drug resistance and
ultimately reducing the global burden of TB. The initiative is
coordinated by the GLC Secretariat, which is hosted and
administered by WHO. The Global Drug Facility (GDF), an arm
of the stop TB partnership, which is also hosted and
administered by WHO, carries out drug procurement for GLC-
approved programs. Technical assistance to MDR-TB program
is coordinated and delivered by WHO and its technical
partners.
HIV Infection and Risk of Tuberculosis
HIV increases the susceptibility to infection with M. tuberculosis.
In a person infected with Mycobacterium tuberculosis, HIV is a
potent cause of progression of tuberculosis infection to disease.
Compared to an individual who is not infected with HIV, an
individual infected with HIV has a 10 times increased risk of
developing tuberculosis.
 Communicable
As HIV infection progresses, CD4 lymphocytes decline in
number and function. The immune system is less able to
prevent the growth and local spread of M.tuberculosis. The
duration of TB in HIV infected persons is more difficult on
account of more non-TB respiratory diseases, more smear
negative, disseminated and extrapulmonary TB and X-rays
being less specific. Fortunately more than 90 percent of
surviving HIV infected TB can be cured provided complete
treatment is taken regularly.
LEPROSY
Leprosy continues to be a social and public health problem but
the situation is gradually improving.
History
Milestones
1955 National Leprosy Control Program
1983 National Leprosy Eradication Program (MDT
started)
1991 World Health Assembly resolution to eradicate
leprosy
by 2000 AD
1993 World Bank supported the MDT program Phase I
1997 Mid-term appraisal
1997- Ninth Five Years Plan
2002
2000 NLEP Project Phase II
It is a disease of antiquity. The causative organism,
Mycobacterium lepreae was discovered in 1873 by Hanson
Norway.
Sulphon drugs were introduced for treatment of leprosy in 1943.

Burden of Leprosy
World
There are around 1.3 million cases of leprosy in the world
(1996). Leprosy remains a public health problem in 55
countries, but 16 countries account for 91 percent of the total
number of registered cases and five of them (Brazil, India,
Indonesia, Myanmar, and Nigeria) account for about 82
percent. Globally 60 percent of the estimated cases are
contributed by India.
India
• Prevalence rate (PR) is 3.74/10,000 population (March
2001) which was 57/10,000 in 1981.
• Elimination level (<1/10,000) achieved in 13 states—
Nagaland, Haryana, Punjab, Mizoram,Tripura, Himachal
Pradesh, Meghalaya, Sikkim, Jammu and Kashmir,
Rajasthan, Manipur, Assam, and Kerala.
• States close to achieve elimination—Gujarat, Arunachal
Pradesh, Daman and Diu.
 34 Essentials of Community Medicine—A Practical Approach
• Leprosy is endemic mainly in states of Bihar, Jharkhand,
Chhattisgarh, UP, West Bengal, Orissa and MP where 64
percent are found.
• Bihar has 24 percent of recorded leprosy cases in India.
• A total of 5.59 lakh cases were detected in India by 2000-
2001 due to intensification of the program, the highest
number of cases detected in any year.
• Annual new cases detected were 4 to 7.8 lakh. Out of the
total
18.5 percent were children.
• Deformity cases (Grade II and above) among new cases
were
2.7 percent.
• MB cases among new cases were 34 percent.

Essential Indicators for Leprosy

An indicator is a calculation, which is used to measure
different aspects of leprosy control. Indicators can give
different information:
a. They can tell how big or how serious is the problem of
leprosy in the area. It can help one to analyze the situation
regarding leprosy in the area.
b. They can help to assess how well the leprosy control
program is functioning. This will help to plan and run
program more efficiently. The following indicators are
mainly used.

Prevalence Rate (Point Prevalence Rate)

Prevalence indicates the quantum of morbidity due to leprosy
in the community. Prevalence rate is calculated by using the
following formula.

No. of Regd cases in the project are at a

PR = point of time Estimated mid-year × 10,000
population

A reduction in prevalence rate from year to year indicates a

favorable impact of the measures taken.

New Case Detection Rate

NCDR or annual case detection rate ACDR. It is calculated as follows:

No. of new cases detected in the

NCDR
new =
year × 10,000
Mid-year population

New case detection roughly indicates the quantum of

transmission. A reduction in new case detection rate indicates
a reduction in transmission.
 Communicable
Disability Rate Among New Detection
It can be calculated as follows:
No. of new cases having disability grade '2'
= No. of new cases detected during the year × 100
It indicates the efficiency in early detection of cases.

Proportion of Children among New Detection

It can be calculated as follows:
No. of children (0-14 year) cases among new cases
= Total new cases detected during the year × 100
Reduction of this rate in the later years indicates favorable
impact on disease transmission.

Multibacillary (MB) Rate

It can be calculated as follows:

= No. of MB cases among new × 100

cases
Total new cases detected
during the year

Proportion of Single Skin Lesion (SSL) Case Rate

It can be calculated as follows:

= No. of SSL cases detected during the × 100

year
Total no. of new cases detected
during the year

Cohort Cure Rate MB/PB

a. The No.of MB/PB cases put under treatment during the year.
b. The No.of those patients of the Cohort group who have
completed full course of treatment during the next one and
half years.

Cohort cure rate × 100

b
Epidemiology =
a

Agent (Mycobacterium leprae)

1. Sources of infection: Lepromatous and borderline
lepromatous cases in the family or among close contacts.
2. Mode of
transmission:
a.Droplet infection
b.Contact transmission.
3. Period of communicability: Lepromatous and borderline
cases become noninfectious within two weeks of treatment
with rifampicin or three months of treatment with dapsone.
 36 Essentials of Community Medicine—A Practical Approach
4. Incubation period: Long, usually three to five years, shorter
incubation in tuberculoid leprosy.
5. Secondary attack rate: Five to twelve percent.

Host
1. Age: Occurs at all ages, with maximum incidence during 10 to 20
years
2. Sex: More in males, M:F is 3:2 in all types of leprosy
and 3:1 in lepromatous type of leprosy.
Environmental and Social Factors
1. Physical environment
2. Social environment
3. Biological environment.
Physical environment: The factors are:
a. Large family size
b. Over crowding
c. Poor ventilation
d. Urban slum.
M. leprae can remain viable in dried nasal secretions for 9
days and in moist soil for 46 days.
Social environment: Deep rooted prejudices lead to social
ostracism of patients with leprosy, Thus, there is delay in
seeking treatment, thereby increasing the possibility of
transmission.
Biological environment: Wild armadillos in limited area of USA
have been found to be infected.
a. Genetic factor-HLA linked gene
b. Migration

Mode of Transmission

1. Droplet infection
2. Contact transmission
3. Other routes
a.Breast milk
b.Insect vector
c.Tattooing needles.

Clinical Features
Presentation depends upon cell mediated immunity of the
patient (Tables 4.9 and 4.10).
 Communicable
Table 4.9: Classification of leprosy
NLEP Ridely and Jopling Indian International (Madrid)
Paucibacillary Indeterminate Indeterminate Indeterminate
TT Tuberculoid Tuberculoid
BT Pure neuritic
Multibacillary BB Borderline Borderline
BL Lepromatous
LL Lepromatous Lepromatous

Table 4.10: Immunological status and type of leprosy

Immunological status Type of disease
1. Poor immunity Lepromatous (LL) leprosy
2. Intermediate immunity Borderline leprosy (BB, BL, BT)
3. Good immunity Tuberculoid (TT) leprosy

Lepromatous Leprosy
Early manifestations commonly missed by patients include:
1.Nasal symptoms:
a. Stuffiness
b. Crust formation
c. Blood stained discharged from nose.
2.Edema of legs and ankles:
a. Bilateral and symmetrical
b. More marked in the
evening. Other overt
manifestations include:
1. Skin lesions:
a. Macules (more common, papules and nodules.
b. Bilateral symmetrical and large.
c. Sites: Face, arms, buttocks, legs and trunk.
d. Hypopigmented.
2. Leonine facies:
a. Thickening of skin of forehead, causes deepening of the natural
lines.
b. Ear lobes are thickened.
c. Eyebrows are lost (madarosis).
d. Nasal bridge may collapse.
3. Superficial nerves:
a. Thickened
b. Glove and stocking anesthesia.
4. Testicular atrophy leading to:
a. Sterility
b. Impotence
c. Gynecomastia.
 38 Essentials of Community Medicine—A Practical Approach
5. Bone:
a. Periostitis
b. Disuse osteoporosis.
6. Eye:
a. Superficial punctate keratitis.
Diagnosis
1. Clinical examination
2. Bacteriological examination
3. Foot-pad culture
4. Histamine test
5. Biopsy
6. Immunological tests.
Clinical Examination
Diagnosis is fairly easy in lepromatous and non-lepromatous
cases if the disease is just kept in mind. Simple diagnostic
guidelines have been outlined by WHO. Difficulty may arise in
the indeterminate type. It should be confirmed by
bacteriological examination of the material obtained by the
routine ‘slit-and-scrape’ method from the edge of the lesion or
from the lobule of the ear. Nasal smear may also be used. Skin
and nerve biopsy may be performed in non-lepromatous cases.
Early detection of subclinical cases is obviously of great
importance in control of leprosy.
The following three are helpful in this:
i. Enlargement of great auricular nerve.
ii. Search for AFB in ear lobes of contacts of leprosy patients.
iii. Immunological test aimed at assessing cell mediated or
humoral immunity. The most commonly used test for cell
mediated immunity is the lepromin test, using either the
Mitsuda or Dharmendra lepromin preparation. There is
evidence that the tests for humoral immunoresponse,
such as FLA-ABS, may be much more sensitive than
lepromin test alone.
The government has brought out a simple guide for medical
officers to help them to diagnose and manage leprosy patients.
Some practical guidelines for diagnosis are given below.
What are the principles of skin examination? How does one examine
the skin?
1. Choose a spot where good light is available.
2. As far as possible, choose a spot where there is privacy.
3. Always examine the whole skin from head to toe.
4. Use the same order of examination always so that you do
not forget to examine any part of the body.
5. Compare both sides of the body.
 Communicable
What should one look for in the skin?
The following features must be noted when examining a patch on the
skin:
• Site: This is useful for follow-up.
• Number: The number of lesions indicates the severity of the
disease. This is useful for classification and follow-up.
• Color: May be hypopigmented (lighter in color than the rest
of the skin), or erythematous (red). Lesions of leprosy are
never depigmented. Erythematous color can be used to
identify disease activity or a reactional state (Active lesions
or those in reaction are often red).
• Sensory loss: This is useful both for diagnosis and classification
of leprosy. Loss of sensation is a cardinal sign of leprosy.
• Tenderness on gentle tapping: This is seen in reactional states.
• Presence of infiltration: This term refers to skin which is
thickened, shiny and erythematous. All three features must
be present in the same area. This may be seen in severe
forms of leprosy.

How should One Test for Sensation?

Remember the cardinal sign: Hypopigmented or reddish skin
lesion(s) with definite loss of sensation.
It is very important to pick up the skill of eliciting sensory
loss in skin patch.
• You will need a ball point pen/pin, etc.
• Explain to the person what you are going to do and demonstrate it.
• Touch the skin with the pen/pin. Ask the person to count
aloud each time he feels the pen/pin. Alternatively, ask the
individual to point to the spot touched with his finger.
• Repeat this procedure a few times until the patient is
familiar and comfortable with the procedure.
• Now ask the patient to close his eyes and repeat over the
area to be tested. Alternatively, the person should be
blindfolded or some barrier should be used to prevent his or
her from watching the procedure.

Remember
1. Do not keep asking the patient whether he feels the pen/pin
or not. You may get misleading results.
2. When testing for sensation, touch the skin lightly with the
pen/pin. Do not stroke.
3. Proceed from the normal skin to the abnormal.
4. Give only one stimulus at a time.
5. Vary the pace of testing.
What are the General Principles of Nerve Palpation?
Examination of nerves in all the patients is very important for
prevention of deformity. This involves two aspects:
 40 Essentials of Community Medicine—A Practical Approach
• Palpation of the nerves for thickening, tenderness and consistency.
• Assessment of nerve function.
1. When palpating the nerves, you should look for three
things: Thickening, tenderness and consistency.
2. When palpating the nerve, the patient should be properly
positioned. The examiner should also be positioned
correctly.
3. Always compare both sides to assess thickness and consistency.
4. Look at the patient’s face while palpating the nerve to
elicit tender- ness.
5. Always palpate across the course of the nerve.
6. Feel along the nerve as far as possible in both directions.
7. Palpate gently with the pulp of the finger, not the tip.
How should We assess Nerve Function?
Nerve function assessment includes both motor and sensory
function, i.e. Voluntary Muscle Test (VMT) and Sensory Test
(ST). Both VMT and ST should be done for:
a. All patients with nerve thickening.
b. All patients with multibacillary leprosy.
How is Voluntary Muscle Testing done?
Voluntary muscle testing is done by first checking the range of
movement to see whether movement is normal, reduced or
absent due to paralysis. If movement is normal, a test for
resistance is then done (Fig. 4.2). Press gently in the opposite
direction while asking the patient to maintain position,
resisting pressure as strongly as possible. Then gradually
press more firmly and judge whether resistance is normal,
reduced or absent. Always compare the right side with the
left. The grading of the result can be done as follows:
• S (Strong)—Able to perform the movement against full resistance.
• W (Weak)—Able to perform the movement but not
against full resistance.
• P (Paralysed)—Not able to perform the movement at all.

Bacteriological Examination
• Skin smear
• Nasal smear
• Nasal scraping.

Bacterial Index (BI)

Bacterial Index (BI) is the only objective way of monitoring the
benefit of treatment. The WHO grading of smears for BI is as follows:
Negative : No bacilli found in 100 fields
One plus (+) : One or less than one bacillus in each
microscopic field
 Communicable

Fig. 4.2: Diagram of the human body showing nerves commonly invoiced in leprosy

Two plus (+ +) : Bacilli found in all

fields Three plus (+ + +) : Many bacilli
found in all fields
Add G to the entry if globi are present
Bacterial index is calculated by totalling the number of +
given to each smear and dividing this number by the smears
collected. A minimum of seven sites should be examined;
smears from four skin lesions, one nasal swab, and smears
from both ear lobes, e.g.
Right ear +++
Left ear +++
Nasal smear +++
First skin lesion +++
Second skin lesion ++
Third skin lesion +++
Fourth skin lesion +
+
1
9
Bacterial index (BI)= 7 sites of examination
 42 Essentials of Community Medicine—A Practical Approach
In paucibacillary leprosy the bacterial index is less than two; in
multibacillary leprosy, it is greater than two.
Two other types of grading are also in use for reporting bacterial
index,
e.g. Dharmendra’s scale and Ridley’s scale.

Morphological Index (MI)

During the course of microscopic examination of smears, it is
possible to distinguish and count the number of solid staining
organisms (organisms that stain completely) and irregularly
staining bacilli. The percentage of solid staining bacilli in a
stained smear is referred to as Morphological Index (MI). The
total of the MIs for all sites divided by the number of sites
gives the average MI for the body. The criteria for calling the
bacilli solid rods are:
a. Uniform staining of the entire organism
b. Parallel sides
c. Rounded ends
d. Length five times that of the width.
It has been widely believed that only solid-staining organisms are
viable.
Recently, however, doubts have been raised about this notion.

Histamine Test (Table 4.11)

This is very reliable method of detecting at an early stage
peripheral nerve damage due to leprosy. The test is carried
out by injecting 0.1 ml of 1:1000 histamine phosphate
intradermally into the hypopigmented patches or in areas of
anesthesia.
Table 4.11: Histamine test—result and interpretation
Result Interpretation
Bright flare (triple response) Normal skin
Delayed and feeble flare Indeterminate
Flare absent (BB)
Tuberculoid (TT)

Sweat Test (Table 4.12)

This test is recommended when difficulty is experienced in the
diagnosis, as for example, indeterminate leprosy.
0.2 ml of 1:1000 solution of pilocarpine is injected intra-
dermally. Paint with iodine and dust with starch powder.
Table 4.12: Sweat test—result and interpretation
Result Interpretation
Blue discoloration No color Normal skin Leprosy

Lepromin Test
It is used to classify the type of lesion.
 Communicable
0.1 ml of antigen is injected intradermally. The reaction
is read at 48 hours and 21 days.
Early reaction (Fernadez reaction): An inflammatory response
develops within 24 to 48 hours and this tends to disappear
after 3 to 4 days. It is evidenced by redness and induration at
the site of inoculation. If the diameter of the red area is more
than 10 mm at the end of 48 hours, the test is considered
positive. The early positive reaction indicates whether or not a
person has been previously sensitized by exposure to and
infection by the leprosy bacilli. The early reaction is induced by
soluble constituents of the leprosy bacilli. The reaction
corresponds to Mantoux reaction in TB.
Late reaction (Mitsuda reaction): The test is read at 21 days.
If there is a nodule more than 5 mm in diameter at the site of
inoculation, the reaction is said to be positive. The late
reaction is induced by the bacillary component of the antigen.
It indicates cell mediated immunity.
Value of the lepromin test: Lepromin test is not a diagnostic
test. It evaluates the immmune status of leprosy patients. It
helps in classification of leprosy.
This test also helps in assessing the prognosis in cases of
leprosy of all types.
Utility of lepromin test: In classifying the types of leprosy (Table
4.13).
Table 4.13: Classifying the types of leprosy
Test Type of leprosy
+++ TT BT
++ BB, BL, LL
–ve
Lepromin positive individuals either escape the clinical
disease (the majority) or develop paucibacillary disease.
Lepromin negative individuals are at a higher risk of developing
progressive multibacillary leprosy.
Deformities Occurring in Leprosy (Table 4.14)
Table 4.14: Deformities occurring in leprosy
Face Mask face, facies leonina, sagging face, lagophthalmos,
loss of eye-brows (superciliary madarosis) and eyelashes
(ciliary madarosis), corneal ulcers and opacities,
perforated nose, depressed nose, ear deformities, e.g.
nodules on the ear and elongated lobules
Hands Claw hand, wrist-drop, ulcers, absorption of digits, thumb-
web contracture, hollowing of the interosseous spaces and
swollen hand
Feet Plantar ulcers, foot-drop, inversion of the foot, clawing of
the toes, absorption of the toes, collapsed foot, swollen
foot and callosities
Other deformities Gynecomastia and perforation of the palate
 44 Essentials of Community Medicine—A Practical Approach
Features of Lepra Reactions (Reversal Reaction) (Table 4.15)
Table 4.15: Features of lepra reactions (reversal reaction)
Features Type 1 (Reversal reaction) Type 2 (Erythema nodosum
leprosum reaction)
Skin Existing lesions suddenly become Red, painful, tender, subcutaneous
red, swollen warm, and tender. (deep) nodules (ENL) appear
New lesions may appear commonly on face and arms and
legs. They appear in groups and
subside within a few days
Nerves Lesions when subsiding may Nerves may be affected but not as
show scales on the surface. commonly as in type 1
Nerves close to the skin may
become enlarged, tender and
painful (neuritis) with loss of
nerve function
Other Not affected Other organs like eye, joints, bones,
organs testes, kidney may be affected
General Not common Fever, joint pains, fatigue symptoms

Clinical Difference between Reversal Reaction and Relapse (Table

4.16)
Table 4.16: Clinical difference between reversal reaction and relapse
Reversal reaction Relapse
Time Generally occurs during Usually occurs only when
interval chemotherapy or within chemotherapy has been
6 months of stopping treatment discontinued, after an interval of
usually more than 6 months
Onset Abrupt and sudden Slow and insidious
Old lesions Existing lesions become Lesions may show erythema and
edematous, erythematous infiltration, but no tenderness
or tender
New Several new lesions appear New lesions are few
lesions
Ulceration Lesions may ulcerate Ulceration does not occur
Nerve Multiple nerve involvement Nerve involvement may occur only
involve- common, painful and tender in a single nerve; usually no pain,
ment tenderness
General May have fever, joint pains, Not usually affected
condition malaise
Response Rapid Nil
to steroid
treatment

Treatment of Reversal Reaction

During reversal reaction (multidrug therapy) MDT should be
contained without interruption along with antireaction
treatment.
 Communicable
Antileprosy Drugs and their Characteristics (Table 4.17)
Table 4.17: Antileprosy drugs and their characteristics
Drug Dose (mg) Bactericidal activity
Dapsone 100 +
Rifampicin 600 +++
Ethionamide 375 ++
Prothionamide 375 ++
Clofazimine 100 +

Patient Grouping for MDT (Table 4.18)

Table 4.18: Patient grouping for MDT
Group criteria PB single skin lesion PB (Paucibacillary) MB (Multibacillary)
(patch) PB-SSL leprosy leprosy
Skin lesions 1 skin lesions 2-5 lesions 6 and above
asymmetrically Symmetrically
distributed distributed
Nerve No nerve No nerve More than one
involvement involvement involvement/ nerve trunk
only one nerve trunk involvement
Skin smear Negative at all sites Negative at all sites Positive at all sites

Dosage Schedule for MDT (Table 4.19)

Table 4.19: Dosage schedule for MDT
Drugs used Dosage Frequency of Criteria for cure
(adults) administration
MB leprosy Rifampicin 600 mg Once monthly Completion of 12
Dapsone 100 mg Daily monthly. Pulses
Clofazimine 300 mg Once monthly within 18 months
50 mg Daily
PB leprosy Rifampicin 600 mg Once monthly Completion of 6
Dapsone 100 mg Daily monthly. Pulses
within 9 months
Single skin Rifampicin 600 mg Single dose Administration of
lesion Ofloxacin 400 mg Single dose single dose
leprosy Minocycline 100 mg Single dose treatment (ROM)

If there is no nerve involvement-rest and analgesics only are

used. If there is nerve involvement-corticosteroids
(Prednisolone) are given in addition to rest and analgesics.
A suggested course of prednisolone for an adult patient is as
follows:
• 40 mg once a day for the first 2 weeks then
• 30 mg once a day for 3 and 4 weeks
• 20 mg once a day for 5 and 6 weeks
• 15 mg once a day for 7 and 8 weeks
• 10 mg once a day for 9 and 10 weeks
• 5 mg once a day for 11 and 12 weeks.
The daily dose of prednisolone should not exceed 1 mg/kg body
weight.
 46 Essentials of Community Medicine—A Practical Approach
Treatment of ENL Reaction
ENL reaction occurs only in MB cases.
• For mild reactions, bed rest, aspirin or paracetamol are sufficient.
• In case of nerve involvement, treatment with prednisolone
should be started immediately during ENL reaction. MDT
should be continued without interruption along with
antibiotic treatment.
Completion of Treatment and Cure
• Any SSL patient who has taken one dose of ROM should be
considered as cured.
• Any PB patient who has taken six months of PB-MDT within
9 months should be considered as cured.
• Any MB patient who has taken 12 months of MB-MDT within 18
months should be considered as cured
• All such patients should be told about the early signs of
reactions and relapse and asked to report any such events
promptly to the center. If the individual has sequelae due
to the disease, such as disabilities he/she should be
encouraged and helped to use the available facilities at the
health centre or at an appropriate referral center.
It is important to remember that a leprosy patient who has
completed a full course of treatment should no longer be
regarded as a case of leprosy even if some sequelae of leprosy
remain.
Side Effects of Anti-leprosy Drugs (Table 4.20)
Table 4.20: Side effects of anti-leprosy drugs
Common Signs and What to do if side
side effects symptoms effects occur
Dapsone
Anemia Paleness inside the lower eyelids, Give anti-worm treatment
tongue and finger nail and iron tablets. Continue
Tiredness, edema of feet and dapsone
breathlessness
Severe skin Extensive scaling, itching, ulcers Stop dapsone. Refer to
complication in the mouth, the eyes, jaundice hospital immediately.
(Exfoliative and reduced urine output Never restart
dermatitis)
Abdominal Abdominal pain, nausea, and Symptomatic treatment.
symptoms vomiting on high doses Reassure the patient
Liver damage Jaundice (Yellow color Stop dapsone. Refer to
(Hepatitis) of skin, eyeballs and urine), hospital, restart after the
loss of appetite and vomiting jaundice subsides.
Kidney damage Edema of face and feet Stop dapsone. Refer to
(Nephritis) Reduced urine output hospital
Contd....
 Communicable
Contd....
Rifampicin
No significance Reddish coloration of urine, Reassure the patient
saliva and sweat
Hepatitis Jaundice (yellow color of skin, Stop Rifampicin. Refer
to (liver damage) eyeballs and urine) hospital restart after the
jaundice subsides
Flu-like illness Fever,malaise and body ache Symptomatic treatment
Allergy Skin rash Stop rifampicin
Clofazimine
No significance Brownish-red discoloration Reassure the patient, it will
of skin, urine, and body fluids go after completion of
treatment
Ichthyosis Dryness and thickening of the Apply oil to the skin
skin, itching Reassure the patient
Eye Conjuctival dryness Moistening eye drops
Abdominal Abdominal pain, nausea and Symptomatic
treatment symptoms vomiting on high doses
Reassure the patient
Ofloxacin*
Abdominal Abdominal pain, nausea and Symptomatic
treatment symptoms vomiting on high doses
Reassure the patient Central nervous Sleeplessness,
headaches, Symptomatic treatment system dizziness,
nervousness, Reassure the patient complaints hallucinations
Dizziness — Reassure the patient
Discoloration — Reassure the patient
of the teeth in
children
Pigmentation — Reassure the patient
of the mucous
membranes
Abdominal Abdominal pain, nausea and Symptomatic
treatment symptoms vomiting on high dose
Reassure the patient
* With a single dose regimen (ROM) complications are rare. However, this drug is also not
recommended for use in pregnant women and children below five years of age.
• Any patient showing a positive skin smear, irrespective of
the clinical classification, should be treated with the MDT
regimen for MB leprosy.
• When classification is in doubt, the patient should be
treated with the MDT for MB leprosy.

LEPROSY CONTROL

Leprosy Control Programs

1. Medical measures
a. Estimation of the problem
b. Early case detection
 48 Essentials of Community Medicine—A Practical Approach
c. Multidrug therapy
d. Surveillance
e. Immunoprophylaxis
f. Chemoprophylaxis
g. Rehabilitation
h. Health education
i. Others
2.Social support
3.Program management
4.Evaluation.

Candidate Vaccines
In view of the variable protective effect of BCG vaccine
against leprosy, several alternative vaccine preparations are
under development. They should more appropriately be called
“ Candidate Vaccines” (Table 4.21).
Table 4.21: Candidate vaccines
Category I (based on M. leprae) Category II
(based on cultivable mycobacteria)
Killed M. leprae BCG
Killed M. leprae + BCG AcetoacetylatedBCG
M. leprae
+ M. vaccae
Killed ICRC bacillus

Health Education

Leprosy Educational Messages

1.Leprosy is the least communicable of all infectious diseases.
2.Four out of five leprosy cases in India are of the noninfectious
kind.
3.The treatment available today renders infectious cases
noninfectious in as little as five or six weeks with the help
of MDT.
4.Leprosy does not strike overnight. It can take years to
manifest itself. A very prolonged exposure to untreated,
infectious cases is necessary for the signs of the disease to
become manifest.
5.Leprosy is neither hereditary nor a curse. It is caused by a germ.
6.Leprosy is completely curable.
7.Leprosy need not result in deformities at all. If detected
and treated early, it leaves no physical scars.
8.The nerve and limb complications that lead to deformity
are not inevitable; they are the result of neglect.
9.Leprosy can be cured even at an advanced stage, though it
may not be possible to correct all the deformities.
10. Leprosy is not a poor man’s disease. It can occur in
any social or economic class, even among the affluent.
11. Leprosy is not only an adult’s disease: 20 percent of all
newly detected cases are children.
 Communicable
12. Leprosy is more than just a medical problem and, for
the disease to be fully treated, community support is as
important as medical help.
13. The leprosy patients can stay at home without any risk
and continue to work because, once the treatment is
started, the disease is contained.
14. The first signs of leprosy are:
a. A pale or red patch which could be oily, smooth or dry.
The patch is neither painful nor itchy.
b. Loss of hair and lack of sweating in the discolored area.
c. Numbness in the patch.
d. A tingling or “ant-crawling” sensation along the affected nerve.
15. Leprosy is curable. All it needs is:
a. Early detection
b. Early intervention
c. Sustained treatment
d. Community support throughout.
16. Treatment of leprosy is absolutely free.

Rehabilitation
All cured cases should be provided suitable jobs through
government or private agencies. Modern plastic and
orthopedic surgery and physio- therapy should be used to treat
disfiguration and deformities and to restore appearance and
function. Burnt out cases with marked deformities may be
kept in special rehabilitation centers.

Leprosy Organizations in India

There are many voluntary organizations working in the field of
leprosy in India. These include:
1. Leprosy Mission: This was the first voluntary organization
for leprosy work in India. It was started in 1874 by Bailey in
Chamba, Himachal Pradesh. Its headquarter is presently in
Purulia, West Bengal.
2. Hind Kushth Nivaran Sangh: This pioneer organization was
established in India in 1947 as a branch of the British
Empire Leprosy Relief Association founded in London in
1925.
3. Gandhi Memorial Leprosy Foundation, Sevagram, Wardha.
4. Belgium Leprosy Center (Polambakkam, Chennai).
5. Danish Save the Children Fund.
6. Bharat Sewashram Sangh, Jamshedpur, Bihar.
7. Kashi Kushth Seva Sangh ,Varanasi, UP.
8. Tapovan, Amravati, Maharashtra.
9. Hindu Mission, Chennai, Tamil Nadu.
Two other important organizations active in the field of
leprosy are the Jalma Central Institute of Leprosy (taken over
by ICMR in 1975) and the Central Leprosy Teaching and
Research Institute, Chingleput, Tamil Nadu.
 50 Essentials of Community Medicine—A Practical Approach
National Leprosy Eradication Program (NLEP)
This program was started in 1983.
Strategies
The program has the following four strategies:
1. Provide domiciliary treatment (MDT) in endemic districts
through staff trained in leprosy.
2. Provide services through mobile leprosy treatment units
with the help of primary health care staff in moderate and
low endemic districts.
3. Organize health education to patients, their families and the
community to increase awareness and to remove stigma.
4. To Provide deformity and ulcer care and medical
rehabilitation services to the needy patients.
Infrastructure
It is shown in Table 4.22.
The term elimination refers to the reduction in the prevalence
of leprosy to below one case per 10,000 population. There will
be drastic reduction in the prevalence of a disease to the
extent that it no longer remains a public health problems.
Eradication refers to the complete stopping of transmission
as a result of total disappearance of the diseases causing
organism. The aim is to reduce case load to 1 or less than 1
per 10,000 population.
Modified Leprosy Elimination Campaigns
The Modified Leprosy Elimination Campaigns (MLEC)
approach is actually organizing camps for one or two weeks
duration in which services like cases detection, treatment and
referral to reconstruction facilities are available. A wide level
information about camps services and about disease
disseminated through radio, TV, newspapers, loudspeaker, etc.
Table 4.22: Infrastructure
Unit Scale No existing Remarks
Leprosy control unit One per 4.5 lakh 778 In endemic rural
(LCU) or modified LCU population areas headed by a
Medical Officer
Urban leprosy center (ULC) One for 50,000 907 Manned by one
population paramedical worker
responsible to the
MO of a dispensary
or hospital
Survey education and One per 25,000 5744 In low endemic
areas,
treatment center (SET) population attached to a PHC or
hospital manned by a
paramedical worker
under guidance of
MO, PHC
Contd...
 Communicable
Contd....
Mobile leprosy treatment 350 In non-endemic
units (MLTU) districts headed by a
Medical Officer.
Temporary hospitalization 290
ward (THW)
Reconstructive surgery 75
units (RSU)
Samples survey cum 40
assessment unit (SSAU)

MLEC has proved quite effective for case finding and has been
employed during phase II. Two rounds of MLEC will be held
during phase II; the specific MLEC strategy is varied
according to the endemicity of different regions:

Action Plan of MLEC (Table 4.23)

Table 4.23: Action plan of MLEC
Endemicity 1 MLEC year 1 2 MLEC year 2 Year 3
High endemic Active search statewise Mixed approach Special action
states in UP, Bihar, West active search and projects for the
Bengal, mix of active VRCs depending elimination of
search and VRCs in upon endemicity of leprosy (SAPEL)
Orissa and Madhya individual districts/ and LECs in tribal
Pradesh pockets areas. In Bihar,
voluntary reporting
centers (VRCs)
Moderate/low VRCs for 2 days VRCs for 2 days For 2 days
endemic with training and with training and
states IEC support support
Very low IEC activity, passive IEC activity,
endemic reporting passive reporting
states

Special Action Projects for the Elimination of Leprosy

Special Action Projects for the Elimination of Leprosy (SAPEL)
is an initiative aimed at providing MDT services to patients
living in special difficult to access areas or situation or to
those belonging to neglected population groups. The most
important thing is for the elimination program to reach
everyone who needs MDT services. Innovative and practical
strategies involving mainly operation solutions are be used in
order to provide MDT to these patients.

Global Leprosy Elimination Program

Revised Intensified Strategy 2000-2005 (Modified Leprosy
Elimination Campaign and SAPELS).
 52 Essentials of Community Medicine—A Practical Approach
Elements of the Intensified Program
1. Identification of endemic districts
2. Integration of MDT services with general health services
3. Monitoring elimination at district level
4. Promoting community action
5. Social marketing/advocacy
6. Re-motivating the research community
7. Prevention of disability and rehabilitation.
FILARIASIS
Filariasis is a global problem. (More than 1.1 billion people
live in areas where there is a risk of infection.) It is estimated
that globally 751 million population is exposed to the risk of
filariasis. Half of these cases are in India.
Burden of Disease
Lymphatic filaria is prevalent in 18 states and union territories.
Bancroftian filariasis is widely distributed while brugian
filariasis caused by Brugia malaya is restricted to 6 sates—
Uttar Pradesh, Bihar, Andhra Pradesh, Orissa, Tamil Nadu,
Kerala, and Gujarat. The WHO has estimated that 600 million
people are at risk of infection in South-East Asia and 60 million
are actually infected in the region (WHO-SEARO 1999). There
are about 454 million people (75.6%) at the risk of infection
with 48 million (80%) infected with parasite are contributed
only by India.

Epidemiology

Human Filarial Infections

Agents
1. Wuchereria bancrofti
2. Brugia malayi
3. Brugia timori
4. Onchocerca volvulus
5. Loa loa
T. perstans
T. streptocerca
6. Mansonella ozzardi
Vectors
1. Culex mosquitoes
2. Mansonia mosquitoes
3. Anopheles mosquitoes
4. Simulum flies
 Communicable
5. Chrysopes flies
6. Culicoides.
Host
Man is the definitive host and mosquito is the intermediate host
of Bancroftian filariasis.
• Age — All age group
• Sex — Higher in males
• Social factors — Urbanization, industrialization, poverty, illiteracy

Environmental Factors
Climate: It influences the breeding of mosquitoes.
• Temp 22 to 38.°C
• Humidity—70 percent
• Town planning—this disease is associated with bad
drainage.Vectors breed profusely in polluted water.
• Incubation period = 8 to 16 months.
Clinical Manifestations
I. Lymphatic filariasis
II.Occult filariasis
Lymphatic Filariasis
a. Asymptomatic amicrofilaremia
b. Asymptomatic microfilaremia
c. Stage of acute manifestation
d. Stage of chronic obstructive lesions—elephantiasis of leg,
scrotum, arms, penis, vulva and breasts.
Survey
1. Mass blood survey
a. The thick film
b. Membrane filter concentration
c. DEC provocation test
(DEC—100 mg—administered orally, microfilaria begin to
reach peak in 15 minutes and begin to decrease 2 hours
later, the blood may be examined one hour after
administration of DEC).
2. Clinical survey
3. Serological test
4. Xenodiagnosis
5. Entomalogical survey.
Control Measures
1. Chemotherapy
2. Vector control.
 54 Essentials of Community Medicine—A Practical Approach
Chemotherapy
For the individual case treatment: Diethylcarbamazine (DEC)
is given for Bancrofti filariasis in the dose of 6 mg/kg body
weight orally daily for 12 days in divided doses after meal (a
total of 72 mg per kg of DEC). For the Brugian filariasis, DEC
is given 3 to 6 mg/kg body weight per day up to total dose of
18 to 72 mg per kg.
Mass treatment: Every member of the community irrespective
of infection are treated with DEC. This mode of control has
been tried in many areas. In some areas selective cases of
microfilaria positive are treated with DEC.
Revised strategy: Single dose mass treatment of
diethylcarbamazine (DEC) alone or combined with
Ivermectine, repeated at six months or one year, is claimed to
bring down the microfilaria rate by over 80 percent. DEC-
fortified table salt brings the microfilaria rate to a negligible
level within eight months of its introduction.
Vector Control
1. Antilarval measures
2. Antiadult measures
3. Personal prophylaxis.

National Filaria Control Program

It was launched in 1955. In June 1978, the operational
component of the National Filaria Control Program (NFCP)
was merged with urban malaria scheme. The program has
been extended to rural areas since, 1994.
1. Delimitation of the problem in the hitherto unsurveyed areas.
2. Control in urban areas through recurrent anti-larval
measures and antiparasitic measures.
3. Filaria clinic were established at the rate of one clinic for 50,000
population. Work involves collection of night blood samples
by home visiting. Each unit is expected to cover the alloted
population in 2 to 2.5 years. Cases are treated with 72 mg
DEC.

National Health Policy

“Elimination of lymphatic filariasis by 2015”.

DIARRHEA AND DYSENTERY

Diarrhea is one of the most common causes of death in under-five
children. Almost 99 percent of death can be prevented by
treating with ORS solution.

Definition
Diarrhea is defined as the passage of loose liquid watery
stools. The liquid stools are usually passed more than three
times a day. The recent change
 Communicable
in consistency and character of stools rather than frequency
that is more important.
Acute diarrhea — Lasts for three to seven
days Chronic diarrhea — Lasts for three
weeks or more
What is Not Diarrhea?
• Passage of frequent formed stools
• Passage of pasty stools in a breastfed child
• Passage of stools during or immediately after feeding
• Passage of frequent loose greenish yellow stool in the 3rd
and 4th day of life (Transitional diarrhea).

Dysentery
If blood is visible in stools the condition is called dysentery.

Gastroenteritis
The term gastroenteritis is used to describe acute diarrhea.

Problem of Diarrheal Disease

The median diarrheal incidence rate ranges from 1.0 to 4.7
episodes per year. In slum areas of major cities an incidence
as high as 10.5 episodes per child per year was also reported.
About 3 million deaths globally are associated with diarrhea.
India alone account for one-third of these deaths. Around 65
percent of deaths are due to dehydration, 20 to 35 percent
due to persistent diarrhea and remaining 15 percent due to
dysentery. Beside this there is problem of re-emergence of new
strains of Cholera, Escherichia and Shigella that need to be
tackeld properly otherwise nation may face the severe
epidemics.
Upto one-third of total pediatric admissions are due to diarrhea
disease
and up to 17 percent of all deaths in indoor pediatric patients
are diarrhea related.

Causes of Diarrhea (Table 4.24)

Table 4.24: Causes of diarrhea
Pathogen % of cases
Virus Rotavirus 15-25
Bacterial Escherichia coli 10-20
Shigella 5-15
Campylobacter jejuni 10-15
Vibrio cholerae 5-10
Salmonella 1-5
Protozoans Cryptosporidium 5-15
No pathogen found 20-30
 56 Essentials of Community Medicine—A Practical Approach
Diarrhea Control Program
Components of diarrhea disease control program—started in
1978. Since 1985 to 86 Nation has started oral rehydration
therapy.
Short-term
1. Appropriate clinical management
2. Appropriate feeding
3. Chemotherapy.
Long-term
1. Better MCH care practices
a. Maternal nutrition
b. Child nutrition :
i. Promotion of breastfeeding
ii. Appropriate weaning practices
iii. Supplementary feedings.
2. Preventive strategies
a. Sanitation
b. Health education
c. Immunization
d. Antifly measures
3. Preventing diarrhea epidemics.

CHOLERA
Cholera is a notifiable disease all over India as well as to
WHO. Being a disease of poor sanitation, poor water, and food
hygiene, it occurs as endemic, sporadic and pandamic.
Typical cases are characterized by the sudden onset of profuse,
effortless, watery diarrhea followed by vomiting, rapid
dehydration, muscular cramps and suppression of urine
formation.
Case fatality rate is 30 to 40 percent varies from 10 to
80 percent. Epidemiology, clinical features,
complication and investigation.

Epidemiology

Agent
Vibrio cholerae: There are two types of vibrio cholerae:
1. Classical vibrio cholerae
2. ELT or vibrio cholerae
There are two serotypes:
a. Ogawa
b. Inaba
 Communicable
Source of infection: Contaminated food and water.
Period of communicability: The patient is infective during the
later part of incubation period and during the periods of
disease and convalescence which lasts for 7 to 10 days.
Mode of transmission: Feco-oral route
Incubation period: One to five days , usually 12 hours to 2 days.

Clinical Features
Stage of evacuation
1. Profuse vomiting.
2. Frequent loose motions, watery, copious, with flakes of
mucus (Rice water stool).
Stage of collapse
1. Hypovolemic shock, due to massive diarrhea and vomiting.
2. Tachycardia and tachypnea.
3. Oliguria.
4. Cold and clammy skin.
Stage of recovery
1. Vomiting and loose motions decrease.
2. Hydration improves.
3. Normal temperature returns.

Atypical Presentation
Cholera sicca: It is a fatal variety, in which there is very little
or no diarrhea or vomiting, and patient develops collapse very
rapidly with overt manifestations.
Complications
1. Hypovolemic shock
2. Acute renal failure
3. Electrolyte disturbances (hypokalemia)
4. Enteritis
5. Cholecystitis
6. Stroke in the elderly patient.
Investigations
1. Leucocytosis with polymorphonuclear predominance.
2. Stool swab, for demonstrating darting motility, of V. cholerae
3. Stool culture for V. cholerae
4. Slide agglutination using polyvalent anti-cholera, dignostic serum.
 58 Essentials of Community Medicine—A Practical Approach
Control of Cholera
1.Verification of the diagnoses
2.Notification
3.Early case finding
4.Establishment of treatment centers
5.Rehydration therapy
6.Adjuncts to therapy
7.Epidemiological investigation
8.Sanitation measures
9.Chemoprophylaxis
10. Vaccination
11. Health education.

Rehydration Therapy
Oral rehydration: The introduction of oral rehydration, by
WHO in 1971, has greatly simplified the treatment of cholera
and other acute diarrhea diseases. The aim of oral fluid therapy
is to prevent dehydration and reduce mortality (Tables 4.25 and
4.26).
Table 4.25: Composition of ORS—bicarbonate
Ingredient Quantity
Sodium chloride 3.5 g
Sodium bicarbonate 2.5 g
Potassium chloride 1.5 g
Glucose (dextrose) 20.0 g
Potable water 1 liter

Table 4.26: Composition of ORS—citrate

Ingredient Quantity
Sodium chloride 3.5 g
Trisodium citrate dehydrate 2.9 g
Potassium chloride 1.5 g
Glucose 20.0 g
Potable water 1 liter
Assessment of Dehydration (Table. 4.27)

Table. 4.27: How to assess your patient

FOR DEHYDRATION FOR OTHER PROBLEMS
A B C
1. Ask about: Diarrhea Less than 4 liquid stools per day 4 to 10 liquid stools per More than 10 liquid stools per day Longer than 14 days duration. Blood in the stool
Vomiting None or a small amount day Some Very frequent
Thirst Normal Greater than normal Unable to drink
Urine Normal A small amount, dark No urine for 6 hours
2. Look at: Condition Well, alert Unwell, sleepy or irritable Very sleepy, unconscious Severe undernutrition
floppy or having fits
Tears Present Absent Absent
Eyes Normal Sunken Very dry and sunken
Mouth and Wet Dry Very dry
Tongue
Breathing Normal Faster than normal Very fast and deep
3. Feel: Skin A pinch goes back quickly A pinch goes back slowly A pinch goes back very
Pulse Normal Faster than normal slowly Very fast, weak or you
cannot feel it
Fontanelle Normal Sunken Very sunken
(in infants)
4. Take temperature Fever-38°C (or 101°F) or greater
5. Weigh if possible Loss of less than 25 grams Loss of 25-100 grams Loss of more than 100 grams
for each kilogram of weight for each kilogram of weight for each kilogram of weight
6. Decide The patient has no signs of If the patient has 2 or more If the patient has 2 or more of If your patient has: Then:
dehydration of these signs, he has these danger signs, he has Blood in the stool Treat with an appropriate oral

Communicable
some dehydration severe dehydration and diarrhea for less antibiotic for shigella dysentery
than 14 days If this child is also
– Dehydrated
– Severely undernourished or
– Less than 1 year of age,
reassess the child’s
progress in 24-48 hours.
For the severely
undernourished child, also
refer for treatment of severe
Diarrhea for longer undernutrition
Continue feeding and refer for
than 14 days with or treatment
without blood Show the mother how to cool
Severe undernutrition the child with a wet cloth and
Fever - 38 °C fanning.
(or 101°F) or greater Look for and treat other causes
(for example, pneumonia, malaria).
 60 Essentials of Community Medicine—A Practical Approach
Treatment of Mild Dehydration (Table 4.28)
1. Amount of ORS solution to give in first four to six hours
2. If the mother can remain at the health center
• Show her how much solution to give her child.
• Show her how to give it—a spoonful every one to two minutes.
• Check from time to time to see if she has problems.
Table. 4.28: Amount of ORS solution

Patient’s age1 2 4 6 8 10 12 18 2 3 4 6 8 15 adult

m
onths  years 
Patient’s weight in
Wt in kg Under 5 5-7.9 8-10.9 11-15.9 16-29.9 30 or over
kilograms
ORS solution (ml) 200-400 400-600 600-800 800-1000 1000-2000 2000-4000

1
Use the patient’s age only when you do not know the weight.
Note: Encourage the mother to continue breastfeeding.
If the patient wants more ORS, give more.
If the eyelids become puffy, stop ORS and give other fluids. If diarrhea continues, use ORS
again when the puffiness is gone.
If the child vomits, wait 10 minutes and then continue giving ORS, but more slowly.

Treatment of Severe Dehydration (Flow chart 4.3)

Flow chart 4.3: Treatment of severe dehydration

Follow the arrows. If the answer to the question is ‘yes’, go across. If it is ‘no’, go
down.

Can the child Yes  1. Start treatment with ORS

drink? solution, as in Treatment Plan
B
 No

Are you trained to Yes  1. Start rehydration using the tube

use a nasogastric 2. If IV treatment is available
tube for rehydration? nearby, send the child for
 No immediate IV treatment

Note:URGENT:
If the child Send
is above two years of age and cholera is known to be currently occurring in
your the
area, suspect
child cholera and give an appropriate oral antibiotic once the child is alert.
for IV
treatment
 Communicable
Intravenous Rehydration
The recommended dose of the IV fluid to be given is 100 ml/kg
divided as follows (Table 4.29).
Table 4.29: Treatment plan for rehydration therapy
Age First give 30 ml/kg in Then give 70 ml/kg in
Infants (under 12 months) 1 hour 5 hours
Older 30 minutes 2½ hours

Maintenance Therapy (Table 4.30)

Table 4.30: Maintenance therapy

Amount of diarrhea Amount of oral fluid
Mild diarrhea 100 ml/kg body weight per day until
(not more than one stool every 2 hours or diarrhea stops
longer or less than 5 ml stool per kg per hour)
Severe diarrhea Replace stool losses volume for
(more than one stool every 2 hours, or volume; if not measurable, give
more than 5 ml of stool per kg per hour) 10-15 ml/kg body weight per hour
For more than 25 years WHO and UNICEF have
recommended a single formulation of glucose based Oral
Rehydration Salts (ORS) to prevent or treat dehydration from
diarrhea irrespective of the cause or age group affected. This
product, which provides a solution containing 90 mEq/l of
sodium with a total osmolarity of 311 mOsm/l, has proved
effective and without apparent adverse effects in worldwide
use. It has contributed substantially to the dramatic global
reduction in mortality from diarrheal diseases during the
period.
For the past 20 years, numerous studies have been undertaken
to develop an “ improved” ORS. The goal was a product that
would be at least as safe and effective as standard ORS for
preventing or treating dehydration from all types of diarrhea
but which, in addition, would reduce stool output or have
other important clinical benefits. One approach has consisted
in reducing the osmolarity of ORS solution to avoid possible
adverse effects of hypertonicity on net fluid absorption. This
was done by reducing the solution super glucose and salt
(NaCl) concentrations.
Oral rehydration therapy is now preventing about one
million dehydration deaths (Table 4.31).
Table 4.31: Oral rehydration therapy
Reduced osmolarity ORS Grams/liter Reduced osmolarity ORS mmol/liter
Sodium chloride 2.6 Sodium 75
Glucose anhydrous 13.5 Chloride 65
Potassium chloride 1.5 Glucose, anhydrous 75
Trisodium citrate, dehydrate 2.9 Potassium 20
Citrate 10
Total osmolarity 245
 62 Essentials of Community Medicine—A Practical Approach
Adjuncts to Therapy
Antibiotics used in the treatment of cholera (Table 4.32)
Table 4.32: Antibiotics used in the treatment of cholera
Antibiotics (a) Children Adults
Doxycycline once — 300 mg (b)
Tetracycline 4 times a 12.5 mg/kg 500 mg
day for 3 days
Trimethroprim (TMP) TMP 5 mg/kg and SMX TMP 160 mg
sulfamethoxazole (SMX) 25 mg/kg (c) SMX 800 mg
twice a day for 3 days
Furazolidone 4 times 1.25 mg/kg 100 mg (d)
a day for 3 days
a. Erythromycin and chloramphenicol may also be used when none of the other
recommended antibiotics are available, or when Vibrio Cholerae 01 is resistant to the latter.
b. Doxycycline is the antibiotic of choice for adults (excepting pregnant women since a single
dose suffices.
c. TMP-SMX is the antibiotic of choice for children. Tetracycline is equally effective, but is not
available everywhere in pediatric form.
d. Furazolidone is the antibiotic of choice for pregnant women.

Disinfection
Both concurrent and terminal disinfections are important in
respect of cholera. This can be done by the following
measures:
a. Mix with cholera stools and vomit an equal quantity of 5
percent lysotol of 5 percent cresol or 30 percent bleaching
powder. Allow to stand for 2 hours and bury the mixture.
b. If stools and vomit fall on the floor, the area around the
patient should be covered with a thin layer of lime or
bleaching powder.
c. A practical and cheap method is to immerse the pans and
receptacles containing vomit and stools in boiling water.
d. Immerse the soiled clothes in boiling water or in 2 percent
lysotol for some time.
e. Whitewash the walls and floors with lime or throw boiling
water on them. Mud floors may be burnt with cowdung
cakes.
f. Boil the utensils and burn cheap fomites.
g. Cots and linen may be disinfected by 10 percent formalin, 5
percent lysotol spray or exposure to sun. Steam disinfection
may also be done.
h. Wash hands with soap and water. Dipping hands in 1
percent lysotol is also useful.
i. Well or tank water should be disinfected with bleaching
powder so as to get 1.5 to 2.0 ppm of chlorine. This should
be the first step when a report is received about occurrence
of cholera. Potassium permanganate should not be relied
upon.
 Communicable
Diarrheal Diseases Control Program
The National Cholera Control Program is now termed has
diarrheal diseases control program

Investigation of an Epidemic
The occurrence of an epidemic always signals some significant
shift in the existing balance between the agent, host and
environment. It calls for a prompt and thorough investigation
to prevent further spread. Emergencies caused by epidemics
remain one of the most important role to play in the
investigation of epidemics. The objectives of an epidemic
investigation are:
a. To define the magnitude of the epidemic outbreak or
involvement in terms of time, place and person.
b. To determine the particular conditions and factors
responsible for occurrence of the epidemic
c. To identify the cause, source(s) of infection, and modes of
transmission to determine measures necessary to control
the epidemic
d. To make recommendations to prevent recurrence.
An epidemic investigation calls for inference as well as
description. Frequently, epidemic investigations are called for
after the peak of the epidemic has occurred. In such case, the
investigation is mainly retrospective. No step by step
approach applicable in all situations can be described like a “
cook - book’’ . However, in investigating an epidemic, it is
desired to have an orderly procedure or practical guidelines as
outlined below which are applicable for almost any epidemic
study.

Verification of Diagnosis
A clinical examination of a sample of cases may well suffice.
Laboratory investigations wherever applicable, are most
useful to confirm the diagnosis but the epidemiological
investigations should not be delayed until the laboratory
results are available.

Confirmation of the Existence of an Epidemic

This is done by comparing the disease frequencies during the
same period of previous years. An epidemic is said to exist
when the number of cases (observed frequency) in excess of
the expected frequency for the population, based on past
experience. An arbitrary limit of two standard errors from the
endemic occurrence is used to define the epidemic threshold
for common diseases such as influenza, often the existence of
an epidemic is obvious needing no such comparison, as in the
case of common—source epidemics of cholera, food poisoning
and hepatitis A.
 64 Essentials of Community Medicine—A Practical Approach
Defining the Population at Risk
Obtaining a map of the area: Before beginning the investigation,
it is necessary to have a detailed and current map of the area.
It should contain information concerning natural landmarks,
roads and the location of all dwelling units along each road or
in isolated areas. Within each section, the dwelling units
(houses) may be designed by numbers.
Counting the population: The denominator may be related to
the entire population or sub groups of a population. It may
also be related to total events. Without an appropriate
denominator of “population at risk” attack rates cannot be
calculated.

Rapid Search for all Cases and their Characteristics

Medical survey: Concurrently a medial survey should be

carried out in a defined area to identify all cases including
those who have not sought medical care, and those possibly
exposed to risk.
Epidemiological case sheet: The epidemiologist should be
armed with an “epidemiological case sheet” for collecting data
from cases and from persons apparently exposed but unaffected.
The epidemiological case sheet or “case interview form” should
be carefully designed (based on the findings of a rapid
preliminary inquiry) to collect relevant information. This
includes: name, age, sex, occupation social class, travel,
history of previous exposure, time of onset of disease, signs
and symptoms of illness, personal contacts at home, work,
school and other places, special events such as parties
attended, foods eaten and exposure to common vehicles such
as water, food and milk; visits out of the community, history of
receiving injections or blood products, attendance at large
gathering, etc. The information collected should be relevant to
the disease under study. For example, if the disease is food-
borne, detailed food histories are necessary. A case review
form will ensure completeness and consistency of data
collection. If the outbreak is large, it may not be possible to
interview all the cases (e.g. influenza). In such cases, a random
sample should be examined and data collected.
Searching for more cases: The patient may be asked if he
knew of other cases in the home, family, neighborhood,
school, work place having an onset within the incubation of
the index case. Cases admitted to the local hospitals should
also be taken into consideration. This may reveal not only
additional cases but also person-to-person spread. The search
for new cases (secondary cases) should be carried out
everyday, till the area is declared free of epidemic. This period
is usually taken as twice the incubation period of the disease
since the occurrence of last case.
 Communicable
Evaluation of Ecological Factors
An investigation of the circumstances involved should be
carried out to undertake appropriate measures to prevent
further transmission of the disease. Ecological factors which
have made the epidemic possible should be investigated such
as sanitary status of eating establishments, water and milk
supply; breakdown in the water supply system; movements of
the human population, atmospheric changes such as temperature
humidity and air pollution, population dynamics of insects and
animal reservoirs. The outbreak can be studied in a case
control fashion. One of the primary concerns of the
epidemiologist is to relate the disease to environmental
factors to know the source(s) of infection, reservoirs and
modes of transmission.

Further Investigation of Population at Risk

A study of the population at risk or a sample of it may be
needed to obtain additional information. This may involve
medical examination, screening tests, examination of
suspected food, faces, blood samples, biochemical studies,
assessment of immunity status, etc. The approach may be
retrospective or prospective. For example, serological study
may reveal clinically inapparent cases and throw light on the
pathogenesis of the condition. Healthy individuals (those who
are not ill) from the same universe may be studied in a case
control fashion. This will permit classification of all members
as to:
a. Exposure to specific potential vehicles
b. Whether ill or not.

Data Analysis
The data collected should be analyzed on ongoing basis, using the
classical epidemiological parameters time, place and person.
If the disease agent is known, the characteristics of time,
place and person may be rearranged into the Agent-Host-
Environment model.
Time: Prepare a chronological distribution of dates of onset
and construct an “epidemic curve”, Look for time clustering of
cases. An epidemic curve may suggest: (a) a time relationship
with exposure to a suspected source,
(b) whether it is common-source or propagated epidemic,
and (c) whether it is a seasonal or cyclic pattern suggestive of
a particular infection.
Place: Prepare a “spot map” (geographic distribution) of
cases, and if possible their relation to possible, sources of
infection, e.g. water supply, air pollution, foods eaten,
occupation, etc. Clustering of cases may indicate a common
source of infection. Analysis of geographic distribution may
provide evidence of the source of disease and its mode of
spread.
 66 Essentials of Community Medicine—A Practical Approach
Person: Analyze the data by age, sex, occupation and other
possible risk factors. Determine the attack rates/case fatality
rates, for those exposed and those not exposed and according
to host factors. For example, in most food borne outbreaks,
food-specific attack rates must be calculated for each food
eaten to determine the source of infection.
The purpose of data analysis is to identify common event or
experience, and to delineate the group involved in the
common experience.

Formulation of Hypotheses
On the basis of time, place and person distribution or the
Agent-Host- Environment model, formulate hypotheses to
explain the epidemic in terms of:
a.Possible source
b. Causative agent
c.Possible modes of spread, and
d. The environmental factors which enabled it to occur.
These hypotheses should be placed in order of relative
likelihood. Formulation of a tentative hypotheses should guide
further investigation.

Testing of Hypotheses
All reasonable hypotheses need to be considered and weighed
by comparing the attack rates in various groups for those
exposed and those not exposed to each suspected factors. This
will enable the epidemiologist to ascertain which hypotheses is
consistent with all the known facts. When divergent theories
are presented, it is not easy to distinguish immediately
between those which are sound and those which are merly
plausible. Therefore, it is instructive to turn back to
arguments which have been tested by the subsequent course
of events.

Writing the Report

The report should be complete and convincing with all the
information of the epidemic in prescribed format.

SCABIES
It is a contagious disease more common in low socioeconomic
group, who have poor personal hygiene, more so in children.

Epidemiology

Agent
Sarcoptes scabiei
Source of infection: Infected patients and their clothes and
linen.
 Communicable
Mode of Transmission
1. Direct contact with patients
2. Fomites.
Period of communicability: Till such time as the infection persists
in untreated cases, usually four to six weeks. Patient becomes
noninfective within three days of effective treatment.
Incubation period: Usually seven days.
Secondary attack rate: Around 80 percent in children and
around 30 percent in adult contacts.

Host
1. Age: Maximum incidence in school going children and
occurs at all ages.
2. Sex: Equal in both sexes.
3. Poor personal hygiene.

Environmental and Social Factors

1. Maximum incidence in winter season
2. Over crowding
3. Low socioeconomic living style
4. Limited availability of water for washing.

Clinical Features
1. Severe itching, which is worse at night.
2. Common with other family members.
3. Burrow is the greyish, serpentine, dotted line on the skin
which represents the tunnel made by the female mite.
4. Sites of Burrows are:
a. Interdigital folds
b. Flexor aspects of wrists
c. Anterior axillary folds
d. Umibilicus
e. Lower abdomen
f. Genitalia
g. Buttocks and thighs.

Complications
1. Secondary infections
2. Urticaria and eczema
3. Glomerulonephritis.
 68 Essentials of Community Medicine—A Practical Approach
Variants
1. Scabies in clean and healthy person.
2. Scabies incognito: It occurs in a patient taking steroids.
3. Norwegian scabies: It occurs in immunocompromised
persons.
4. Facial scabies in infants.
a. Secondary infections should be treated.
b. All the drugs used locally should be applied below the
neck on three consecutive days.

Control of Scabies
1. Benzyl Benzoate
a. First application with 25% BB Lotion
b. Second application 12 hours after 1st application
c.Bath given 12 hours after 2nd application.
2. HCH 0.5 to 1.0 percent (Lindane)—should be rubbed on
affected skin at an interval of two to three days.
3. Tetmosal 5 percent—3 daily applications.
4.Sulphur ointment—2.5 to 10 percent—daily for four days.

SEXUALLY TRANSMITTED DISEASES

The sexually transmitted diseases are a group of
communicable diseases that are transmitted predominantly by
sexual contact and caused by wide range of bacterial, viral,
protozoal and fungal agents and ectoparasites.

What are Sexually Transmitted Diseases?

• Sexually transmitted diseases, commonly called STDs, are
diseases that are predominantly spread by sexual contact.
• One can get sexually transmitted disease from sexual
activity that involves the mouth, anus, vagina, or penis.
• There are at least 25 different types of common STDs. Most
of these are curable.
• Some of the viral STDs, which cannot be cured, are
preventable. for example hepatitis B can be prevented by
vaccination.

Why is STD Control an Important Component of

HIV/AIDS Prevention?
• STDs increase the risk of acquiring HIV or transmitting HIV
• Treatment of STD reduces the risk of transmission of HIV
• Prevention of STD will prevent the sexual transmission of
HIV, which is the main route of HIV transmission
• STDs present earlier than HIV/AIDS. Hence, it offers an
opportunity to counsel the patient for behavior change and
condom use
 Communicable
• In a person with HIV/AIDS, repeated STD increases the HIV
viral load and therefore shortens the life span of HIV
• STDs do not become AIDS.

What are the Symptoms of STDs?

At Least Half of STDs in Women do not produce any Symptoms
Some of the common symptoms of STD are:
• Ulcers, sores or, warts near the penis or vagina. In a person
who practices oral or anal sex, these ulcers or blisters may be
present around the mouth or anus.
• Discharge from the urethra (males) or vagina or more
specifically cervical discharge in women. This group of
individuals may also complain of pain or burning sensation
while passing urine.
• Swellings in the groin , swelling of the scrotum in males.
• Chronic lower abdominal pain in women, may be a symptom
of STD.

How can One Protect Oneself from STDs?

Here are some basic steps that one can take to protect oneself
from STDs:
• Abstinence or not having sex or sexual relations: This is the
only sure way to prevent STDs. However, this is not
practical for a lifetime. Abstinence could be recommended
pre-maritally. Delaying sexual debut can reduce the risk of
STD/HIV transmission.
• Practice monogamy: This means have sex with only one
person who is also mutually faithful.
• Use a latex condom every time one has sex (If one uses a
lubricant, make sure it is water-based).
• Limit the number of sexual partners. The more partners one
has, the more likely such a person is to get an STD.
• Choose sex partners with care. Don’t have sex with persons
who have multiple sexual partners or have an STD.
• Get checked for STDs.
• Don’t use alcohol or drugs, before having sex. One may be
less likely to use a condom if one is drunk or high.
• Know the signs and symptoms of STDs. Look for them in
both the sex partners.

How can Reinfection of STDs be prevented?

Reinfection is very common, especially among women. Men
and women can prevent reinfection by:
• Getting prompt, correct and complete treatment if they do have
an STD. Any genital symptoms such as discharge or burning
during urination or an unusual sore or swelling should be a
signal to stop having sex and to consult a doctor
immediately. Even if there are no symptoms
 70 Essentials of Community Medicine—A Practical Approach
but one thinks that he/she is infected, it is recommended to
avoid sexual contact and to consult a health care provider.
• Getting the sexual partner also treated concurrently. If one
is told that he/she has STD and receives treatment, such
person should notify all of his/her recent sex partners, so
that they can see a doctor and be treated.
• Avoiding sex during treatment for a STD or use condoms
during this time.
• Using condoms correctly, continuously (from the beginning of
sex to the end) and consistently (every time) one has sex. The
use of latex or ployurethane condoms during vaginal
intercourse can prevent the transmission of STDs. However,
condoms do not provide complete protection from all STDs.
Sores and lesions of STDs on infected men and women may
be present in areas not covered by the condom, resulting in
transmission of infection to another person.
• Reducing the number of sex partners, reducing the
frequency of change of partner, practicing sexual
abstinence, or limiting sexual contact to one uninfected
partner, are other options.

What are the Approaches to STD Management?

Etiological Diagnosis
An attempt is made to identify the specific cause based on
laboratory investigations . Note that VDRL test is a test that
can only tell whether a person has been infected with syphilis
or not. It is not a test that detects all VDs or STDs.

Clinical Diagnosis
Diagnosis is made on the basis of clinical symptoms. It is
possible to diagnose many STD and on the basis of clinical
presentation. But misdiagnosis can lead to failure of
treatments and continued transmission. Hence, syndromic
approach is the most useful and effective approach.

What is the Syndrome Approach?

It is a scientific method of treating STDs in health fecilities
that lack laboratory equipments or skills to make an
etiological diagnosis.
A syndrome is a combination of the symptoms complained
by patients and signs found on examination. Even though
different organisms cause STDs these organisms give rise to
only a limited number of syndromes.
Syndromic management is based on the identification of a
consistent group of symptoms and easily recognizable signs.
The provision of treatment will deal with the majority of
organisms responsible for producing the syndrome.
 Communicable
The Steps Involved in Adopting a Syndromic Approach
• Classify the main causative agents by clinical syndromic they
produce.
• Choose the appropriate treatment flow-chart for each
syndrome.
• Choose the appropriate treatment flow-chart if laboratory
investigations are available.
• Treat the patients for all the important causes of the
syndrome as per directions on the respective flow-chart,
after examination of the patient.
• Ensure that the partners are treated, patients are educated,
and that the use of condoms promoted.
Syndromic Case Management necessitates
Clinical Examination of the Patient
It is not symptomatic treatment! identifying the syndromes
in STD (Table 4.33).
Table 4.33: The syndromes in STD are grouped
Common clinical Most common Etiology
signs causes
Genital ulcer in Genital ulcer on Syphilis Treponema pallidum
males or females penis or Chanchroid Hemophilus ducreyi
scrotum Genital Herpes Herpes simplex
in men, on labia, Lymphogranulo- virus, Chlamydia
vagina or cervix ma venereum, trachomatis ( L1-L3)
in women Donovanosis Calynomato-bacterium,
granulomatis
Gonorrhoea N. gonorrhoea
Urethral discharge, Urethral discharge Non-gonococcal C. trachomatis or
dysuria in males on milking urethra urethritis ureplasma urealyticum
Cervicitis: N. gonorrhoea
Vaginal discharge Abnormal vaginal Gonorrhoea C. trachomatis
and/or cervical Chlamydial
discharge infection
Vaginal inflamma-
tion cervical Vaginitis: Trichomonas vaginalis
friability Trichomoni- Gardenella vaginalis,
cervical motion asis anaerobes
tenderness Bacterial- Candida albicans
vaginosis
Candidiasis
Gonorrhoea N. gonorrhoea
Lower abdominal Adnexal + cervical Chlamydial C. trachomatis
pain in women, motion tenderness infection
dyspare-unia, Vaginal or cervical Anaerobes Anaerobes
irregular bleeding discharge (some-
times) fever Lymphogranu- C. trachomatis (L1-L3)
Inguinal swelling Inguinal loma-venereum
lympha- or bubo in males denopathy
with Gonorrhoea N. gonorrhoea
or females or without Non-gonococcal C. trachomatis or
ulceration Scrotal swelling or Red + Urethritis Ureplasma
edematous pain in males scrotum Urealyticum
Urethral signs
 72 Essentials of Community Medicine—A Practical Approach
Syndromic Case Management
The aim of syndromic case management is to identify one of
these six syndromes and manage it accordingly. It includes
only those syndromes that are caused by organisms, which
both respond to treatment and lead to severe consequences if
left untreated. Some STD syndromes such as genital warts are
not included in this program, as the presence of these lesions
contributing to the transmission of HIV has not been
adequately documented.
Roles and Responsibilities of the Doctors while giving
Quality Care for Patients with STD
Compliance: Ensure that the patient takes full course of
treatment as prescribed. This means that you need to spend
some time communicating with him/her the importance of
completing the treatment.
Contact treatment: Treat the sexual partner (s) for the same
STD condition and initiate the treatment of the partner at the
same time as the patient. Partner treatment is necessary even
if the partner does not have symptoms.
Condom promotion: Advice, prescribe, distribute or
demonstrate how condoms must be used correctly. Insist on
use of condoms every time there is sexual contact.
Counseling counsel: The patient or refer him/her for
counseling. Counseling includes risk reduction counseling and
pre-test counseling for HIV/AIDS.
Continued support: Follow-up the patient to ensure that there
is total cure of the condition, not only disappearance of
syndromes. During follow- up once more emphasize on safer
behaviors. Refer the patient to a STD specialist if there is no
improvement after treatment or developing of complications
such as super- added infection or sequel of the condition.
Collection of essential data: Maintenance of basic records for
STD patients will not only help to document follow-up but will
also be useful to track social, demographic and behavioral
characteristics of patients with STD.
Advantages of the Syndromic Case Management
• The treatment for each syndrome is immediate and is given
at the first line health facility.
• There is wider access to treatment catering to a large needy
population.
• There are ample opportunities for preventive measures and
promotion of condom use.
Syndromic Case Management
• Scientific
• Simple
• Free from errors in clinical judgment
 Communicable
• Effective against mixed infections
• Cost-effective in the long run as it does not require
laboratory tests.

Treatment for the Most Common STD Associated Syndromes

Treatment of Urethral Discharge

Ciprofloxacin 500 mg as a single oral dose
• Alternatively, the patient may be treated with:
• Norfloxacin 800 mg single oral dose, or
• Cefixime 400 mg single oral dose, or
• Ceftriaxone 250 mg single IM dose, or
• Spectinomycin 2 g single IM dose.
Plus
Give doxycycline 100 mg orally twice daily for 7 to 14 days for
(chlamydial urethritis). Alternatively, the following drugs may
be used:
• Tetracycline 500 mg orally 4 times a day for 7 days, or
• Erythromycin 500 mg orally 4 times a day for 7 days.

Genital Ulcers
Treatment for syphilis
• Give Benzathine pencillin 2.4 million units intramuscularly
• Alternatively, if the person is allergic to penicillin, use;
• Tetracycline 500 mg orally 4 times a day for 15 days , or
• Doxycycline 100 mg orally twice daily for 15 days, or
• Erythromycin 500 mg orally 4 times a day for 15 days.
Plus
Treatment for chancroid
• Give Erythromycin 500 mg orally 4 times, daily for 7 days
• Alternatively, the following may be used:
• Ciprofloxacin 500 mg single oral dose, or
• Ceftriaxone 250 mg single IM dose, or
• Spectinomycin 2 g single IM dose, or
• Trimethoprim 160 mg/Sulfamethoxazole 800 mg (2
tablets) orally twice daily for 7 days.
Treatment for herpes
Acyclovir 200 mg orally 5 times daily for 7 days.

Treatment of Vaginal Discharge

• Metronidazole 2 g as a single oral dose, or
• Metronidazole 400 mg given orally twice daily for 7 days.
Note: Do not use Metronidazole in the first trimester of
pregnancy.
 74 Essentials of Community Medicine—A Practical Approach
Plus
• Nystatin (100,000 units one pessary), inserted
intravaginally daily at night for 14 days (for vaginal
candidiasis ), or
• Miconazole or Clotrimazole 200 mg may be inserted into
the vagina daily for 3 days, or
• Clotrimazole 500 mg is inserted into the vagina once only.
• Ciprofloxacin 500 mg in a sinlge oral dose for gonococcal
infection, or
• Norfloxacin 800 mg single oral dose, or
• Cefixime 400 mg single oral dose, or
• Ceftriaxone 250 mg single IM dose, or
• Spectinomycin 2 g single IM dose.
• Doxycycline 100 mg orally twice daily for 7 to 14 days for
chlamydial infection, or
• Tetracycline 500 mg orally four times a day for 7 days, or
• Erythromycin 500 mg orally four times a day for 7 days.
Note: Ciprofloxacin, Doxycycline and Tetracycline
should not be used in pregnancy.

Treatment of Lower Abdominal Pain in the Female

Treatment for gonorrhea
• Ciprofloxacin 500 mg single oral dose, or
• Norfloxacin 800 mg single oral dose, or
• Cefixime 400 mg single oral dose, or
• Ceftriaxone 250 mg single IM dose, or
• Spectinomycin 2 g single IM dose.
Plus
Treatment for chlamydial infection:
• Doxycycline 100 mg oral twice daily for 14 days, or
• Tetracycline 500 mg orally four times daily for 14 days ,or
• Erythromycin 500 mg orally four times daily for 10 days.
Treatment for anaerobic bacterial infection:
• Metronidazole 400 mg given orally twice daily for 14 days.
Note: Ciprofloxacin, Doxycycline and Tetracycline, should
not be used during pregnancy and lactation,
Metronidazole should not be used in the first trimester of
pregnancy.

National STD Control Program

It was started in India as a pilot project in 1949. It has
following main components:
a. Teaching and training
b. Research
c. Community education
d. Epidemiology
 Communicable
The control of STD now forms part of the National AIDS
Control Program.

BIBLIOGRAPHY
1. A Guide to Leprosy Control WHO, 1980.
2. Annual Report: Ministry of Health and Family Welfare, Govt of
India, 1998-99.
3. Das BC, Malini Shobha, Text of Community Medicine with Recent
Advances, 1st edn, 2003.
4. Govt of India, Leprosy—National Leprosy Eradication Programme
in India 1989. Guidelines for Multidrug Treatment in Endemic
Districts, Leprosy, Division, DGHS, New Delhi, 1989.
5. Govt of India. TB India: RNTCP Status Report. Central TB
Division, DGHS, Ministry of Health and Family Welfare, New
Delhi, 2001.
6. Govt of India—SIDA, WHO. Review Committee Report, 1992.
7. Govt. of India. Annual Report 2001-2002. Ministry of Health
and Family Welfare. Govt of India.
8. Gupta MC and Mahajan BK Textbook of Preventive and Social
Medicine, 3rd edn, 2003.
9. Job CK, et al Leprosy: Diagnosis and Management, Hind Kusht
Nivaran Sangh, New Delhi, 1975.
10. Kishore J , National Health Programmes of India, 4th edn, 2002.
11. WHO. Revising challenges towards the elimination of
leprosy (Leprosy Elimination Project. Ind Join Lepr 2000;
72(1 :2000).
12. WHO: Techn Rep Ser 675, 1982.
13. WHO: Techn Rep Ser 542, 1974.
14. WHO: Techn Rep Ser 702, 1984.
15. WHO: Techn Rep Ser 768, 1988.
16. Worndorff van Diepen. Clafazimine resistant leprosy. A case
report. Int Join. Lepre 1982; 50:139-42.
 Chapter
5 Noncommunicable
Diseases
Chapter Outline
CORONARY HEART DISEASE HYPERTENSION
OBESITY RHEUMATIC HEART DISEASE
MENTAL HEALTH DIABETES MELLITUS
CANCER CAUSES OF CANCER
NATIONAL CANCER CONTROL PROGRAM (NCCP)

Chronic noncommunicable diseases are assuming increasing

importance among the adult population in both developed and
developing countries. The impact of chronic disease on the
lives of people is serious when measured in terms of loss of
life, disablement, family hardship and poverty and economic
loss to the country. Some cases of non-communicable diseases
are kept for case presentation. They are discussed briefly in
the following pages.

CORONARY HEART DISEASE

Coronary heart disease (CHD) is becoming a major health
problem in India. The WHO has drawn attention to the fact
that CHD is our modern “epidemic”. However, there is no
national program on prevention in the offing. As per current
estimates at least 50 million people are suffering from CHD.
Prevalence rate (Age group 35-64 years).
10.9% in urban
male 5.5% in
rural male 10.2% in
urban female 6.4%
in rural
female.

Definition
Coronary heart disease has been defined as “impairment of
heart function due to inadequate blood flow to heart compared
to its needs, caused by obstructive changes in the coronary
circulation to the heart”.

Manifestations
a. Angina pectoris of effort
b. Myocardial infarction
 Noncommunicable
c. Irregularities of
heart d. Cardiac
failure
e. Sudden death.

Measurement the Burden of Disease

It can be done by:
a. Proportional mortality ratio—in men 30 percent of deaths
and women in 25 percent of deaths in western countries
b. Loss of life expectancy
c. CHD incidence rate
d. Age specific death rate
e. Prevalence rate
f. Case fatality rate
g. Measurement of risk factor levels
h. Medical care.

Epidemiology
No single agent can be pinpointed as the causative agent for
coronary heart disease. The disease is caused by interaction of
a variety of factors web of causation of myocardial infarction.

Risk Factors for CHD

Nonmodifiable Risk Factors

• Age—40 plus
• Sex—predominantly male
• Post—menopausal female
• Personalities—type A
• Family history of CHD
• Genetic factors are probably the most important
determinants of a given individuals TC and LDL levels.

Modifiable Risk Factors

• Cigarette smoking—it is responsible for 25 percent of
CHD death under 65 years in men.
• Hypertension—accelerates the atherosclerotic process
• Serum cholesterol—>220 mg/dl is risk for CHD
• Diabetes—the risk of CHD is two-three times higher in
diabetes.
• Obesity and sedentary habits—physical exercise increases
the HDL levels
• Stress.
 78 Essentials of Community Medicine—A Practical Approach
Complications of Myocardial Infarction
Early
a. Arrhythmias
b. Cardiac failure
c. Embolization
d. Cardiac rupture
i. Ventricular septal defect
ii. Rupture through free wall causing cardiac tamponade.
e. Papillary muscle dysfunction
f. Cardiogenic shock.
Late
a. Ventricular aneurysm.
b. Dressler’s syndrome
c. Shoulder hand syndrome.
Medical Treatment
For Angina
a. Control of risk factors like hypertension, diabetes, etc.
b. Bedrest and sedatives
c. Nitrates—isosorbide dinitrate-nitroglycerine ointment two
percent
d. -blockers
e. Calcium channel blockers.

For Unstable Angina and Myocardial Infarction

Relief of pain
i. Complete bedrest
ii. Nitrates sublingually and intravenously
iii. Analgesics
iv. Heparin
v. Thromobolytic therapy.
Supportive treatment
i. Prevention of deep vein thrombosis
ii. Proper laxatives
iii. Liquid diet initially during attack
iv. Sedative to allay the anxiety
v. Treatment of complications like cardiac failure,
arrhythmia, etc.
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Surgical treatment
Coronary arterial bypass grafting (CABG).
 Noncommunicable
Prevention and Control
WHO expert committee recommended the following
strategies:
a. Population strategy
i. Prevention in whole populations
ii. Primordial prevention in whole populations.
b. High-risk strategy
c. Secondary prevention.

Population Strategy
Population strategy is based on mass approach focussing
mainly on the control of underlying causes (risk factors) in
whole populations not merely in individuals, small changes in
risk factor levels in total population can achieve the biggest
reduction in mortality.

Specific Intervention
1. Dietary changes
a. Reduction of fat intake by 20 to 30 percent of total
energy intake
b. Consumption of saturated fats must be limited to less than
10 percent of total energy intake
c. A reduction of dietary cholesterol to below 100 mg per
1000 Kcal per day
d. An increase in complex carbohydrate consumption.
2. Regular exercises and yoga practices
3. Hypertension and diabetes kept under control
4. Avoid undue stress
5. Avoid smoking and alcohol consumption.

Legislation
1. Banning the sale of cigarettes and alcohol
2. Making compulsory the printing of the statutory warning
that smoking and drinking alcohol is injurious to health
3. Banning the advertisement of cigarettes and alcohol.

Secondary Prevention
1. Early diagnosis
a. High-risk screening
b. Routine periodic investigation
2. Prompt and effective treatment.
 80 Essentials of Community Medicine—A Practical Approach
Tertiary Prevention
1. Disability limitation
a. Balloon angioplasty and cardiac bypass surgery
b. Laser and ultrasonic destruction of clots
2. Rehabilitation
a. Physical rehabilitation
b. Occupational rehabilitation
c. Psychological rehabilitation.

HYPERTENSION
Hypertension is an iceberg disease, it has worldwide
prevalence. Rules of halves or 50 percent of the patients
were aware of their state.
• Fifty percent of those aware were taking treatment
• Fifty percent of those being treated, were treated properly.

Prevalence
59.9 per 1000 — In urban male population
69.9 per 1000 — In urban female population
35.5 per 1000 — In rural male population
35.9 per 1000 — In rural female population
The sixth report of the Joint National Committee (JNC) on
detection, evaluation and treatment of high blood pressure,
provides new guidelines for hypertension control (Table 5.1).
Table 5.1: Classification of blood pressure for
adults aged 18 years and older *
Blood pressure, mmHg
Category
Systolic diastolic
Optimal + < 120 and < 80
Normal < 130 and < 85
High-normal 130-139 or 85-89
Hypertension 2+

Stage 1 140-159 or 90-99

Stage 2 160-179 or 100-109
Stage 3  180 or  110
* When systolic and diastolic blood pressures fall into different category, should be selected
to classify the individual’s blood pressure status.
+
Unusually low readings should be evaluated for clinical significance.
2+
Based on the average of two or more readings taken at each of two or more visits after an
initial screening

Risk Stratification
The risk of cardiovascular disease in patients with
hypertension is determined not by the level of blood pressure
but also by the presence of target organ damage (TOD),
clinical cardiovascular disease (CCD) or other risk factors
such as smoking, dyslipidemia and diabetes. These
 Noncommunicable
factors independently modify the risk of subsequent
cardiovascular disease. Based on the BP reading, the patient’s
risk factors and presence or absence of TOD/CCD,
hypertensive patients have been stratified into risk groups.
The treatment to be initiated depends on the risk group of the
patient (Table 5.2).

Pharmacologic Treatment Initiation

The decision to initiate pharmacologic treatment requires
consideration of several factors: the degree of BP elevation,
the presence of target organ damage (TOD) and the presence
of clinical cardiovascular disease (CCD) or other risk factors
(Flow chart 5.1 and Table 5.3).
Table 5.2: Risk stratification and treatment *
Blood pressure Risk group A Risk group B Risk group C
stages (mm Hg) (No risk factors; (At least 1 risk factor, (TOD/CCD
no TOD/CCD) 2+ not including and/or diabetes
diabetes, with or without
no TOD/CCD) other risk factors)
High – normal Lifestyle Lifestyle Drug therapy 
(130-139/85-89) modification modification
Stage 1 Lifestyle Lifestyle Drug therapy
(140-159/90-99) modification modification
(up to 12 months) (up to 12 months)
Stage 2 and 3
( 160/ 100) Drug therapy Drug therapy Drug therapy
* Major risk factors include smoking, dyslipidemia, diabetes mellitus, age > 60 years, sex
(men and postmenopausal women), family history of cardiovascular disease; and includes
heart diseases (left ventricular hypertrophy, angina or prior myocardial infarction, prior
coronary revascularization, heart failure), stroke or transient ischemic attack, nephropathy,
peripheral arterial disease, retinopathy.
2+
For patients with multiple risk factors, clinicians should consider initial drug therapy plus
lifestyle modifications.
 For those with heart failure, renal insufficiency or diabetes.

Table 5.3: Concomitant condition and antihypertensive drug of choice

Concomitant condition Antihypertensive drug of choice
Angina -blockers, long-acting calcium antagonists
Postmyocardial -blockers, with intrinsic sympathomimetic activity,
infarction ACE inhibitors, verapamil/diltiazem ACE inhibitors in
conjunction with digoxin/diuretics, hydralazine plus
isosorbide dinitrate, carvedilol, losartan
Renal disease ACE inhibitors ACE inhibitor plus diuretic, loop diuretic,
loop diuretics plus long acting thiazide diuretic
Dyslipidemia -blockers
Diabetes mellitus ACE inhibitors, -blockers, calcium channel blockers,
diuretics (in low doses)
Elderly Thiazide diuretics -blockers plus thiazide diuretics,
long-acting calcium channel blockers
 82 Essentials of Community Medicine—A Practical Approach
Flow chart 5.1: Algorithm for the treatment of hypertension

OBESITY
It is defined in terms of a body mass index (BMI) of 30 or more
in male and 28.6 or more in female indicate obesity.

Types
• Hypertrophic obesity—increase in number of fat cell
• Hyperplastic obesity—increase in size of fat cell.

Prevalence
In adult—twenty to forty
percent. In children—ten to
twenty percent.

Epidemiological Factors
Age
It can occur at any age and generally increase with age. Infants
with excessive weight gain have an increased incidence of
obesity in later life.
 Noncommunicable
Sex
Men were found to gain more weight between the age of 29
and 35 years. Women gain most between 45 and 49 years of
age.
Socio-economic factors
Directly proportional to the per capita income.
Family tendency
1. Due to rich diet pattern
2. Overeating associated with pregnancy and lactation in well to
do families.
Individual eating habits
1. Preference for energy rich diets in marked excess to
the daily requirement
2. Frequent eating
3. Alcohol consumption
4. Psychological overeating as a result of anxiety neurosis,
depression, etc.
5. Junk food.
Physical exercise (enquire about)
1. Nature of job
2. Time devoted to sports or other physical activity
3. Recent illness particularly those which lead to long-term
restriction of physical activity, e.g. fractures.

Endocrine Disorders
1. Cushing’s syndrome
2. Cretinism and hypothyroidism
3. Pituitary disorders
4. Maturity onset diabetes mellitus
5. Insulinoma
6. Hypothalamic disorders.

Drug Intake
1. Corticosteroids
2. Estrogens.

Assessment of Obesity
Some indicators that are commonly used to measure obesity.

Broca’s Index
The individual height in cms minus 100 = maximum
permissible weight of the individual in kg.
For example: For a person with a height of 182 cm. 182-100
= 82 kg is the max permissible weight. Anything in excess of
82 kg will make the person to be considered as obese.
 84 Essentials of Community Medicine—A Practical Approach
Body Mass Index
Weight (in kg)
BMI =
[Height (in meters)]2

Males
1. Twenty to twenty-five desirable range
2. Twenty-two desirable ideal
3. Greater than 30 obese
Females
1. Nineteen to twenty four desirable range
2. Twenty one desirable ideal
3. Greater then 28.6 obese

Corpulence Index
Actual weight (in kg)
CI Desirable weight (in kg)
=
In obesity this should exceed 1.2.

Ponderal Index
Ht (in cms)
PI
= 3 Wt (in kg)

Lorentz’s Formula
[Ht in(cms) –150]
LF (Males) = [Ht (in cms) –100] –
4
[Ht in(cms) –150]
LF (Females) = [Ht ( in cms) – 100] –
2
Fat Fold Thickness (Skin Fold Thickness)
The fat fold thickness is measured using skin callipers at the
following sites, mid triceps, biceps, subscapular and suprailiac
region.
The sum total of the above measurements from all four sites
should not be more than 40 mm for adult males and 50 mm for
adult females.
Normograms showing the ideal for males and females at
various ages are available.

Total Body Mass

The total body mass is also calculated by weight/volume studies
using water displacement technique.
 Noncommunicable
Clinical Features of Obesity
1. Weight gain
2. Buffalo hump
3. Moon face
4. Prone to develop
a. Diabetes
b. Hyperlipidemia
c. Gallstones

Complications
1. Respiratory
a. Pickwickian syndrome
2. Cardiovascular
a. Hypertension
b. Cor pulmonale
c. Varicose veins
3. Gastrointestin
al
a. Hiatus hernia
b. Fatty liver
c. Gallstones
4. Musculoskelet
al
a. Osteoarthritis
b. Sciatica
c. Flat foot
5. Miscellaneous
a. Hernia

Treatment
1. Treatment of the secondary causes, like hypothyroidism,
Cushing’s syndrome, etc.
2. Diet:
a. Restrict the calorie intake.
b. Excessive eating should be avoided particularly at night.
c. Small and frequent meals should be preferred.
d. High roughage diet (which will have less calories) is
preferred.
3. Exercise: It selectively decreases the body fat, while
preserving the lean body mass.
4. Behavior modification: It is advisable to treat abnormal
patterns of eating behavior.
5. Drugs:
a. Fenfluramine: 20 mg/day
b. Diethylpropion: 25 mg thrice a day
 86 Essentials of Community Medicine—A Practical Approach
c. Biguanides
d. Thyroid extract
e. Amphetamine
6. Other
methods:
a. Body massage
b. Steam-bath (sauna)
7. Surgery:
a. Gastric pouch by gastroplasty.
b. Jejunoileal shunt.
c. Gastric balloon: Balloon is introduced through
gastroscope and kept inflated, so that the patient gets a
sense of satiety (feeling of fullness) after a small feed.
d. Lipectomy: Removal of omental fat by laparotomy or
liposuction.

Prevention and Control

Primordial Prevention
Avoidance of lifestyles leading to obesity and inculcation of
habits for a healthy lifestyle:
1. Dietary control
2. Physical exercises.

Secondary Prevention
Identification of risk individuals:
1. Obese children
2. Those with familial tendencies and starting them on obesity
manage- ment regimes at an early age.
3. Treatment as outlined above.

Tertiary Prevention
1. Physical rehabilitation, e.g. physiotherapy.
2. Occupational rehabilitation.

RHEUMATIC HEART DISEASE

Rheumatic fever and rheumatic heart disease cannot be
separated from epidemiological point of view. The antecedent
streptococcal pharyngitis causes rheumatic fever that may
lead to rheumatic heart disease. Once heart disease is
established, patient has to be treated surgically or by other
interventions and the financial burden increases.

Prevalence
Two per thousand population.
 Noncommunicable
Epidemiological Factors

Agent—group A streptococcus
Special emphasis is M type 5 which is frequently
associated with rheumatic fever.
Recently coxsackie B-4 has been suggested as a causative
factor and streptococcus acting as a conditioning agent.

Host and Environmental Factors

• Age— in 5 to 15 years
• Sex—both sexes equally
• Socioeconomic status—common in low socioeconomic status
• Environmental factors:
– Overcrowding
– Poor housing conditions
– Poor health care facilities (Particularly school health
facilities).

Clinical Features
1. Fever
2. Polyarthritis—in 90 percent cases in large joints
3. Carditis—in 60 to 70 percent cases
4. Nodules—small painless non-tender
5. Brain—abnormal jerky purposeless movement
6. Skin—various types of skin rashes.

Diagnosis
A WHO expert committee in 1988 has recommended use of
revised Jones criteria (Table 5.4) for diagnosis of acute
rheumatic fever.
The presence of two major or one major and two minor
manifestation plus evidence of preceding streptococcal
infection indicate high probability of rheumatic.
Table 5.4: Jones criteria (revised) for
diagnosis of acute rheumatic fever
Major manifestations Minor manifestations
CarditisClinical
PolyarthritisFever
ChoreaArthralgia
Erythema marginatumPrevious history of RF or RHD Subcutaneous nodulesLaborato
Abnormal ESR
C-reactive protein Leukocytosis
Prolonged P-R intervals
 88 Essentials of Community Medicine—A Practical Approach
Prevention and Control
Primary Prevention
a. Health promotion: Health education regarding RF, RHD, to
school children, teachers and parents.
b. Specific protection (throat swab): If culture facility is not
available, it is justified to treat all sore throat with
penicillin. For this purpose one injection of penicillin
containing 300,000 units of crystalline penicillin, 300,000
units procaine penicillin and 600,000 units benzathine
penicillin (available as one injection).

Secondary Prevention
1. Early diagnosis
a. Surveillance of school children for RF and RHD
b. Throat swab for detection of group A Streptococci.
2. Prompt and effective treatment
a. Injection penidure 1.2 mega unit deep IM once in three
weeks
b. Salt and water restriction and diuretics
c. Bed rest.

Tertiary Prevention
1. Disability limitation: Cardiac surgery
2. Rehabilitation, physical rehabilitation, occupational
rehabilitation, psychological rehabilitation.

MENTAL HEALTH
Mental health disorder is defined as a clinically significant
behavior or psychological syndrome or pattern that occurs in
a person and that is associated with a significantly increased
risk of suffering death, pain, disability or an important loss of
freedom.

Prevalence
In India 18 to 20 per 1000.

Classification
1. Depressive disorders
2. Schizophrenia
3. Substance abuse disorders
4. Disorders of childhood and adolescence
5. Suicidal tendencies.
 Noncommunicable
Etiology
1. Idiopathic
2. Organic condition
3. Sociopathological cause
4. Heredity.

Organic Conditions

Prenatal Causes
a. Chromosomal anomalies
i. Down syndrome
ii. Turner’s syndrome
b. Inborn errors of metabolism
i. Phenyl ketonuria
ii. Galactosemia
iii. Mucopolysaccharidoses
c. Cranial malformations
i. Microcephaly
ii. Hydrocephaly.

Perinatal Causes
a. Infections, e.g. TORCH
b. Physical causes
i. Birth trauma
ii. Radiation
c. Prematurity
d. Intoxications like bilirubin.

Postnatal Causes
a. Infections
i. Meningitis
ii. Encephalitis
b. Head injury
c. Malnutrition.

Social Pathological Causes

1. Worries
2. Anxieties
3. Stress
4. Broken home
5. Industrialization and urbanization.
 90 Essentials of Community Medicine—A Practical Approach
Environmental Factors
1. Toxic substances
2. Psychotropic drugs
3. Radiation
4. Trauma.
Warning Signals of Poor Mental Health
1. Are you always worrying?
2. Are you unable to concentrate because of unrecognized
reasons?
3. Are you continually unhappy without justified cause?
4. Do you lose your temper easily and often?
5. Are you troubled by regular insomnia?
6. Do you have wide fluctuations in your moods from
depression to elevation, back to depression, which
incapacitate you?
7. Do you continually dislike to be with people?
8. Are you upset if the routine of your life is disturbed?
9. Do your children consistently get on your nerves?
10. Are you “browned off” and constantly bitter?
11. Are you afraid without real cause?
12. Are you always right and the other person always
wrong?
13. Do you have numerous aches and pains for which no
doctor can find a physical cause?

Prevention and Control

Primary Prevention
Health promotion
a. Health education regarding causes and how to avoid some
of them
b. Prospective genetic counseling
c. Marriage
counseling d.
Specific prevention
e. Good quality of MCH care.

Secondary Prevention
Early detection
Screening programs in schools, universities, and industry.
Prompt treatment
By using antipsychotic drugs.

Tertiary Prevention
Disability limitation
Rehabilitation
a. Specialized institution to impart care and training for the
mentally handicapped
 Noncommunicable
b. Occupational therapy
c. Half-way homes and family service
programs d. Public education.

National Mental Health Program

The Government of India has launched the National Mental
Health program in 1982, keeping in view the heavy burden of
mental illness in the community, and the absolute
inadequacy of mental health care infrastructure in the
country to deal with it (a total of about 20764 beds available
or 1 bed for 15400 population). Around 10 to 60 percent of the
OPD patients have mental illness which is usually mild in
nature. In the community the prevalence of mental illness
range from 10 to 20 percent, whereas severe type of mental
illness is around 1 to 2 percent of the population. The program
envisages a primary health care approach in the rural areas
supported by professional psychiatric supervision from the
district level and referral services by the mental hospitals and
mental health units of the general hospitals.

Aims
1. Prevention and treatment of mental and neurological
disorders and their associated disabilities.
2. Use of mental health technology to improve general health
services.
3. Application of mental health principles in total national
development to improve quality of life.

Objectives
1. To ensure availability and accessibility of minimum mental
health care for all in the foreseeable future, particularly to
the most vulnerable and under-privileged sections of
population.
2. To encourage application of mental participation in the
mental health knowledge in general health care and in
social development.
3. To promote community participation in the mental health
services development and to stimulate efforts towards self-
help in the community.

Strategies
1. Diffusion of mental health skills to the periphery of the
health services system: Through the primary health centers
which is the most extensive health care system reach up to
the most remote rural and tribal areas the mental health
can be provided. It requires the training of all level of
primary health care workers.
2. Appropriate appointment of tasks in the mental health care:
The tasks to be specified at all level of the health care
delivery from village to District health center.
 92 Essentials of Community Medicine—A Practical Approach
DIABETES MELLITUS
Diabetes is an “iceberg” disease. The prevalence of diabetes
mellitus in adult is around 4 percent worldwide (1995), which
will be 5.4 percent in 2025.
In India, 2.4 percent in rural, 4.0 to 11.6 percent in urban
dwellers.
It is a one Potential Diabetic who has a risk of developing
DM due to genetic reasons (e.g. having a first degree
relative with DM).

Latent Diabetic
It is a one who has risk of developing DM due to stressful
conditions like pregnancy, surgery, trauma, infections, etc.
they may return to normal if stress is removed.

Black Zone
It is a state of affairs in a Type 2 DM patients in whom blood
glucose levels are high but do not have symptoms, although
the process of complications is going on.
The factors that allow the patients to slip into the black zone
are:
• Lack of health services provided to diabetics
• Lack of knowledge in the patient
(Or Defects in the health education program provided to
diabetics)
• Negligence by the patient (i.e. not accepting the presence
of disease and practicing a self-damage) behavior such as
alcoholism.
Clinical Classification of Diabetes Mellitus as Adopted by WHO
1. Diabetes mellitus
a. Insulin-dependent diabetes mellitus
i. Juvenile diabetes mellitus
ii. Adult diabetes mellitus
b. Noninsulin dependent diabetes mellitus
c. Malnutrition-related diabetes mellitus
2. Impaired glucose tolerance
3. Gestational diabetes mellitus.

Epidemiology

Agent
1. Pancreatic disorders—inflammatory, neoplastic, cystic
fibrosis.
2. Defects in formation of insulin.
3. Decreased insulin sensitivity.
4. Autoimmunity.
 Noncommunicable
Host
a. Age—any age
NIDDM usually at middle age group
b. Sex—male-female ratio is about equal
c. Genetic factor
d. Genetic marker—HLA B8 and B15
e.Immune mechanisms
f. Obesity.

Environmental Factors
1. Sedentary lifestyle
2. Diet and alcoholism
3. Malnutrition
4. Viral infections (rubella, mumps, etc.)
5. Chemical agents
6. Stress.

Social Factors
a. Occupation
b. Marital status
c. Urbanization
d. Changes in lifestyle.

Clinical Features
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Weight loss
5. Repeated infections—like skin infections, urinary infections
and others
6. Fatigue.

Complications
1. Diabetic ketoacidosis
2. Hyperosmolar hyperglycemic nonketotic coma
3. Latic acidosis
4. Diabetic retinopathy
5. Diabetic neuropathy
6. Nephropathy
7. Dermopathy
8. Fungal infections.
 94 Essentials of Community Medicine—A Practical Approach
Investigations
1. Urine sugar and ketone bodies.
2. Fasting and postprandial blood sugar.
3. Glucose tolerance test (GTT) (Table 5.5).
4. Glycosylated hemoglobin.

Prevention and Care

High-risk Screening
Screening of the whole population is not a rewarding exercise.
However, screening of “High-risk” groups is appropriate.
These groups are:
• Individuals above 30 years of age
• Those with a strong family history of DM
• Obese individuals
• Sedentary workers with lack of exercise.
Other than high-risk group, the following group of persons
should also be screened for diabetes as a routine.
• A patient with premature atherosclerosis
• A person complaining polyurea, polyphagia, polydipsia
sudden loss of weight, repeated infections, nonhealing
ulcer (purities vulvae in a lady).
• Patients undergoing surgery, including tooth extraction
• All expectant mothers attending antenatal clinic
• A pregnant mother gaining more than 3 kg body weight in
any month
• A woman who has given birth to a baby weighing more
than 3.5 kg at birth.

Primary Prevention
1. Population strategy
2. High-risk strategy—avoid alcohol, smoking, oral
contraceptives.
Table 5.5: Diagnostic values for the
oral glucose tolerance test (mg/dl)
Whole blood Plasma
Venous Capillary Venous Capillary
Diabetes mellitus
a. Fasting value  120  120  140  140
b. 2 hours after glucose load  180  200  200  200
Impaired glucose tolerance
a. Fasting value < 120 < 120 < 140 < 140
b. 2 hours after glucose load 120-180 140-200 140-200 160-200
 Noncommunicable
Secondary Prevention
1. Maintain blood glucose level
2. Maintain ideal body weight.

Treatment
It is based on:
1. Diet alone—small balanced meals more frequently
2. Diet and oral antidiabetic drugs
3. Diet and insulin
4. Self-care—adherence to diet and drug regimens, examination
of his own urine and blood glucose monitoring self-
administration of insulin: maintenance of optimum weight,
estimation of glycosylated hemoglobin at half yearly interval.

Tertiary Prevention
To prevent complication like:
1. Blindness
2. Kidney failure
3. Coronary thrombosis
4. Gangrene of the lower extremities.

National Diabetes Control Program

Government of India started National Diabetes Control
Program on pilot basis during 7th five year plan in 1987 in
some districts of Tamil Nadu, Jammu and Kashmir and
Karnataka, but due to paucity of founds in subsequent years
this program could not be expanded further in remaining
years. However, a sum of 12 lakh during 1995-1996 was
allocated for the program. In 1997 to 1998, an allocation of 1
crore was made.

Objectives
1. Prevention of diabetes through identification of high-risk
subjects and early intervention in the form of health
education.
2. Early diagnosis of diseases and appropriate treatment to
reduce morbidity and mortality with reference to high-risk
group.
3. Prevention of acute and chronic metabolic, cardiovascular,
renal and ocular complications of the disease.
4. Provision of equal opportunity for physical attainment and
scholastic achievement for the diabetic patient.
5. Rehabilitation of those partially or totally handicapped
diabetic people.
 96 Essentials of Community Medicine—A Practical Approach
CANCER
Cancer is a major cause of death in India.

Prevalence
Cancer in all forms are causing about 12 percent of deaths
throughout the world.
In India, it is estimated there are approximately 2 to 2.5
million cases of cancer in India at any given point of time with
around 7,00,000 new cases being detected each year nearly
half of these dies each year (Fig. 5.1).

Fig. 5.1: Cancer among Indians

Cancer registration: It provides a base for assessing the
magnitude of the problem and for planning the necessary
services. There are two types of registers (Flow charts 5.2 and
5.3).

Sex Differences
Ranking order by site of eight selected cancer.
Flow Chart. 5.2: Cancer registration

Noncommunicable
 98 Essentials of Community Medicine—A Practical Approach
Flow chart 5.3: Cancer registration

CAUSES OF CANCER

Environment
Tobacco, Alcohol, Diet, Radiation, Occupation, Parasites, Viral
infection Ebstein Bar Virus (EBV), Cytomegalovirus (CMV).
Human Immunodeficiency (HIV), Human Papilloma Virus
(HPV).
Genetic
Retinoblastoma, leukemia.
Primary Prevention
1. Avoid consumption of tobacco, alcohol
2. Diet control
3. Occupation, environmental (Protect from carcinogen)
4. Sunlight
5. Sexual reproductive factor
6. Control of air pollution
7. Treatment of precancerous lesions
8. Legislation—to control known environmental carcinogens.

Health Education Regarding “Danger Signals”

1. A lump or hard area in the breast
2. A change in a wart or mole
3. A persistent change in digestive and bowel habits
4. A persistent cough and hoarseness
5. Excessive loss of blood at the monthly period or loss of
blood outside the exact date
6. Blood loss from any natural orifice
 Noncommunicable Diseases
99

7. A swelling or sore that does not get better

8. Unexplained loss of weight.

Secondary Prevention
Early detection of cases.

Treatment for Cancer

1. Chemical therapy
2. Radiotherapy
3. Surgical therapy
4. Palliative care.

NATIONAL CANCER CONTROL PROGRAM (NCCP)

Basic Steps
1. Assess magnitude of National cancer problem
2. Setting measurable cancer control objectives
3. Evaluating possible strategies
4. Choosing priority of action.

Goals of NCCP
1. To prevent future cancers
2. To diagnose cancer early
3. To provide curative therapy
4. To ensure freedom from suffering
5. To reach all in population.

District Cancer Control Program

1. Cancer education
2. Cancer screening camps
3. Ca cervix—pap test

Carcinoma of Breast
1. Self-examination
2. Clinical
3. Thermography
4. Mammography.

Carcinoma of Lung
1. MMR
2. Sputum cytology.
 100 Essentials of Community Medicine—A Practical Approach
BIBLIOGRAPHY
1. El Kholy A, et al. Bull WHO 1978;56:887.
2. Kishore J, National Health Programmes of India, 4th edn, 2002.
3. Mann JI, et al. Brit Med J 1976;2:445.
4. Park’s Textbook of Preventive and Social Medicine, 16th edn, Nov
2000.
5. Seshubabu VVR, Review in Community Medicine. 2nd edn, 1996.
6. Shaper AG, et al. Brit Med J 1981;283:179.
7. Strasser T, et al. Bull WHO 1981;59:285-94.
8. The Sixth Report of the Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High Blood Pressure.
Arch. Intern Med 1997; 157:2413-44.
9. WHO. Sixth Report World Health Situation part I, 1980.
10.WHO. Techn Rep Ser, No. 695, 1983.
11.WHO. Techn Rep Ser 727, 1985.
12.WHO. Techn Rep Ser 764, 1988.
Chapter Maternity and Child

6 Maternity and Child Health

Chapter Outline
REPRODUCTIVE AND CHILD HEALTH PROGRAM MAJOR ELEMENTS OF RCH PROGRAM
ANTENATAL CARE MATERNAL AND CHILD HEALTH
INTRANATAL CARE POSTNATAL CARE
MALNUTRITION PROTEIN-ENERGY MALNUTRITION
BREASTFEEDING

In any community mother and children constitute a priority

group. They comprise 70 percent of population.
In India:
Women in reproductive age group constitute—19
percent Children under 15 years constitute—40
percent
Total 59 percent population, but they are also a “
vulnerable” or special risk group.
In Developing Countries
One woman dies every minute.
190 women face unwanted or unplanned pregnancy every
minute. 110 women face pregnancy complication.
40 women have unsafe abortion.
Causes of Maternal Death
Direct causes — 80
percent Indirect causes —
20 percent
Direct Causes
Hemorrhage — 25 percent
Sepsis — 15
percent Unsafe abortion —
13 percent
Eclampsia — 12
percent Obstructed labor —
8 percent
Other — 7
percent
Indirect Causes
Anemia — 23 percent
Viral hepatitis — 20 percent as compared to 1 percent in
non-
pregnancy
Malaria — 30 to 35 percent
Tetanus — 2 to 6 percent
HIV complications are more during pregnancy.
102 Essentials of Community Medicine—A Practical Approach
 102 Essentials of Community Medicine—A Practical Approach
Conceptual Framework of Safe Motherhood
Four important aspects are to be considered equity, accessibility,
affordability, and accountability for quality care (Fig. 6.1).
Improvement of women’s pre-pregnancy health is also
important (Table 6.1)

Fig. 6.1: Maternity emergency care

Risk Approach
The central purpose of antenatal care is to identify “High-risk”
cases from a large group of antenatal mothers.
1. Elderly primi (30 years and over)
2. Short statured primi (140 cm and below)
3. History of previous cesarean or instrumental delivery
4. Antepartam hemorrhage threatened abortion
5. Twins—hydramnios
6. Pre-eclampsia and eclampsia
7. Previous stillbirth, intrauterine death, manual removal of
placenta
8. Elderly grand multiparas
9. Prolonged pregnancy (14 days after expected date of
delivery)
10. Anemia
11. Malpresentations, viz. breechs, transverse lie, etc.
12. Pregnancy-related general disease, viz.
cardiovascular disease, kidney disease, diabetes,
tuberculosis, liver disease, etc.
Table 6.1: Milestones of Family Welfare Program
1880 – Establishment of training for dais in Amritsar
1902 – Ist Midwifery Act to promote safe delivery
1930 – Setting up of Advisory Committee on Maternal
Mortality 1951-56 1st Plan Family Planning Program adopted by
Government of India,
first of its kind in the world
1961-66 3rd Plan – Extension education approach
– Department of Family Planning created in Ministry of
Health
– Created Target Oriented Approach
– Lippe’s loop introduced
Maternity and Child
Contd...
 104 Essentials of Community Medicine—A Practical Approach
Contd...
1969-74 4th Plan Family planning services under Primary Health Center
All India Hospital Postpartum Program
Medical Termination of Pregnancy (MTP) Act, 1971 Renaming Fam
Community Involvement
1974-79 5th Plan
Child Marriage Restraint Act 1978 National Health Policy
Strengthening of Maternal and Child Health
Strengthening Family Welfare
1983 Further inclusion of various programs under MCH Child Survival an
1980-85 6th Plan International Conference on Population and Development (ICPD), Cairo
Target Free Approach
1985-90 7th Plan Review of Safe Motherhood Component of CSSM Reproductive and
1992-97 8th Plan (CSSM plus STD and RTI components) RTI = Reproductive Tract In
1993-94

1996

1997-02 9th Plan

REPRODUCTIVE AND CHILD HEALTH PROGRAM

The Reproductive and Child Health (RCH) Program for the
Ninth Plan is a very ambitious program which aims to
effectively bring all the reproductive and child health services
within easy reach of the community. Reproductive and Child
Health Program marks a significant paradigm shift in the
India context—a change from a population control approach
through a top-down, target-driven program, to one that
provides high quality services that are gender-sensitive and
responsive to the needs of clients, especially women who are
the major users but have a serious
problem of access, both physical and social to health services.
Definition of RCH
“People have the ability to reproduce and regulate their
fertility, women are able to go through pregnancy and child
birth safely, the outcome of pregnancies is successful in terms
of maternal and infant survival and well being and couples are
able to have sexual relations free of fear of pregnancy and of
contracting diseases.”

Components of RCH (Fig. 6.2)

Fig. 6.2: Components of RCH

 Maternity and Child
MAJOR ELEMENTS OF RCH PROGRAM
Reproductive Health Elements
1. Responsible and healthy sexual behavior
2. Intervention to promote safe motherhood
3. Prevention of unwanted pregnancies—increase access to
contraceptives
4. Safe abortion
5. Pregnancy and delivery services
6. Management of RTI/STD
7. Referral facilities by government/private sector for
pregnant woman at risk
8. Reproductive health services for adolescents
9. Screening and treatment of infertility, cancers and other
gynecological disorders.

Child Survival Elements

1. Essential newborn care
2. Prevention and management of vaccine preventable disease
3. Urban measles campaign
4. Neonatal tetanus elimination
5. Surveillance of vaccine preventable diseases
6. Cold chain system
7. Polio eradication: Pulse polio program
8. Acute respiratory infections (ARI) control program
9. Diarrhea control program and ORS program
10. Prevention and control of vitamin A deficiency among
children
11. Baby Friendly Hospital Initiatives (BFHI).
 106 Essentials of Community Medicine—A Practical Approach

State Committee on Voluntary Action

For RCH implementation and flow of funds, the states who
have established their ability for expenditure, utilization of
funds and based on their performance will be provided funds
through State Finance Department as at present. Otherwise,
funds will be routed through a State Committee on Voluntary
Action (SCOVA), a registered society with the State Chief
Secretary as chairman and State Health Secretary (FW) as
vice-chairman. This will provide flexibility in fund utilization
on various activities like selection of contractual staff and
experts.

Contents of Kits Supplied to Subcenter

and First Referral Unit (FRU)
Under the CSSM program supplies of drugs are being made to
the sub- centers. These kits are supplied twice a year. There
are two types of drug kits.
Drug kit A is supplied to all health workers while drug kit B
is supplied to health workers in selected areas of the country
only.
 Maternity and Child
These kits will reach once in six months. The PHC/district
medical officer, will have to ensure that the kits are
supplied/distributed in turn to all health workers and monitor
the use of individual items in the kits.
Subcenter Drug Kits
(Twice a year to each subcenter)
Drug Kit A (For all districts under CSSM)
1. IFA (large) 15000 tablets
(100 mg)
2. IFA (small) 13000 tablets
(20 mg)
3. Vitamin A 6 bottles (100 ml each) (1 ml=1 lakh IU)
4. Cotrimoxazole 1000 tablets (pediatric)
5. ORS packets 150 packets
Drug Kit B (For selected districts)
1. Methylergometrine 500 tablets
(0.125 mgm)
2. Paracetamol 500 tablets
(500 mg)
3. Tablet antispasmodic 250 tablets
4. Methylergometrine 10 ampoule
(0.2 mg/ml)
5. Mebendazole 300 tablets
(100 mg)
6. Chloramphenicol 500 eye applicants
(1%)
7. Cetrimide powder 125 gms
8. Providone ointment 5 tubes (Iodine 5% tube of 25 gm each)
9. Cotton bandage 120 rolls (4 cm x 4 meter)
10. Cotton absorbent One roll (500 gm)

Under RCH Program

Health facilities that can function as FRUs get kit E to kit P. The
different types of kits are given below:
Kit E Laparotomy set
Kit F Mini-laparotomy set
Kit G IUD insertion set
Kit H Vasectomy set
Kit I Normal delivery set
Kit J Vaccum extraction set
Kit K Embryotomy set
Kit L Uterine evacuation set
Kit M Equipment for anesthesia
Kit N Neonatal resuscitation set
Kit O Equipment and reagents for blood
test Kit P Donor blood transfusion set
 108 Essentials of Community Medicine—A Practical Approach
Methods to Estimate Requirements for MCH Services
• Probable number of pregnancies = Population of area ×
Birth rate of the area.
• Antenatal registration = Probable number of pregnancies +
10 percent (for pregnancy wastage)
• Fifteen percent of the antenatal women registered are high-
risk
• Fifty percent of the registered antenatal mothers are anemic
• Ten percent of the live birth babies are sick or high-risk and
need referral services
• Infants alive at one year in the area = number of live birth–
infant mortality rate of the area
• Three percent of the total population is children below three
years of age
• Thirteen percent of the total population is children below
five years of age.

ANTENATAL CARE
Objectives of Antenatal Visit
1. Preventive services for mothers
2. Prenatal services
3. Prenatal advice
4. Specific protection
5. Mental health
6. Family planning
7. Pediatric care.

Prenatal Services
1. First visit—history, physical examination, investigation
2. Subsequent visit—physical examination, investigation
3. Distribution of iron and folic acid tablets
4. Immunization
5. Health education
6. Home visit
7. Referral services
8. High-risk approach
9. Maintenance of records.

Prenatal Advice
Prenatal advice regarding:
1. Diet
2. Personal hygiene—personal cleanliness, diet, rest, exercise,
abstinence from smoking and alcohol, dental care, sexual
intercourse.
3. Drugs
 Maternity and Child
4. Radiation
5. Warning signals:
a. Swelling of the feet b. Convulsions
c. Headache d. Blurring of vision
e. Bleeding and discharge per vagina f. Any other unusual
symptom
6. Child care.

Specific Protection
1. Anemia
2. Nutritional deficiency disorder
3. Toxemia of pregnancy
4. Tetanus
5. Syphilis
6. German measles
7. Rh-Status
8. HIV infection
9. Prenatal genetic screening.

MATERNAL AND CHILD HEALTH

RCH-II and Family Planning

The RCH-II is the flagship program of the Government of India
on reproductive, child and maternal health under National
Rural Health Mission. The program has been reoriented and
revitalized to give it a pro-outcome and pro-poor focus.
Under RCH-II it is envisaged that 50 percent of PHCs and
all CHCs would be made operational as 24 hours delivary
centers; in phased manner; by the year 2010. These centers
would be responsible for providing basic emergency obstetric
care and essential new born care and basic newborn
resuscitation services round the clock. Beside these all the
FRUs will also made operational for providing emergency
obstetric care by the end of RCH-II.
New areas-components and elements in RCH-II at various
levels:
1. Village level: One “Link worker” or ASHA in each village.
2. Subcenter: Location; analysis of subcenter and necessary
relocation as per the need.
3. PHC: Location; analysis of PHC and necessary relocation
as per the need.
4. CHC: Ensure full staff; five specialists (OBG, pediatrics,
anesthetiology, general surgeon and physician) seven staff
nurses, one pharmacist and two laboratory technicians and
one radiographer. Gradually 50 percent of CHCs should
become first referral units (FRUs) for emergency obstetric
care.
 110 Essentials of Community Medicine—A Practical Approach
5. District: The chief medical officer/civil surgeon will be
provided adequate training and knowledge of public health
functions.
6. State: To build capacity in management (planning and
decentralization and management information and
evaluation system).

Program Implementation Plan (PIP)

Differential approach for implementation of RCH-II
program in empowered action group (EAG) states based on
the level of infant mortality rate, institutional deliveries and
strengthening of the health system.
i. Integrated management of neonatal and childhood illness
(IMNCI) introduction in phased manner.
ii. Adolescent health initiative in selected districts (75
districts) for adolescent friendly health services and
counseling and once a week clinic at PHC/CHC.
iii. Strengthening of social marketing of contraceptives in
rural areas, through rural health practitioners and
community mobilization through satisfied acceptor
couples.
iv. Urban health: Provision of quality integrated primary
health care services to urban poor by establishing urban
health center for 1:50,000 population with one medical
officer, 3-4 ANMs, one laboratory assistant, one public
health nurse/lady health visitor, one clerk and one
chowkidar and a peon.
Second tier referral center it could be district
hospital/maternity home/private and NGO nursing home
(by public private partnership).
v. Tribal health will be given primacy.
vi. Establishing newborn care corner in phased manner in
the existing FRUs/CHCs/PHCs/subcenters and priority
will be given to EAG states.
vii. Hospital generated waste management/infection control.
viii. Incorporation of new areas (adolescent health, urban
primary health care infrastructure, tribal health, adverse
sex ratio in different states, PNDT Act) in the matrix of
priorities for behavior change communication strategy
(BCC).
ix. Revamping of training in RCH at various levels
especially training under newer areas incorporated
under RCH-II.
Janani Suraksha Yojana
Promoting hospital delivery among poor families. It is 100
percent centrally sponsored scheme to help all pregnant
women (19 years and above) from ‘below poverty line’
families.
Janani Suraksha Yojana (JSY) has the main objectives of
reducing maternal and infant mortality by focusing on
promoting institutional delivery care during pregnancy,
delivery and post-delivery by linking
 Maternity and Child
delivery care to antenatal check-up and neonatal care along
with appropriate referral and transport assistance, in the BPL
groups.
An Accredited Social Health Activist (ASHA) will be an
effective link between the field level Government machinery
and the poor pregnant women and they will make available
the delivery services to the intended beneficiaries,
encouraging antenatal care, institutional delivery, adopting
small family norms. In addition, ASHA will escort the poor
pregnant women and also stay with the women during
delivery.
Important Features of JSY
a. The scheme is 100 percent centrally sponsored and
intended all women from BPL families, of age 19 years or
above. Benefit available up to two live birth. In 10 low
performing states (LPS) (namely; Bihar, Chhattisgarh,
Jharkhand, Orissa, UP, Uttarakhand, Rajasthan, Madhya
Pradesh, Assam and Jammu and Kashmir) the benefit will
be available for the woman on her own accord, chooses to
undergo sterilization, after the delivery.
b. Scale of Assistance
NB 1: LPS: Low performing States (10 states)
HPS: High Performing States (Remaining states/ UTs)
NB 2: Cash benefit of Rs. 500/- per live birth is to be given
to all pregnant women (BPL) after registration and at the
time of delivery, irrespective of the place of delivery.
NB 3: Such eligible beneficiaries under the scheme who
deliver in health institutions would get an additional cash
benefit of Rs. 200/- if they belong to rural areas and Rs.
100/- if they belong to urban areas of ten low performing
states (namely; Bihar, Chhattisgarh, Jharkhand, Orissa,
UP, Uttarakhand, Rajasthan, Madhya Pradesh, Assam and
Jammu and Kashmir).
c. The package for ASHA or an equivalent worker where
ASHA has not been recruited includes:
• The referral transport assistance to go to the nearest health
center,
• The compensation for ASHA or an equivalent worker if
she stays with the pregnant woman in the health center
for delivery.
d. Placement of imprest money with the ANMs: To quicken
the process of disbursement, all ANMs will be having an
imprest of Rs. 5000/to make all payment of cash
assistance.
Note: Where Panchayati Raj Institutions (PRIs) exist and an elected
body is in place, the State Governments/District society will be at
liberty to keep the money with Panchayati Raj Institutions and
empower Auxiliary jointly with the Gram Panchayat through a simple
procedures to recoup the imprest periodically. All disbursements
should be made immediately after delivery, if possible, in the
hospital itself.
e. Disbursement of cash assistance: As the scheme is
targeting the poor women who would generally be short of
cash, it is essential that the cash assistance provided under
112 Essentials of Community Medicine—A Practical Approach
the scheme is made available to her in the shortest
possible time. With a view to quicken the process of
 Maternity and Child
disbursement, ANM should keep a contingency amount of
atleast Rs. 1500/- with the ASHA or AWW (if ASHA has not
been recruited) and replenishment thereafter as already
stated in the JSY guidelines.
f. Linking antenatal check-up, institutional delivery and
neonatal care: Beneficiaries should register themselves
with the Health Workers at the subcenter/primary health
centers for availing of at least three antenatal check-ups,
postnatal care and neonatal care.
g. Encouraging pregnant women to undergo
tubectomy/laparoscopy: If hospitalization for delivery is
followed immediately by tubectomy/ laparoscopy, the
beneficiary will also get compensation money available
under the existing family welfare scheme.
h. Provision of cesarean section: Where government
specialists are not available, assistance up to Rs. 1500/-
per case will be provided for hiring services of private
experts to carry out the surgery either in a government
medical facility or in private hospital, nursing home, etc.
i. Partnership with private sector: Benefits proposed under
JSY would also be available to such beneficiaries delivering
in an accredited private health institutions. Provision of five
percent (4% for the district authorities and 1% for the
state) of the fund released towards administrative
expenses for monitoring, IEC and office expenses for
implementation.

Mamta Scheme—An Example of Public Private Partnership in

Health Care
India suffers from high maternal and neonatal mortality. One
of the reasons of this high mortality is home delivery
conducted by untrained personnel. In Delhi, approximately 3.2
lac deliveries take place every year and 63 percent (as per
NFHS 3 survey report, 2005) of these are institutional
deliveries and in some areas there are much lower rates of
institutional deliveries. Government of NCT of Delhi is
committed to provide equitable, quality health care for its
citizens especially, the maternal and child segment of its
population. An important component of health care aimed at
reducing the maternal and infant mortality is provision of
“Institutional Delivery” for pregnant women. The
Government is trying to universalize institutional deliveries.
However, there are constraints like lack of adequate
Government health facilities equipped and functional to
provide the comprehensive obstetric services for the mother
and the newborn and overburdened Government hospitals.
Therefore, PPP model was chosen wherein Private Hospitals
were approached to express their intention to join the Mamta
scheme. For comprehensive care, which includes antenatal Rs.
4000/- by the district societies, however, these are part
packages also, wherein for institutional deliveries alone Rs.
3000/- is given. If only antenatal care is provided Rs. 2000/-is
 114 Essentials of Community Medicine—A Practical Approach
given (Kishore and Charu, 2008).
 Maternity and Child
Health Care Services for the Beneficiaries under the Scheme
1. At least three antenatal check-ups with all necessary
investigations including ultrasound of pregnant woman
registered under the scheme.
2. Provision of injection TT and iron folic acid tablets to all
pregnant women as per RCH schedule, provision of
institutional delivery facilities, including emergency obstetric
care to all care to the newborn including administration of
birth doses of vaccines to newborns.
3. One postnatal check-up within first week of delivery but
not later than 14 days.
Eligibility Criteria for Beneficiaries under the Scheme
a. The pregnant woman must belong to the BPL/SC/ST
category and should be a resident of Delhi.
b. The pregnant woman should not be less than 19 years of age.
c. The pregnant woman should not have more than one living
child.

Registration of Beneficiaries under the Scheme

The pregnant woman shall be enrolled under Mamta only after
production of the following documents:
a. Proof of age: Ration card/school certificate/birth
certificate/affidavit/ any other relevant document/clinical
assessment of the attending doctor in absence of any
other proof. Proof that she is a resident of Delhi (Ration
card/election I-card/any other document indication
specific address).
b. Affidavits regarding number of living children.
c. Registration of pregnant women will be preferably done in
the first trimester (12 weeks).
d. BPL card/certification of BPL status from the
SDM/certificate of SC/ST issued by competent authority.

Prevention of Patient to Child Transmission (PPTCT)

Prevention of Parent to Child Transmission of HIV Infection
When a child or infant is infected with HIV from an infected
mother it is known as vertical transmission and this can occur
during pregnancy, child birth and through breastfeeding. In
general, the level of transmission can vary in accordance with
several variables, however, it is estimated that 35 percent of
the children of seropositive women can acquire HIV, 10
percent in pregnancy, 10 percent during the child birth and
15 percent by breastfeeding.
In resource poor setting such as India the reported rate of
mother-to- child transmission ranges from 13-60 percent.
According to Kumar et al the vertical transmission rate in
India is 48 percent. Another study
 116 Essentials of Community Medicine—A Practical Approach
conducted by ARCON in Mumbai, Dongaonkar et al reported
a mother to child transmission rate of 36 percent.
1. All pregnant women attending the antenatal clinic are
group counseled and offered HIV testing. Those who opt to
be tested undergo pre-test counseling for HIV.
2. Testing is done as per NACO guidelines with 3 ELISA/Rapid
test.
3. If the mother is found to be HIV positive, she is counseled
after the test. The post-test counseling focuses on
disclosing the results of the test, options to the mother
with regard to breastfeeding of the child and about HIV.
Confidentiality is maintained.
4. The spouse of the HIV positive women is offered HIV
counseling and testing.
5. Nevirapine prophylaxis at the time of delivery is
administered to both the mother at the time of delivery
and to the child immediately after delivery, to reduce HIV
transmission to the child.

Various Types of Antiretroviral Regimens

a. Short–Short course wherein the mother receives the ARV
from 35 weeks of gestation and the infant for up to 3
days;
b. Long–Long course wherein the ARV from 28 weeks of
gestation and the infant for up to 6 weeks;
c. Short–Long course wherein the ARV from 35 weeks of
gestation and the infant for up to 6 weeks;
d. Long–Short course wherein the ARV from 28 weeks of
gestation and the infant for up to 3 days.
Role of maternal and child health services in the prevention of HIV
infection in infants and young children program.

Maternal and child health services:

• PPTCT programs need to be integrated as an essential part
of MCH care. MCH care encompasses a broad range of
educational and clinical services that help mothers, their
children and their families lead healthy lives. Although, all
four prongs of a comprehensive PPTCT programs are
important, antenatal care is the most common entry point
for women into those programs. MCH programs facilitate
PPTCT by providing:
– Essential antenatal
– Family planning services
– ARV prophylaxis
– Safe delivery practices
– Counseling and support for the woman’s chosen infant
feeding method.
 Maternity and Child
Integration of PPTCT within Postnatal MCH Services
Effective integration of PPTCT within postnatal MCH services
is likely to increase community acceptance of PPTCT
programs and strengthen maternal care, infant care and
family care.
• Maternal care: MCH postpartum care services help protect
the mother’s health by providing medical and psychosocial
care.
• Infant care: MCH postnatal care services offer assessment
of infant growth and development, nutritional support
services may include ARV treatment.
• Family care: MCH services provide social support, testing
and counseling for family members; referrals to community-
based support programs; and assistance in dealing with
stigma.

Key Points
• A comprehensive approach is needed to prevent HIV
infection in infants and young children
• The four prongs of comprehensive care in PPTCT are:
– Primary prevention of HIV-infection.
– Prevention of unintended pregnancies in HIV-infected
women
– Prevention of HIV transmission from HIV-infected women
to their infants
– Provision of treatment, care and support to HIV-infected
women, their infants and their families.
• Without intervention the risk of MTCT is 25 to 49 percent
• Combination interventions can reduce the MTCT rate by upto
40 percent in breastfeeding populations.
• Because ARV prophylaxis alone does not provide long-term
benefit to the mother’s infection, ongoing care and support
are needed.
• MCH services can act as an entry point to the range of
services that can provide care and support to HIV-positive
women and affected family members.
• Linkages to community services provide enhanced care
support PPTCT Services for the HIV-2 infected women. The
HIV-2-infected women should have access to the entire
range of neonatal, labor and childbirth, and postnatal
services a linkages designed for HIV-1-infected women.
Offering the HIV-2-infected other short-course ARV
prophylaxis to prevent MCT should follow national and local
policy, if such a policy statement exits. The following
information, adapted from the US Centers Disease Control
and Prevention (October 1998) provides pertinent
background on HIV for consideration:
• HIV-2 infections are predominantly found in West Africa.
• HIV-2 infections:
– Have the same modes of transmission as HIV-1
– Are associated with the similar opportunistic infections
 118 Essentials of Community Medicine—A Practical Approach
– Develop more slowly and appear less virulent than HIV-1
– Appear to be less transmissible from mother to child than
HIV-1.
• Testing for both HIV-1 and HIV-2 should be considered in
the following situations:
– When demographic or behavioral risk factors are present
– When illnesses (such as opportunistic infections) appear
in someone whose HIV-1 test is negative
– When an HIV-1 Western blot indicates certain
indeterminate test band patterns.
• The best approach to clinical treatment of HIV-2 is unclear:
– Not all drugs used to treat HIV-1 are as effective against
HIV-2.
– Treatment response is more difficult to monitor than in
HIV-1; CD4 + T-cell counts and physical sings of immune
deterioration are currently being used.
• Non-nucleoside reverse transcriptase inhibitors, such as
nevirapine, are not effective against HIV-2; therefore,
zidovudine therapy should be considered for HIV-2-infected
expectant mothers and their newborn infants to reduce
MTCT risk, especially for women who become infected
during pregnancy.
• Woman’s wishes: The healthcare provider should have a
frank discussion with the HIV-2-infected woman to explain
the prevailing policy and practice and support her incoming
to a decision with which she is comfortable.
• Continued surveillance to monitor the further spread of
HIV-2 is necessary.

Infant Feeding Formula (Table 6.2)

For infants from birth to six months old, modify animal milk to
create infant formula following these directions:
Table 6.2: Infant feeding formula
60 ml (One feeding for a 1-month-old infant)
Type of milk Milk Water Sugar
Cow, goat, or camel 40 ml 20 ml 4 g (1 teaspoon)
Sheep and buffalo 30 ml 30 ml 3 g (3/4 teaspoon)
90 ml (One feeding for a 2-month-old infant)
Cow, goat, or camel 60 ml 30 ml 6 g (1 ¼ teaspoon)
Sheep and buffalo 45 ml 45 ml 5 g (1 teaspoon)
120 ml (One feeding for a 3 to 4 -month-old infant)
Cow, goat, or camel 80 ml 40 ml 8 g (2 teaspoon)
Sheep and buffalo 6 g (1 ¼ teaspoon)
150 ml (One feeding for a 5 to 6 -month-old infant)
Cow, goat, or camel 100 ml 50 ml 10 g (2 teaspoon)
Sheep and buffalo 75 ml 75 ml 8 g (2 teaspoon)
 Maternity and Child
INTRANATAL CARE
1. Thorough asepsis
2. Delivery with minimum injury to mother and child
3. Readiness to deal with complications such as prolonged labor,
antepartum hemorrhage, convulsion, mal-presentation,
prolapse of cord, etc.
4. Care of the baby at delivery.

Care at Birth
Five Cleans
Clean hands, clean surface, clean cord tie, clean razor blade and
clean cord stump (no applicant).

POSTNATAL CARE
Care of the mother and baby after delivery.

Objectives of Postnatal Care

1. To prevent complications of postnatal
period
Immediate Late
a. Puerperal sepsis Subinvolution
b. Thrombophlebitis Retroverted uterus
c. Secondary hemorrhage Prolapse
uterus d. Others Cervicitis
2. Restoration of mother to optimum health
a. Physical: Postnatal examination
i. Twice daily for three days
Once daily—till umbilical cord
falls Once in month up to six
months
Once in two to three months up to 1 year
ii. Anemia correction
iii. Nutritional deficiency treatment
iv. Postnatal exercises to strengthen perineal muscles
b. Psychological: Eliminate anxiety, fear insecurity, Rx
postpartum psychosis if it occurs.
c. Social:
3. Breastfeeding
4. Family planning
5. Basic health education regarding—personal hygiene,
environment hygiene, nutrition of mother and child,
importance of health check-up, spacing, birth registration.
 120 Essentials of Community Medicine—A Practical Approach
Warm Chain
The warm chain is a set of ten interlinked procedures carried
out at birth and later, which will minimize the likelihood of
hypothermia in all newborns. The elements of warm chain are:
1. Warm delivery room (250C)
2. Warm resuscitation
3. Immediate drying
4. Skin-to-skin contact between baby and the mother
5. Breastfeeding
6. Postpone bathing
7. Appropriate clothing and bedding
8. Mother and baby nursed together
9. Warm transportation
10. Training and awareness raising of health care providers.
At risk infants: Identification of these neonates and giving special
care is important.
High-Risk Infants
1. Birth weight (1800-2500 gm)
2. Multiple births
3. Cesarean section
4. Suspected sepsis
5. At risk for isoimmunization
6. Born to mothers with previous bad obstetric history
7. At risk for hypoglycemia.
MALNUTRITION
Definition
Malnutrition has been defined as “a state resulting from a
relative or absolute deficiency or excess of one or more essential
nutrients”.
Classification
1. Undernutrition
2. Overnutrition
3. Imbalance
4. Specific deficiency.
Children under 15 years of age are main victims.
 Maternity and Child
Nutritional Problems (Table 6.3)
Table 6.3: Nutritional problems
Nutritional problem Prevalence
a. PEM By clinical examination 3% in (0-6 years
children)
By anthropometric 4% in (0-6 years children)
b. Vitamin A deficiency Conjuctival xerosis 5-10%
Corneal involvement 0.12% (in 0-6 years
children)
c. Anemia By Hb estimation 90% in pregnant women and
60% in 0-6 years children
d. Endemic Goiter Thyroid enlargement in 33% of the community
at risk.

Epidemiology
Conditioning Influences
1. Diarrhea
2. Intestinal parasites
3. Malaria
4. Measles
5. Whooping cough.

Cultural and Social Factors

Harmful cultural patterns and habits related to:
a. Breastfeeding
b. Weaning
c. Food taboos
d. Feeding of pregnant and lactating women
e. Repeated pregnancy.

Infections
a. Gastrointestinal infections
b. Worm infestation
c. Respiratory
infection d. Measles.

Health and Other Services

1. Nutritional surveillance
2. Nutritional rehabilitation
3. Nutritional supplementation
4. Health education.
 122 Essentials of Community Medicine—A Practical Approach
PROTEIN-ENERGY MALNUTRITION
Definition
A range of pathological condition arising from deficiency of
protein and energy, normally associated with infection.
Protein-energy malnutrition (PEM) is major health problem
and a leading cause directly or indirectly of death during an
emergency.
It is not only an important cause of childhood mortality and
morbidity, but also leads to permanent impairment of physical
and possibly of mental growth of those who survive.
Most commonly affecting children are between the age of
six months and five years.
The condition may result from lack of food or from
infections that causes loss of appetite while increasing the
body’s nutrient requirements. Children between 12 and 36
months old are especially at risk since they are the most
vulnerable to infections such as GIT infection and
measles.
Incidence of PEM in preschool age children is one to two
percent.

Types of PEM
1. Marasmus
2. Kwashiorkor
3. Dwarfism (Subnormal physical development)
4. Marasmus-Kwashiorkor.

Marasmus
If deficiency arises early in the infancy marasmus is likely to
supervene. Marasmus is due to deficiency of protein and
energy, characterized by severe wasting of fat and muscle,
which the body breaks down for energy leaving skin and
bones. This is most common form of PEM in nutritional
emergencies.
Nutritional marasmus is due to prolonged starvation.
Secondary marasmus is due to the result from chronic or
recurrent infection with marginal food intake.

Clinical Features
1. Low body weight for age
2. Loss of subcutaneous fat
3. One of the cardinal sign is muscle wasting [Signs—(a) old man
face,
(b) Baggy pants] (the loose skin of the buttocks hanging
down).
4. No edema
5. Mental retardation
6. Infection.
 Maternity and Child
In Kwashiorkor (Moonface)
In kwashiorkor, energy is adequate but lack of protein is the
cause. Kwashiorkor is mainly due to lack of protein
(hypoalbuminemia).

Clinical Features
1. Low body weight
2. Muscle wasting
3. Dermatitis
4. Enlargement of liver
5. Changes in hair
6. Mental retardation
7. Infection
8. Edema.

Signs
Tick Sign
In kwashiorkor, if you start treatment edema start
disappearing which leads to weight loss, afterwards baby
starts gaining weight, this sign is known as tick sign.

Flag Sign
The hair is thin, dry, brittle, easily pluckable, sparse and
devoid of their normal shine. It becomes straight and
hypopigmented.
The length of hair that grows during the period of nutritional
deprivation appears reddish brown, during phases of better
nutrition, the growing part of the hair gets appropriately
pigmented. This gives appearance of alternate bands of
hypopigmented and normally pigmented hair.

Classification of PEM
Gomez’s Classification (Weight for Age)
Normal 90-110
Grade I 75-89
percent Grade II
60-74
percent
Grade III Less than 60 percent

Dr Udani’s Classification (Calorie Deficiency Classification)

Grade I Twenty percent less than
expected Grade II Subcutaneous fat
reduced in buttock
Grade III Subcutaneous fat reduced all over the body except
cheeks Grade IV Subcutaneous fat reduced all over the
body including
cheeks.
 124 Essentials of Community Medicine—A Practical Approach
Waterlow’s Classification defined Two Groups for PEM (Table 6.4)
– Malnutrition with retarted growth, in which a drop in the
height/age ratio points to a chronic condition—shortness or
stunted.
– Malnutrition with a low weight for a normal height in which
the weight for height ratio is indicative of an acute condition
of rapid weight loss or wasting.
wt/ht = wt of the child/wt of the normal child at same height
× 100 ht/age = ht of the child/ht of normal child at same
age × 100

Table 6.4: Waterlow’s classification

Nutritional status Stunting (% of ht/age) Wasting (% of wt/ht)
Normal > 95 > 90
Mild impaired 87.5-95 80-90
Moderate impaired 80-87.5 70-80
Severly impaired < 80 < 70

Harward’s Classification
Fifty percent Harward standard.
Arrange children of same birth date in ascending or
descending order, take 50th child as Indian standard.

Jellyfish Classification
Grade I 81-90% of the 50th Harward
Grade II 71-80% of the 50th Harward
Grade III 61-70% of the 50th Harward
Grade IV Less than 60% of the 50th Harward

NSIAP (National Subcommittee of Indian Academy of Pediatric)

Grade I 71-80% of 50th Harward
Grade II 61-70% of 50th Harward
Grade III 51-60% of 50th Harward
Grade IV Less than 50% of 50th Harward
Waterlow’s Classification
When child age is known, measurement of weight enables
almost instant monitoring of growth (Table 6.5).
Table 6.5: Measures of height assess the effect of
nutritional status on long-term growth
W/H > m-2D < m-2D
H/A
> m –2D Normal Stuntend
< m – 2D Wasted Wasted and stunted
 Maternity and Child
Epidemiology of Malnutrition
Poverty Cycle

Vicious Cycle
1.

2.

Agent Factor
1. Ignorance—of nutritional awareness in the country.
2. Inadequate diet—in terms of quality and quantity.
3. Infection—most common is diarrhea, ARI, measles, worm
infestation
4. Weaning—gradual withdrawal of the child from the breast
of the mother and introduction of supplimentary
(semisolid) food.
 126 Essentials of Community Medicine—A Practical Approach
Breast milk is—birth right of child
After four months breast milk alone is insufficient for
development of child.
Next choice is cow’s milk.
• Belief—customs and habits
• Misuse of antibiotics and self-medication.

Host Factors
1. Age—five years
Six months to two years most vulnerable group
2. Sex—female children > vulnerable.
3. Birth order—chance of PEM increases with increasing birth
order 1st child > PEM
4. Family size—larger the family size > PEM
5. Literacy state—PEM is more in baby of illiterate mother
6. Socioeconomic state—PEM > in low socioeconomic state
7. Knowledge Attitude Practice (KAP)—regarding PEM
a. Cow dung application for umbilical cord
b. Brand marking if child weeps, suspecting for abdominal
pain and sometime purgatives are given
c. Postnatal mother kept in for one month with child in dark
room. d. Child is not put to breast during first three days of
birth because of
belief that colostrum might be harmful. Instead child is put
on sugar solution and water.

Social Problems
A crucial role in the causation of PEM
1. Addiction in relation to alcohol
2. Reasons for smoking
3. Divorce and broken homes
4. Food habits and food fads
5. Cooking practices—open cooking pan lose all nutrients
6. Food storage
7. Food habits of mother.

Environmental Factors
1. Poor housing
2. Inadequate water supply
3. Food production and availability
4. Infection and malnutrition—against six killer diseases, i.e.
DPT and MTP (Measles, TB and Polio)
5. Economical status—political will to improve economic status
6. Control of population explosion.
 Maternity and Child
Examination of the Case
Hair : Luster, gray color, straight, easily pluckable
Face : Moon face in Kwashiorkor, pigmentation (due to
specific vitamin deficiency) old man face in
marasmus
Eye : Anemia
Bitot
spots
Conjunctival—xerosis
Corneal—xerosis
Keratomalacia
Night blindness
Lips : Pigmentation, angular stomatitis
Tongue : Raw tongue, dry tongue pigmentation
fissure Teeth : Caries, mottled
Gum : Bleeding
Glands : Enlarged (inguinal
glands) Skin : Dermatitis
Flaky paint dermatitis
Nail : Koilonychia, brittle nail, bridged
nail Subcutaneous fat—edema
Musculoskeletal system—
wasting Frontal and parietal
bossing Hepatomegaly
Mental
confusion
Sensory loss
Calf tenderness

Body Measurement Techniques

Responsible personnel should be trained to measure and
record weight, height, and/or arm circumference as
described in the following paragraphs.

Weight
Weight should be measured to the nearest 100 g (0.1 kg).
Although, various types of scales are used for weighing infants
in the field, the most commonly used is the hanging spring
balance scale, which can weigh up to 25 kg.

Weighing Procedure (Fig. 6.3)

Note: If the parent or carer or other untrained person is
acting as the assistant, the measurer should carry out the
weighing and record the weight on the record form.
1. Measurer or assistant: Hang the scale from a tree branch,
ceiling beam, tripod, or pole held by two people, using a
rope if necessary, so that the scale is at eye level. Make
sure that it is secure. Ask the parent or carer to undress
the child.
128 Essentials of Community Medicine—A Practical Approach

1. Put hands through leg holes

2. Grasp feet
3. Child hangs freely
4. Assistant with record form
5. Measurer reads scale at eye level

Fig. 6.3: Use of the hanging spring balance for weighing infants

2. Measurer: Attach a pair of weighing pants (or infant sling

or basket) to the hook of the scale and adjust the scale to
zero; then remove the pants.
3. Measurer: Put your arms through the leg holes of the
weighing pants (if used) while the parent or carer holds
the child, grasp the child’s feet and pull his or her legs
through the leg holes; make certain that the strap of the
pants is in front of the child.
4. Measurer: Attach the strap of the pants to the hook of the
scale. Do not carry the child by the strap alone. Gently
lower the child and allow him or her to hang free.
5. Assistant: Stand behind and to one side of the measurer
ready to record the weight (arrow 4). Have the record form
and a pencil ready to hand.
6. Measurer or assistant: Check the child’s position—make
sure he or she is hanging free and not touching anything.
7. Measurer: Hold the scale and read the weight to the nearest
completed
0.1 kg call out the measurement when the child is still and
the scale needle has stopped moving; even the most active
child will eventually become still long enough for a reading
to be taken.
8. Assistant: Immediately record the weight and show your
record to the measurer.
9. Measurer: Take hold of the child in one arm and gently lift
him or her; release the state from the hook of the scale
with your free hand. Do not lift the child by the strap of the
weighing pants.
 Maternity and Child
10. Measurer: Check the recorded weight on the form for
accuracy and eligibility. If there are any errors instruct the
assistant to erase and correct them.

Height or Length (Fig. 6.4)

Every effort should be made to measure children’s height or
length accurately, to the nearest 0.1 cm if possible.
Measurement errors of 2 to 3 cm can easily occur and cause
significant errors in classifying nutritional status. Shoes and
other footwear should be removed before measurements are
made.

Length
A child two years old or shorter than 80 cm (or 85 cm in a
population that is not chronically undernourished) should
be measured lying

1. Record form and pen

2. Assistant on knees
3. Measurer on knees
4. Hands cupped over ears—head against base of board
5. Arms comfortably straight
6. Line of sight perpendicular to base of board
7. Child flat on board
8. Hands on knees or shins legs straight
9. Feet flat against foot piece.
Fig. 6.4: Measuring a child’s length
 130 Essentials of Community Medicine—A Practical Approach
on its back. The child should be quiet, relaxed, and lying
straight, with the head resting against a fixed head-board; the
child’s should be looking vertically upwards. The help of the
childs parent or carer is often valuable. Using one hand, the
measurer should keep the legs straight by applying gentle
pressure to both knees of the child and ensure that the
movable slide is in contact with the surface of the soles and
heels of the child’s feet (not just the toes).

Height (Fig. 6.5)

A child over two-years old (or taller than 80 or 85 cm) should
normally stand to be measured. The child’s heels should be
together, at the back of the fixed foot-board. The buttocks, the
backs of the heels, the upper back, and the head should touch
the measuring board, which should have a metal tape-measure
attached. The child’s knees should not be bent. The movable
head-board, which must be horizontal, should be

1. Record form and pencil

2. Assistant on knees
3. Measurer on knees
4. Right hand on shins heels against back and base of board
5. Left hand on knees. Knees together and leg straight
8. Line of sight
9. Hand on chin
10. Shoulder level
11. Hands at side
6, 7, 12, 13, 14 Body flat against board
15. Head piece firmly on head.
Fig. 6.5: Measuring a child’s height
 Maternity and Child
slowly lowered until it rests firmly on the crown of the head
(not just lightly on the hair). The vertical tape-measure is read
opposite the highest point of the head when the child is
looking straight ahead.

Midarm Circumference
Arm circumference is measured on the upper left arm. To
locate the correct point for measurement, the child’s elbow is
flexed to 90 degree, with the palm facing upwards. A
measuring tape is used to find the midpoint between the end
of the shoulder (acromion) and the tip of the elbow
(olecranon); this point should be marked. The arm is then
allowed to hang freely, palm towards the thigh, and the
measuring tape is placed snugly around the arm at the
midpoint mark. The tape should not be pulled too tight (Figs
6.6 and 6.7).

Fig. 6.6: Arm tapes

Fig. 6.7: These three children are being measured using an arm
tape. Which child is weak and thin?
 132 Essentials of Community Medicine—A Practical Approach
Head and Chest Circumference
At birth the head circumference is about 34 cm. It is about 2
cm more than the chest circumference. By six to nine months
the two measurements become equal, after which the chest
circumference overtaken the head circumference. In severely
malnourished children, this overtaking may be delayed by
three to four years due to poor development of thoracic cage.
In a ICMR study, the crossing over of chest and head
circumference did not take place unitl the age of two years
and six months, this has been attributed to growth retardation
in poor Indian children.

General Procedures
for Treatment of Severe PEM
1. Initial treatment phase
2. Rehabilitation phase.

Initial Treatment Phase

Initial treatment phase begins with admission to the
therapeutic feeding center and lasts until the child condition
is stable and his or her appetite has returned (Usually after 2-
7 days).
Growth chart is a visible display of the child’s physical
growth and development. The WHO prototype (home-based)
chart is shown in Figure 6.8. It has two reference curve. The
upper reference curve represents the median (50th percentile)
for boys (slightly higher than that for girls), and the lower
reference curve the 3rd percentile for girls (slightly lower
than that for boys). Thus, the chart can be used for both sexes.
The space between two growth curve in Figure 6.8 has been
called the “road-to-health”.
“Acute severe PEM” is as much a medical emergency, as
say a heart attack even with utmost care, mortality rates are
often 20 to 30 percent or higher. Deaths commonly occur
during the first 24 to 48 hours after admission.

Complications
Commonly include:
1. Dehydration
2. Localized and generalized infection
3. Septic shock
4. Hypothermia
5. Hypoglycemia
6. Anemia
7. Vitamin A deficiency
8. Fluid and electrolyte imbalance.
 Maternity and Child

Fig. 6.8: The WHO prototype growth

 134 Essentials of Community Medicine—A Practical Approach
Preventive Measures
There is no simple solution to the problem of PEM. Many
types of action are necessary. The following is adopted from
the 8th FAO/WHO expert committee on nutrition for the
prevention of PEM in the community.

Health Promotion
1. Measures are directed to pregnant and lactating women
(education, distribution of supplements like food, iron and
folic acid tablets).
2. Promotion of breastfeeding
3. Development of low cost weaning foods, the child should
be made to eat food at frequent intervals.
4. Measures to improve family diet
5. Nutrition education promotion of correct feeding practices
6. Home economics
7. Family planning and spacing of births
8. Family environment.

Specific Protection
1. Child’s diet must contain protein and energy rich foods,
milk, eggs. Fresh fruits should be given if possible
2. Immunization
3. Food fortification.

Early Diagnosis and Treatment

1. Periodic surveillance
2. Early diagnosis of any lag in growth
3. Early diagnosis and treatment of infection and diarrhea
4. Development of programs for early rehydration of
children with diarrhea
5. Development of supplementary feeding programs during
epidemics
6. Deworming of heavily infested children.

Rehabilitation
1. Nutritional rehabilitation services
2. Hospital treatment
3. Follow-up care.

Calculation of Expected Weight of the Child

Age (months) + 9
For 3 to 12 months old child :
2
For 1 to 6 years of child : (Age in years × 2) + 8
(Age in years × 7) – 5
For 6 to 12 years of child :
2
 Maternity and Child
Calculation of Expected Height of the Child
At birth : 50 cm
At one year of age : 75 cm
For 2 to 12 years of age : (age in years × 6) × 77

Surface Area According to Weight

Range Surface area (meter2)
1-5 kg : (0.05 × kg ) + 0.05
6-10 kg : (0.04 × kg ) + 0.1
11-20 kg : (0.03 × kg) + 0.2
20-40 kg : (0.02 × kg) + 0.4

Calculation of Pediatrics Doses

Age
Young’s formula : × Adult
dose Age + 12

Age
Dilling’s formula: × Adult dose
20

BREASTFEEDING

A to Z Benefits for Baby

A—Antibodies B—Brain development
C—Colostrum D—Digestion
E—Easy F—Fresh
G—Growth promoting H—Healthy
I—Immunity factor J—Joyful K
—Knotting with baby L—Loving
M—Magnificent N—
Nutrition
O—Obesity prevention P—Promotes
development Q—Quantity unlimited R—
Recommended S—Satisfactory T—Time
tested
U—Unique V—Valuable
W—White blood X—Xenial
Y—Yummy Z—Zephyr

Advantages to Mother
1. Feeling of motherhood
2. Reduces postpartum bleeding
 136 Essentials of Community Medicine—A Practical Approach
3. Natural birth spacing method
4. Reduces risk of cancer
5. Economical
6. Reduces chances of osteoporosis
7. Helps to lose weight.

BIBLIOGRAPHY
1. Belavady B, Gopalan C. Indian J Med Res 1959;47:234.
2. Govt of India. RCH II and family planning—program
implementation plan (PIP). New Delhi: Ministry of Health and
Family Welfare, Govt of India: 2004.
3. Gopalan C, Kamala Jaya Rao. In: Prevention in childhood of
health problem in adult life F, Falkner (Ed), Geneva, WHO, 1980.
4. Govt of India, Reproductive and Child Health Service in Urban
Areas. Ministry of Health and Family Welfare, Nirman Bhawan,
New Delhi.
5. Kohler KA, et al. Vaccine-associated paralytic poliomyelitis in
India during 1999: decreased risk despite massive use of oral
polio vaccine. Bull WHO 2002;80:210-6.
6. Lallemant M, Jourdain G, Le Couer S. A trial of shortend
zidovudine regimens to prevent mother to child transmission of
human immunodeficiency virus type 1. N Engl J Med
2000;343:982-91.
7. NFHS-3 IIPS, Mumbai, India, 2005-06.
8. Park’s Textbook of Preventive and Social Medicine, 16th edn, Nov
2000.
9. Planning Commission. Tenth five year plan 2002-07. Vol II.
New Delhi: Planning Commission GOI;2002.
10.The Management of Nutrition in Major Emergencies. Authorized
reprint. WHO Geneva, 2002.
11.Venkatachalam PS, et al. Nutrition for Mother and Child, Spl Rep
Ser, No 41, ICMR, New Delhi, 1971.
12.WHO. Risk Approach for MCH Care, WHO Offset Publication No. 39,
1978.
13.WHO. Techn Rep Ser, No. 600, 1976.
14.WHO. The Health Aspects of Food and Nutrition, A manual for
developing countries in the Western Pacific Region, 1979,p49.
15.WHO. Techn Rep Ser, No. 477, 1971.
16.WHO. The World Health Report 1996, Report of the Director
General.
 Maternity and Child
Chapter
134 Essentials of Community Medicine—A

7 Reproductive and
Child Health

Chapter Outline
SUBCUTANEOUS DMPA AND HOME INJECTION
MANUAL VACUUM ASPIRATION (MVA)
CALCULATION OF THE EFFECTIVE COUPLE PROTECTION RATE (ECPR)

INTRODUCTION
Birth control services involve guidance about the timing,
spacing and number of children, education regarding
contraceptive methods and provision of facilities for the same,
unless we understand the exact technique of use, advantages
and disadvantages. It is not possible to motivate eligible
couples to use them. Every doctor is expected to know the use
of contraceptives thoroughly.

Qualities of Good Contraceptives

The wide variety of contraceptives available today reflects the
fact that an ideal contraceptive is yet to be developed. The
desirable qualities in a good contraceptive are listed below.
1. Reliability — 100 percent effectiveness
2. Safety — Freed from associated side effect or
complication
3. Reversibility — Complete return to fertility when the
method is discontinued
4. Low cost
5. Convenience
6. Consumer control
7. Cultural acceptability.
Cafeteria Choice
That is to offer all methods from which an individual can
choose according to his needs and wishes and to promote
family planning as a way of life.
Conventional Contraceptive
Contraceptive is used to denote those methods that required
action at the time of intercourse, i.e. condoms, spermicides,
etc.

Contraceptive Failure Rate (CFR) (Table 7.1)

It is calculated as:
 Reproductive and Child Health
135

No. of accidental pregnancies ×

CFR =1200
No. of patients observed × months
of use
Example: If 100 couples have used a method for a period of
one year and has resulted in 20 accidental pregnancies then
the pregnancy rate (contraceptive failure rate) would be:
20 × 1200 20
100 × 12HWY ,
where HWY is hundred women years.
Table 7.1: Failure rate of contraceptives
Contraceptive Failure rate
methods (Pregnancies per
100 women years)
None used 80
Natural methods
Rhythm method 25
Withdrawal (coitus interruptus) 25
Barrier methods
Condom 10-14
Spermicidal 30
Douching 40
Dutch cap 4-6
Today (nanoxynol-9) 9-30
IUCD
Progestasert 0-3
Lippes loop 3
Copper-7 1.9
Cu-T-200 3.0
Cu-T-200c 0.9
Nova T 0.7
Multiload 250 0.5
Multiload 375 0.1
Oral pills
Postcoital:
– Ethinyl estradiol 1-1.5
– Stilbestrol 5 days 0-2.4
Combined (Mala N,D) 0.1
Minipills 2-3
Injected and implants
Depot (Medroxyprogesterone acetate) 1.0
Depot (Norethisterone Oenanthate) 0.6
Norplant 1.1
Silastic vaginal rings (SVR) 3.5
Centchromen 1.83
Sterilization
Mini-laparotomy (Pomeroy’s method) 0.4
(Madlener method) 7.0
Laparoscopic sterilization 0.6
Hysteroscopic sterilization 1.5
136 Essentials of Community Medicine—A Practical Approach

Pregnancy Rate
It is calculated as:
CFR = Twenty per hundred women years (HWY) of
exposure. (Do not forget to write the rate in terms of
HWY or you will lose
valuable marks).

Methods of Family Planning (Flow chart 7.1)

Flow chart 7.1: Family planning methods

Newer Contraceptives
To expand choices for women, CuT 380A, a long-term
intrauterine device has been added in the National Family
Welfare Program. This will provide long-term (upto 10 years)
protection for women and will be useful for women who have
completed their family size but do not want to undergo for
terminal methods (Table 7.2).
 Table 7.2: A brief account of contraceptives

Method How it works Advantages Disadvantages

Low-dose When a woman swallows No need to do anything at the Some women have upset stomach
combined oral a pill each day, her ovaries stop time of sex. (especially in first 3 months) and/or
contraceptives releasing eggs. She cannot become Monthly periods are regular, light short; spotting or bleeding between
(the pill) pregnant without an egg. milder, fewer cramps. menstrual periods, missed periods,
Effectiveness: Very effective if Helps to prevent iron deficiency anemia, mild headaches, breast tenderness
taken every day. Effective as usually ectopic pregnancy ovarian and uterine and/or slight weight gain.
used. cancer, and pelvic inflammatory Some women cannot remember pill
• No STD protection. disease (PID) a every day.
Also can be used for emergency In rare cases the pill causes stroke,
contraception heart attack, or clots deep in the
especially in woman with high leg
blood pressure and in woman who
smoke and also are 35 or older.
Condom A very thin, flexible sheath that covers Only method proved to prevent STDs, Must take the time to put condom
the man’s erect penis during sex. including HIV/AIDS, and also on erect penis before sex.

Reproductive and Child

It keeps sperm out of the woman’s pregnancy when used correctly May decrease sensation.
vagina. Also prevents many STDs with every act of sexual intercourse. May cause itching for a few people
from passing between sex partners. Helps prevent conditions caused by allergic to latex rubber.
Effectiveness: Effective if used STDs, such as pelvic inflammatory
correctly and every time. Only disease (PID) in women and infertility
somewhat effective as usually used*. in both women and men.
Best method for STD prevention. No need to see a health care provider
before using.
Contd...
Contd...

138 Essentials of Community Medicine—A

Method How it works Advantages Disadvantages
Female A specially trained health care A single procedure leads to effective, Usually painful for a few days after
sterilization provider makes a small surgical lifelong family planning. the procedure. Slight chance
opening in the woman’s abdomen Nothing to remember and no repeated if infection or bleeding at incision,
and closes off both tubes that carry clinic visits needed. internal infection or bleeding, or
eggs from the ovaries to the womb. No known long-term side effects injury to internal organs.
Then eggs cannot meet the man’s or health risks. Usually not reversible.
sperm. The woman still has menstrual A woman can still have sex as usual.
periods.
Effectiveness: Very effective and
permanent. * No STD protection.
Vasectomy A specially trained health care A single quick procedure leads to Not effective at once. Couple must
provider makes a small surgical effective, lifelong family planning. use another method for at least the
opening in the man’s scrotum (the A man can still ejaculate and have first 20 ejaculations or 3 months.
sac of skin that holds the testes) sex as usual. Usually some discomfort for a few
and closes off both tubes that carry No known long-term side effects of days after the procedure. Possibly
sperm from his testes. The man still health risks. also some pain, bruising in the
produces semen, but it has no sperm scrotum.
in it to make a women pregnant. Usually not reversible.
Effectiveness: Very effective and
permanent. * No STD protection.
Long-acting Injectables Depo-Provera (DMPA) Private. No one else can tell that the Changes in menstrual bleeding are
injectable and Norethisteron enanate (NET EN) woman is using contraception. normal—such as light spotting at
contraceptives stop ovaries from releasing eggs. A Long-term yet reversible. Each injection first and no periods after the first
woman cannot become pregnant lasts at least 3 months (DMPA) or 2 year of use. (Some women
without an egg. They also thicken months (NET EN). The woman has consider no periods an advantage).
cervical mucus so sperm cannot pass. to remember only to return for next Some women gain some weight.
Effectiveness: Very effective when injection. (Some women consider this an

Contd...
Contd...
Method How it works Advantages Disadvantages
spaced 3 months apart (for DPMA) or advantage).
2 months apart ( for NET EN )*.
Norplant implants Small plastic capsules placed under Lasts at least 5 years; fertility returns
Changes in menstrual bleeding
the skin of a woman’s arm slowly when capsules are taken out. are normal—especially spotting or
release a hormone. The hormone Nothing to remember. No need to do bleeding between periods. Some
thickness cervical mucus so sperm anything at the time of sex. women have no periods. (Some
cannot pass. Sometimes also stops Helps prevent iron deficiency anemia women consider no periods an
ovaries from releasing eggs. and ectopic pregnancy. advantage).
Effectiveness: Very effective. Clinic procedure needed to start or
*No STD protection. stop use.
Intrauterine device A small, flexible plastic frame, often
Effective prevention of pregnancy for Many women at first have longer,
(IUD) with copper wire or sleeves on it. as long as 10 years; fertility returns heavier menstrual periods, bleeding
A health care provider inserts the when IUD is taken out. or spotting between periods, or
more
IUD into the woman’s womb through No need to do anything at the time of menstrual cramps or pain.

Reproductive and Child

her vagina. The IUD stops egg and sex. Can be inserted just after childbirth. Clinic procedure needed to start or
sperm from meeting. stop use.
Effectiveness: Very effective. Pelvic inflammatory disease is more
*No STD protection. likely to follow STD infection if a
woman is using an IUD.
Fertility awareness A woman learns to recognize the No physical side effects. More effective methods take 2 or 3
based methods fertile time of her menstrual cycle. Very little or no cost. months to learn. Calendar method
(Including periodic To prevent pregnancy, a couple Most couples can use these takes 6 months of recording
Contd...
Contd...

140 Essentials of Community Medicine—A

Method How it works Advantages Disadvantages
abstinence) avoids vaginal sex during the fertile methods if committed to them. cycle length before it can be used.
time or else uses a barrier method or Acceptable to some religious Long abstinence may cause tension.
withdrawal. groups that objects to other Some methods may be less reliable
Effectiveness: Effective if used or more difficult to use if woman is
correctly. Only somewhat effective as sick, has a vaginal infection, or is
usually. breast-feeding.
*No STD protection
Vaginal methods A woman places a spermicide, or Woman—controlled method for use May cause irritation. Can make
(Spermicides, else a diaphragm or cap with when needed. urinary tract infections more
diaphragm, spermicide, in her vagina before sex. May help prevent some STDs and common.
cervical cap) Spermicides kill sperm or stop their conditions caused by STDs. Possibly Woman must put method in vagina
movement. some protection against HIV/AIDS, before every act of sexual
Diaphragms and caps keep sperm but this is not proved. intercourse.
out of the womb. No need to see a health care provider
Effectiveness: Effective if used before using spermicides.
correctly and every time. Only
somewhat effective as usually used.
* Help prevent STDs.
 Reproductive and Child
What to do if you miss one or more pills (Flow chart 7.2)

Flow chart 7.2: Every time you miss one or more active pills (days 1-21:)

Anti-fertility Vaccines
Under development.
1. Anti-hCG Vaccines— subunit of hCG linked chemically to a
carrier protein.
2. Immunization of female using specific antigen-Zona
pellucida, trophoblastic surface antigen, sperm-inhibine
antigen.
3. Anti GnRH Vaccine—Hocks LHRH activity prevents
spermatogenesis/ ovulation.

No Scalpel Vasectomy
It is an improvement on the conventional vasectomy as it is
safe, convenient and more acceptable to male. In this
operation the pair of scissors is used to pierce the skin and
through small opening the vas is tied and cut. No stitch is
required. This new method is being offered to men, who have
completed their families on a voluntary basis.

Emergency Contraceptives
Experience gained from clinic-based trials is not adequate from
the point
 142 Essentials of Community Medicine—A Practical Approach
of program operations. Without careful planning and
preparation, the new methods may be poorly accepted and the
dropout and pregnancy rates may be unacceptably high. It
also damages the reputation of family planning program.
Emergency contraceptives are as follows:
1. High-dose estrogen in a dose of 5 mg daily for 5 days
2. Estrogen-progesterone combination:
a. Yuzpe method: EE 50 μg + LNG 250 μg of 2 pills given
as soon as possible after unprotected coitus and repeat
after 12 hours
b. EE 30 μg + LNG 150 mg of 4 pills are taken as soon
as possible after unprotected coitus and 4 more pills
after 12 hours
c. EE 200 μg + dl – norgestrel 2 mg or 1 mg/LNG 1 mg of
one pill as the first dose followed by another pill after 12
hours.
3. Progesterone-only pill: LNG 0.75 mg as soon as possible
after unprotected sex followed by another pill 12 hours
later
4. Antiprogesterone-mifepriston (RU-486) in 600 mg single
dose
5. Intrauterine contraceptives (IUD) insertion within 5 days of
unprotected sex
6. Danazol
7. GnRH antagonist
EE = ethinyl estradiol
LNG = levonorgestrel

Emerging Oral Contraception

Emergency oral contraception can prevent pregnancy. It is
also called as postcoital or “morning after“ contraception. Any
women can use emergency oral contraception if she is not
already pregnant.
Emerging oral contraception should be started up to 72
hours after unprotected sex.
It mainly stops ovulation but perhaps also works in other
ways. It does not disrupt existing pregnancy. It seems to
prevent at least three- fourths of pregnancies that would
otherwise have occurred. (Average chance of pregnancy due
to one act of unprotected intercourse in the second or third
week of the menstrual cycle is 8 percent; after emergency oral
contraception—1-2%). The sooner emergency oral
contraceptive are used, the better they prevent pregnancy.
Emergency oral contraception should not be used in place
of family planning methods. It should be used only in an
emergency for example:
• A woman has had sex against her will or has been forced
to have sex (rape).
• A condom has broken.
• An IUD has come out of place.
• A woman has run out of oral contraceptives, has missed 2
or more progestin only oral contraceptives, or is more than
a few weeks late for a DMPA injection and has had sex
without using other family planning.
 Reproductive and Child
• Sex took place without contraception, and woman wants to
avoid pregnancy.
Emergency oral contraception does not prevent sexually
transmitted diseases.

Give Specific Instructions

1. Upto 72 hours after unprotected sex, the woman should
take 4 low dose or 2 “standard dose” combined oral
contraceptives, or else take 20 or 25 progestin
contraceptives, and then take another equal dose 12 hours
later.
Important: If she takes pills from a 28 days packet of
combined oral contraceptives, she must be sure to take
hormone-containing pills. Show her which pills contain
hormones.
2. If willing, she should start another method immediately,
such as condoms and/or spermicide, or she should avoid
sex until she can start her preferred methods.
Progestin-only pills better for emergency contraception.
A large WHO study has found that progestin-only pills are
better than combined oral contraceptives (progestin +
estrogen) for emergency contraception. Used for emergency
contraception, progestin – only pills were more effective and
caused less nausea and less vomiting.
Dosage: Either 20 or 25 progestin-only oral contraceptive
tablets up to 72 hours after unprotected sex. Then 20 or 25
more tablets 12 hours later.
Note: Special-purpose pills, each containing 0.75
milligrams levonorgestrel may be available in some places.
Table 7.3 tells us how many pills to take according to their
formulation:

Table 7.3: Pills and their formulation

Formulation (Examples of brands) Number of pills Number of pills
to swallow within to swallow
72 hours 12 hours later
Progestin-only oral contraceptive containing 20 20
0.075 milligrams (75 micrograms) of
norgestrel (Ovrette, Neogest, Norgeal)
Progestin-only contraceptives containing 25 25
0.03 milligrams (30 micrograms) of
levonorgestrel (Follicle, Microval, Microlut,
Microluton, Mikro–30 Wyeth,
Mikro-30, Norgestin, Nortel).
Low dose COCs containing 0.15 or 4 4
0.25 milligrams of levonorgestrel or
0.5 milligrams of norgestrel plus
0.03 milligrams (30 micrograms) of ethinyl

Contd...
 144 Essentials of Community Medicine—A Practical Approach
Contd...
Formulation (Examples of brands) Number of pills Number of pills
to swallow within to swallow
72 hours 12 hours later
estradiol (Lo-feminal, Lo-ovral, Mala–D (India),
Nordette, Microgynon-30)
“Standard-dose” COCs containing 0.125 or 2 2
0.25 milligrams of levonorgestrel or 0.5 milligrams
of norgestrel plus 0.05 milligrams (50 micrograms)
of ethinyl estradiol (Eugynon 50, Nordiol, Ovral,
Microgynon – 50, Nordette – 50)
Levonorgestrel 0.75 mg (Postinor – 2) 1 1
COC = Combined oral contraceptive

Important
Other combined oral contraceptive pills may work too but their
effectiveness for emergency contraception has not been tested.
(Note that equal weights of different hormones do not mean
equal strength).

Give Advice on Common Problems

• Nausea: Suggest that she eat something soon after taking
the pills to reduce any nausea. Prescription anti-nausea
medicines such as Dramamine and Marezine can reduce
the risk of nausea when taken half hour before taking
emergency contraceptive pills and every four to six hours
thereafter.
• Vomiting: If the woman vomits within two hours after
taking the pills, she need to take another dose. Otherwise,
she should not take any extra pills. Extra pills will not
make the method more effective and they may increase
nausea. If vomiting continues, she can repeat dose by
vaginal replacement.
• Her next monthly period may start a few days earlier or
later than expected. Reassure her that this is not a bad
sign.

Explain Specific Reasons to Return to the Health Care Provider

1. Advise her to return or see another health care provider if
her next period is quite different from unusual for her,
especially if it is:
• Unusual light (possible pregnancy).
• Dose not starts within four weeks (possible pregnancy).
• Unusually painful (possible ectopic pregnancy. But
emergency oral contraception does not cause ectopic
pregnancy).
2. Describe the symptoms of sexually transmitted diseases,
for example, unusual vaginal discharge, pain or burning on
urination. Advise her to see a health care provider if any of
these symptoms occur.
 Reproductive and Child
Introduction to Injectable Contraceptives
• Depot-medroxyprogesterone acetate (DMPA) is given every
three months. It contains a progestin, similar to the natural
hormone that a woman’s body makes. The hormone is
released slowly into bloodstream also known as depot-
medroxyprogesterone acetate, Depo-proverai, Depo and
Mejestron.
• There are other injectable contraceptives. NET EN-also
called Noristrat, norethindrone enanthate and
norethisterone enanthate is given every two months.

Mechanism of Action
• Mainly stops ovulation (release of eggs from ovaries).
• Also thickens cervical mucus, making it difficulty for sperm
to pass through.
DMPA does not work by disrupting existing pregnancy.
Failure rate
0.3pregnancies per women in first year of use (1 in every 333)
when injections are regularly spaced three months apart.
Pregnancy rates may be higher for women who are late for
injection or who miss an injection if provider runs out of
supplies.

Advantages and Disadvantages of Injectable Contraceptives

Advantages
• Very effective
• Private. No one else can tell that a women is using it.
• Long-term pregnancy prevention but reversible. One
injection prevents pregnancy for at least three months.
• Does not interfere with sex.
• Increased sexual enjoyment because no need to worry
about pregnancy.
• No daily pill taking.
• Allows some flexibility in return visits. Client can return as
much as two week early or weeks late for next injection.
• Can be used at any age.
• Quantity and quality of breast milk do not seem to be
harmed. Can be used by nursing mothers as soon as six
weeks after childbirth.
• No estrogen side effect. Does not increase the risk of
estrogen related complications such as heart attack.
• DMPA prevents ectopic pregnancies in user
• DMPA prevents endometrial cancer in user
• DMPA prevents uterine fibroids in user
• DMPA help prevents ovarian cancer in user.
 146 Essentials of Community Medicine—A Practical Approach
• Special advantages for some women:
– May help in preventing iron deficiency anemia.
– May make seizures less frequent in women with
epilepsy.
– Makes sickle cell crisis less frequent and less painful.
Disadvantages
• Common side effects (not sign of sickness)
• Changes in menstrual bleeding are likely including:
• Light spotting or bleeding. Most common at first.
– Heavy bleeding can occur at first but rare
– Some women will have amenorrhea, especially after first
year of use. It may cause weight gain (average of 1-2 kilo
or 2-4 lbs each year). Some women see weight gain as
advantage.
• Delayed return of fertility (until DMPA levels in the body
drop). About four months longer wait before pregnancy
than for women who had been using combined oral
contraceptives, IUDs, condoms or a vaginal method.
• Requires another injection every three months.
• May cause headaches, breast tenderness, moodiness,
nausea, hair loss, less sex drive and/or acne in some
women.
• Does not protect against sexually transmitted diseases
including HIV/ AIDS. Table formulations, injection
schedules and availability of injectable contraceptives are
given in Table 7.4.
Table 7.4: Injection schedules and availability of injectable contraceptives

Common trade names Formulation Injection type and schedule

Progestin-only injectables
Depo-provera, Depot One intramuscular (IM)
Mejestron, contracep, medroxyprogesterone injection every three
Depo-prodasone acetate (DMPA) 150 mg months
Depo-sub provera DMPA 140 mg One subcutaneous
140 (DMPA – SC) injection every
three months
Noristrat, Norigest, Norethisterone enanthate One IM injection every
Doryx (NET- EN) 200 mg two months
Combined injectables (progestin + estrogen)
Cyclofem, Medroxyprogesterone One IM injection every
Ciclofeminina, Lunelle scetate 25 mg + month
Estradiol cypionate
5 mg (MPA/E2V)
Deladroxate, Perlutal, Dihydroxyprogesterone One IM injection every
Topasel, Patectro, (algestone) month
Nomagest acetophenide 150 mg+
Estradiol enanthate 10 mg
Anafortan, Yectames Dihydroxyprogesterone One IM injection every
(algestone) month
acetophenide 75 mg +
Estradiol enanthate 5 mg
 Reproductive and Child
SUBCUTANEOUS DMPA AND HOME INJECTION
A new lower dose formulation of DMPA, depo-subQ provera
104 (also called DMPA-SC) is injected under the skin rather
than in the muscle. It contains 104 mg of DMPA rather than
the 150 mg in the intramuscular formulation. Like the
intramuscular formulation, DMPA-SC is given at three months
intervals.
Approved first in the United States and the United
Kingdom, subcutaneous injection of DMPA may be available in
some developing countries by 2008. DMPA-SC is available
only in prefilled, single use syringes. In developing countries
it will be available only in prefilled Uniject devices designed
as the formulation for subcutaneous injection. DMPA-SC is
just as effective as the formulation injected into the muscle
and the patterns of bleeding changes and amount of weight
gain are similar. One year continuation rates in clinical trails
were high, 68 percent on average at sites in North and South
America and 80 percent in Europe and Asia. Despite the lower
dose, DMPA-SC is effective for over weight
or obese women.
Injections of DMPA-SC are given in the upper thigh or
abdomen. DMPA- SC should not be injected intramuscularly
and intramuscular formulation should not be injected
subcutaneously. The intramuscular formulation cannot be
diluted to make the lower dose subcutaneous formulation.
Injectables work mainly by preventing the development and
release of eggs from the ovaries (ovulation). They also thicken
cervical mucus, which blocks sperm from meeting the egg.
Both progestin-only and combined injectables are very
effective when users return on time for their next injections.
Long-term studies of the health risks and benefits are under
way, but few results are available yet. Still combined
injectable contraceptives contain the same types of hormones
as combined oral contraceptives (COCs). Therefore
researchers assume that most of the findings about COCs also
apply to combined injectables. A difference is that monthly
injectables are not processed by liver before entering the
bloodstreams, as are medication taken by mouth. As a result,
monthly injectable have less effect.
Centchroman
This oral contraceptive does not contain any steroidal
hormones, developed by the Central Drug Research
Laboratory, Lucknow. It is marked under the brand names
“Saheli” and “Centron”. It is taken twice weekly for intial two
months and thereafter once a week and has no known side
effects, except that in about 8 percent of users there is delay
in menses. It is advised to use barrier method for the initial
two months of start. Fertility typically returns within six
months of discontinuation of Centchroman. However 80
percent of the women do not know about them (Vatsayan A et
al, 1996).
 148 Essentials of Community Medicine—A Practical Approach
Family Planning Insurance Scheme
Government of India is introducing a Family Planning
Insurance Scheme for acceptors of sterilization and indemnity
cover for doctors performing sterilization procedures in both
government and private/NGO/ corporate health facilities. The
insurance scheme will be operated by the Oriental Insurance
Company Ltd. (OCIL). The insurance scheme is as follows:
Section I:
1. Death due to sterilization in hospital Rs.1,00,000
2. Death due to sterilization within 30 days of discharge from
hospital
Rs. 30,000
3. Failure of sterilization (including first insurance of
conception after sterilization) Rs.
20,000
4. Medical complication occurring within 60 days of
sterilization operation Rs.
20,000
*To be reimbursed on the basis of actual expenditure
incurred, not exceeding Rs.
20,000.
Section II:
All the doctors/health facilities including doctors/health
facilities of central, state, local-self governments, other public
sectors and all accredited doctors/health facilities of non-
governmental and private sectors rendering Family planning
services, conducting such operations shall stand identified
against the claims arising out of failure of sterilization, death
or medical complication resulting there from up to a maximum
amount of Rs. 2 lakhs per doctor/health facility in court, which
would be borne by the insurance company within certain
limits.
All persons undergoing sterilization operation in public
health facility/ accredited health facility in private/NGO sector
are covered under section I of the policy. The consent form
filled by the person at the time of enrolling himself/herself for
sterilization operation shall be proof of coverage under the
scheme.
The scheme is uniformly applicable for all States/Union
territories. Government of India has paid entire premium for
Insurance policy. States do not have any expenditure under
this scheme.
The claim settlements has been decentralized at state and
District levels and nominated officers of third party
administrators (TPAs) will co-ordinate with existing machinery
of the States/UTs.
The present scheme will do away with the complicated
process of payment of ex-gratia to the acceptors of
sterilization for the treatment of postoperative
complications, medical complications or deaths
 Reproductive and Child
attributed to the procedure of sterilization or deaths resulting
from sterilization but would also provide indemnity cover to
the Doctor/ health facility affirming sterilization procedure.

Medical Methods of Abortion

Medical abortion methods are especially effective in the first
trimester, most effective before 49 days of pregnancy. This is
due to the fact that both Mifepristone and Methotrexate cause
detachment of the trophoblast (outer layer of developing
embryo which ultimately forms the placenta) from the uterine
wall, which is easier to accomplish the less developed the
pregnancy.

Mifepristone and Misoprostol

Mifepristone (aka RU486) is more effective, earlier in the
pregnancy it is used: “women with pregnancy durations of
seven weeks or less LMP experience a complete abortion
about 95 percent of the time. Success rates decrease to about
80 percent in the ninth week LMP.”Mifepristone acts primarily
as an anti-progestational agent. The progesterone receptors in
the endometrium are blocked, and the disruption of the
embryo and trophoblast lead to a decrease in human chorionic
gonadotropin (hCG) produced by the placental tissues and
therefore a withdrawal of hormonal support for the corpus
luteum. This provides the rationale for why this method is
more effective the earlier the pregnancy, because the more
dependent the pregnancy is on progesterone produced by the
corpus luteum, the more likely the action of the progesterone
antagonist, mifepristone, will result in abortion. The regimen
involves three visits to an abortion provider. On the first visit,
the woman takes 600 mg mifepristone orally. She returns two
days later for administration of Misoprostol, a prostaglandin
which serves to soften and open the cervix and cause
contractions of the uterus, expelling the contents of the
pregnancy. In five percent of pregnancy, mifepristone alone is
enough to induce abortion, but in all other cases 400 to 800
ug of misoprostol is administered orally or vaginally.
Following administration of misoprostol, “three-fourths
experience expulsion within 24 hours and 80 to 95 percent
abort within two weeks.” The third visit is for follow-up.

Side Effects
Most of the side effects when using this early abortion option
are caused by the second medication, misoprostol. Side-effects
may include heavy bleeding, headache, nausea, vomiting,
diarrhea, and heavy cramping.
 150 Essentials of Community Medicine—A Practical Approach
Criteria
Abortion medication may be an option if you:
• Are less than eight weeks since your last menstrual period.
• Are willing and able to give informed consent.
• Have the support you need such as access to reliable
transportation and ability to communicate with the clinic
by telephone.
• Live no more than two hours away from emergency
medical care (a hospital).
• Are able to come back to the clinic for one to three
follow-up appointments.
• Agree to have a surgical abortion if the misoprostol does
not induce termination.

Contraindications
• Blood clotting problem or women on anticoagulant
medicine.
• Severe anemia.
• Adrenal failure.
• Long-term systemic corticosteroids.
• Ectopic pregnancy.
• Mass in the tubes or ovaries.
• Inherited porphyria.
• Allergy to mifepristone, misoprostol or other prostaglandin
medicine.
• Severe diarrhea.

Future Fertility
According to studies of the Food and Drug Administration
(FDA) and the National Abortion Federation, there are no
known long-term risks associated with using mifepristone and
misoprostol. Therefore, women may pursue another
pregnancy whenever they feel the time is right after having a
Medical Abortion.

MANUAL VACUUM ASPIRATION (MVA)

Methods of Uterine Evacuation

Surgical Methods of Evacuation

The primary surgical methods of uterine evacuation following
incomplete abortion in the first trimester are dilation and
curettage (D and C) and vacuum aspiration (VA).
The decision on which method should be used to empty the
uterus should be based on:
 Reproductive and Child
• The duration of gestation
• Availability of equipment and supplies
• Training and skill level of staff and facility.
D and C also called sharp curettage uses mental surgical
instruments to empty the uterus. The use of D and C may
entail operating theater facilities and staff trained in surgical
techniques and general anesthesia. VA uses a vacuum of at
least 55 mm Hg with a cannula made of flexible plastic,
rigid plastic or metal to evacuate the uterus. This technique
has low complication rates and involves very little trauma. It
can often be performed in a clinic or outpatient setting
that requires fewer
resources and fewer staff.
Currently VA is preferred to D and C because of the lower
complication rates and the reduced need for transporting the
woman to a high level facility with an operating theater.

Types of Vacuum Aspiration

Two types of vacuum aspiration (VA) are available:
1. Electric vacuum aspiration uses an electric pump and rigid
cannula for uterine evacuation in the first trimester.
2. Manual vacuum aspiration (MVA) uses a hand held vacuum
syringe and flexible plastic cannula. Foot-operated pumps
also available in some areas. MVA was developed in the
early 1970s in the US. MVA is a safe, effective and low cost
method of uterine evacuation. MVA is a very similar to the
better known technique of menstrual regulation (MR).

Mechanism of MVA
The MVA cannula is inserted through the cervix and attached
to a syringe that contains a vacuum. A valve or two valves are
compressed which creates this vacuum. When the valve is
released, the contents of the uterus are emptied by suction
into the syringe. The syringe aspirates (provides suction),
while the cannula reaches into the uterus.

Key Aspects of MVA Mechanism

• It does not require electricity
• It is portable
• The syringe has two functions: source of vacuum and a
container
• The syringe (double and single valve) holds 60 cc of
aspirated fluid and tissue.
The Government of India has approved the use of MVA for
termination of pregnancy up to eight weeks of gestation. The
MTP Act special provision for this and Ministry of Health and
Family Welfare (MOHFW) has issued guidelines for use of
MVA.
 152 Essentials of Community Medicine—A Practical Approach
Uses of MVA Equipment
The single and double valve syringes may be used for
performing abortion or for treatment of incomplete abortion
up to 8 weeks from the last menstrual period (LMP)
(confirmed by bimanual examination), and the double valve
syringes may be used for MVA for abortion or treatment of
incomplete abortion up to 12 weeks LMP.
The single valve syringes are also appropriate for use in
obtaining an endometrial biopsy. MVA can be used in
outpatients setting, thus increasing women’s access to care.

Advantages of MVA
• Incidence of hemorrhage, pelvic infection, cervical injury
and uterine perforation are lower than with D and C.
• Because no general anesthesia is used, the recovery time is
quicker.
• Less cervical dilation is necessary.
• Heavy sedation is required.
• Costs for procedure, time of staff and resources are lower.
CALCULATION OF THE EFFECTIVE COUPLE
PROTECTION RATE (ECPR)
Suppose a village is having a population of 2000, with 320
eligible couples. Sixty of the eligible couples were using
condoms, ten were using oral contraceptives, ten got IUCD
inserted, four have got vasectomy and sixteen tubectomy.
Calculate the effective couple protection rate of this village?

Effective Protection
Effective protection of contraceptive accepted:
• Sterilization (Vasectomy/Tubectomy): 100%
• Oral contraceptive: 100%
• IUCD: 95%
• Conventional contraceptives: 50%
Based on these rates the effective protection is calculated:
20
• Sterilization = = 20
× 100
100
10
• Oral contraceptive = = 10
× 100
100
10
• IUCD = =
× 95 9.5 60 × 50
100
• Conventional = 30
10
contraceptives =
0
 Reproductive and Child
20  10  9.5  30
• ECPR = × 100 = 21.7%
320
Pearl Index
Pearl index give rise to the failure rate of the
contraceptives. It is calculated by the formula:
No.
= of accidental pregnancies

No. of women observed × months
1200
of use

Important Facts about Contraceptives (Tables 7.5 and 7.6)

Table 7.5: Important fact about contraceptives

Intrauterine contraceptive devices (IUCD)

• Removal rate at the end of one year due to 15.16%
complication and side effects
• Expulsion rate 5.15%
• Perforation rate 1-3 per 1000 insertion
• Ectopic pregnancy 1-30 pregnancies
• Copper T 200 effective for 3 years
• Copper T 380 effective for 6-8 years
• NOVAT 5 years
Vasectomy reversibility
• After anastomoses 60-70%
Tubectomy reversibility by tuboplasty
• For laparoscopic sterilization 70%

Table 7.6: Choice of contraceptives

Subject Contraceptive
Newly married Pill
Postabortal Pill
Postpartum nonlactating Pill
Women below 35 years of age Minipill or injectable steroid
Above 35 years of age Pill
Women who smoke and above IUCD
35 years of age
Diabetic mothers/overt diabetic IUCD
Pulmonary tuberculosis on Barrier methods (condom)
chemotherapy
Heart disease (incomplete family) IUCD
Heart disease decompensated with Barrier methods (condom)
complete family Permanent sterilization of husband
 154 Essentials of Community Medicine—A Practical Approach
BIBLIOGRAPHY
1. Clive Wood. Contraception Explained, Geneva, WHO, 1975.
2. Dalsimer I, et al. Barrier Methods, Population Report Series H:I,
1973.
3. Medical methods for first trimester abortion Cochrane review on
methods available for first trimester abortions.
4. Medical methods for termination of pregnancy report of a WHO
scientific group technical report series, No. 871.
5. National Population Policy Action Plan 2002-2003, Department of
Family Welfare, Ministry of Health and Family Welfare,
Government of India.
6. Park’s Textbook of Community Medicine, 16th edn.
7. Sherris JD. Barrier Methods, Population Report Series H:6, 1982.
8. WHO. The Work of WHO 1976-77, Biennial Report, 1978.
 Chapter Immunization

8 Immunization

CHAPTER OUTLINE
NATIONAL IMMUNIZATION SCHEDULE

NATIONAL IMMUNIZATION SCHEDULE

The age at which the vaccines are best given and the number
of doses of each vaccine is called the immunization schedule.
The immunization schedule is framed keeping in view the
epidemiological pattern of the diseases, the types of vaccines
available and the administrative and economic feasibility of
providing the services. In our country we give:
• Two doses of TT to pregnant women
• Three doses each of DPT and OPV and one dose each of
BCG and measles vaccines to infants
School children are given DT and TT vaccines.

Immunization of Pregnant Woman

The pregnant woman develops adequate antibody titers to
protect herself and her child after birth from tetanus (NNT)
only two to three weeks after the second dose. It is
recommended that the first dose be given on first contact
during pregnancy. The second dose should be given ensuring
at least one month’s interval after the first completing the
schedule as early as possible.

Reactions after Vaccination

Reactions after vaccination are in general mild and of a short
duration. These may be:
• Mild fever
• Local pain, swelling at the site of injection
• Mild rash one week after measles vaccination
• A lump or papule appears in the third or fourth week after
BCG vaccination.
• It is generally not painful but is tender to touch. The papule
increases in size to 6 to 10 mm in diameter by the sixth
week. The nodule softens with the formation of pus. No
treatment is necessary. At the end of 10 to 12 weeks only a
small scar is visible .
In rare cases convulsions or collapse after DPT vaccination
have been observed. In such cases further doses of DPT
should be stopped. Instead,
 156 Essentials of Community Medicine—A Practical Approach
one dose of DT may be given (second dose). If two doses of
DPT have already been administered, further doses are not
required.

Complications
Abscess formation is usually due to the use of unsterilized or
inadequately sterilized syringes and needles.
The injections are painful if blunt needles are used.

Determine Needs and Requirement

Estimation of Eligibles
Your aim is to provide universal immunization coverage in
your area. In order to do this you must have an estimate of the
total annual number of pregnant women and infants. The
numbers can be calculated by using the formula given below:
Population × Birth rate = No. of pregnant women
Population × BR × (1-IMR) = No infants at one
year of age. For example,
If the population served by a health center is 50,000, the
birth rate- 30/1000.
And IMR 100/1000 live births, the expected number of
pregnant woman and infants will be:
50,000 × 0.03 = 1500
50,000 × 0.03 × (1-0.01) = 1350
The estimates of the pregnant women and infants should be
worked out at each level locally and compare with the list
maintained by the health worker to ensure completeness of
registration.
The health workers should have a list of the pregnant
women and infants in the areas covered by them. The list
should be kept up to date. The information can easily be
obtained during, their visits to the villages and also through
the village level workers such as dais,VHGs, anganwadi
workers (AWWs) and others. The name of the child should be
registered soon after birth, the vaccinations being given when
the child reaches the right age.
At any given time, 100 percent of the total estimated annual
number of infants and 60 percent of the pregnant women
should be registered. If the numbers do not fall within 10
percent of your estimates, it is your responsibility to get the
lists updated immediately. You may already have the required
information in the Eligible Couples and Child Register (ECCR).

Estimation of Number of Contacts

The number of vaccination sessions to be scheduled depends
upon the number of children to be vaccinated in the area
served by the health center or vaccination site. If there are ten
or more children to be vaccinated
 Immunization
each day, schedule daily sessions. This will ensure that all
children can be vaccinated at the earliest acceptable age and
will therefore, give them the best protection against disease.
If there are fewer than ten children to be vaccinated each
day,the vaccines and the time of the health staff may be
wasted by holding daily sessions, so it is better to plan fewer
vaccination sessions.
To determine the number of children to receive vaccinations
per month (monthly target population), divide the number of
children to receive vaccinations for the year by 12 and
multiply by the number of doses of the vaccine which need to
be given.
Contaminated vaccines can lead to severe reactions
including death. Use only sterile syringes and needles to mix
vaccines and to draw them from the vials or ampoules (Measles
and BCG vaccines). Use a single sterile syringe and needle for
each injection. Do not use opened vials in subse- quent
sessions. Display these instructions at all sites where
immunization sessions are conducted.
The parents should be informed of the expected side effects
so that they do not worry. If there is any anxiety they should
be encouraged to return to the health center for consultation.

Difference between EPI and UIP

Expanded Program of Immunization (EPI)
• Started in 1978
• High coverage of children under two years and pregnant
women
• DPT, BCG and TT vaccines
• DT and TT vaccines for school children
• Oral polio vaccine added in 1979.

Universal Immunization Program (UIP)

• Started in 1985
• Universal coverage of infants and pregnant women
• Measles vaccine added to the program
• Strengthen cold chain
• Take up districts in phases.

National Immunization Schedule (Tables 8.1 and 8.2)

Table 8.1: Schedule of National Immunization
a. For Infants
At birth (for institutional deliveries)$ • BCG and OPV-O dose Hepatitis B*
At 6 weeks • BCG (if not given at birth) Hepatitis B
• DPT-1 and OPV-1 Hepatitis B
At 10 weeks • DPT-2 and OPV-2 Hepatitis B
At 14 weeks • DPT-3 and OPV-3 Hepatitis B
At 9 months • Measles
Contd...
 158 Essentials of Community Medicine—A Practical Approach
Contd...
b. At 16-24 months • DPT and OPV (Booster 1)
c. At 5-6 years • DPT (Booster 2) OPV #
d. At 10 and at 16 years • Tetanus toxoid—The second dose of TT
vaccine should be given at an interval of
one month if there is no clear history or
documented evidence of previous
immunization with DPT, DT or TT
vaccines
e. For pregnant women • TT1 – TT2
Early in pregnancy
One month after
Note: i. Interval between two doses should not be less than one month.
ii. Minor cough, colds and mild fever are not a contraindication to vaccination
iii. In some states Hepatitis B vaccine is given as routine immunization.
$ For institutional delivery OPV and Hepatitis B is considered as zero dose.
# Initially DT used to be given recently DPT is advocated

Table 8.2: Some more vaccines in the immunizations schedule

Vaccine Dose Age Cost per dose
1. Hepatitis A 1st Dose Before 1st year of birth
2nd dose After 1 year of birth Rs 900
2. Chickenpox One dose After 1st year within 2 years Rs 1,300-1,500
3. Typhoid After 3 years, repeated Rs 150
every 3 years
4. Meningitis 1st dose 1½ months Rs 450
2nd dose 2½ months
3rd dose 3½ months
Note: i. Interval between doses should not be less than one month
ii. The dose of all vaccines is 0.5 ml except BCG which is 0.1 ml polio vaccine is
given by mouth in 2 drops.
iii. Check the label of the vial before use.

The Indian Association of Pediatrics recommends four more

vaccines in the immunization schedule which is not recognized
by the WHO. Although these are optional, it is safe to get them
done.
A PHC would roughly be required to keep 400 to 500 vials a
month.
Such quantities can be easily stored in an ordinary
refrigerator.
Cold boxes, vaccine carriers and day carriers would be
needed to carry vaccines to the lower formations and to the
field. The total numbers will depend on the number of the
centers, the staff in position and the strategies adopted for
coverage.
Estimation of Requirements of Syringes and Needles
The total number of syringes and needles that you would
require will depend on the number of pregnant women and
infants you plan to immunize. It is expected that an ordinary
glass syringe would be used at least 50 times and a needle 10
times before replacements are made. Reusable plastic
syringes are also being supplied to the UIP districts. Such
syringes can be steam sterilized up to 200 times.
 Immunization
The calculations of syringes and needles is quite
simple: Total number of pregnant women and
infants to be covered
× number of doses of each vaccine (total number of
injections)
– ÷ 50 (glass syringes)
– ÷ 200 (plastic syringes)
– ÷ 10 (number of needles)
This calculation gives annual requirement of syringes and
needles. However, for any session syringes to be carried will
depend on the expected number of injections to be given. At
this rate about 500 syringes and needles are required for each
PHC.
A sterile syringe and needle should be used for each
injection. The total number of syringes and needles at each
PHC session should not be less than the expected number of
children and pregnant women during the session. The
syringes and needles should be sterilized before the session.
You must ensure that adequate quantities of the syringes
and needles have been distributed to the field workers and
replacements are made to them periodically or autoclaved
syringes and needles should be provided on the day of session.

Estimation of Requirements of Sterilization Equipment

Arrangements must be made for the sterilization of syringes
and needles for the immunization sessions.
Each visit to the health center or vaccination site for
vaccination is called as contact. Minimum four contacts are
required for one child to receive the complete series of
vaccinations, so the total number of contacts will be four times
greater than the number of children in the target population.
Two contacts with each pregnant woman are expected.

Estimation of Vaccine Needs

Estimation of vaccine requirements and ordering for the right
quantities of vaccine is critical for the success of your
program. The requirements depend on the population to be
covered and the number of sessions to be held (periodicity of
supply).
The vaccine requirements will depend on the number of
pregnant woman and children and on the number of sessions
held.
The calculations for vaccine requirements are
simple: Total number of infants/pregnant women
to be covered
– No. of doses of the vaccine
– WMF (Wastage Multiplication Factor)*
– No. of sessions proposed to be held.
* WMF: 1.33 for DPT, DT, TT and OPV, 2 for BCG and Measles.
 160 Essentials of Community Medicine—A Practical Approach
The vaccines are supplied in 10 or 20 doses vials or
ampoules. The required number of doses are divided by 10 or
20 and rounded off to the next nearest number of vials or
ampoules.
You must always check your previous balance stocks before
placing order for fresh.
You must monitor the performance reports from the centers
to which you supply vaccines to ensure that the expected
number of pregnant women and infants are being immunized
and the vaccines are not wasted. If the attendance is low,
vaccine supplies must be suitably reduced till you can find out
the reasons and take corrective measures to step up
coverage.
Health centers should not keep more than one month’s
requirements and no vaccine should be stored at a subcenter.

Estimation of Cold Chain Requirements

All vaccines must be kept at +2°C to + 8°C otherwise they
lose their effectiveness to protect against diseases. The cold
chain requirements will depend on the quantities of vaccines
to be stored and the period for which they will be stored.
It is estimated that cold storage facilities for roughly 30,000
to 40,000 vials of all vaccines will be necessary at the district
level (>3 month’s requirements of an average district of 2.5
million population).
Storage capacity of around 900 to 1200 liters is required to
store the above quantities of vaccines.
Each task described in the task description must be included
somewhere in a job description of an individual staff member.
Otherwise it will not be clear who is to perform which tasks
and some steps may not always be performed or may not even
be performed at all.
Make a list of the activities and allocate job responsibilities to
the staff.
Ensure that the following tasks are covered:
a. Vaccination coverage of pregnant women and infants.
b. Stores including vaccines. The person concerned should
indent the required quantities of vaccines and other
supplies in time. He should be responsible for the
distribution of the required quantities to the lower
formations and also for monitoring that the supplies are used
properly.
c. Monitoring and supervision of services.
d. Preparation and display of health education material,
advance plan for health talks in the community prior to
outreach operation and compaigns.
e. Recording and keeping reports in order, compilation and
analysis of the reports. Forwarding the reports to the higher
formations and providing feedback.
f. Surveillance of diseases.
 Immunization
Although, you may delegate some of the duties to others,
the final responsibility for ensuring that the immunization
sessions are organized efficiently and effectively is yours.

Determine Training Needs

You are expected to immunize all pregnant women and infants
in your area. This means that you must contact all the
eligibles. Since some of the vaccines require repeated dose,
each child must be contacted at least five times.
It is clear that unless the quality of the services is high it
will not be possible to achieve universal immunization
coverage. The planning and implementation of the program
must be meticulous. There is no scope for any default in the
services. Even temporary dislocation can prove disastrous.
Critical to the success of the program will be the high quality
and easy accessibility of the services.
It is expected that the Medical Officers at the PHC level
responsible for the immunization program will attend four day
course at the district level. The course will cover the modules
on surveillance, cold chain and organization of immunization
sessions. In addition, the manual for the health workers
should also be covered.
All the MPWs and their supervisors are expected to undergo
a two day task oriented course and cover the manual for the
health workers. The course should include practical
demonstration of all the items covered in the manual. The
manuals are available in the regional languages.
Each PHC has been provided with an autoclave. The
syringes and needles required for the sessions held at the
PHC can be autoclaved the previous evening.
Three or four subcenters may organize vaccination sessions
on the same day. These subcenters must be supplied vaccines
from the PHC on the day of the sessions. The feasibility of
autoclaving the required number of syringes and needles at
the PHC and supplying them to the subcenters along with the
vaccines must be seriously considered. This will ensure proper
sterilization of the syringes and needles, save the time of the
ANMs at the subcenters and also avoid the logistics of
supplying kerosene and sterilization equipment to the
subcenters.
Where the above arrangements are not operationally
feasible stoves and pressure sterilizers must be provided to
the subcenters. It will also be your responsibility to ensure
that adequate stocks of kerosene are available. This should be
replenished regularly.
Boiling of syringes and needles at outreach sites should be
done only as an emergency and not on a routine basis.
Sufficient number of sterilised syringes and needles should be
taken by the health staff to the outreach sessions. The
numbers taken should be at least 10 percent more than the
 162 Essentials of Community Medicine—A Practical Approach
expected number of children and pregnant women to be
vaccinated on that day.
Estimation of Requirements of Immunization Cards
Vaccination cards must be given to all the pregnant women
and infants. The card used for the pregnant women can be
later used for the infant after the birth of the child. The cards
should be in the regional language. During the first year of the
program you will, however, need more cards for the infants.
The number of cards you would need is as follows:
• First year—total number of pregnant women and infants
+10 percent
• Later—total number of pregnant women + 10 percent.

Manpower Needs
You must clearly define:
Task description of all the steps to be performed in order to
carry out each major step. Task descriptions describe what
must be done.
Job responsibilities describe the tasks to be performed by the
staff member. Job responsibilities describe who will do the
work.

Enumerate Eligibles
The vaccine requirements depend on the eligibles and the
number of sessions to be held. The simplest and best way to
know the eligible is house to house enumeration of pregnant
women and infants. The village wise enumeration at a
particular period should get the information of infants
according to month of birth. Though enumeration can be done
at any time in the year, it is ideal to do in the first week of
April every year. Thereafter, regular updating of the eligibles
must be done during the routine visits. However, the number
of eligibles in the future months can be assumed to be same as
the corresponding period of the previous year. Pregnant
women should be registered at the earliest period of
pregnancy and expected date of delivery (EDD) should be
worked out.
Obtain Vaccines
Estimation of the vaccine requirements and ordering for the
right quantities of vaccines is critical for maintaining the cold
chain. The requirements depend on the population to be
covered and the number of sessions to be held (periodicity of
supply). Estimation based on the following formula will enable
the supervisors to assess the vaccine requirements and to
verify the correctness of enumeration.

Estimation of Vaccine Requirements

Total number of pregnant women/infants in the area.
× Proposed coverage
× Number of doses of the vaccine to be given (including
 Immunization
booster dose)
 164 Essentials of Community Medicine—A Practical Approach
• Vaccine administration rate *(VAR).
• Periodicity of supply (depending on the number of sessions
held per month).
For example, in an area with a population of 5,000 birth
rate of 30/ 1000 and IMR of 100/1000 live births, the
estimated number of pregnant women and infants is
calculated as follows:
Eligibles:
Pregnant women = Population × BR
Infants = Population × BR × (1
– IMR) Pregnant women = 5,000 × 0.03 =
150
Infants = 5,000 × 0.03 × (1 – 0.0) = 150 ×
9 = 135
Vaccine requirements are calculated based on the following
formula: Number of vials required = Number of eligibles ×
expected coverage
Number of doses ÷ VAR ÷ Number
of doses per vial.
Instead of dividing by VAR you can multiply by wastage
multiplication factor (WMF) as indicated by equivalents below:
VAR WMF
50% 2
75% 1.33
90% 1.11
Thus, the formula using WMF will be:
No. of eligibles × expected coverage × No. of doses × WMF
÷ No. of doses per vial continuing with the example on
previous page.
Requirement of TT = 150 × 100/100 × 2 × 1.33 =
400 doses. This is annual requirement of TT for
pregnant women.
Monthly requirement = 400 ÷ 12 = 34 doses ÷ 10 = 4
vials.
If sessions are held fortnightly, divide by 24 and if weekly,
divide by 52.
Although minimum coverage required for DPT, OPV, BCG and
measles is 85 percent, it is better to calculate vaccine
requirements for 100 percent. Accordingly in the example
cited, requirement of DPT/OPV will be:
135 × 100/100 × 4 × 1.33 = 720 doses (4 doses include 3
primary and
one booster)
Accordingly, monthly and fortnightly requirements will be
60 and 30 doses.
BCG/Measles = 135 × 100 ÷ 100 × 1 × 2 = 270 doses.
Accordingly, monthly and fortnightly requirements will be
25 and 13 doses.
The vaccines are supplied in 10 or 20 dose vials or
ampoules. The required number of doses are divided by 10 or
20 and rounded off to the next higher number of vials or
ampoules.
 Immunization
Since, the subcenters are not supposed to keep vaccines
there will be no balance stocks from previous supplies.
(Note:*Vaccine administration rate: It is the number of doses actually
administered to beneficiaries out of one hundred doses of the
vaccine).
 166 Essentials of Community Medicine—A Practical Approach
You must monitor the performance reports from the
subcenters to ensure that the expected number of pregnant
women and infants are being immunized and the vaccines are
not wasted. If the attendance is low, vaccine supplies must be
suitably reduced till you can find out the reasons and take
corrective measure to step up coverage.

Maintain Vaccines
When administrating vaccine to expectant mothers and infants
at the vaccination site, you must take great care not to expose
the vaccine to heat and sunlight. To do this:
• Select a vaccination site that is as cool as possible,
preferably inside a room. If a room is not available,
vaccinate in the shade. Do not vaccinate in the sunlight.
• Open the carrier only when necessary
• Remove vaccine and diluent from the vaccine container,
only when you need it.
• Take only vial of one type of vaccine from the container at a
time. Do not take the second vial from the carrier until it is
needed.
• Secure the lid tightly after opening as soon as possible
• Wrap the BCG ampoules in a dark paper to protect them
from heat and light.
• When you take vaccine out of the container, place vials
inside a cup containing ice. If the ice melts and no mothers
and children are waiting, put the vials back into the cold
chain container until a mother arrives. Then place the vials
inside the cup with ice.
• When the vaccination session is completed, return all vials to
the health center store, if ice packs in the carrier still
contain ice, mark unopened vials by putting rubber band,
and return them to the refrigerator. Be sure to use these
marked vials during the next vaccination session.
Do not take the same vial of the vaccine out to the field
more than three times. If a vial of vaccine has been taken to
the field third time, return it to the PHC after marking
‘Discard’. You must, however, be careful that vaccines are
not wasted in this way too often.
– Keep opened vials in plastic bag and return these to PHC
at the end of the session for discarding by an identified
person.
– If the ice in the cold chain container is completely melted
for less than one day:
i. Discard polio vaccine, so that no one else can use.
ii. Mark the remaining DPT, tetanus toxoid, measles and
BCG vaccine, return it to the refrigerator, and use it
during the next vaccination session.
– If the ice in the cold chain container is completely melted
for more than one day throw away all vaccines.
• Keep a record of the vaccine you administer.
 Immunization
• Keep record of the batch numbers and the expiry dates of
the vaccines used.
• Keep a record of vaccines returned to PHC.
The administration rate of the vaccines will depend on the
number of sessions held and the attendance at the sessions.
The fewer the number of pregnant women and infants per
session the lower will be the administration rate. This is
because opened vials must be discarded at the end of the
session. On an average, the administrative rates of all
vaccines is estimated to be 75 percent except BCG and
measle-vaccines for which the administration rate is around
50 percent.
Sometimes the services may have to be intensified to cover
up the back logs. On the other hand, due to various reasons,
such as heavy rains, priorities of other programs, vacant
posts, etc. services may be considerably reduced during some
months of the year. Thus, the monthly requirements will be
more in some months and less in others. The supplies to the
subcenters must be adjusted accordingly with less vaccines
being supplied over some months and more during the others.
This must be part of your planned activities.
Before the vaccines are despatched, make sure to check the
ice packs of the vaccine carriers. These should be frozen solid.
If using thermocol carrier, these should be packed at least
1/3rd with ice.
Check that the types and amounts of vaccine and diluent
are the same as you estimated.
Check that the expiry date on each vial of vaccine has not
passed.
Check that DPT, DT, TT vaccines have not been frozen. The
solution of such vaccines, on shaking is not uniform. Small
granules or floccules will be seen. Such vaccine also forms
sediment faster than the normal vaccine (shake test).
If you are sending vaccines to more than one subcenter see
that the subcenters fall on the same route and if one person
can deliver the vaccines taking the shortest route. The
vaccines should reach the subcenters in time for the
vaccination sessions.
Any unused vaccine left at the end of the day should be
returned to the PHC on the same day. No vaccine should be
stored at the subcenter. These vials should be kept in a
separate box in the refrigerator marked “returned”. Put a
rubber band around the vial to indicate that it was taken out
once, two rubber bands if taken out twice. Any vial which has
been taken out three times and not used, must be discarded.
You must, however, be careful that this does not happen too
often.
Maintain Equipment
Vaccine and diluent taken from cold storage can be kept for
several hours if packed properly in well insulated cold chain
containers. To do this, three types of cold chain containers are
available for your use:
• A cold box
 168 Essentials of Community Medicine—A Practical Approach
• Vaccine carrier
• A day carrier.

Vaccine
BCG

History: Developed in the year 1927 by Calmette and Guérin

from bovine bacilli after 230 subcultures (Table 8.3).
Table 8.3: Milestones in vaccination
1796 - First vaccination. Jenner tests for smallpox resistance
1883 - Vaccination for children against rabies
1892 - Cholera vaccine
1913 - Toxoid, antitoxin immunization against diphtheria
1921 - BCG vaccine
1923 - Diphtheria toxoid
1923 - Pertussis vaccine
1927 - Tetanus toxoid
1937 - Influenza vaccine
1937 - Yellow fever vaccine
1949 - Mumps vaccine
1954 - Salk’s polio vaccine
1957 - Sabin’s oral polio vaccine
1960 - Measles vaccine
1962 - Rubella vaccine
1968 - Type C meningococcus vaccine
1970 - Researchers in Israel proved that injection of a peptide from a virus or
disease can induce the production of antibodies that recognize the entire
virus or disease
1971 - Type A meningococcus vaccine
1980 - First commercial vaccine for Hepatitis B
1982 - First vaccine produced through genetic engineering (vaccines for diarrhea
in pigs)
1982 - First synthetic vaccine created at Institute Pasteur and at Weizmann
Institute from diphtheria toxin.

Aim: To induce benign artificial primary infection which will

stimulate an acquired resistance to possible subsequent
infection with virulent TB bacilli and thus reduce mortality
and morbidity from pulmonary TB among those most at risk.
Vaccine
• It is a live bacterial vaccine. It consists of living bacteria
derived from an attenuated bovine strain of TB bacilli
• Vaccine is prepared from “Danish 1331” strain since Jan
1967 at BCG laboratory Guindy, Chennai.
 Immunization
Potency
• Vaccine is stable for up to one year if stored below 10°C
• At room temp—one month
• During summer—one weeks
• After reconstitution with normal saline—three hours.

Protection
Protect it from sunlight.
Types of vaccine: Liquid vaccine (fresh) and freeze dried
vaccine
Storage: Wrapped in a double layer of red or black cloth.
Dosage:
• 0.1 ml for infant
• 0.05 ml for neonate (< 4 weeks)
• 0.1 ml in neonate penetrats into deeper tissue and gives rise
to local abscess formation and lymphadenopathies (axillary).

Route of Administration
Intradermal using a tuberculin syringe—omega microstate
syringe fitted with 1 cm steel 26 gauge intradermal needle.
Site: Just above the insertion of the deltoid muscle. A
satisfactory injection should produce a wheal of 5 mm in
diameter. The vaccine must not be contaminated with an
antiseptic or detergent.
Age: Immediately after birth for institutional delivery or at six
week of age simultaneously with DPT and polio, it should
always be completed by one year. It can be given up to 20
years irrespective of tuberculine status.

Complication
Ulceration at site and suppurative lymphadinitis occur in—1 to
10 percent of vaccination.
Osteomyelites, disseminated infection occur in—<1
percent/million vaccination.
Abscess formation—Rx incision and drainage—Rx with PAS
or INH powder.
Protective value: Range of protection 0-80 percent is from 15
to 20 years, it gives protection against childhood TB,
tubercular meningitis.

Contraindications
1. Generalized eczema
2. Infective dermatitis
 170 Essentials of Community Medicine—A Practical Approach
3. Hypogamma globulinemia
4. History of deficient immunity.

Oral Polio
Oral polio vaccine was described by Sabin in 1957.
• It contains live attenuated vaccine (Type 1, 2 and 3)
• Grown in monkey kidney HDCC (Human Deploid Cell
Cultures). The vaccines contain:
i. 300000 TCID 50 g type 1 polio virus
ii. 100000 TCID 50 g type 2 polio virus
iii. Over 30000 TCID 50 g type 3 polio virus per dose.

National Immunization Schedule

BCG may be given at the same time as the oral polio vaccine.
DPT vaccine may also be given at the same time as BCG but in
different areas:
• Three doses of OPV at one month interval commencing first
dose when the child is 6 weeks old.
• It is very important to complete vaccination for all infants
before six months of age.
Because most of the polio cases occur at the ages of six
months and three years one booster dose OPV is
recommended 12 to 18 months later.
If vaccine is spoon fed spoon should be boiled in water and
cooled in ice water before administering vaccine. Don’t use
disinfectant for sterilization of spoon.

Development of Immunity
Live vaccine strains infect intestinal epithelial cells after
replication, the virus is transported to the payer’s patches
where secondary multiplication with subsequent viraemia
occurs. The virus spreads to other areas of body, resulting in
production of circulating antibodies and prevent paralytic
polio.
Intestinal infection stimulates the production of IgA
secretory antibodies which prevent subsequent infection of
the alimentary tract with wild strains of polio virus and is
effective in limiting virus transmission in the community.
Oral Polio Vaccine (OPV)
It includes both local immunity and systemic immunity. Virus is
excreated in feces and secondary spread occurs to house hold
contacts and susceptible contacts in the community.
Nonimmunized persons may therefore be immunized. Thus,
widespread “herd immunity” results, even if only 66 percent
approximately of community is immunized.
 Immunization
Therefore, this property of OPV has been exploited in
controlling epidemics of polio by administration of vaccine
simultaneously in a short period to all susceptibles in a
community. This procedure, virtually eliminates wild polio
strains in the community. Wild polio is replaced by attenuated
strains.
Failure of Three Dose Regimen
The proportion of children developing antibody after three
doses of trivalent vaccine can be as low as 30 percent in
tropical countries as against the more usual 90 percent in
temperate climate countries.
Failure of OPV
Increased gradually from – 5 percent in 1960 to 30 percent
currently.
To overcome this failure Indian academy of pediatric has
recommended five dose of OPV in clinic based programs.
Some have recommended yearly dose up to eight years.
At the vaccination clinic, the bottle containing the OPV
should not be frozen and thawed repeatedly. It would be
preferable to keep the vials of the vaccine in ice during its
administration to children.
Breastfeeding does not impede the effectiveness of OPV.
However, hot water, hot milk or hot fluids should be with held
for about half an hour after the administration of the vaccine.
The vaccine should be administered preferably in a cool room,
rather than in a hot, humid and crowded room.
Complications
Risk of vaccine associated paralysis is 1 case/1 million
vaccination. Risk of close contact of vaccine developing
paralytic polio is about 1 case/5 million dose of vaccination.
Contraindications
For administration of OPV are fever, diarrhea, dysentery,
leukemia’s, malignancy, those receiving corticosteroids. These
are only relative contraindications.
Storage
OPV(Heat stabilized) can be stored without losing potency for
a year at 4°C and for a month at room temperature. Nonheat
stabilized vaccine should be stored at –20°C in a deep freeze.
If deep freeze is not available it might be stored temporarily in
freezing chamber of refrigerator.
Salk Polio Vaccine
Inactivated by formaline. It contains 20, 2, and 4 D antigens
unit—type 1, 2 and 3 respectively.
 172 Essentials of Community Medicine—A Practical Approach
third dose—at an interval of one to two
months fourth dose—6-12 months after
3rd dose
Additional doses—recommended prior to school entry and
then every five years until the age of 18 years. One or two
dose of OPV are given safely as booster after an initial course
of immunization.
• Induce—humeral antibodies (IgM and G, A) serum
antibodies.
Advantages
Safe to administer in:
1. Person with immune deficiency disease.
2. To person undergoing corticosteroid and radiation therapy.
3. For those over 50 years who received vaccine for 1st time.
4. During pregnancy.

Strategies for Polio Eradication

1. Conduct Pulse Polio Immunization (PPI) days every year for
three to four years or until polio myelitis is eradicated.
2. Sustain high level of immunization coverage.
3. Monitoring OPV coverage at district level and below.
4. Improve surveillance capable of detecting all cases of Acute
Flaccid Paralysis (AFP) due to polio and non-polio etiology.
5. Ensure rapid case investigation, including the collection
of stool samples for virus isolation.
6. Arrange follow-up of all cases of AFP at 60 days to check for
residual paralysis.
7. Conduct outbreak control for cases confirmed or suspected
to be polio myelitis to stop transmission.
Even a single case is treated as an out break and preventive
measures are initiated, usually within 48 hours of notification
of case. Reporting of all cases of acute flaccid paralysis in
children under 15 years of age is mandatory and line lists of
all reported cases of polio are maintained.

Current Four Basic Strategies to Eradicate Polio

Routine Immunization
Immunize every child aged < 1 year with at least four doses of
oral polio vaccine.
National Immunization Days (NIDs)/Pulse Polio
Immunization (PPI) Program
Conduct by giving additional doses of OPV, four to six weeks
apart to every child aged < 5 years. Intensification of the Pulse
Polio Immunization
 Immunization
Program can be done by adding additional rounds, house-to-
house “search and vaccinate” component to the fixed post
approach. Intensifica- tion of PPI needs a meticulous planning
of the program along with intensive supervision and
monitoring besides social mobilization effort.

National Immunization Days

In India, transmission of polio has dramatically reduced from
1934 laboratory confirmed cases in 1998 to 1126 in 1999 and
just 263 in 2000. It is decided that there is a need to make
extra-efforts to reach the unreached during Pulse Polio
Immunization Days. For that reason Intensified Pulse Polio
Immunization was proposed and just after the National
Immunization Day a immunisation team would go to house to
check whether the child has received pulse polio vaccine and
if not given then child must be given a dose. An elaborative
work plan has been proposed for each supervisor to ensure
that no child is left without polio vaccine.

Surveillance of Acute Flaccid Paralysis (AFP)

To identify all reservoirs of wild poliovirus transmission.

Objective
To find places with circulation of wild poliovirus.

Components

Establishment and maintenance of reporting units (RUs):

Reporting units form the backbone of surveillance network.
These are hospitals, pediatricians, doctors, and medical/health
establishments in government or private sectors who are
likely to see a case of Acute Flaccid Paralysis (AFP). The
reporting units are well distributed to cover all areas in the
country. Apart from reporting AFP cases immediately, the RUs
send a weekly AFP surveillance report to the District
Immunization Officer (DIO) irrespective of whether or not they
see a case of AFP during the work. Each RU has a nodal
officer responsible for reporting and upkeep of records. At
present, 8,453 RUs are participating in AFP surveillance
throughout India. Apart from these, numerous small clinics,
private practitioners, doctors of Indian systems of medicine,
quacks (all together termed as informers) report AFP cases
whenever they see them. Both the Surveillance Medical
Officer (SMO) and DIO are involved in the creating of a sound
reporting network and visiting regularly to the reporting units
in their area and conducting active case searches in the RUs
at regular intervals to look for any cases that might not have
been reported.
 174 Essentials of Community Medicine—A Practical Approach
AFP case notification: The RUs and informers notify AFP cases
immediately to the DIO. Since very important activities like
stool specimen collection, outbreak response immunization,
active case search in the community, etc. should occur early,
rapid notification is very essential.
AFP case investigation: An AFP case is immediately
investigated, usually within 48 hours of notification, by DIO or
SMO. After confirming the case as AFP, the DIO clinically
examines the child, takes history and fills a standard Case
Investigation Form (CIF).
Stool specimen collection and transportation: From every
case of AFP, 2-stool specimens are collected. The aim is to
get these specimens at the earliest, within 14 days of onset of
paralysis (or maximum of eight weeks) and at least 24 hours
apart. Each specimen is 8 grams or about adult thumb size
collected in a clean, dry screw capped container. The container
need not be sterile and no preservative/transport media is
used. The specimens are collected, labeled and transported in
cold chain to the designated national lab. A standard Lab
Request Form (LRF) is filled that accompanies the stool
specimen. Special stool specimen carriers have been provided
to districts for this purpose. Stool specimens are collected
from all AFP cases detected within eight weeks from the onset
of paralysis.

Virological Classification Scheme (Flow chart 8.1)

Flow chart 8.1: Virological classification scheme

** 2 Specimen at least 24 hours apart and within 14 days of onset paralysis: each specimen
must be of adequate volume (8-10 grams) and arrive at a WHO accredited laboratory in good
condition (i.e. no desiccation, no leakage; adequate documentation and evidence that the cold
chain was maintained)
 Immunization
Process of AFP Surveillance (Flow chart 8.2)

Outbreak response immunization (ORI): Following stool

specimen collection, outbreak response immunization is
organized in the community. All 0 to 59 months old children
are given one dose of oral polio vaccine irrespective of their
previous immunization status while going house to house. The
recipients include all target children in the village/locality. At
least 500 children are vaccinated. The ORI is performed as
soon as possible. The travel history of the child may suggest
additional places of stay where ORI should also be conducted.
While conducting the house-to-house immunization during ORI
active case search is conducted in the community.
Active case search in the community: In the community where
an AFP case lives, a house-to-house active case search is
organized to find more AFP cases if they have occurred. This
activity is carried out immediately along with Outbreak
Response Immunization (ORI). The case definition used
during searches is: Flaccid/floppy paralysis in a child
between 0-15 years of age with onset within last 60 days. All
the cases that are found are investigated immediately and
have two stool specimens taken before the child is given Oral
Polio Vaccine (OPV). The purpose of the search is to fully
uncover additional polio cases, if any, in the community.
Sixty days follow-up examination: The District Immunization
Officer or Surveillance Medical Officer revisits every case of
AFP 60 days after the onset of paralysis to confirm the
presence or absence of residual weakness. Child is assessed
for weakness, asymmetrical skin folds, and difference in
left/right mid-arm/mid-thigh circumference. The child has
residual weakness, if any of the above is present, even if
minimal. This activity is completed before 70th day of onset of
paralysis.
Cross notification and tracking of cases: The cases are
investigated anywhere in India irrespective of where the
child lives. A very advanced communication system
(telephone/fax/e-mail) has been established that sends
information to DIO of the resident district of AFP case
immediately. The AFP case is constantly tracked by SMOs to
complete all the activities related with surveillance. This also
leads to realistic and complete epidemiological picture at
district level.
Data management and analysis: At the end of each week, DIO
reports to the State EPI Officer the line of all new AFP cases,
reported during that week. He summarizes the activities and
reports the current status of investigation and the follow-up of
AFP cases. Reporting takes place even when no cases of AFP
have been identified. The data is entered into computers at
National Polio Surveillance Unit (NPSU) and is used for
program monitoring, checking quality of data and assessing
progress towards eradication. The data is analyzed for taking
appropriate action.
 176 Essentials of Community Medicine—A Practical Approach
Flow chart 8.2: Process of AFP surveillance

Case classification: When lab results and 60 days follow-up

examination reports are available, the cases are classified at
NPSU as polio or non- polio. Until 1999, the clinical system of
classification was being used. According to this scheme, a
case is classified as polio if wild poliovirus is isolated. If two
adequate stool specimens have been collected (24 hr apart)
from the case within 14 days of onset of paralysis and the
stool results are negative then the case is non-polio. If the
case had inadequate stool specimen and the AFP case had
residual weakness, died or lost to follow-up then that case is
classified as polio. From January 2000, India has shifted to the
advanced virological system of classification. Cases with
inadequate stool specimen and having residual weakness, died
or lost to follow-up are subjected to special investigation and
are presented for the review by the Expert Group at national
level. The Expert Group classifies the case as compatible or
discarded. This has been possible due to the achievement of a
high level of surveillance of AFP.
Feedback: In order to give feedback, the reports and maps,
which are generated by NPSU, are on the website. NPSU also
sends line lists of the cases to the states twice a month.

Conduct Extensive House-to-House

Immunization Mopping-up Campaigns
In the final stages in focal areas where wild poliovirus
transmission persists.
 Immunization
Mopping-up: Conduct extensive house-to-house immunization
mopping- up campaigns: Experience in previous years has
shown that though the National Immunization Days (NIDs
called as Pulse Polio Immunization or PPI in India) decrease
polio transmission and delay the annual peak in high endemic
states, the virus persists and bounces back in the later half of
the year. But to achieve eradication quickly, it will be critical
to target the remaining districts with extra rounds of house-to-
house immunization early in 2001 before the onset of the hot
summer and the subsequent high season of polio during the
rains.
Mopping-up is not a Sub-National Immunization Day
(SNID). SNIDs are done when there is widespread and
dispersed transmission in a part of the country and is aimed
at reducing the transmission to clearly delimited, focal areas.
SNIDs are not an end-game strategy and can be repeated a
few times if needed. On the other hand, mopping-up is aimed
at stopping transmission in a defined area. This can’t be
repeated too many times. In mopping-up the virus from an
area or population, there are no shortcuts to reaching all
children. Going house-to-house or family- to-family are tools to
achieve that elusive goal of reaching all eligible children.

Line Listing of Cases

Started in 1989.
Aim of line listing of cases
1. To check for duplication (Same case reported more than
once).
2. Year of onset of illness to screen the children with residual
paralysis.
3. Identification of high-risk pockets.
4. Documentation of high-risk age groups.

Intensive Pulse Polio Immunization (IPPI)

1. It will reduce number and size of high-risk areas.
2. Increase in the involvement of health official in the planning
process. AFP surveillance information in planning of
immunization activities by helping and monitoring of the
technique.

Strategies Involved to Achieve Intensification of PPI

Conduct Nation wide four Pulse Polio Immunization (PPI)
rounds based on June 1999 recommendation of “Global
Technical” consultative group in polio myelitis eradication.
• Four rounds—with four weeks apart from 1999-2000
• First day—booth based 2nd and 3rd day—house-to-house
search
• Aim—hundred percent immunization.
In addition—2 supplementary rounds in February 27th to
29th and March 26th to 28th in eight priority states Uttar
Pradesh, Madhya Pradesh, West Bengal, Bihar, Rajasthan,
Assam, Gujarat, and Orissa.
 178 Essentials of Community Medicine—A Practical Approach
Vaccine Vial Monitoring
During the IPPI there is a need to reach every
eligible child with potent oral polio vaccine. The
Vaccine Vial Monitor (VVM) is a simple tool,
which enable the vaccinator to know whether
vaccine is potent at the time of administration.
On the vaccine vial there is a circle mark in
which a small square is printed which is either
white or lighter than the color of circle that
indicate that the vaccine is potent and can be
used. However, if the color of square is dark or
of same color as circle mark then the vaccine
should be discarded.

Measles Vaccine
Measles is best prevented by active
immunization. Only live attenuated vaccines are
recommended for use.
No egg culture vaccine are produced at all today.
• All are tissue culture vaccine—chick embryo, HDCC (Human
diploid cell culture)
• It is a freeze dried product.

Age
1. The most effective compromise is immunization as close to
the age of nine months as possible.
2. If there is measles outbreak in community, measles vaccine
should be started at sixth month.
3. For infants immunized between six and nine months of age,
a second dose should be administered as soon as possible
after the child reaches the age of nine months provided that
at least four weeks have elapsed since the last dose.
4. In countries where the incidence of measles has declined,
the age of immunization is being raised to 15 months in
order to avoid the blocking effect of persistent
transplacentally acquired antibody.

Storage
Heat stable measles vaccines able to maintain their potency
for more than 2 years at 2 to 8°C have been developed.

Administration
It is administered in a single subcutaneous dose of 0.5 ml.
 Immunization
Diluting fluid for reconstituting the vaccine must be kept cold
at 4 to 8°C.
• The reconstituted vaccine should be kept on ice and used
within one hour
• Measles vaccine has recently been adapted for aerosol
administration.

Reactions
When injected into the body—attenuated virus multiplies and
induces a mild “measles illness” (fever and rash) 5 to 10 days
after immunization
• But reduced in frequency and severity. This may occur in
15 to 20 percent of vaccinees.
• Fever may last for—one to two days and the rash for one
to three days.
There is no spread of the virus from the vaccinees to
contacts.

Immunity
Develops within 11 to 12 days after vaccination
• Appears to be of long duration probably for life.
• One dose of vaccine offers 95 percent protection.

Contacts
Susceptible contacts over the age of 9 to 12 months may be
protected against measles if vaccine is given within three days
of exposure. This is because incubation period of measles
induced by vaccine is about seven days compared to 10 days
for the naturally acquired infection.

Contraindications
1. Pregnancy is positive contraindication
2. Acute illness
3. Defective cell mediated immunity
4. Steroids and immunosuppressive drugs.

Adverse Effects of Vaccine

Toxic shock syndrome (TSS) occurs when measles vaccine is
contaminated or same vial is used for more than one session on
the same day or next day.
Vaccine should not be used after four hours of opening the
vial. TSS is totally preventable. TSS symptoms are:
1. Fever (high degree)
2. Watery diarrhea
 180 Essentials of Community Medicine—A Practical Approach
3. Vomiting within few hours of measles vaccination.
Case fatality rates are high. May cause death within 48
hours.

Combined Vaccine
It can be combined with other live attenuated vaccines such
as mumps and rubella vaccines (MMR vaccines) and such
combinations are highly effective.

Immunoglobulin
Measles may be prevented by administration of
immunoglobulin early in the incubation period, the dose
recommended by WHO is 0.25 ml per kg of body weight. It
should be given within 3 to 4 days of exposure. The person
passively immunized should be given live measles vaccine 8
to 12 weeks later.
Eradication is possible because:
1. Highly potent vaccine is available
2. Need a single dose of vaccine
3. Vaccine can be stored for long time and gives long lasting
immunity
4. Case detection and surveillance is possible
5. By primary health care approach-universal immunization
program facilities are made available even in remote areas.

Urban Measles Campaign

Measles is a highly contagious viral disease occurring in
overcrowded areas where poor people live and coverage of
measles vaccination is poor. These areas are needed special
vaccination drive initiated by UNICEF in 1998 covering 13
cities and in 1999-2000, 50 more cities are also covered. The
main focus is on covering all unprotected children up to the
three years.

Diphtheria Immunization
Current prophylactics. These may be grouped as below:

Combined or Mixed Vaccines

• DPT (Diphtheria, pertussis-tetanus vaccine)
• DT (Diphtheria and tetanus toxoid)
• dT (Diphtheria and tetanus, adult type).

Single Vaccines
• FT (Formal toxoid)
• APT (Alum-precipitated toxoid)
 Immunization
• PTAP (Purified toxoid aluminum phosphate)
• PTAH (Purified toxoid aluminum hydroxide)
• TAF (Toxoid-antitoxin floccules).
Antisera
Diphtheria antitoxin
• Combined vaccines DPT vaccine.
Advantages
1. The infant can be immunized simultaneously against—three
diseases viz. diphtheria, pertussis and tetanus.
2. Pertussis component enhances the potency of the diphtheria
toxoid. Two types of vaccines—plain and adsorbed.
Adsorbtion is carried out on a mineral carrier like
aluminum phosphate or hydroxide.

Composition of DPT Vaccines (Table 8.4)

Table 8.4: Composition of DPT vaccines
Contents Glaxo (Per/0.5ml) Kasauli
Diphtheria toxoid 25 Lf 30 Lf
Tetanus toxoid 5 Lf 10 Lf
B. pertussis (millions) 20,000 32,000
Aluminum phosphate 2.5 mg 3.0 mg
Thiomersal, BP 0.01% 0.01%

Storage
Vaccines should not be frozen. They should be stored in a
refrigerator between 4 to 8°C.
• Optimum age is six weeks after birth
• No of doses: 2-3 doses
• Two dose of DT gives > 80 percent protection
• But two doses of pertussis gives—50 percent protection
• Three dose of DPT offers better protection than two doses
of DPT.
Interval between Doses
An interval of four weeks between three doses with a booster
injection at 1½-2 years followed by another booster dose (DT
only) at age five to six years.
Mode of Administration
Deep IM upper outer quadrant of the gluteal region.
In 1984, Global Advisory Group recommended DPT vaccine
for children under one year of age, DPT—should be
administered in lateral aspect of thigh.
 182 Essentials of Community Medicine—A Practical Approach
Reactions
Fever and mild local reactions are common two to six percent
of vaccinees develop fever of 39°C or higher 5 to 10 percent
experience swelling and induration or pain lasting more than
48 hours.

Neurological Complications
These are due to the pertussis component of the vaccine.
• Encephalitis
• Encephalopathy
• Prolonged convulsions
• Infantile spasms
• Reye’s syndrome.

Contraindications
Minor illness such as cough, cold, mild fever are not
considered contra- indications to vaccination.
DPT—should not be repeated if a severe reaction occurred
after a previous dose.
Such reactions include collapse or shock like state,
persistent screaming episodes, temp > 40°C, convulsions,
anaphylactic reaction. In case of DPT subsequent
immunization with a DT only is recommended without
pertussis component.

Tetanus Toxoid
1. Active immunization
2. Passive immunization.

Aim
Protective level of antitoxin approximately—0.01 IU/ml serum
throughout life.
All persons should be immunized regardless of age.

Two Preparations
1. Combined vaccine-DPT
2. Monovalent vaccines
a. Plain or fluid (formal) toxoid
b. Tetanus vaccine, adsorbed (PTAP, APT).

Monovalent
• 0.5 ml injected into arm—one to two months interval
• First booster dose—one year after the initial two dose
• Second booster dose—five year after 3rd dose
 Immunization
• It can be stored up to 5 hours at 4 to 10°C
• It must not be allowed to freeze at any time.
All wounds should receive surgical toilet (Flow chart 8.3)
Flow chart 8.3: All wound receive surgical toilet

A = Has had a complete course of toxoid or a booster dose within the

past five years.
B = Has had a complete course of toxoid or a booster dose more than
five years ago and less than 10 years ago.
C = Has had a complete course of toxoid or a booster dose more than
10 years ago.
D = Has not had a complete course of toxoid or immunity status is
unknown.

Passive Immunization
Temporary protection against tetanus can be provided by
injection of Human tetanus hyperimmunoglobulin or ATS.
It is best prophylactic to use. The dose for all ages is 250-
500 IU. It does not cause serum reactions. It gives longer
passive protection up to 30 days or more compared to 7 to 10
days for Horse ATS. Human tetanus Ig is now available in
India and it is produced by the Serum Institute of India, Pune.

ATS (Equine)
If human antitoxin is not available—equine antitoxin (ATS) is
used. The dose is 1500 IU-SC after sensitivity testing.
• Gives passive protection for about 7 to 10 days.
• Being foreign protein ATS is rapidly excreted from the
body and there may be very little antibody at the end of
two weeks.
 184 Essentials of Community Medicine—A Practical Approach
Therefore, it does not cover the tetanus incubation period
(IP) in all cases. It causes sensitivity reaction in many cases.
Person receiving first time may tolerate—subsequent injection
with horse serum may lead to allergic reaction varying in
severity from rash to anaphylactic reaction. It stimulates
formation of antibodies.
Active and Passive Immunization
The patient is given:
— 1500 IU of ATS or 250-500 IU Human Ig in one arm, and
— 0.5 ml of adsorbed TT (PTAP or APT) into other arm or
gluteal region
— Booster dose after—six weeks later (0.5 ml), and
— Third dose—one year later.
Elimination of Neonatal Tetanus
Neonatal tetanus is still a common problem in many districts.
Fortunately this disease can be eliminated by immunising all
women in reproductive age group with tetanus toxoid. The
National Program of Elimination of Neonatal Tetanus
includes:
• Reducing the incidence to less than 1 case per 1000 live
births by 1995 and later it was extended to 2000
• Component of RCH
• Interventions:
1. Coverage of all pregnant women with two doses of tetanus
toxoid
2. Extensive IEC efforts to promote clean deliveries: Five
Cleans— Clean Hands, Clean Surface, Clean Blade, Clean
Stump, and Clean Tie.
3. Providing disposable delivery kits.
4. Community based surveillance of neonatal deaths and
investigation and control measures in case of neonatal
deaths.
Anti-rabies Vaccine (Table 8.5)

Table 8.5: Dosage schedule

Class Adult Children Duration Booster dose (Bd)
Treatment recommended by Central Research Institute Kasauli
Class I 2 ml 2 ml 7 days No
Class II 5 ml 2 ml 10 days 1 Bd to be given 3 weeks or
later after 10th inj.
Class III 5 ml 2 ml 10 days 1st Bd 7 days after 10th inj
2nd Bd 2 weeks or later
after 1st Bd
Recommended by Pasteur Institute Coonoor
Class I 2 ml 1 ml 7 days No
Class II 3 ml 3 ml 10 days
Class III 5 ml 3 ml 10 days
 Immunization
Cell Culture Vaccine
Six doses 1 ml each on days—0, 3, 7, 14, and 28
• Bd on day 90. Injected IM on deltoid muscle.
• Multisite schedule
• Reduced multisite in regimen (2-1-1) (0.5/ml)
• (0.5/1 ml) deltoid
– 2-1-1 regimen on days 0-7- 21
• Intradermal (Id): 2 Site regimen (2-2-2-0-1-1) on days 0, 3,
7, 28 and 90 dose: 1 Id dose = 1/5th of IM dose (1.0 or
0.5 ml) Id per site
• Intradermal regimen: 8 Site (8-0-4-0-1-1) on days
0,7,28,90 dose—
1/5th of IM dose.
Pre-exposure Prophylaxis
Cell culture vaccine is given either as 1 ml IM of 0.1 ml Id on
days, 0.7 and 28.
If serum titers of virus neutralizing antibodies are less than
0.5 IU/ml, booster doses of 1 ml IM or 0.1 ml intradermally
should be administered until antibodies become demonstrable.
Further booster injections should be administered at intervals
of two years as long as exposed person remains at risk.

Re-exposure to Animals after Anti-rabies Vaccination

Re-exposure after six months of completion of course of anti-
rabies vaccination (with nervous tissue vaccine). It should be
considered as fresh case.
Re-exposure within six months:
Class I risk within 6 month—1 Bd 2 ml
vaccine Class I infected by class II and
III wound
• Full course vaccine to be given.
If Patient has been treated earlier for class II and III wound
next exposure is also same class—2 Bd of 5 ml—1st dose
immediately and 2nd dose – after a week.
In tissue culture vaccine—Re-exposure after 5 years should
be treated as fresh case.
Re-exposure within 5 years: 2 Bd—Spaced a week apart
No anti-rabies serum indicated up to 5 years following
primary immunization.
Adverse Reactions
General: Headache, insomnia, giddiness, palpitation
Local: Pain, tenderness, redness swelling
Allergic: Urticaria, syncope, angioneurotic edema
Neuroparalysis: Post-vaccinal paralysis due to sensitization
 186 Essentials of Community Medicine—A Practical Approach
Advice to Patients
1. They should abstain from alcohol during and one
month after completion of anti-rabic Rx—it may facilitate
paralytic accident.
2. Undue physical and mental strain should be avoided
3. Corticosteroid and other immunosuppressive agent should not
be used
4. Rabies may develop following inadequate immunization.

Anti-Snake Venom
Polyvalent anti-snake venom serum should be given to
neutralize the poison.
• Serum should be injected soon after the bite
• 20 ml is given IV after test dose
Repeated after one hour or even
earlier
• If symptoms persist, further dose repeated every sixth hour
—until symptoms disappear completely.

Prepared by
Hyper immunizing horse against—venom of four common
poisonous snake, i.e. cobra, common krait, russels, viper (saw
scaled viper).
Plasma obtained from hyperimmunized horses is
concentrated and purified.
Serum is lyopolised by drying it from frozen state under
high vaccum. It is prepared in Haffkins Institute, Bombay
and Kasauli—in India Available in the form of lyopolized
powder in an ampoule, dissolved
in distilled water before being injected.
It is useful when given within 4 hours, doubtful value after—
24 hours
• Serum will produce serum sickness and even acute
anaphylaxis in sensitive persons
• To test the sensitivity
0.05 to 0.1 ml in 1:10 dilution of serum is injected
intradermally. +ve reaction—wheal 1 cm surrounded by
erythema of same width develop in 5 to 20 minutes
For desensitization—1/2 to 1 ml of antiserum is injected
subcutaneously
• 40 ml of anti-venom is given IV and repeated as required. It
is effective for cobra and russel
• In case of viper bite—inject anti-snake venom around to the
site of bite
• If there are signs of neuroparalysis—give 1/2 mg
neostigmine 1/2 hr before each injection 1/2 mg atropine
should be given to block muscarinic side effects of
neostigmine
Heparin 1000 to 5000 IU if clotting abnormality is present
• Inject TT
• Broad spectrum antibiotics.
 Immunization
Newer Vaccines
HIV Vaccine
There are three different approaches to HIV vaccination:
Preventive vaccine: To prevent HIV-negative persons from
being infected.
Perinatal vaccine: To vaccinate HIV-infected pregnant
women, in order to protect the fetus or the newborn child
from being infected.
“Therapeutic” or post-infectious vaccine: To delay the
progression to AIDS in HIV-positive persons.

Leprosy Vaccine
Three leprosy vaccines are currently undergoing large scale
human trials. The first is the WHO vaccine developed by Dr J
Convict in Venezuela. It is a combined vaccine containing BCG
and heat killed M. leprae, harvested from armadillo. The
rationale for incorporating BCG in it is the fact that BCG has
some protective action against leprosy. The other two are
Indian vaccines—the ICRC vaccine developed by Dr MG Deo
at Cancer Research Institute, Mumbai and the MW vaccine,
developed by Dr GP Talwar at National Institute of
Immunology, New Delhi from Mycobact. W, which is a
nonpathological atypical Mycobacterium sharing antigens
with M. leprae.

Chickenpox Vaccine
A live attenuated vaccine (OKA strain) developed by Takashasi
in Japan has been extensively studied in field trials. The
frequency of mild local reactions at the site of inoculation is
about one percent. A general reaction to the vaccine, after
vaccination, in healthy seronegative children is over 90
percent. The vaccine has proved safe and effective in
preventing the disease.

Rubella Vaccines
In 1979, the RA 27/3 vaccine, produced in human diploid
fibroblast has replaced all the other vaccines. This is because
RA 27/3 vaccine induces higher antibody titers and produces
an immune response more closely paralleling natural infection
than the other vaccines. There is evidence that it largely
prevents subclinical superinfection with wild virus.
RA 27/3 vaccine is administered in a single dose of 0.5ml
subcutaneously. It may provoke mild reactions in some
subjects such as malaise, fever, mild rash and transient
arthralgia, but no serious disability. Seroconversion occurs in
more than 95 percent vaccinees. Vaccine-induced immunity
persists in most vaccinees for at least 14 to 16 years and
probably is lifelong.
 188 Essentials of Community Medicine—A Practical Approach
MMR: Rubella vaccine is also available as combined measles,
mumps and rubella (MMR) vaccine. It is equally effective. It is
given at 15 months of age in a dose of 0.5 ml
intramuscularly/subcutaneously.

Influenza Vaccines
Split-virus vaccine: Also known as sub-virion vaccine. It is a
highly purified vaccine, producing fewer side effects than the
“whole virus” vaccine. Because of its lower antigenicity, it
requires several injections instead of a single one. It is
recommended for children.
Neuraminidase specific vaccine: It is a sub-unit vaccine
containing only the N antigen, which induces antibodies only
to the neuraminidase antigen of the prevailing influenza virus.
Antibody to neuraminidase reduces both the amount of virus
replicating in the respiratory tract and the ability to transmit
virus to contacts. It significantly reduces clinical symptoms in
the infected person, but permits subclinical infection that may
give rise to lasting immunity.
Recombinant vaccine: By recombinant techniques, the
desirable antigenic properties of a virulent strain can be
transferred to another strain known to be of low virulence.
Effort to improve influenza vaccine are continuing in several
directions.

Hepatitis B Vaccines
Active immunization can be done using a vaccine prepared
from plasma of HbsAg carriers. The whole virus is removed
and inactivated with formalin. It is available as Hepativax-B
(MSD) and Hevac-B (Pasteur) and is indicated only for high-
risk groups.
A 3 ml vial of Hepativax-B contains 20 micrograms of the
vaccine. Recent observations suggests as the routine higher
dose and provides protection for 5 years. The use of this
smaller 0.1 ml dose considerably lowers the cost of
immunization (Table 8.6).
Table 8.6: Hepatitis B vaccine—immunization schedule
1st dose 1 ml at selected date
2nd dose 1 ml 1 month later
3rd dose (booster) 1 ml 6 months after the first dose
Note: Children under 10 years of age should be given half of above dosage at the same time
intervals.

rDNA-yeast derived vaccine: A subunit HbsAg containing

vaccine made by recombinant DNA (rDNA) technology is also
available. It is costlier but safer. The reason is that the plasma
derived vaccine carries the risk of infection, especially AIDS.
A combination of DPT with HB vaccine is also available.
 Immunization
Malaria Vaccines

Asexual blood-stage vaccines based on antigens derived from

the blood states of P. falciparum present in man. These
vaccines are designed to reduce severe and complicated
manifestations of the disease.
A synthetic “ cocktail” vaccine for P. falciparum, called SPf 66
is developed by Dr M Patarroyo in Colombia. It reduces the
risk of developing clinical malaria by about 30 percent.
Pfs25 vaccine: As far as transmission blocking vaccines are
concerned, Pfs25 is a leading candidate and a preparation
based on it has gone into clinical trials in the USA and Africa
during 1995.

Meningococcal Vaccines
Effective vaccines prepared from purified Group A, Group
C, Group Y, and/or Group W135 meningococcal
polysaccharides are now available. They may be monovalent (A
or C) or polyvalent (A-C; A-C-Y, etc). Recent field trails have
indicated that immunity lasts for about three years, and
boosters every three years would be reasonable. High-risk
population should be identified and vaccinated. The vaccine is
not recommended for use in infants and children under two
years. The vaccine is contraindicated in pregnant women.

BIBLIOGRAPHY
1. Ann Rev of PH 1988; 209.
2. Desai HG. Prevention and Control of Hepatitis B virus.
Medical times (sandoz)1984;14:4.
3. Jawetz E, et al. Review of Medical Microbiology, 14th edn, Lang
Med Pabl California, 1980.
4. Kallings LO. CARC Calling 1993; 6:(1) 3-5.
5. Ministry of Health and Family Welfare Govt. of India New Delhi.
Conduct immunisation, 1989.
6. National Health Programmes of India, J Kishore 4th edn, 2002.
7. Pan American Health Organisation. Bull PAHO 1978;12(2):162.
8. Park’s Textbook of PSM, 16th edn, 2000.
9. Peckham CS. Med Int 1988;51:2107.
10.Textbook of PSM, MC Gupta and BK Mahajan, 3rd edn, 2003.
11.Wahdan MH, et al. Bull WHO 1973;48:667-73.
12.Wahdan MH, et al. Bull WHO 1977;55:645-51.
13.WHO. Tech RCP Ser No. 693,1983.
14.WHO. Tech RCP Ser No. 771,1988.
15.WHO. The World Health Report 1995 Bridging the gaps,
Report of the Director General WHO,1995.
 188 Essentials of Community Medicine—A
Chapter
9 Nutrition
CHAPTER OUTLINE
BALANCED DIETS

INTRODUCTION
The importance of nutritional support was realized in the late
1970’s. Nutritional support is not merely administering
calories and proteins, it also includes the provision of all
nutritional substrates to facilitate the biological processes of
inflammation and healing.

Dietetics
Dietetics is the practical application of principles of nutrition
for the well and sick persons.

Balanced Diet
A balanced diet is defined as one which contains a variety of
foods in such quantities and proportions that the need for
energy, amino acids, vitamins, minerals, fats, carbohydrate
and other nutrients is adequately met for maintaining health,
vitality, and general well-being and also makes a small provision
for extra nutrients to withstand short duration of leanness.

An Indian Reference Man

An Indian reference man is between 20 and 39 years of age
and weighs 60 kg (Tables 9.1 and 9.2). He is free from disease
and physically fit for active work. On each working day he is
employed for eight hours in occupation that usually involves
moderate activity, while not at work he spends eight hours in
bed, four to six hours sitting and moving around and two
hours in walking and in active recreation or household duties.

An Indian Reference Woman

An Indian reference woman is between 20 and 39 years of
age, healthy and weighs 50 kg (Tables 9.1 and 9.2). She may be
engaged for eight hours in
 Nutrition
general house hold work, in light industry or in other
moderately active work. Apart from eight hours in bed, she
spends four to six hours sitting or moving around only through
light activity and two hours in walking or in active recreation
or in household duties.
Table 9.1: Indian reference men and women
Reference man Reference woman
1. Age 20-39 years 20-39 years
2. Weight 60 kg 50 kg
3. Household works 8 hours 8 hours
4. Sleep 8 hours 8 hours
5. Light activity 4-6 hours 4-6 hours
6. Active recreation (walking) 2 hours 2 hours

Table 9.2: Appropriate body weights for men and women

Men Women
Height (cm) Average (kg) Acceptable Average Accept able
range (kg) range (kg) range (kg)
145 — — 46.0 37.53
148 — — 46.5 37.54
150 — 39.58 47.0 38.55
152 — 40.59 48.5 39.57
156 — 43.62 49.5 39.58
158 55.8 44.64 50.4 40.58
160 57.6 44.65 51.3 41.59
162 58.6 46.66 52.6 42.61
164 59.6 47.67 54.0 43.62
166 60.6 48.69 55.4 44.61
168 61.7 41.71 56.8 45.65
170 63.5 51.73 58.1 45.66
172 65.0 52.74 60.0 46.67
174 66.5 53.75 61.3 48.69
176 68.0 54.77 62.6 49.70
178 69.4 55.79 64.0 51.72
180 71.0 58.80 65.3 52.74
182 72.6 59.82
184 74.2 60.84
186 75.8 62.86
188 77.6 64.88
190 79.3 66.90
192 81.0 68.93

The dietary sources of energy are:

Protein 4 kcal/gm
Fat 9 kcal/gm
Carbohydrate 4 kcal/gm
 190 Essentials of Community Medicine—A Practical Approach
Macronutrients: These are proteins, fats and carbohydrates.
These are also called as “proximate principles” which form the
major bulk of food.
Micronutrients: These are vitamins and minerals. They are
required in very small quantities.
Energy expenditure for work:
Persons require energy for daily activities—sitting, standing,
walking, talking.
Male: 1250 kcal for 8 hours of work
Female: 820 kcal for 8 hours of
work
Energy requirements: Energy requirements for persons doing
1. Light work 1.7 kcal/kg/hr
2. Moderate work 2.5 kcal/kg/hr
3. Heavy work 5 kcal/kg/hr
Energy requirement decreases as age advances, after 40
years, there is 5 percent decrease per decade up to 60 years,
another 10 percent decrease during 60-70 years and
further 10 percent decrease after 70 years of age.
Nutrition: Nutrition signifies a dynamic process in which the
food that is consumed is utilized in the human body for
nourishment.
Nutrient: Chemical compounds found in food which are needed
for the body.
Meal: It is sum of the total food ingested at one feeding.
Diet: It is sum of the meals per day.
Dietary: It is the prescription of course of diet.
Food: It is composite mixture of various substances in various
quantities.
Foodstuff: Anything which can be used as food is foodstuff.

Assessment of Nutritional Status

The assessment of nutritional status involves various
techniques. Proper evaluation demands many angled approach.
The assessment method includes:
1.Clinical examination
2.Anthropometry
3.Biochemical evaluation
4.Functional assessment
5.Assessment of dietary intake
6.Vital and health statistics
7.Ecological studies
8.Weighment of raw food
 Nutrition
9.Weighment of cooked food
10. Oral questionnaire method
11. Mortality data
12. Morbidity
13. Food balance sheet
14. Socioeconomic factors
15. Health and educational services
16. Conditioning influences.

Assessment of the Energy Requirement for Family

The recommendation co-efficients for calculating energy need
of different members of the family are given in Table 9.3.
Table 9.3: Assessment of the energy requirements of a group of family
Category Co-efficient
(for calculating energy requirements)
Adult male (sedentary worker) 1.0
Adult male (moderate worker) 1.2
Adult male (heavy work) 1.6
Adult female (sedentary) 0.8
Adult female (moderate worker) 0.9
Adult female (heavy worker) 1.2
Adolescents—12 to 21 years 1.0
Children—9 to 12 years 0.8
Children—7 to 9 years 0.7
Children—5 to 7 years 0.6
Children—3 to 5 years 0.5
Children—1 to 3 years 0.4

Cereals and Millets

In India, cereals like wheat, rice and maize form the staple
food of people. Millets (smaller grains that are eaten without
removing the outer layer) are also used to fair extent by same
segment of the population. More common among the millets
are jawar and bajra.
Cereals and millets are rich in carbohydrates and sources of
dietary protein. They are a good source of minerals and several B
complex vitamins (Table 9.4).

Milling Process Deprives

Thiamine—15 percent
Riboflavine—75 percent
Protein—60 percent
Washing and cooking—60 percent loss of water soluble
vitamins.
 192 Essentials of Community Medicine—A Practical Approach
Table 9.4: Food value per 100 g
Cereals Carb- Fat Protein Calcium Iron Energy Limiting
name of ohyd- (gm) (gm) (mg) (mg) (kcal) amino acid
foodstuff rates
(gm)
Jawar 72.6 1.9 10.4% 25 4.1 349 Lysine and
threonine
Bajra 67.5 5 11.9 42 8 361
Ragi 72 1.3 7.3 344 3.9 328
Maize 66.2 3.6 11.1 50 3.8 342 Tryptophan and
(dry) lysine
Wheat 71.2 1.5 11.8 50 5.3 346 Lysine and
(whole) threonine
Rice 78.2 0.5 6.8 23 6.6 345 Poor source of
(row, milled) A1, C and D
vitamins

Parboiling
Process starts with soaking the paddy in hot water at 65 to
70°C for three to four hours which swells the grain. This is
followed by draining of water and steaming the soaked paddy
in same container for 5 to 10 minute. The paddy is then dried
and home pounded or milled. During steaming, greater part of
vitamins and minerals present in outer aleurone layer of rice
grain are driven into the inner endosperm. With subsequent
drying process the germ get attached more firmly to the grain.
It results in the grains becoming resistant to insect invasion
and more suitable for storage than raw rice. The starch also
get gelatinized which improves keeping qualities of rice.

Pellagra
It is a nutritional deficiency disease. High leucine content in
jawar and maize interferes in the conversion of tryptophan
into niacin and thus aggravates the pellagragenic action of
maize and jawar.
• Pellagra manifestations—3D’s
• Diarrhea
• Dementia
• Dermatitis

Pulses (Legumes)
Pulses are called “poor man’s meat”. In fact pulses contain
more protein than egg, fish and flesh food, but in regards to
the quality, pulse’s protein is inferior to animal protein. Pulses
are poor in methionine and to a lesser extent in cystein and
are rich in lysine (Table 9.5).
Soyabean is exceptionally rich in protein, containing up to 40
percent.
 Nutrition
Table 9.5: Nutritive value of pulses
Food Energy Protein Fat Carbo- Iron Thia- Ribo- Niacin Vit
stuff (kcal) (gm) (gm) hydrate (mg) mine flavin mg ‘C’
Bengal 360 17.1 5.3 202 4.6 0.30 0.15 2.9 0
gram (whole)
Black 347 24.0 1.4 154 3.8 0.42 0.20 2.0 0
gram (dhal)
Red 335 22.3 1.7 73 2.7 0.45 0.19 2.9 0
gram (dhal)
Soya 432 43.2 19.5 240 10.4 0.73 0.39 3.2 0
bean

Germination and Fermentation

The simple measures of soaking pulses in water for 2 to 3
hours improves their nutritive value and vitamin ‘A’ and
vitamin ‘C’ content.
Germination increases the content of folic acid and other
vitamin ‘B’ group by a factor of two or three. Pulses contain an
antidigestive factor (trypsin inhibitor) which is destroyed by
cooking.
Anti-nutritional factors: In the raw state, pulses have some
anti-nutritional factors such as phytate and tannins most of
anti-nutritional factors destroyed by heat.
Presence of certain sugar known as oligosaccharides is
known to be associated with flatulence.

Lathyrism
Lathyrism is a paralyzing disease of human and animal,
occuring mostly in adults consuming the pulse, lathyrus
sativus in large quantity (more than 30% of this dhal over a
period of 2-6 months).
In humans it is referred to as
neurolethyrism. In animals it is
referred to as osteolethyrism.
Toxin present in lathyrus seeds has been known as (Beta-
oxalyl amino alanine) BOAA .

Manifestation (in Different Stages)

1. Latent stage
2. No stick stage
3. One stick stage
4. Two stick stage
5. Crawler stage.

Intervention
1. Vitamin “C” prophylaxis
2. Banning the crop
 194 Essentials of Community Medicine—A Practical Approach
3. Removal of toxin
a. Steeping method
b. Parboiling
4. Education
5. Genetic approach.

Vegetables
Vegetables are classed as “protective
foods” Vegetables are divided into:
1. Green leaves
2. Roots and tubers
3. Other vegetables.
Leafy vegetables are high in water content and dietary
fiber. These vegetable contain a high proportion of cellulose,
which human intestinal juices (unlike those of herbivorous
animals) can not digest. It thus remains unabsorbed and
increase bulk of the intestinal contents.
The bioavailability of calcium and iron from green
vegetables is rather poor because of the presence of high
amount of oxalates.
Don’t soak cut leaves for a long time, by doing so water
soluble vitamins “B” and “C” will be dissolved in water and are
wasted.
Addition of baking powder will not only destroy the flavor
and texture but vitamin “B” will also be lost.
Don’t cook in excess water, avoid over cooking and
reheating to avoid vitamin “C” loss.
The recommended daily intake of green leafy vegetables is
about 40 gm for an adult.

Fruits (Fructua—to Enjoy)

Fruits are protective foods.
The costly fruits are not necessarily the best one. Banana is
the cheapest when considered as a food rather than a fruit.
Grape and apple are not of high nutritional value.

Composition of Fruits per 100 gm (Table 9.6)

Clinical use
Banana
a. Acts as a mild laxative
 Nutrition
Table 9.6: Composition of fruits per 100 gm
Fruits Protein Fat Carbohydrate Vit “A” Vit “C” Caloric
(gm) (gm) value
Apple 0.2 0.5 13.4 Trace 2 59
Banana 1.2 0.3 27.2 Trace 1 116
Grapes (pellagra) 0.5 0.3 16.5 15 31 71
Mango 0.6 0.4 16.9 800 13 74
Papaya (ripe) 0.6 0.1 7.2 2020 46 32
Jack fruit 1.9 0.1 19.8 540 10 88
Lemon 1.0 0.9 11.1 0 39 57
b. A high-banana diet probably increases the butyric acid
concentration in intestine and this may control diarrhea.
c. Steamed banana leaves are effectively used for dressing burn
wounds.
Mango
a. Eating mangoes in season may provide a store of vitamin “A”
in the liver, sufficient to last for the rest of the year.
Papaya
a. Papaya can be prescribed for dyspeptic patients as the
pepsin may help in the digestion of proteins.
b. Papaya seeds have an antihelminthic action.
c. A protein digestive enzyme chymopapain derived from
papaya is used as injection into herniated intervertebral
lumbar disks to relieve pain caused by pressure on nerves.

Nuts and Oil Seeds

The common nuts consumed in the tropics are coconut,
groundnut, cashew nut, almonds and pista.
They are rich in proteins, fat, carbohydrates, minerals, and
factors of vitamin “B” complex. Nuts approach on ideal food
by supplying high calories in a palatable form. Groundnut is
palatable and cheap—used in multipurpose food Balahar, used
as balanced malt food due to high fat content and partly
cellulose content.
Aflatoxin: Stored groundnut may be contaminated with the
fungus
Aspergillus flavors which produce toxins known collectively as
aflatoxins.

Sweet Food and Sweetening Agents

Sugar is almost pure sucrose—A diasaccharides made up of
glucose and fructose (levulose). One gm of sugar supplies—4
kcal.
One teaspoonful (5 g) gives—20 kcal.
The average consumption of sugar is well over 100 gm a day
per person.
 196 Essentials of Community Medicine—A Practical Approach
Honey: Golden colored syrup made by bees from the nectar of
flowers which contains mixture of glucose and fructose which
gives it a particular sweetness.
Composition
• Glucose—25 to 37 percent
• Fructose—34 to 43 percent
• Sucrose—0.5 to 12 percent
• Maltose—5 to 12 percent
• 100 gm honey provides—288 Kcal
Honey may contain the bacteria Clostridium botulinum
which may produce infant botulism.
1. Honey 50 mg/liter recommended instead of sugar in oral
rehydration fluid.
2. Honey in warm water or milk can be a soothing drink for
patients with pharyngitis and tracheitis.

Nutrient Requirements during Pregnancy (Tables 9.7 to 9.14)

Table 9.7: Daily allowances for nutrients for expectant and nursing mothers
(ICM R Nutrition Export Group, 1998)
Nutrient Sedentary Moderate Heavy Pregnancy Lactation
work work
Calories (kcal) 1900 2200 3000 +300 +700
Proteins (g) 45 45 45 55 65
Calcium (g) 0.45-0.5 0.4-0.5 0.4-0.5 1.0 1.0
Iron (g) 30 30 30 40 30
Vitamin (A)
as Retinol (g) 750 750 750 750 1150
Or
as Carotene (mg) 3000 3000 3000 3000 4600
Thiamine (mg) 1.0 1.1 1.5 +0.2 +0.4
Riboflavin (mg) 1.0 1.2 1.7 +0.2 +0.4
Nicotinic acid (mg) 13 15 20 +2 +5
Ascorbic acid (mg) 50 50 50 50 80
Folic acid (mg) 100 100 100 150-300 150
Vitamin B12 (mg) 1.0 1.0 1.0 1.5 1.5
Vitamin D (IU) 200 200 200 200 200

Table 9.8: Suggested substitution for nonvegetarians

Food item which can be deleted from non- Substitution that can be suggested for
vegetarian diets deleted item or items
1. 50% of pulses 1. One egg or 30 g meat or
fish (20-30 g) 2. Additional 5 g fat or oil
2. 100% of pulses 1. Two eggs or 50 g of meat or fish,
(40-60 g) one egg plus 30 g meat
2. 10 g of fat or oil
 Nutrition
Table 9.9: Additional allowances during pregnancy and lactation
Food items During Calories During Calories
pregnancy (kcal) lactation (kcal)
Cereals 35 g 118 60 g 203
Pulses 15 g 52 30 g 105
Milk 100 g 83 100 g 83
Fat – – 10 g 90
Sugar 10 g – 40 10 g 40
Total 293 521
Diet: For a child suffering from protein calorie malnutrition
and weighing 12 kg, the daily calorie intake should be about
12 × 140 = 1680 kal and protein intake should be 12 × 4 or 5
= 48 to 60 g.
Table 9.10: Diet for a child suffering from kwashiorkor or
marasmus (Body wt 12.12 kg calories 1700 kcal protein 50-60 g)
Foodstuffs Diet for Ist to 10th day Diet for 11th to 30th day
Milk, skimmed (ml) 1000 –
Milk, skimmed (ml) 1000 2000
Cane sugar (g) 100 100
Dextrimaltose (g) 50 –
Ripe banana (two) (g) 150 150
Corn or wheat flour (g) 25 50
Bread and biscuit (g) 25 10-100
Vitamins Daily requirements added to milk

Table 9.11: Daily menu for a child suffering from kwashiorkor or marasmus
1st day to 10th day 11th day to 30th day
Morning 6.00 am Morning 6.00 am
Milk (half fat) Milk (full fat)
With sugar—1 cup With sugar—1 cup
Breakfast 8.00 am Breakfast 8.00 am
Corn flour milk pudding—1 serving Bread (1 slice) with milk
Banana (one) Banana (one)
Milk with sugar—1 cup Corn flour milk pudding—1 serving
Milk with sugar—1 cup
10.00 am 10.00 am
Milk with sugar—1 cup Milk with sugar—1 cup
1.00 pm (lunch) 1.00 pm (lunch)
Bread soaked in milk—1 slice Bread—2 slices (with milk)
Banana—1 Banana—1
Milk with sugar—1 cup Milk pudding—1 serving
Milk with sugar—1 cup
4.00 pm 4.00 pm
Milk with sugar—1 cup Milk with sugar—1 cup
Biscuit —2
Contd...
 198 Essentials of Community Medicine—A Practical Approach
Contd...
1st day to 10th day 11th day to 30th day
7.00 pm (Dinner) 7.00 pm (Dinner)
Bread soaked in milk—1 slice Same as lunch
Banana—1
Milk with sugar—1 cup
10.00 pm 10.00 pm
Milk with sugar—1 cup Milk with sugar—1 cup

Table 9.12: Daily menu for adults suffering from tuberculosis

Vegetarian Nonvegetarian

Early morning
Milk with sugar—1 cup Milk with sugar—1 cup

Breakfast

Bread—4 slices or Bread—4 slices or

Idli—4 or Idli— 4 or
Dosa—2 or Dosa—2 or
Poori—3 Poori—3
Cheese—1 slice Boiled egg—1
Nuts—2 tablespoons Nuts—2 tablespoons

Mid-morning
Fruit juice—1 glass Fruit juice—1 glass

Lunch
Cooked rice or chappati—1 serving Cooked rice or chappati—1 serving
Vegetable curry—1 serving Mutton or fish curry—1 serving
Dal soup—1 cup Vegetable curry—1 cup
Curd—1 cup Dal soup—1 cup
Milk pudding—1 serving Milk pudding—1 serving
Fruits—1 serving Fruits—1 serving

Mid-afternoon
Fruit juice—1 glass Fruit juice—1 glass

Tea
Biscuits—2 Biscuits—2
Nuts—2 tablespoons Nuts—2 table spoons
Milk with sugar—1 cup Milk with sugar—1 cup
Cheese—1 slice Cheese—1 slice
Fruits—1 serving Fruits—1 serving
Dinner
Same as lunch
 Nutrition
Table 9.13: Diet in severe jaundice in viral hepatitis for an adult (g/caput/day)

Proteins, 40-45 g; Fats 25-30 g; Carbohydrates 300-340 g

and Calories 1600-1700 Kcal
Cereals 200
Skimmed milk 500
Potato 100
Leafy vegetables 50
Fruits (apple, mango, papaya or banana) 200
Fruit juice 600
Fat and oils 15
Sugar and Jam 60
One multivitamin tablet providing the daily requirements of all vitamins should be included along
with the diet.
Table 9.14: Daily menu for severe jaundice

Morning
Fruit juice 1 glass
Breakfast
Corn flakes with skimmed milk and sugar 1 serving
Toast with a little butter and jam 2 slices
Fruits 1 serving
Tea or coffee 1 cup
Mid morning
Fruit juice 1 glass
Lunch
Cooked rice or bread or chappati 1 serving
Vegetable soup 1 cup
Cooked vegetables 1 serving
Fruits 1 serving
Skimmed milk pudding 1 serving
Tea
Biscuits 2
Fruit juice 1 glass
Dinner
Similar to Lunch

Rich Sources of Essential Nutrients

• Richest source of poly unsaturated fatty acid: Safflower oil—
75 percent.
• Richest source of saturated fatty acid is coconut oil—92
percent.
• Richest source of Linoleic acid (EFA) is safflower oil—73
percent.
• Richest source of vitamin A (retinol) is Halibut liver oil—
(900,000 mcg/ 100 g) and cod liver oil (18000 mcg/100 g).
• Green leafy vegetable rich in vitamin A (Carotene) is
Colocasia leaves—12000 mcg/100 g. Others are Amaranth,
Spinach.
 200 Essentials of Community Medicine—A Practical Approach
• Vegetable rich in vitamin A is carrot—1167 mcg/100g.
• Fruit rich in vitamin A is Ripe mango.
• Richest source of vitamin D is halibut liver oil (50-10,000
mcg/100 g) and cod liver oil.
• Thiamine rich foods—wheat, rice parboiled, bengal gram
dhal, gingelly seeds.
• Rich source of riboflavin in sheep liver—1.70 mg/100 mg.
• Rich source of niacin-ground nut (22.1/100 g), sheep liver.
• Fruits rich in vitamin C—amla (600 mg/100 g), guava (212).
• Pulse with high vitamin C—content bengal gram.
• Vegetables rich in vitamin C—amaranth (99), cabbage (124).
• Rich source of calcium—ragi (344 g/100 g).
Protein Requirements
Men and women 1
gm/kg/day
Infants (0-6 mon) 1.8-2.3
Infants (6-9 mon) 1.65
Children (1-6 years) 1.52-1.83
Children (6-9 years) 1.48
Adolescent males 1.3-4.6
Adolescent females 1.21-1.45

Principles in Calculating Balanced Diet

India
• Energy from cereals not to be more than 75 percent.
• Cereal protein to pulse protein ratio to be kept at 4:1.
• Vegetables to constitute 80 gm.
• Inclusion of green leafy vegetables.
• Minimum milk intake of 100 ml needed.
• Fat not to contribute more than 15 percent of energy.
• Energy from refined carbohydrates kept around 5 percent
and total calories from sugar not to exceed 20 percent.
BALANCED DIETS (TABLE 9.15)
Table 9.15: Balanced diets (The quantities are given in grams)

Adult man Adult woman

Food items Sedentary Moderate Heavy Secondary Moderate Heavy
worker worker worker worker worker
Cereals 460 520 670 410 440 575
Pulses 40 50 60 40 45 50
Leafy vegs 40 40 40 100 100 50
Other vegs 60 70 80 40 40 100
Roots and tubers 50 60 80 50 50 60
Milk 150 200 250 100 150 200
Oils and fats 40 45 65 20 25 40
Sugar 30 35 55 20 20 40
 Nutrition
Balanced Diet for Children (Table 9.16)
Table 9.16: Balanced diet for children

Children Children Boys Girls

Food items 1-3 years 4-6 years 10-12 years 10-12 years
Cereals 175 270 420 380
Pulses 35 35 45 45
Leafy vegs 40 50 50 50
Other vegs 20 30 50 50
Roots and tubers 10 20 30 30
Milk 300 250 250 250
Oil and fats 15 25 40 35
Sugar/jaggery 30 40 45 45
Food items Approx Approx Protein Calories
Quantity Weight (gm) (gm)
Musambi 1 average 150 1.2 63
Watermelon 100 0.5 28
Strawberries 10 large 100 0.8 37
Almonds 100 20.8 655
Cashewnuts 100 20.2 596
Groundnut 100 26.7 559
Pista 100 19.8 626
Coconut 100 6.8 662
Butter 100 0.0 729
Cheese 100 24.1 348
Curds 100 3.1 60
Buffalo milk 1 cup 200 8 206
Cow’s milk 1 cup 200 7 160
Goats milk ½ cup 100 3.3 75
Milk powdered 1 table spoon 7 1.9 35
Human milk 100 1.1 65
Ice cream 1 spoon 100 4.1 196
Ghee 1 table spoon 5 0.0 45
Chicken boiled 1 serving 100 17.0 132
Egg boiled 1 medium 48 6.1 77
Egg omlet 1 62 6.6 120
Mutton (Goat) 5-6 pieces 100 21.0 120
Beef boiled 100 25.4 242
Pork 1 serving 100 24.6 317
Fish 1 plate 100 18 81
Limbu juice 1 glass 240 0.0 73
Rice gangi 1 glass 193 8.7 312
Ragi ganji 1glass 280 6.9 263
Butter milk 1 glass 200 2.4 66
Biscuit 2 in number 16 1.6 64
Milk chocolate 1 piece 28 2.4 152
Bengal gram 1 cup 200 7 105
Chana Dal 1 cup 200 7 105

Contd...
 202 Essentials of Community Medicine—A Practical Approach
Contd...
Food items Approx Approx Protein Calories
Quantity Weight (gm) (gm)
Black gram, Green 1 cup 200 7 105
gram, Masor dal, Toor
dal, Beans baked,
Peas dried
Cabbage cooked ½ cup 85 1.2 20
Carrot cooked ½ cup 75 0.5 23
Carrot raw 1 large 100 1.2 42
Cauliflower, Brinjal, 125 3.0 36
Bhendi, Bitter guard
Cooked
Cucumber ½ medium 50 0.4 06
Green leafy 125 3.0 32
(palak, menthe)
Potato 100 1.6 97
Radish 99 0.7 17
Sweet potato 100 1.2 120
Beet root 85 1.7 43
Pumpkin 79 1.4 25
Tomato 150 1.5 30
Banana 1 big 100 1.2 99
Mango 1 in no. 100 1.0 54
Apple 1 medium 150 0.3 66
Grapes 22.24 100 1.4 70
Guava 1 medium 100 0.9 51
Orange 1 medium 150 1.4 68
Papaya 1 medium 100 0.6 32
Pineapple 1 slice 84 0.3 44
Whisky 1 peg 30 ml 91
Neera 1 glass 200 ml 0.8 90
Toddy 1 glass 200 ml 0.2 20
Beer 1 glass 240 ml 98
Brandy 1 peg 30 ml 98
Gin 1 peg 30 ml 84
Rum 1 peg 30 ml 98
Red wine 1 glass 100 ml 82
Champagne 1 glass 100 ml 78
Cola/Orange/ 1 bottle 300 ml 84
Lemon drink
Soda 1 bottle 300 ml 00
Samosa 1 2.0 94
Kachori 1 3.0 152
Rasagolla 1 3.0 162
Burfi 1 4.0 74
Bournvita 1 cup 230 ml 10.2 625

Contd...
 Nutrition
Contd...
Food items Approx Approx Protein Calories
Quantity Weight (gm) (gm)
Horlicks 2 table spoon 30 4.1 113
Ovaltine 2 table spoon 30 3.8 109
Chapati 2 57 5 193
Poori 2 32 2.2 136
Jowar roti 2 150 7.5 232
Ragi roti 3 185 8.0 460
Ragi balls 1 336 8.0 446
Plain rice 1 plate 170 4.2 200
Wheat bread 1 slice 30 2.3 75
Wheat bread, butter 1 slice 40 2.6 130
and jam—1 tea
spoon each
Wheat bun 1 average 35 2.6 120
Wheat parota 1 60 4.8 256
Bajra roti 1 45 3.5 108
Mazia roti 1 45 3.3 102
Idli 1 no 68 2.3 65
Plain dosa 1 no 50 2.0 108
Masala dosa 1 no 101 4.6 212
Uppit/Upma 1 plate 128 3.8 163
Uttappa(onion dosa) 1 no 132 7.3 337
Rava Idli 2 in no 114 5.0 212
Shira(Kesari bath) 1 plate 180 4.0 564
Uddin wada 2 in no 50 5.1 138
Bajji 6 in no 40 2.3 132
Chakli 3 in no 44 8.6 408
Dahi wada 2 in no 99 6.5 177
Tomato omelette 1 in no 56 3.2 100
Poha 1 plate 30 1.8 114
Mysorepak 1 piece 56 2.6 345
Bundi laddu 1 no 34 1.8 150
Rava laddu 1 in no 57 2.9 285
Halva 2 pieces 109 2.6 342
Jalabi 2 in no 41 1.4 313
Cake plain 1 piece 75 3.5 218
Custard ½ cup 130 7.1 164
Preparation Weight Measure Calories Proteins Fats (g) Carbo-
(g) (kcal) (g) hydrates (g)
Chutneys
Coconut 55 2 tbsp 125 2 10 6
chutney
Coriander 20 1 tbsp 45 1 4 2
chutney
Contd...
 204 Essentials of Community Medicine—A Practical Approach
Contd...
Preparation Weight Measure Calories Proteins Fats (g) Carbo-
(g) (kcal) (g) hydrates (g)
Groundnut 20 1 tbsp 65 3 5 3
chutney
Mint chutney 18 1 tbsp 7 - - 2
Tomato 50 ½k 32 1 1 5
chutney
Nonvegetarian
Dam ka chicken 125 1k 260 26 15 4
Fish cutlet 80 Two 190 14 9 12
Fish fried 85 Two 220 18 12 6
Fish jhol 110 1k 140 18 3 12
Liver do-pyaza 140 1k 330 22 22 11
Mutton
ball curry 145 1k 240 10 18 10
Prawn curry 145 1k 220 18 7 22

Average Weight of Vegetables (Table 9.17)

Table 9.17: Average weight of vegetables

Vegetable Weight per piece

Ash gourd 1000

Beans 3
Brinjal (small) 20
Brinjal (long) 50
Brinjal (big) 250
Cabbage 500
Capsicum 30
Carrot 40
Cauliflower 200
Drumstick 30
Fenugreek leaves (bundle) 12
Ladies’ finger 10
Onion (medium) 50
Pumpkin 1100
Radish 150
Raw banana 60
Ridge guard 50
Spinach (bundle) 20
Tomato 40
 Nutrition
Approximate Weight of Foods Equal to 1 Level Katori (Bowl) of 150 ml
Volume (Table 9.18)
Table 9.18: Approximate weight of foods

Item Weight 1 katori (gm)

Cereals
Rice 150
Rice flour 90
Semolina 120
Wheat flour 90
White flour (maida) 80
Pulses
Bengal gram dhal 130
Bengal gram dhal flout 80
Black gram dhal 130
Green gram dhal 140
Lentil dhal 130
Red gram dhal 140
Whole pulses and legumes
Black-eye beans 130
Green gram whole 140
Kabuli chana 130
Kidney beans 120
Lentil whole 125
Source: Pasricha-count what you eat. National Institute of Nutrition Hyderabad,1989

Average Weight of Nuts and Spices (Table 9.19)

Table 9.19: Average weight of nuts and spices

Nuts Measure/number Weight (gm)

Almonds (small) 15 20
Cashewnut 15 25
Coconut (dry) 1 160
Coconut (fresh) 1 150
Groundnuts 20 6
Poppy seeds 1 tsp 4
Raisins 15 5
Sesame seeds 1 tsp 3
Spices
Asafoetida 1 tsp 6
Black pepper 1 tsp 5
Cardamom 10 1
Chilli powder 1 tsp 7
Cinnamom 1 piece 0.5

Contd...
 206 Essentials of Community Medicine—A Practical Approach
Contd...
Nuts Measure/number Weight (gm)
Cloves 12 1
Coriander leaves 1 bundle 3
Coriander powder 1 tsp 7
Curry leaves 1 bundle 5
Cumin 1 tsp 5
Fenugreek seeds 1 tsp 6
Garlic 1 pod 0.5
Green chillies 5 5
Mint 1 bundle 5
Mustard seeds 1 tsp 10
Salt 1 tsp 10
Sugar 1 tsp 7
Turmeric 1 tsp 8
Recommended Dietary Allowances for Indians (Table 9.20)
Table 9.20: Recommended dietary allowances for Indians
Group Particulars Body Net Protein Fat Calcium Iron** Vit μg/d B- Thiami- Ribofla- Nicotin- Pyrido- Ascorbic Folic Vit B12
wt energy g/d g/d mg/d mg/d retinol caro- mg/d vin ic acid xin acid acid μg/d
kg kcal/d tene mg/d mg/d mg/d mg/d mg/d
Men Secondary 2425 1.2 1.4 16
work
Moderate 60 2875 60 20 400 28 600 2400 1.4 1.6 18 2.0 40 100 1
work
Heavy work 3800 1.6 1.9 21
Women Sedentary 1875 0.9 1.1 12
work
Moderate 50 2225 50 20 400 30 600 2400 1.1 1.3 14 2.0 40 100 1
work
Heavy work 2925 1.2 1.5 16
Pregnant 50 +300 +15 30 1000 38 600 2400 +0.2 +0.2 +2 2.5 40 400 1
women
Lactation +0.3 +0.3 +4
0-6 months +550 +25 45 1000 30 950 3800 2.5 80 150 1.5
0-12 months+400 +18 +0.2 +0.2 +0.3
Infants 0-6 months 5.4 108/kg 2.05/kg 500 55 μg/ 65 μg/ 710 μg/ 0.1 25 25 0.2
kg kg kg
6-12 months 8.6 98 kg 1.65 kg 350 1200 50 μg/ 60 μg/ 650 μg/ 0.4
kg kg kg
Children 1-3 years 12.2 1240 22 25 400 12 400 1600 0.6 0.7 8 0.9 30
4-6 years 19.0 1690 30 18 400 2400 0.9 1.0 11 0.9 40

Nutrition
7-9 years 26.9 1950 41 26 600 2400 1.0 1.2 13 1.6 60
Boys 10-12 years 35.4 2190 54 22 600 34 600 2400 1.1 1.3 15 1.6 70

Contd...
Contd...

208 Essentials of Community Medicine—A

Group Particulars Body Net Protein Fat Calcium Iron** Vit μg/d B- Thiami Ribofla- Nicotin- Pyrido- Asorbic Folic Vit B12
wt energy g/d g/d mg/d mg/d retinol caro- mg/d vin ic acid xin acid acid μg/d
kg kcal/d tene mg/d mg/d mg/d mg/d mg/d
Girls 10-12 years 31.5 1970 57 19 1.0 1.2 13 1.6 40 70 0.2-1.0
Boys 13-15 years 47.8 2450 70 22 600 41 600 2400 1.2 1.5 16 100
Girls 13-15 years 46.7 2060 65 28 1.0 1.2 14 100 0.2-1.0
Boys 16-18 years 57.1 2640 78 22 500 50 600 2400 1.3 1.6 17 2.0 100
Girls 16-18 years 49.9 2060 63 22 30 1.0 1.2 14 100 0.2-1.0
** On mixed cereal diet with absorption of 3% in man, 5% in woman 8% in pregnant woman.
Approximate Nutritive Value of Some Common Food Preparations (Table 9.21)

Table 9.21: Approximate nutritive value of some common food preparations (per serving and per 100
g)

Food Qty (per Wt. Calories Protein Fat Carbohy- Calcium Phos- Iron Vitamin Thia- Nicotin- Ribo- Vit-
prepara- serving) (per (Kcal) (g) (g) drate (g) (g) phorus (mg) A value min ic acid flavin min
tions serving) (g) (IU) (mg) (mg) (mg) C (mg)
Ragiputtu 1 plate 146 422 4.4 7.4 2.0 0.20 0.20 3.0 280 0.20 0.6 0.06 –
” - 100 289 3.3 5.1 57.7 0.14 0.14 5.5 193 0.14 0.4 0.4 –
Pulse pre- 1½ cup 151 284 9.0 16.4 25.2 0.07 0.13 3.8 366 0.14 2.4 0.10 2.0
parations,
Bengal gram
dal cooked
” – 100 188 6.0 10.9 16.7 0.05 0.9 2.5 242 0.10 1.6 0.7 1.2
Green 1½ cup 142 171 7.0 7.7 18.4 0.08 0.9 2.7 33 0.14 2.4 0.11 1.6
gram
dal
cooked
” – 100 120 4.9 5.4 12.9 0.06 0.06 1.9 23 0.10 1.7 0.08 1.1
Red gram ½ cup 96 110 6.4 2.0 16.4 0.05 0.07 2.6 64 0.13 0.7 0.7 –
dal
cooked
” – 100 115 6.7 2.1 17.1 0.05 0.07 2.7 67 0.14 0.73 0.73 –
Dal
rasam 1½ cup 196 29 1.5 0.9 3.8 0.03 0.03 0.9 72 0.03 0.2 0.2 1.5

Nutrition
” – 100 15 0.8 0.5 1.9 0.02 0.02 0.5 37 0.02 0.1 0.1 0.8
Amaranth 1½ cup 140 97 5.1 2.7 13.0 0.50 0.08 8.0 2009 0.07 0.7 0.03 53.0
sambar
” – 100 69 3.6 1.9 9.3 0.36 0.06 5.7 1435 0.05 0.5 0.02 37.9
Radish
sambar 1½ cup 196 101 4.1 3.6 13.1 0.04 0.07 2.2 73 0.07 0.05 0.03 3.0
Contd...
Contd...

210 Essentials of Community Medicine—A

Food Qty (per Wt. Calories Protein Fat Carbohy- Calcium Phos- Iron Vitamin Thia- Nicotin- Ribo- Vit-
prepara- serving) (per (Kcal) (g) (g) drate (g) (g) phorus (mg) A value min ic acid flavin min
tions serving) (g) (I.U.) (mg) (mg) (mg) C (mg)
” – 100 52 2.1 1.8 6.7 0.02 0.04 1.1 37 0.04 0.26 0.02 1.5
Green gram 1 plate 142 259 13.1 9.2 30.9 0.08 0.20 4.8 120 0.24 1.2 0.10 1.1
Sundal
” – 100 182 9.2 6.5 21.8 0.06 0.14 3.4 85 0.17 0.9 0.07 0.8
Bangal 1 142 272 13.2 11.1 29.7 0.11 0.15 5.5 198 0.16 1.4 0.08 1.1
plate gram
Sundal
” – 100 192 9.2 7.8 20.1 0.08 0.11 3.9 140 0.11 0.98 0.06 0.8
Cowpea 1 142 255 13.5 8.8 30.3 0.05 0.20 2.5 71 0.30 0.9 0.15 1.1
plate Sundal
” – 100 180 9.5 6.2 21.4 0.03 0.14 1.8 50 0.21 0.6 0.11 0.8
Vegetable ½ plate 28 47 1.4 2.3 5.1 0.04 0.04 6.6 1942 0.03 0.4 0.03 51.0
prepara-
tions ama-
ranth curry
” – 100 168 5.6 8.2 17.6 0.14 0.14 23.6 6934 0.11 1.4 0.11 182.2
Brinjal curry ½ plate 45 122 1.4 10.7 4.9 0.02 0.05 0.9 9 0.03 0.5 0.06 10.1
” – 100 266 3.1 23.8 10.9 0.04 0.11 2.0 20 0.07 1.1 0.13 22.5
Amaranth ½ plate 42 46 1.2 2.6 4.4 0.05 0.05 6.8 1946 0.02 0.4 0.02 55.0
maseal
” – 100 110 3.0 6.2 10.3 1.2 0.12 16.2 4634 0.05 0.95 0.05 119.1
Cabbage ½ plate 56 81 1.5 5.6 6.1 0.04 0.12 0.9 1028 0.04 0.3 0.03 38.0
and carrot
curry
” – 100 145 2.7 10.0 10.9 0.07 0.21 1.6 1835 0.07 0.05 0.05 67.9

Contd...
Food Qty (per Wt. Calories Protein Fat Carbohy- Calcium Phos- Iron Vitamin Thia- Nicotin- Ribo- Vit-
prepara- serving) (per (Kcal) (g) (g) drate (g) (g) phorus (mg) A value min ic acid flavin min
tions serving) (g) (IU) (mg) (mg) (mg) C (mg)
Preparations – 100 52 1.9 1.7 7.2 0.05 0.05 0.10 77 0.02 0.09 0.09 0.7
containing
milk:coffee
” 1 cup 200 104 3.8 3.4 14.4 0.10 0.10 1.20 154 0.04 0.18 0.18 1.4
Tea – 100 36 0.7 0.8 6.5 0.03 0.02 – 38 0.01 0.05 0.05 0.3
” 1 cup 200 72 1.4 1.6 13.0 0.06 0.0.4 – 76 0.02 0.10 0.10 0.6
Cocoa 1 cup 200 174 7.5 7.0 20.2 0.20 0.15 0.30 306 0.08 0.2 0.34 2.7
” – 100 87 3.8 3.5 10.1 0.10 0.08 0.15 153 0.04 0.1 0.17 1.35
Wheat
Payasam 1 cup 154 178 3.4 4.3 31.5 0.09 0.08 0.40 160 0.05 0.1 0.12 –
” – 100 116 4.2 2.8 20.5 0.06 0.05 0.26 104 0.03 0.06 0.08 –
Rice 1 cup 154 178 3.2 4.2 31.7 0.09 0.08 0.40 160 0.05 0.1 0.26 –
Payasam
” – 100 116 2.1 2.7 20.6 0.06 0.05 0.26 104 0.03 0.06 0.17 –
Bengal 1 cup 140 221 7.7 5.1 35.9 0.07 0.14 4.7 197 0.05 0.2 0.40 –
gram dal
Payasam
” – 100 158 5.5 3.6 25.5 0.05 0.10 3.4 141 0.04 0.14 0.28 –
Sago 1 cup 266 227 3.7 4.0 44.0 0.14 0.10 0.17 204 0.06 – 0.23 2.0
porridge
” – 100 85 1.4 1.5 16.5 0.05 0.04 0.26 77 0.02 – 0.09 0.8

Nutrition
Rice 1 cup 280 263 7.6 6.2 44.3 0.30 0.20 0.7 306 0.10 0.3 0.34 2.0
porridge
” – 100 94 2.7 2.2 15.2 0.11 0.07 0.25 109 0.04 0.11 0.123 0.8

Contd...
Contd...
Contd

212 Essentials of Community Medicine—A

Food Qty (per Wt. Calories Protein Fat Carbohy- Calcium Phos- Iron Vitamin Thia- Nicotin- Ribo- Vit-
prepara- serving) (per (Kcal) (g) (g) drate (g) (g) phorus (mg) A value min ic acid flavin min
tions serving) (g) (I.U.) (mg) (mg) (mg) C (mg)
Wheat 1 cup 193 317 8.7 8.0 52.7 0.24 0.22 1.0 408 0.13 0.2 0.28 1.6
porridge+
” – 100 164 4.5 4.1 27.3 0.12 0.11 0.52 211 0.07 0.1 0.13 0.8
Ragi 1 cup 280 263 6.9 6.3 44.7 0.30 0.20 1.7 321 0.20 0.2 0.34 2.0
porridge
” – 100 94 2.5 2.2 16.0 0.11 0.07 1.61 115 0.07 0.07 0.12 0.7
Milk 1 cup 200 130 7.0 7.4 9.8 0.24 0.20 0.8 280 0.06 0.2 0.34 4.0
(cow’s)
” – 100 65 3.5 3.7 4.9 0.12 0.10 0.4 140 0.03 0.1 0.17 2.0
Milk 1 cup 200 216 8.4 16.0 9.2 0.42 0.30 0.8 368 0.06 0.2 0.42 3.4
(buffalo)
” – 100 108 4.2 8.0 4.6 0.21 0.15 0.4 184 0.03 0.1 0.21 1.7
Butter milk 1 cup 200 36 1.8 2.8 2.0 0.07 0.07 0.2 102 0.03 0.10 0.11 0.9
(curd from
cow’s milk)
” – 100 18 0.9 1.4 1.4 0.04 0.04 0.1 51 0.02 0.05 0.06 0.45
Butter-milk 1cup 200 66 2.4 5.4 2.8 0.07 0.07 0.2 92 0.02 0.10 0.10 0.9
(curd from
Buffalo milk)
” – 100 33 1.2 2.5 1.4 0.04 0.04 0.1 46 0.06 0.05 0.05 0.45
Egg, Fish 1 cup 39 77 5.8 5.7 0.5 0.03 0.10 1.0 940 0.06 0.1 0.15 –
and Meat
Prepara-
tions:
Omelette
Omelette – 100 187 14.9 14.6 1.3 0.08 0.26 2.6 2410 0.15 0.26 0.38 –

Contd...
214 Essentials of Community Medicine—A Practical Approach
Food Qty (per Wt. Calories Protein Fat Carbohy- Calcium Phos- Iron Vitamin Thia- Nicotin- Ribo- Vit-
prepara- serving) (per (Kcal) (g) (g) drate (g) (g) phorus (mg) A value min ic acid flavin min
tions serving) (g) (IU) (mg) (mg) (mg) C (mg)
Meat curry 1 serving 128 220 11.6 18.0 2.7 0.10 0.07 2.1 227 0.10 0.9 2.20 2.4
” – 100 172 9.1 14.1 2.1 0.08 0.08 1.6 2.16 0.08 0.7 0.16 1.9
Meat fry 1 serving 142 339 21.8 26.0 4.5 0.23 0.20 3.3 294 0.23 7.8 0.30 7.6
” – 100 239 15.4 18.8 3.2 0.16 0.14 2.3 207 0.16 5.5 0.21 5.4
Fish fry 1 serving 100 220 17.5 16.2 1.4 0.05 0.45 1.2 216 0.11 1.3 0.02 1.0
” – – – – – – – – – – – – – –
Rice 2 servings 341 686 20.4 39.0 63.6 0.10 0.22 3.5 100 0.20 6.0 0.20 1.1
Mutton
Pulav
” – 100 201 6.0 11.4 18.7 0.03 0.06 1.03 29 0.06 1.8 0.06 0.32

Nutrition
 Contd

BIBLIOGRAPHY
1. Behar M. In: Nutrition in Preventive Medicine, WHO Monograph
Ser No 62, 1976.
2. Clinical Dietetics and Nutrition, 4th edn, Second impression, FP
Antia and Philip Abraham, 2001.
3. Food and nutrition facts and figures. Kusum Gupta and others, 5th
edn, 2000.
4. Gopalan C, et al. Nutritive Value of Indian Foods, National
Institute of Nutrition, Hyderabad, 1989.
5. ICMR. Recommended Dietary Intakes for Indians, New Delhi,
1990.
6. Narsinga Rao BS. Nutrition, 1986;20(1)14.
7.Nutritive value of Indian foods. Gopalan C and others. NIN (ICMR)
Hyderabad, Revised Edition-1989.
8. Ramachandran LK. Science Reporter, Feb 1978, Council of
Scientific and Industrial Research, New Delhi, 1978.
9. Swaminathan MC. Nutrition Oct. 1970 NIN.
10. Swaminathan M. Handbook of Food and Nutrition, Ganesh &
Co, Madras, 1977.
11. Taber’s Cyclopedic Medic al Dictionary, 17th edn, 1993; vol.
2:2222.
 214 Essentials of Community Medicine—A Practical Approach
Chapter
Medical Entomology
10
and Worm Infestations
Chapter Outline
ARTHROPODS
PUBLIC HEALTH IMPORTANCE OF WORM INFESTATION

ARTHROPODS
Arthropods comprise the most numerous and varied of the
living things in the environment of man. Some of them are
man’s allies helping in the fertilization of flowers, but the
majority of arthropods, in general, are either of no use to man
or his most dangerous enemies. They destroy man’s crops and
his food reserves; and some which live close to man act as
vectors or carriers of disease. A study of the arthropods of
medical importance is known as medical entomology which is
an important branch of preventive medicine.

Arthropods of Medical Importance

The arthropods of medical importance are given below.

Class: Insecta (Flow chart 10.1)

Flow chart 10.1: Class: Insecta

Distinctive Characters
Distinctive characters of class: Insecta (Fig. 10.1)
Body divisions—head, thorax, abdomen
1. Three pairs of legs
2. One pair of antennae
3. One or two pairs of wings, some are wingless
4. They are found on land
216 Essentials of Community Medicine—A Practical Approach

Fig. 10.1: Characteristics of insecta

 Medical Entomology and Worm
Class: Archnida (Flow chart 10.2)
Flow chart 10.2: Class: Archnida

Distinctive Characters
Distinctive characters of class: Archnida
1. Body divisions—cephalothorax and abdomen (no division) in some cases
2. Four pairs of legs
3. No antennae, no wings
4. Found on land.

Class: Crustacea (Flow chart 10.3)

Flow chart 10.3: Class: Crustacea

Distinctive Characters
Distinctive characters of class: Crustacea
1. Body divisions—cephalothorax and abdomen
2. Five pairs of legs
3. Two pairs of antennae
4. Found in water.

Mosquito
General Description
Mosquitoes constitute the most important single family of
insects from the standpoint of human health. They are found
all over the world. The four important groups of mosquitoes in
India which are related to disease transmission are the
Anopheles, Culex, Aedes and Mansonia (Fig. 10.2 and Table
10.1).
Mosquito-borne Diseases
Apart from their pestiferous nature, mosquitoes play an
important role in the transmission of human disease. They act
as vectors of many diseases in India (Flow chart 10.4).
218 Essentials of Community Medicine—A Practical Approach

Fig. 10.2: Characteristics of mosquitoes

 Medical Entomology and Worm
Table 10.1: Differentiation between anopheline and culicine
Tribe genus Anopheline—Anopheles Culicine—Culex, Aedes
mansonia
Eggs A. Laid singly A. Laid in clusters or rafts, each
B. Eggs are boat-shaped, and raft containing 100-250 eggs
provided with lateral floats ( except-Aedes)
B. Eggs are oval-shaped, and
not provided with lateral floats
Larva A. It has segmented body A. Suspended with head
consisting of head and rest downwards at an angle to
parallel to water surface water surface
B. No siphon tube B. Siphon tube is long and
C. Palmate hairs present on slender
abdominal segments C. No palmate hairs
Pupae A. Siphon tube is broad and A. Siphon tube is long and
short narrow
Adults A. When at rest, inclined at an A. When at rest, the body
angle to surface exhibits a hunch back
B. Wings spotted B. Wings unspotted
C. Palpi long in both sexes C. Palpi short in female,
long and tapering in male
D. In male D. In male
1. Proboscis not adopted for 1. Proboscis bent at an angle
piercing and suckling blood with the body
2. No public health importance 2. No public health importance
E. In female E. In female
1. Proboscis specially 1. Proboscis specially
adopted for piercing skin and adopted for piercing skin
and suckling blood suckling blood
2. Public health importance—
vector of malaria
3. Proboscis in straight line with body
F. Breeds in clear water and F. Breeds in dirty water like
slow—running streams cesspools, stagnant drains
containing organic materials
and polluted water

Flow chart 10.4: Mosquito-borne diseases

 220 Essentials of Community Medicine—A Practical Approach
Mosquito Control Measures
While there are many methods of mosquito control, experts
now recommend an “integrated approach”, that is, an
approach which avoids the excessive use of any one method
(e.g. insecticides) but tries to combine one or more methods
with a view to obtain maximum results with minimum inputs
and also to prevent environmental pollution with toxic
chemicals and development of insecticide resistance. The
various methods of mosquito control may be classified as
below:

Anti-larval Measures
a. Environmental control
b. Chemical control
c. Biological control.

Anti-adult Measures
a. Residual sprays
b. Space sprays
c. Genetic control.

Protection against Mosquito Bites

a. Mosquito net
b. Screening
c. Repellents.

Ticks
• Ticks are blood sucking parasites.
• They are found in warm climate, and are nocturnal in
habits.
• Natural hosts for ticks are domestic animals like dogs, cats,
and cattle. They attack man only accidentally.
• They can live without food for two to three years.

Families of Medical Importance (Flow chart 10.5)

Flow chart 10.5: Families of medical importance
 Medical Entomology and Worm
Public Health Importance of Ticks (Flow chart 10.6)
Flow chart 10.6: Public health importance of ticks

Control Measures (Flow chart 10.7)

Flow chart 10.7: Control measures for ticks

Houseflies
Houseflies are the commonest and most familiar of all insects
which live close to man.
The most important of these are:
• Musca domestica
• Musca vicinia
• Musca nebulo
• Musca sorbens.

Life History
Egg: The female lays about 120 to 150 eggs at one sitting. The
fly lays from 600 to 900 eggs during lifetime.
Larva: Measures about 12 mm, larval period lasts for two-
seven days.
 222 Essentials of Community Medicine—A Practical Approach
Pupa: Dark brown barrel shaped, measures about quarter of
an inch, Pupal stage lasts for three to six days.
Adult: Complete life cycle from egg to adult lasts for five to
six days. Life span 15 days in summer and 25 days in winter.
Diseases Transmitted
1. Typhoid and paratyphoid
2. Diarrheas and dysenteries
3. Cholera and gastroenteritis
4. Amoebiasis and giardiasis
5. Helminthic infestations
6. Poliomyelitis
7. Anthrax
8. Yaws
9. Trachoma.
Routes of Transmission
1. Mechanical transmission
2. Through vomit drop
3. Defecation.
Control Measures for Houseflies (Flow chart 10.8)
Flow chart 10.8: Control measures

Control measures

Spread of Diseases (Flow chart 10.9)

1. Sandfly
2. Lice
3. Cyclops
4. Rat flea
 Medical Entomology and Worm
Flow chart 10.9: Spread of diseases

Control Measures
Sandfly (Flow chart 10.10)
Flow chart 10.10: Control measures for sandfly

Lice (Flow chart 10.11)

Flow chart 10.11: Control measures for lice
 224 Essentials of Community Medicine—A Practical Approach
Cyclops (Flow chart 10.12)

Flow chart 10.12: Control measures for cyclops

Cyclops

Ratflea (Flow chart 10.13)

Flow chart 10.13: Control measures for ratflea

Itch mite (Flow chart 10.14)

Flow chart 10.14: Control measures for itch mite

PUBLIC HEALTH IMPORTANCE OF WORM INFESTATION

Ascariasis (Table 10.2)

Table 10.2: Ascariasis treatment
Infestation Drug Dose
Ascariasis Mebendazole or 100 mg bd x 3 days
(round worm) pyrentel pamoate 10 mg/kg single dose
 Medical Entomology and Worm
Symptoms of Ascariasis
1. Passage of worm in stool or vomitus
2. Vomiting, diarrhea, abdominal distention, flatulence
3. Cough
4. Skin rashes
5. Encephalopathy.
Prevention
1. Personal hygiene
2. Untreated sewage should not be used as fertilizer
3. Proper disposal of sewage.

Enterobius vermicularis (Table 10.3)

Table 10.3: Enterobius vermicularis treatment
Infestation Drug Dose
Enterobius Pyrentel pamoate or 10 mg/kg single dose
vermicularis Albendazole 100 mg once
(pin worm) (repeated after 4 weeks)

Symptoms
1. Irritability
2. Perianal itching
3. Loss of appetite
4. Symptoms of appendicitis.
Prevention
1. Personal hygiene
2. Nails to be cut and trimmed
3. Washing of nails and perianal area with soap and water.

Trichuris trichiura (Table 10.4)

Table 10.4: Trichuris trichiura treatment

Infestation Drug Dose
Trichuris trichiura Mebendazole 100 mg bd x 3 days
Albendazole 400 mg/kg once

Symptoms
1. Asymptomatic, if light infection
2. Vague abdominal pain
3. Mild diarrhea
4. Blood in stool
5. Tenesmus
6. Loss of weight
 226 Essentials of Community Medicine—A Practical Approach
7. Failure to grow if heavy infection
8. Rectal prolapse
9. Volvulus.

Prevention
1. Personal hygiene
2. Untreated sewage should not be used as fertilizer
3. Proper disposal of sewage.

Wuchereria bancrofti (Table 10.5)

Table 10.5: Wuchereria bancrofti treatment
Infestation Drug Dose
Wuchereria Diethyl carbamazine 6 mg /kg body weight in divided
bancrofti (DEC) doses × 12 days
Brugia malayi DEC 3-6 mg/kg × 6-12 days
Loa loa DEC 1mg/kg as a single dose
initially double on second day
then 2-3 mg /kg tds daily for 18
days
Onchocerciasis Ivermectin Single dose 200-400 g/kg
annually or biannually

Symptoms
1. Lymphangitis
2. Lymphadenitis
3. Elephantiasis
4. Hydrocole
5. Chyluria.

Prevention
1. Protection against mosquito bite
2. Destruction of mosquitoes
a. Antilarval measures
b. Antiadult measures.

Ancylostoma duodenale (Table 10.6)

Table 10.6: Ancylostoma duodenale treatment
Infestation Drug Dose
Ancylostoma Mebendazole 100 mg bd × 3 days
duodenale, or Pyrentel pamoate 10 mg/kg single dose and
Necator americanus second dose after 2-4 weeks
(Hook worm) needed in North American
 Medical Entomology and Worm
Symptoms
1. Abdominal pain
2. Diarrhea
3. Anemia
4. Dyspnea
5. Swelling of feet.

Prevention
1. Avoid walking bare foot
2. Proper disposal of feces

Strongyloides stercoralis (Table 10.7)

Table 10.7: Strongyloides stercoralis treatment
Infestation Drug Dose
Strongyloides Thiabendazole 25 mg/kg bd 5-7 days
stercoralis

Symptoms
1. Abdominal pain
2. Diarrhea
3. Malabsorption.

Prevention
1. Avoid walking barefoot
2. Proper disposal of feces.

BIBLIOGRAPHY
1. Chatterji KD. Human Parasites and Parasitic Diseases,
Calcutta, 1952. 2. Orkin M. JAMA 1971;217:593.
3. Park’s Textbook of Preventive and Social Medicine, 17th edn,
2002.
4. Puri IM. The House-Frequenting Flies, their relation to Disease
and their control. Health Bulletin No. 31 Manager of
Publications, Govt of India Press Delhi, 1948.
5. Puri IM. Synoptic Table for the identification of the Anopheline
Mosquitoes in India, Health Bulletin No. 10, Manager of
Publications, Govt of India Press, Delhi,1955.
6. Roy DN, Brown AWA. Entomology, Medical and Veterinary,
Excelsior Press, Calcutta, 1954.
7. Sharma MID. J. Com. Dis, 1974;6, 136.
8. WHO. Control Control of Arthropods of Public Health
Importance. WHO Training Leaflet No. 1 Vector Control Series
Geneva, 1966.
9. WHO. Techn. Rep Ser, No.443,1970.
10.WHO. Techn Rep Ser, No.561,1975.
 Chapter
11 Disinfection

Chapter Outline
DEFINITIONS (DISINFECTANT OR GERMICIDE)

Semmelweis (1818-1865) demonstrated the value of

handwashing with antiseptic solutions.

DEFINITIONS (DISINFECTANT OR GERMICIDE)

Disinfectant
It is a substance which destroys harmful microbes (not usually
spores) with object of preventing transmission of disease.
Disinfectants are suitable for application of only to inanimate
objects.
Antiseptic
Antiseptic is a substance which destroys or inhibits the growth
of micro- organisms.
Antiseptic are suitable for application to living tissues. A
disinfectant in low concentrations or dilutions can act as an
antiseptic.
Deodorant
It is a substance which suppresses or neutralizes bad odours,
e.g. lime and bleaching powder.

Detergent
It is a surface cleaning agent which acts by lowering surface
tension,
e.g. soap which remove bacteria along with dirt.

Sterilization
It is a process of destroying all life including spores. This is
widely used in medical practice.

Disinfection
Refers to the killing of infectious agents outside the body by
direct exposure to chemical or physical agents.
It can refer to the action of antiseptic as well as
disinfectants.
 Disinfection
Types of Disinfection
1. Concurrent disinfection
2. Terminal disinfection
3. Precurrent (Prophylactic) disinfection.

Concurrent Disinfection
The disease agent is destroyed as soon as it is released from
the body, and in this way further spread of the agent is
stopped, e.g. urine, feces vomit, contaminated linen, clothes,
hands, dressings, aprons, gloves, etc. throughout the course
of illness.

Terminal Disinfection
Application of disinfective measures after the patient has been
removed by death or to a hospital, or has ceased to be a
source of infection, terminal cleaning is considered adequate,
along with airing and sunning of rooms, furniture and
bedding.

Precurrent Disinfection
For example, disinfection of water by chlorination,
pasteurization of milk and handwashing.

Disinfecting Agents
They are classified as:
1. Natural agent
2. Chemical agent
3. Physical agent.

Natural Agents
1. Sunlight
2. Air.
Physical Agents
1. Burning
2. Hot air
3. Boiling
4. Autoclaving
5. Radiation.
Chemical Agents
1. Phenol and related compounds
2. Quaternary ammonia compounds
3. Halogens and their compounds
4. Alcohols
5. Formaldehyde
6. Miscellaneous.
 230 Essentials of Community Medicine—A Practical Approach
Natural Agents
Sunlight
The ultraviolet rays of sunlight are particularly lethal to
bacteria and some viruses, e.g. bedding, linen and furniture.

Air
Acts by drying or evaporation of moisture which is lethal to
most bacteria.

Physical Agents
Burning
Burning should not be done in open air. It is best done in
incinerator.

Hot Air
For sterlizing articles such as glassware, syringes, swabs,
dressings, vaseline, oils and sharp instruments.
Hot air sterilization is done at hot air oven maintained at
160 to 180°C at least for one hour to kill spores.

Boiling
Boilers provide temperature above 90°C. Boiling for 5 to 10
minutes will kill the bacteria.
The destruction of spores which require 100°C temperature
which can not be achieved in boilers. Boiling is suitable for
disinfection of small instruments which are not used for
subcutaneous insertion. Addition of 1 percent soap and 0.3
percent of washing soda enhances the effect of boiling, e.g.
linens, rubber goods such as gloves.

Autoclaving
Sterilizers, which operate at high temperatures (in excess of
100°C) and pressure are called autoclaves.
Two types: 1 Single chambered 2 double chambered
autoclaves.
It attains temp 122°C under 15 lbs/sq inch pressure.
Absolute sterility can be obtained only by raising the
temperatures of articles to over 135°C, e.g. linen, dressing,
gloves, syringes, certain instruments and culture media.

Radiation
Ionizing radiation is being increasingly used for sterilization of
bandages, dressings, catgut, surgical instruments.
 Disinfection
Chemical Disinfectants
Articles which can not be sterilized by boiling or autoclaving
may be immersed in chemical disinfectants.

Phenol and Related Compounds

Phenol
• Pure phenol or carbolic acid is the best known member of
this group.
• On exposure to air, the colorless crystals of phenol become
pinkish and on long exposure to air, the color deepens to
dark-red.
• Pure phenol is not an effective disinfectant.
Crude phenol: It is mixture of phenol and cresol
• It is dark oily liquid.
• It is effective against gram-positive and gram-negative
bacteria.
• It is slowly effective against spores and acid-fast bacteria.
• It is also effective against certain viruses.
• Its effect is weakened by dilution. So it should not be
used in less than 10 percent strength for disinfection of
fecal matter.
• In 5 percent strength, it may be used for mopping floors and
cleaning drains.
• Aqueous solutions of 0.2 to 1 percent are bacteriostatic.
Cresol: It is an excellent coal-tar disinfectant. It is 3 to 10
times as powerful as phenol.
• Cresol is best used in 5 to 10 percent strength for
disinfection of feces and urine
• A 5 percent solution is prepared by adding eight ounces of
cresol to one gallon of water (or 50 ml to one liter of water)
• Cresol is an all purpose general disinfectant.
Cresol emulsions
• Cresol emulsified with soap is known as “Saponified cresol”.
Lysol contain 50 to 60 percent cresol.
• A two percent solution of lysol may be used for disinfection
of feces.
Chlorhexidine : It is most useful skin antiseptic
• Highly effective against vegetative gram +ve
organisms and moderately active against gram +ve
microbes
• It is soluble in water and alcohol
• It is inactivated by soap and detergents.
• Creams and lotions containing one percent
chlorhexidine are recommended for burns and hand
disinfection.
Hexachlorphane: Highly active against gram +ve organisms,
less active against gram –ve organisms.
 232 Essentials of Community Medicine—A Practical Approach
Dettol : Nontoxic antiseptic. Can be used safely in high
concentrations. Dettol 5 percent is suitable for disinfection of
instruments and plastic equipment, a contact of at least 15
minutes will be required.

Quaternary Ammonia Compounds

Cetrimide: It is manufactured under trade name “cetavlon”.

• Active against gram +ve organisms
• Less effective against gram –ve organisms
• It is soluble in water
• It is used in one o two percent strength.
Savlon: It is a combination of cetavlon and hibitane.
Savlon one in six in spirit is more effective than savlon 1 in 20
aqueous solution.
For example, clinical thermometer may be best disinfected in
savlon one in six in spirit in just under three minutes.

Halogens and their Compounds

Halogens are actively bactericidal agents, and are the
only useful antiseptics with a sporocidal action.
Bleaching powder
• It is chlorinated lime.
• It is white amorphous powder with pungent smell of
chlorine.
• A good sample of bleaching powder contains about 33
percent of available chlorine.
• It kills organisms when used in the strength of one to three
percent.
• It is widely used for disinfection of water, feces and urine
and as a deodorant.
Drawbacks: It is an unstable compound and loses its chlorine
content on storage. Its action is rapid but brief.
Sodium hypochlorite
• A five percent solution is suitable for disinfection of feces
and urine allowing a period of one hour for disinfection.
• Freshly prepared hypo-solution containing 100-200 ppm of
available chlorine has been recommended for sterilizing
infants feeding bottles.
Halazone tablet: One tablet of halazone containing 4 mg of
halazone is sufficient to disinfect about one liter of water in
about half to one hour.
The taste of residual chlorine may be removed by adding
sodium thiosulphate normally in the form of tablets containing
about 5.5 mg.
 Disinfection
Iodine:Iodine in an alcoholic solution of one to two percent is
still one of the most effective skin antiseptics available. Iodine
is cheap, readily available and quick in action.
A drop of tincture of iodine may be added to a one liter of
drinking water for disinfection in an emergency.
Iodophors: These are complexes of iodine and
‘solubilizers’. For example, Povidine-iodine
(Betadin)
It is nonirritant and does not stain the skin.
Alcohols: Seventy percent alcohol is lethal in a period of
seconds to all types of non-sporing bacteria. It has no action
against spores, but will inactivate viruses. Below 50 percent
concentration activity decreases rapidly.
Formaldehyde: It is highly toxic and irritant gas which
precipitates and destroys protein. It is effective against
vegetative bacteria, fungi, and many viruses. Slow effective
against bacterial spores (e.g. tetanus spores). It is used as two
to three percent solution (20-30 ml of 40% formalin in 1 liter
of water) for spraying rooms, walls and furniture.
Formaldehyde gas: Gas is most effective at a high
temperature and at a relative humidity of 80 to 90 percent.
It is used for disinfection of blankets, beds, books and other
valuable articles which cannot be boiled.

Miscellaneous

Lime: About 10 to 20 percent aqueous suspension of lime is

known as “milk of lime”. Feces and urine can be disinfected by
mixing 10 to 20 percent aqueous suspension of lime and
allowing the disinfectant to act for two hours. It is used as a
deodorant in public urinals and latrines.
Ethylene oxide: Heat sensitive articles may be sterilized at 55
to 60°C by ethylene oxide which kills bacteria, spores (e.g.
tetanus spores) and viruses.

BIBLIOGRAPHY
1. Bres P. Public Health action in Emergencies caused by
Epidemics, WHO, Geneva, 1986.
2. Park’s Textbook of Preventive and Social Medicine, 17th edn,
2002.
3. Report by the Public Health Laboratory Service Committee, Brit
Med J 1965; 1:408-13.
4. Today’s Drugs Brit. Med J 1964;2:1513-15.
5. WHO. Techn. Rep Ser, 1972; No. 493, p. 58.
 Chapter
12 Insecticides and
Rodenticides
Chapter Outline
INSECTICIDES AND PESTICIDES

INSECTICIDES AND PESTICIDES

Insecticides are used to kill the insects.
Pesticides—insecticides, herbicides, rodenticides (Table
12.1), repellents, fungicides all come under pesticides which
are used for control of pests.
Table 12.1: Characteristics actions and doses of various rodenticides
Rodenticide Characteristics Mode of action Dose
1. Barium White tasteless It is a single dose It is mixed with
Carbonate powder rodenticide but it is wheat or rice
flour
a weak rodenticide in the proportion
as compared to of 1 to 4 parts
others. On eating of flour. The
mixed the bait, rats are material is mois-
killed in 2 to 4 hours tened with water
and made into
small round marbles
2. Zinc phosphide 1. It is a grayish It is a single dose 1 part of Zinc
powder rodenticide. Rats phosphide to 10
2. It has a garlic are killed in about 3 parts of wheat or
odour hours rice flour mixed
with a few drops of
edible oil in order
to render it more
attractive to the
rats
3. Warfarin White crystalline It is a multiple dose Mixed with
wheat powder, turns (cumulative)
poison, or rice flour 1 : 10 brownish yellow
which causes internal parts and mois-
on keeping hemorrhage and tened with oil.
slow death in 4 to
10 days
4. Cyanogas White/brownish It gives off hydrogen It is prepared in
Powder amorphous powder cyanide gas when powder form and
moistened, which is is pumped into the
Contd...
 Insecticides and
Contd...
lethal to both rats rat burrow by a
and their fleas. The special foot pump
gas is very toxic to (cyanogas
pump). other animals and About 2
ounces of humans also. poison are
pumped into each
burrow after
moistening it and
closing the exit
openings.

Classification
• Contact poisons—DDT, HCH, pyrethrum
• Stomach poisons
• Fumigants.
Class I Organochlorine compounds,
DDT, HCH, chlordane, methoxychlor
dieldrin, Class II Organophosphorous compounds
1. Malathion
2. Fenthion
3. Abate,
etc. Class III
Carbamates
1. Propoxur
2. Carbaryl.

DDT (Dichloro-diphenyl-trichloroethane)
DDT synthesized in 1874, by Ziedler.
Insecticidal properties were discovered by Swiss scientist—
Paul Muller in 1939.
Properties
• It is white amorphous powder
• It is insoluble in water
• Active ingredient of DDT is para-para-isomer (70-80%)
• Soluble in oil and organic solvents.

Action

It is primarily a contact poison.

• It acts on nervous system of insects and permeates into the
insect body through cuticle, after dissolving in the waxy
coverings of feet and it paralyses the legs and wings of
insect and finally leads to death.
• It does not cause immediate death.
236 Essentials of Community Medicine—A Practical Approach

• Residual action lasts up to 18 months.

• It has no repellent action on insects.

Application
It is applied at a dosage of 100 to 200 mg/sq foot area. A five
percent of suspension of DDT is sprayed, at a rate of 1 gallon
over an area of 1000 sq feet.
• Two percent strength used for — mosquito control
• Five percent strength used for — housefly control
and
• Ten percent strength used for — flea
control It should be applied every six months.

HCH (BHC) Hexachlorocyclohexane

Benzene hexachloride or hexachlorocyclohexane or
hexidol or gammexane
• Synthesized earlier than DDT in 1825 by Michael Faraday.
• It is white chocolate powder. The active ingredient is 13 to
16 percent of gamma isomer.
Pure HCH containing 99 percent of gamma isomer is called
lindane.

Action
By direct contact with insects.

Application
Every three months. A dose of 25 to 50 mg/sq foot of gamma
HCH is recommended for residual treatment.

Malathion
• It is yellow or clear-brown liquid with unpleasant smell.
• It is water dispersible.

Dosage
It is 100 to 200 mg/sq foot every three months. It has been
used for killing adult mosquitoes to prevent or interrupt
dengue hemorrhagic fever and mosquito-borne encephalitis
epidemic.

Mineral Oil
Kerosene, fuel oil, crude oil, (mosquito larvicidal oil).
• Kills larvae and pupae within short time after application
• When applied on water, mineral oil spreads and forms thin
film, which cuts off air supply.
 Insecticides and
Dosage
It is 40 to 90 lit/hectare applied once a week.
The killing power of oil is increased by the addition of 1
percent DDT.

Paris Green (Copper aceto-arsenite)

It is emerald green—microcrystalline powder and it is
insoluble in water. A good sample of paris green contains
over 50 percent arsenious oxide.
• It is stomach poison.
• It kills surface feeder Anopheline larvae.
• When applied in granular formulation—it kills bottom
feeder.
• It is applied as two percent dust which is prepared by
mixing 2 kg paris green and 98 kg of diluent such as
soapstone powder or slaked lime in a ‘rotary mixture’.

Dosage
1 kg of paris green/hectare of water surface.

BIBLIOGRAPHY
1. Dhir SL. Swasth Hind 1970;14:269.
2. Park’s Textbook of Preventive and Social Medicine, 16th edn,
Nov 2000.
3. WHO. Techn Rep Ser, No. 125, 1957.
4. WHO. Manual on Larval Control Operations in Malaria, Geneva,
1973.
5. WHO. Techn Rep Ser, No. 553, 1974.
6. WHO. Techn Rep Ser, No. 561, 1975.
 Chapter
13 Environmental Models

Chapter Outline
CHLOROSCOPE/CHLORINOMETER DRY AND WET BULB THERMOMETER (HYGROMETER)
MAXIMUM AND MINIMUM THERMOMETER GLOBE THERMOMETER
KATA THERMOMETER SLOW SAND FILTER
SOAK PIT

CHLOROSCOPE/CHLORINOMETER
It is used to determine the amount of excess/residual chlorine in
water after chlorination.
It consists of:
1. Orthotolidine reagent
2. Standard test tubes or disks.
3. Empty test tube.
4. Plastic or metal container.
Procedure
1. Take the water to be tested and add it up to the mark in the
empty test tube.
2. Add drops orthotolidine reagent 1:10 parts of water.
3. Shake slowly and match the yellow color formed with the
standard tubes/disks. This gives directly the amount of
residual chlorine in the water if read quickly (within 10
seconds of adding the reagent). After 15 to 20 minutes the
color developed is due to free plus combined chlorine.
4. Orthotolidine arsenite (OTA) test is a modification of the OT
test which avoids the errors due to the presence of other
elements like, manganese, iron and nitrites. It also allows the
reading of free and combined chlorine separately.
DRY AND WET BULB THERMOMETER (HYGROMETER)
This is used for measuring the relative
humidity. It consists of:
1. Ordinary mercury thermometer, which measures the room
temperature.
2. Another ordinary mercury thermometer, whose mercury
bulb is kept moist by covering it with a muslin cloth, whose
end is dipping in a small water container.
 Environmental Models
Procedure
1. The continuous evaporation of water through the muslin
cloth, causes reduction in the temperature in that
thermometer (with a cloth) hence it shows a lower reading
than the other thermometer (without a cloth).
2. The drier the air, more rapid will be the evaporation and
hence lower will be the temperature in that thermometer.
3. The difference in the temperatures of the two thermometers
varies inversely with the amount of moisture in the air.
4. The humidity can be read from available charts or slide scale.
5. At 100 percent humidity, both
thermometers will show the same
temperature. Since, then there would
be no evaporation.
6. The thermometers should be
protected from radiant heat, direct
sunlight and rain.

MAXIMUM AND MINIMUM

THERMOMETER
This is used for measuring the
maximum and minimum temperatures
of a place on a given day (Fig. 13.1).
It consists of:
1. A mercury thermometer with a
constriction at the neck of the
mercury bulb.
2. A spirit thermometer with a dumb-
bell shaped rider or index.

Procedure
1. When the temperature rises the
mercury in the mercury
thermometer expands.
2. When the temperature falls, the
mercury cannot fall back into the
bulb, due to the constriction, hence
the mercury column will remain at
the maximum temperature.
3. After taking the maximum reading,
the mercury thermometer is shaken
briskly to push the mercury back Fig. 13.1: Maximum and
into the bulb (like in a clinical minimum thermometer
thermometer).
4. When the temperature falls, the
spirit in the spirit thermometer
contracts and drags the rider down
along with it, due to surface tension.
 240 Essentials of Community Medicine—A Practical Approach
5. When the temperature rises, the spirit expands and runs
past the rider, hence the rider remains stuck at the
minimum temperature.
6. After taking the minimum temperature reading, the rider
can be moved to the surface of the spirit column by gently
tapping with fingers.

KATA THERMOMETER (FIG. 13.2A)

Used for Measuring
a. Cooling power of air.
b. Velocity of air.
It consists of:
1. Two alcohol thermometers each with a bulb of 1.8 cm
diameter and 4 cm length.
2. The bulb of one is covered with a wet muslin cloth. This is
known as the wet kata thermometer and the other one is
known as the dry kata thermometer.

Procedure
1. The bulbs of both katas are immersed in warm water till the
temperature rises above 130°F.
2. The bulb of the dry kata is wiped dry.
3. The muslin cloth over the wet kata is moistened.
4. The kata’s are suspended in air and the time required for
the temperature to fall from 100°F to 95°F is noted for both
kata’s. This is repeated four to five times and the mean of the
last three to four readings is taken.
5. ‘Kata factor’ is written on the thermometer or the instruction
leaflet.
6. Kata factor divided by the mean cooling time gives the
cooling power.
7. Dry kata readings of 6 or more, and wet kata readings of 20
or more, are regarded as an index of thermal comfort.

GLOBE THERMOMETER (FIG. 13.2B)

Used for measuring the Mean
radiant heat. It consists of:
1. A hollow copper globe, 15 cm in diameter, which is coated on
its external
surface with soot or black paint.
2. A mercury thermometer, is inserted into the globe through
an opening, so that the mercury bulb lies exactly at the
center of the globe.

Procedure
1. The black globe absorbs the radiant heat from the
surroundings.
2. The mercury thermometer registers the room temperature
plus the radiant heat.
 Environmental Models

(A) (B)
Figs 13.2A and B: (A) Kata thermometer; (B) Globe thermometer
3. The difference between the readings of a globe
thermometer and an ordinary thermometer kept side by side
is equal to the mean radiant heat.
4. The globe thermometer is also influenced by the air velocity.
Note: A wet globe thermometer is a globe thermometer whose globe
is covered with a wet black cloth. This thermometer exchanges heat
with the surroundings by evaporation, radiation, convection and
conduction, like a human being. Hence, a wet globe thermometer is
considered to provide the most comprehensive measure of the
cooling capacity of the environment and is used extensively to
measure the thermal comfort in industries.

Sling Psychrometer (Fig. 13.3)

This is used to measure the relative
humidity. It consists of:
One dry and one wet bulb thermometer mounted side by side on
a rotating
wooden frame.
Procedure
1. The cloth over the wet bulb is moistened and the wooden
frame is rotated for about 15 seconds at a rate of 4
revolutions per second so as to achieve a rotational speed of
5 meters per second. Note the wet bulb thermometer
reading.
2. The psychrometer is again rotated for 10 seconds and the
wet bulb thermometer reading is noted.
3. This is repeated several times, till the wet bulb
thermometer tempera- ture remains constant, with no
further fall. Now note the dry bulb thermometer reading.
4. Relative humidity can be read directly from available charts.
 242 Essentials of Community Medicine—A Practical Approach

Fig. 13.3: Sling psychrometer

Gully Trap
Three types of pipes are usually
seen on the outer wall of sanitary
blocks in a building. The largest is
the storm or rain water pipe which
drains rain water from the roof into
the gully trap. The medium sized is
the soil pipe while the small sized
pipe is the sullage water pipe
draining bathrooms and sinks (Fig.
13.4).

SOAK PIT Fig. 13.4: Gully trap

In the absence of a drainage system in rural areas, sullage
water spills and stagnates along open streets, leading to
nuisance an unhygienic conditions,
 Environmental Models
apart from acting as breeding source for mosquitoes. The soak
pit is a cheap, simple and sanitary method of disposing sullage
water. Besides acting as a sanitary sullage disposal system,
the soak pit also acts as a device for recharging of ground
water. Improvements in soak pit have been suggested by the
Safai Vidyalaya, the Central Building Research Institute,
Roorkee, and the Consortium on Rural Technology, Delhi. The
steps in constructing an improved soak pit as suggested by
the latter are given below:
1.Choose a proper site which should be away from a house
wall and at least 10 m distant from any well. The water
table should not be very high. Its water is present three to
four meter below ground level, this technology may not be
appropriate.
2.Dig a pit about one meter long, broad and deep. The
bottom of the pit must have a slope of about 15 cm, the
direction of the slope being away from the house.
3.Divide the depth of the pit into roughly four equal parts.
Fill the lowermost part with stones or bricks the size of a
coconut. Fill the second part with stones or bricks the size
of a big apple. The third part is to be filled with stones of
the size of an average lemon. The fourth or uppermost part
is for the inlet chamber.
4.The inlet chamber is constructed as follows:
a. At the center, lay the foundation of the chamber in the
form of 4 bricks arranged as shown laid with a gap of 5
cm between the bricks, leaving a central space of 12.5 ×
12.5 cm (5”× 5”).
b. Lay over these bricks a second layer of bricks without
leaving any space between the joints.
c. If necessary, similarly lay a third or fourth layer of
bricks. This will depend upon the slope of the drain from
the source outlet of waste water to the inlet chamber of
the soak pit.
5.Take a 1 sq m gunny cloth with a hole in the center about
the size of the inlet chamber. Cover the stone layer of the
pit with this gunny cloth.
6.Cover the gunny cloth with a similar sized polythene sheet
having a similar hole in the center.
7.Cover the polythene sheet with soil and fill the pit.
Compact the soil properly. The soak pit is now ready.
8.Make a pucca drain 7 cm (3”) wide and 10 cm (4”) deep
from the water outlet to the soak pit inlet. It should have a
slope of about 8 cm per meter, i.e. about 1” per foot. The
drain should be covered by bricks or flat stones without
joining them. This helps in checking the entry or solid
waste and rain water.
9.Provide a trap near the middle of the drain to check the
entry of suspended solid wastes from entering the pit.
Dimensions of the trap are: length 35 cm (14”), breadth 25
cm (10”) and height, progressively sloping along the flow
of water, so as to be 25 cm (10”) in beginning,
 244 Essentials of Community Medicine—A Practical Approach

Fig. 13.5: Soak pit

22.5 cm (9”) in the middle and 20 cm (8”) at end. At the

middle provided a partition with a 7.5 cm × 7.5 cm (3” ×
3”) hole at the bottom as shown in Figure 13.5.
10. Cover the trap and the inlet chamber of the pit with a flat
stone.
11. Cover the top surface of the soak pit with soil so as to raise
it 5 cm above the surrounding ground level.

SLOW SAND FILTER (FIG. 13.6)

1. Slow sand filter requires ½ to 1½ acre area. So the initial
cost is much more (about 20-30 times) than rapid filter,
maintenance cost is however low.

Fig. 13.6: Slow sand filter

 Environmental Models
2. Total depth of filter is about 3.6 meters and various layers
from below upward are as follows:
Underdrain Two layered bricks
Gravel 15-30 cm
Coarse sand 15-30 cm
Fine sand 0.6 meter
Water on top 1.5 to 1.8 meter

3. Dust free sand insoluble in dilute HCL and having effective

size of
0.25 to 0.35 mm is used in slow sand filter.
4. Heart of slow sand filter vital layer, which formed by algae,
bacteria, plankton and diatoms. The development of vital
layer is called ripening of filter, which removes organic
matter, holds bacteria and oxidises organic material.
5. Loss of head—when vital layer increases in thickness, loss
of head occurs. If this is above 4 feet “Scraping the filter“ is
needed.
6. Quality of work—it removes 99.9 to 99.99% bacteria.

Rapid Sand Filter (Fig. 13.7)

This is introduced to the world after 80 years after the
discovery of slow sand filter.
1. It occupies very little space.
2. Vital layer is not required. Alum block bring about changes
in surface tension which help to clear out the impurities.
3. Quality of work—it removes 98 to 99 percent
bacteria. Washing is easy (back-wash).

Fig. 13.7: A rapid sand filter

 Chapter
14Water Analysis
Chapter Outline
DETERMINATION OF TOTAL HARDNESS
BACTERIOLOGY OF WATER
STEPS IN WELL DISINFECTION

DETERMINATION OF TOTAL HARDNESS

Determination of total hardness of water by
ethylenediaminetetraacetic acid (EDTA) method.

Theory
The characteristic of water that prevents the lathering of soap
is called hardness. EDTA is an excellent complexing agent,
which forms insoluble complexes with divalent ions (Ca ++ Mg+
+
) present in water. Therefore, hardness causing salts of
calcium and magnesium present in water can be estimated by
titrating the given water sample against standard EDTA
solution using Erichrome Black-T as an indicator. The indicator
is effective in the PH range of about 8 to 11, so while
performing the experiment it is essential to maintain the PH of
water sample in between 8 and 11 by adding a suitable buffer
solution.

Procedure
1. Pipette out given 25 ml of hard water into a clean conical
flask.
2. Add 2 ml of buffer solution and shake it well.
3. Add 1 to 2 drops of Erichrome Black–T indicator.
4. Titrate the above sample against standard 0.02 M EDTA
solution from the burette until wine red color changes to
blue. Let this volume of EDTA be V2 ml (Table 14.1).

Example
1. In burette – Standard 0.2 N EDTA solution.
2. By pipette – 25 ml of given water solution.
3. Indicator – Erichrome Black–T
4. Color change – Wine red to blue.
5. Reactions – Wine red to blue.
i. Ca++ + EDTA CaMg EDTA
Stable colorless sample
 Water Analysis

ii. Ca++ + EBT CaMg EBT

++
Mg
Unstable wine red color complex
iii. CaMg EBT + EDTA CaMg EDTA + EBT
Stable complex
Table 14.1: Burette readings
Burette Pilot I II III Mean
Final reading 6.0 11.7 17.7 23.6
Initial reading 0.0 6.0 11.7 17.7
Difference 6.0 5.7 6.0 5.9 5.9

Calculations
1000 ml of 1 M EDTA =100 gm of CaCO3
1 ml of 1 M EDTA =0.1 gm of CaCO3
1 ml of 0.02 M EDTA =0.01 × 0.02 gm of CaCO3
5.9 ml of 0.02 M EDTA =0.1 × 0.02 × 5.9 gm of
CaCO3
i.e. 25 ml of water sample = 0.002 × 5.9 gm of CaCO3
contains
1000 ml of sample contains = 0.002 × 5.9 × 40 gm of
CaCO3
Total hardness of water = 0.02 × 5.9 × 1000 mg of
CaCO3
= 475.2 ppm of CaCO3
BACTERIOLOGY OF WATER
Drinking water has to be visually acceptable, being clear and
colorless, and without disagreeable taste or odor. It should
also be safe, being free from chemical toxins and pathogenic
microorganisms. Many more human diseases, for example,
typhoid fever, cholera and other diarrheal diseases,
poliomyelitis and viral hepatitis A and B are waterborne.
These pathogens reach water sources through fecal or sewage
pollution. It is essential to prevent such contamination, treat
the water suitably to remove or destroymicroorganisms, and
also to ensure the safety of such protected water supplies by
regular bacteriological surveillance.

Bacteriological Examination of Water

Bacteriological analysis of water supplies should be a regular
periodical procedure and not a random exercise.
Plate Count
This consists of counting the numbers of colonies formed in
pourplate cultures of the water samples, on nutrient agar
incubated aerobically, in parallel, at 37°C for 1 to 2 days and
at 22°C for 3 days. Those that grow
 248 Essentials of Community Medicine—A Practical Approach
at 37°C are those most likely to be associated with organic
material of human or animal origin, whereas those growing at
a lower temperature are mainly saprophytes that normally
inhabit water are derived from soil and vegetables.
The agar count at 22°C gives an indication of the amount of
decomposing organic matter in the water available for
bacterial nutrition. Though most bacteria growing at 22°C are
nonpathogenic to human beings, on general grounds, the
greater the amount of organic matter present, the more likely
is the water to be contaminated with parasitic and potentially
pathogenic organisms. The agar count at 37°C is a more
important index of dangerous pollution. A rise in colony count
is the usual signal of some defect in filter beds demanding
immediate attention.

Detection of Coliform Bacteria and E. coli

Presumptive coliform count (Multiple tube technique): The

test is called presumptive because the reaction observed may
occasionally be due to the presence of some other organisms
and the presumption that the reaction is due to coliform
organisms has to be confirmed.
An estimate of the number of coliform organisms is usually
made by adding varying quantities of water (0.1-50 ml) to bile
salt lactose peptone water (with an indicator for acidity) and
incubating at appropriate temperatures. Acid and gas
formations indicate the growth of coliform bacilli. Thus, it is
possible to state the smallest quantity of water containing a
coliform bacillus and to express the degree of contamination
with this group of organisms.
The following ranges are put up:
• One 50 ml quantity of water added to 50 ml double strength
medium.
• Five 10 ml quantities each to 10 ml double strength
medium.
• Five 1 ml quantities each to 5 ml single strength medium.
• Five 0.1 ml quantities each to 5 ml single strength medium.
MacConkey’s fluid medium (modified) is used. The range of
quantities depends on the likely strength of contamination. For
highly contaminated waters, smaller volumes are tested. The
bottles are incubated at 37°C and examined after 18 to 24
hours. The ‘presumptive positives’ are read off and the
remaining negative bottles are reincubated for another 24
hours. Any further positives are added to the previous figures.
The probable number of coliforms per 100 ml are read off
from the probability tables of McCrady. This is known as the
‘presumptive coliform count’ or the most probable number of
coliforms (MPN).
 Water Analysis
Differential coliform test: The Eijkman’s test is usually
employed to find out whether the coliform bacilli detected in
the presumptive test are
E. coli. After the usual presumptive test, subcultures are made
from all the bottles showing acid and gas to fresh tubes of
single strength MacConkey’s medium already warmed to
37°C. They are incubated at 44°C and examined after 24
hours. Incubation at 44°C should be carried out in
thermostatically controlled water baths that do not deviate
more than 0.5°C from 44°C. Those showing gas in Durham’s
tubes contain
E. coli. From the number of positive tubes obtained, results
are read off the probability tables. Further confirmation of the
presence of E. coli can be obtained by testing for indole
production and citrate utilization (Table 14.2).
Table 14.2: Bacteriological quality of drinking water a

Organisms Guideline value

All water intended for drinking
E. coli or thermotolerant coliform Must not be detectable in any 100
ml bacteria b,c sample
Treated water entering the distribution system
E. coli or thermotolerant coliform bacteria b
Total coliform bacteria Must not be detectable in any 100
ml sample
Treated water entering the distribution system Must not be detectable in any 100
ml
sample
E. coli or thermotolerant coliform bacteria b Must not be detectable in any 100 ml
Total coliform bacteria sample
In the case of large supplies where
sufficient samples are examined,
must not be present in 95% of
samples
taken throughout any 12-month period.
a. Immediate investigative action must be taken if either E. coli or total coliform bacteria are
detected. The minimum action in the case of total coliform bacteria is repeat sampling: if
these bacteria are detected in the repeat sample, the cause must be determined by
immediate further investigation.
b. Although E. coli is the more precise indicator of fecal pollution, the count of thermotolerant
coliform bacteria is an acceptable alternative necessary, proper confirmatory tests must be
carried out. Total coliform bacteria are not acceptable indicators of the sanitary quality of
rural water supplies, particularly in tropical areas where many bacteria of no sanitary
significance occur in almost all untreated supplies.
c. It is recognized that, in the great majority of rural water supplies in developing countries,
fecal contamination is widespread. Under the conditions, the national surveillance agency
should set medium term targets for progressive improvement of water supplies.

Membrane filtration method: A measured volume of water is

filtered through a millipore filter. All the bacteria present are
retained on its surface. It is placed on suitable media face
upwards and incubated at the appropriate
 250 Essentials of Community Medicine—A Practical Approach
temperature, and the colonies that develop on the surface of
the membrane are counted. After 18 hours of incubation the
presumptive coliform counts and E. coli counts can be directly
made.

Detection of Fecal Streptococci

Subcultures are made from all the positive bottles in the
presumptive coliform test into tubes containing 5 ml of
glucose azide broth. The presence of Streptococcus faecalis is
indicated by the production of acid in the medium within 18
hours at 45°C. The positive tubes should be plated onto
MacConkey’s agar for confirmation.
Millipore membrane technique can also be adopted for this
purpose.

Examination for Clostridium perfringens

This is tested by incubating varying quantities of the water in
litmus milk medium (anaerobically) at 37°C for five days and
looking for stormy fermentation.

Tests for Pathogenic Bacteria

Under special circumstances, specific pathogens such as
typhoid bacilli or cholera vibrios may have to be looked for in
water. This used to be done by adding the water samples to
ten-fold concentrated liquid media, incubating and
subculturing onto appropriate solid media. A simpler and
more sensitive method is to filter the water, sample through
membrane filters and incubate the filters on appropriate solid
media.

STEPS IN WELL DISINFECTION

Find the Volume of Water in a Well
a. Measure the depth of water column (h) meters
b. Measure the diameter of well (d) meters
Take the average of several readings of the above
measurements
c. Substitute h and d in: 2
3.14 × d × h × 1000
Volume (liters) =
4
d. 1 cubic meter = 1000 liters of water.

Find the Amount of Bleaching Powder

Required for Disinfection
Estimate the chlorine demand of the well water by “Harrock’s
apparatus (for water testing) which contains six white cups
(200 ml capacity). One black cup with a circular mark on
inside, two metal spoons (each holds 2 g of bleaching
powder) seven glass stirring rods, one special pipette,
 Water Analysis
two droppers, starch iodide indicator solution, instruction
folder and calculate the amount of bleaching powder require
to disinfect the well.
= 2.5 gm bleaching powder is required to disinfect 1000
liters of water
= 0.7 mg applied chlorine per liter of water.

Procedure
Take one level spoonful (2 g) of bleaching powder in the black
cup and make it into a thin paste with a little water. Add more
water to the paste and make up the volume up to the circular
mark with vigorous stirring. Allow to settle. This is the stock
solution.
• Fill the 6 white cup with water to be tested up to about a cm
below the brim.
• With the special pipette provided add one drop of the stock
solution to the 1st cup, 2 drops to 2nd cup, 3 drops to 3rd
cup and so on.
• Stir the water in each cup using a separate rod.
• Wait for half hour for the action of chlorine.
• Add 3 drops of starch iodide indicator to each of the white
cups and stir again. Development of blue color indicates the
presence of free residual chlorine.
• Note the first cup which shows distinct blue color,
supposing 3rd cup shows blue color then 3 level spoonfull, 6
gm of bleaching powder would be required to disinfect 4.55
liters of water.

Dissolve Bleaching Powder in Water

The bleaching powder required for disinfecting the well is
placed in a bucket (< 100 g in one bucket of water) and made
into a thin paste. More water is added till the bucket is nearly
¾ full. The content is stirred well and allowed to sediment for
5 to 10 minute then lime settle down. The supernatant solution
which is chlorine solution, it is transferred to another bucket
and the chalk or lime is discarded (Since lime hardens well
water, it should not be poured into the well).

Delivery of Chlorine Solution into the Well

The bucket containing the chlorine solution is lowered some
distance below the water surface, and the well water is
agitated by moving the bucket violently but vertically and
laterally. This should be done several time and so that the
chlorine is mixed intimately to the water inside the well.

Contact Period
A contact period of one hour is allowed before the water is
drawn for use.
 252 Essentials of Community Medicine—A Practical Approach
Orthotolidine Arsenite Test
To test for residual chlorine at the end of one hour contact. If
the residual chlorine itself is < 0.5 mg/lit, the chlorination
procedure should be repeated before any water is drawn.
Wells are best disinfected at night after the days drawn off.
During epidemics of cholera, wells should be disinfected every
day.
National Water Supply and Sanitation Program (1972):
The stipulated norm of water supply is 40 liters of safe
drinking water per capita per day and at least one hand
pump/spot source for every 250 persons. Provide safe drinking
water to all the villages by the turn of century as available to
about 85 percent of the total population and 16 percent
population has access to adequate sanitation.
 Chapter
15 Bacteriology of Milk

Chapter Outline
BACTERIA IN MILK

BACTERIA IN MILK

Types of Bacteria in Milk

1. Acid forming bacteria
2. Alkali forming bacteria
3. Gas-forming bacteria
4. Proteolytic bacteria
5. Inert bacteria.

Bacteriological Examination
The routine bacteriological examination of milk consists of the
following:

Viable Count
This is estimated by doing plate counts with serial dilutions of
the milk sample. Raw milk always contains bacteria, varying in
number from about 500 to several million per ml.

Test for Coliform Bacteria

This is tested by inoculating varying dilutions of milk into
MacConkey’s fluid medium noting the production of acid and
gas after incubation. Contamination with coliforms comes
mainly from dust, dirty utensils and dairy workers.

Methylene Blue Reduction Test

This is a simple substitute for the viable count. It depends on
the reduction of methylene blue by bacteria in milk when
incubated at 37°C in complete darkness. The rate of reduction
is related to the degree of bacterial contamination. Raw milk
is considered satisfactory if it fails to reduce the dye in 30
minutes under standard conditions.
The Resazurin test is similar but the dye resazurin, on
reduction, passes through a series of color changes—from
blue to pink to colorless—the
 254 Essentials of Community Medicine—A Practical Approach
shade of color after incubation with milk for a particular
period of time, depending on the degree of contamination.
Generally, the 10 minute resazurin test is done, in which the
shade of color is noted after incubation with the milk for 10
minutes.

Phosphatase Test
This is a check on the pasteurization of milk. The enzyme
phosphatase normally present in milk is inactivated if
pasteurization has been carried out properly. Residual
phosphatase activity indicates that pasteurization has not
been adequate.

Turbidity Test
This is a check on the ‘sterilization’ of milk. If milk has been
boiled or heated to the temperature prescribed for
‘sterilization’, all heat coagulable proteins are precipitated. If
ammonium sulphate is then added to the milk, filtered and
boiled for five minutes, no turbidity results. This test can
distinguish between pasteurized and ‘sterilized’ milk.

Examination for Specific Pathogens

Tubercle bacillus: The milk is centrifuged at 3000 rpm for 30

minutes and the sediment inoculated into two guineapigs. The
animals are observed for a period of three months for
tuberculosis. Tubercle bacilli may also be isolated in culture.
Microscopic examination for tubercle bacilli is unsatisfactory.
Brucella: Isolation of brucella may be attempted by
inoculating cream heavily on serum dextrose agar or by
injecting centrifuged deposit of the milk sample
intramuscularly into guineapigs. The animals are sacrificed
after six weeks and the serum tested for agglutinins and the
spleen inoculated in culture media.
Brucellosis in animals can be detected also by
demonstrating the antibodies in milk, by the milk-ring or the
whey agglutination tests.
 Chapter
Staining, Culture Media
16
and Microscopy of Slides o

Chapter Outline
GRAM STAIN ZIEHL-NEELSEN STAIN
ALBERT STAIN CULTURE MEDIA
MICROSCOPIC SLIDES

GRAM STAIN
Aim
To study the morphology and arrangement of bacteria and to
classify the bacteria into gram +ve and gram –ve. Gram stain is
a differential stain.

Requirement
1. Methylviolet — 5 gm
2. Grams iodine — 10 gm
Potassium — 20 gm
iodide
Distill water — 1 liter
3. Counterstain — 0.5%
Safarin
Safarin — 5 gm
Distill water — 2 liter

Procedure
1. Cover the smear with methylviolet solution and allow to act
for one minute, wash with water.
2. Cover the smear with Gram’s iodine, keep it for 1 minute.
3. Decolorize with absolute alcohol for 10 to 30 seconds with
gentle agitation till no more stain comes off. Again wash
with water.
4. Apply the counter stain (Safarin) for one to two minutes.
Wash with water and dry between blotting paper. Observe
under oil immersion objective.

Result
Gram +ve bacteria take violet color and gram –ve bacteria are
stained pink.
 256 Essentials of Community Medicine—A Practical Approach
ZIEHL-NEELSEN STAIN
Aim
To demonstrate acid fast bacteria
a. Ziehl-Neelsen carbol fuschin
i. Basic fuschin—10 gm
ii. Absolute alcohol—100 gm
iii. Solution of phenol (5%)—1000 ml in water
b. Twenty percent sulfuric acid solution
c. Counter stain—Loeffler’s methylene blue.

Procedure
1. Smear should be prepared from the thick purulent part of the
sputum.
2. Smears are dried, heat fixed and stained by Ziehl-Neelsen
technique. The smear is covered with strong carbol fuschin
and gently heated to steaming for five to seven minutes,
without letting the stain boil and become dry.
3. The slide is then washed with water and decolorized with 20
percent sulphuric acid till the stain become faint pink and
then decolorize with ethanol for two minutes.
4. After washing, the smear is counter-stained with Loeffler’s
methylene blue or 1 percent picric acid or 0.2 percent
malachite green for one minute. Dry with bloting paper.
5. Under the oil immersion objective, AFB are seen as bright
red rods while the background is blue, yellow or green
depending on the counterstain used.

Result
Acid fast bacilli stain bright red while the tissue cell and other
organisms are stained blue.

ALBERT STAIN
Aim
To demonstrate Corynebacterium diphtheriae, it is a
special stain to demonstrate intracytoplasmic granules.

Requirement
Toludine blue — 15 gm

]
Malachite green — 20 gm
Glacial acetic acid — 100 ml
Alcohol (95%) ethenol — 200 Albert A
ml Distilled water — 1000
ml
 Staining, Culture Media and Microscopy of Slides
Alberts iodine (iodine) — 60

]
gm Potassium iodide — 90
gm Albert B
Distilled water — 900
ml

Procedure
1. Make smear dry and fix by heat.
2. Cover the slide with Albert A and allow to act for two to three
minutes.
3. Cover the slide with Albert B, allow to act for one minute
4. Wash and blot dry.

Result
By this method intracytoplasmic granules stain bluish black,
the protoplasm green and other organisms lightly green.

CULTURE MEDIA

Types of Media
1. Solid media, liquid media.
2. Simple media, complex media, special media.
3. Aerobic media, anaerobic media.

Simple Media
Nutrient broth consists of peptone, meat extract, sodium
chloride and water. Nutrient agar is made by adding two
percent agar to nutrient broth.

Complex Media
In complex media ingredients are added for growth of special
bacteria.

Synthetic or Defined Media

Prepared from pure chemical substances and exact
composition of the medium is known, e.g. simple peptone
water medium, one percent peptone with 0.5 percent sodium
chloride in water.

Enrichment Media (Liquid Media)

In mixed culture wanted bacteria is over grown as compared to
unwanted bacteria, e.g. E. coli overgrow than salmonellae in
fecal culture tetrathionate broth—which inhibits the coliforms
while allowing typhoid and paratyphoid bacteria to grow
freely, e.g. Selinate ‘F’ broth for dysentery bacilli.
 258 Essentials of Community Medicine—A Practical Approach
Selective Media
The inhibiting substance is added to solid media, it enables a
greater number of required bacterium to form colonies than
the other bacteria,
e.g. desoxycholate citrate medium for dysentery bacilli.

Indicator Media
This media contain indicator which changes color when a
bacterium grows in them, e.g. incorporation of sulphite in
Wilson and Blair medium.

MICROSCOPIC SLIDES
Microorganisms which cause diseases of public health
magnitude should be identified and certain important
characteristics related to their identification, special stains
and special media are expected to be known by the students
(Fig. 16.1). The diseases caused by these microorganisms,
their signs and symptoms,their management as well as
prevention and control should also be known to the student.
Important aspects related to the identification, stains and
media are mentioned here. For the disease aspects the
student is advised to refer back to the description of these
diseases in the chapter related to case examination.

Fig. 16.1: Microscopy of slides of public health importance

 Staining, Culture Media and Microscopy of Slides
Mycobacterium tuberculosis

Identification
Mycobacteria means ‘fungus like bacteria’
1. It is an acid fast bacillus (AFB).
2. They are slender rod shaped that sometimes show
branching filamentous forms resembling fungal mycelium.
3. AFB appear pink against a blue background in the Ziehl-
Neelsen stain.
4. They are aerobic, nonmotile, noncapsulated and nonsporing.
5. They are straight or slightly curved rods occurring singly, in
pairs or in small clumps.
6. Solid media for growth includes:
a. Löwenstein-Jensen media
b. Löeffler’s serum slope
c. Dorset’s egg media.

Mycobacterium leprae

Identification
1. They are acid fast bacilli seen singly and in bundles,
intracellularly or lying free outside the cells.
2. They frequently appear as conglomerates the bacilli being
bound together by a lipid like substance, the glia. These
masses are known as “globi”.
3. The parallel rows of bacilli in the globi present a ‘cigar
bundle’ appearance.
4. Mycobacterium leprae appear pink against a blue background
in the Ziehl- Neelsen (5% sulfuric acid) stain.

Treponema pallidum

Identification
1. ‘Trepos’ meaning to turn and ‘nema’ meaning thread.
2. They are slender spirochaetes with fine spirals and pointed
or rounded ends.
3. They are thin, delicate, spirochaete with tapering ends, and
have about ten regular spirals which are sharp and regular
at an interval of about 1μ (1 micron).
 260 Essentials of Community Medicine—A Practical Approach
4. They are motile, exhibiting rotation round the long axis,
backward and forward movements and flexion of the whole
body.
5. It stains light rose red with Giemsa’s stain and can be
stained by silver impregnation.

Neisseria meningitidis

Identification
1. They are Gram-negative, aerobic, nonsporing, nonmotile
cocci, which are both intra- and extracellular.
2. They are spherical cocci arranged in pairs, with the
adjacent sides flattened.
3. Culture media are:
a. Blood agar.
b. Chocolate agar.
c. Müeller-Hinton media.

Clinical Features
1. Meningococcemia
a. Sudden onset.
b. Prodromal symptoms like cough, bodyache, headache,
myalgia.
c. Fever with chills, tachycardia, tachypnea and shock.
d. Petechial rash.
2. Meningitis
a. Fever, headache and vomiting.
b. Altered sensorium and convulsions.
c. Neck stiffness with other meningeal signs.

Complications
a. Addison’s crisis (Waterhouse-Friderichsen syndrome)
b. Deafness and other neurological damage.
c. Disseminated intravascular coagulation (DIC).

Treatment
1. Antibiotics
a. Benzylpenicillin 10 to 20 lacs units intravenously 2 hourly.
b. Chloramphenicol 500 mg intravenously, 6 hourly.
c. Third generation cephalosporins like cefatoxime.
2. Treatment of raised intracranial tension with mannitol.
3. Treatment of shock:
a. IV fluids
b. Steroids
c. Electrolyte imbalance correction.
 Staining, Culture Media and Microscopy of Slides
4. Treatment of Addison’s crisis
a. Saline infusion.
b. Hydrocortisone.

Corynebacterium diphtheriae
Identification
1. They are Gram-positive, nonacid fast, nonmotile rods with
irregularly stained segments and metachromatic granules
and polar bodies.
2. They are nonsporing, and noncapsulated.
3. They show club-shaped swelling, (coryne meaning club),
arranged in pairs or small groups and form various angles
with each other so as to resemble ‘V’ or ‘L’ letter (Chinese
letter arrangement).
4. Culture media are:
• Löeffler’s serum slope
• McLeod’s and Hoyle’s media
• Potassium tellurite blood agar.

Neisseria gonorrhoeae
Identifications
1. They are gram-negative, aerobic, nonsporing, nonmotile
cocci.
2. They are diplococci with adjacent sides concave, the cocci
are reniform or bean shaped.
3. They are found predominantly within the polymorphs, some
cells may contain as many as hundred cocci. Extracellular
forms are also seen.
4. Culture media are:
a. Blood agar.
b. Chocolate agar.
c. Thayer-Martin medium.

Clostridium tetani
Identification
1. They are gram-positive, motile, anaerobic, spore-forming
bacilli.
2. Spores are spherical and placed terminally giving a
‘drumstick appearance’.
3. The spores are wider than the bacillary bodies, giving the
bacillus a swollen appearance resembling a spindle (Closter
means a spindle) hence the name Clostridium.
4. Grown in anaerobic conditions only. Special medium used is
Robertson’s cooked meat broth.
 262 Essentials of Community Medicine—A Practical Approach
Clinical Features
1. Inability to open the mouth (Trismus).
2. Inability to swallow.
3. Repeated fall in case of children due to stiffness of muscles.
4. Risus sardonicus (facial muscle contraction giving the
appearance of a smile).
5. Spatula test becomes positive, i.e. on touching the spatula
to the soft palate, patient forcefully closes the mouth.

Complications
1. Laryngeal spasm.
2. Secretions and chest infection.
3. Autonomic nervous system disturbance like cardiac
arrhythmia, hypotension.

Treatment
1. Anti-tetanus serum (ATS) is given intravenously, dose 5000
to 10,000 units.
2. Antibiotic: Benzathine penicillin is given 0.6 to 1.2
megaunit intra- muscularly.
3. Muscle relaxants:
a. Diazepam
b. Chlorpromazine
c. Barbiturate.
d. Baclofen
4. Ryles tube feeding.
5. Local wound or infection site should be cleaned and antiseptic
applied.

Leptospira
Identification
1. They are elongated, motile, flexible bacteria, they are
twisted spirally round the long axis and stained with Giemsa
stain.
2. They possess numerous coils, set so close together that they
can be distinguished only under dark ground illumination in
the living state or by electron microscopy.
3. Culture media
are:
a. Stuart’s medium
b. Fletcher’s medium.
 Staining, Culture Media and Microscopy of Slides
Clinical Features
1. Leptospirosis
a. Primary phase: Fever, headache and joint pain.
b. Secondary phase:
i. Signs and symptoms of meningeal irritation occurs.
ii.Optic neuritis.
iii.Myelitis.
iv. Peripheral neuropathy.
2. Weil’s syndrome
a. Fever.
b. Jaundice.
c. Hepatorenal failure.
d. Subconjunctival hemorrhages.

Treatment
1. Benzylpenicillin 20 lacs units Intravenous, 6 hourly.
2. Fluid and electrolyte imbalance to be corrected.
3. Blood transfusion if required.
4. Renal dialysis if required.
Note: Leptospirosis is transmitted by rats and is an occupational hazard of
sewage drainage workers.

BIBLIOGRAPHY
1. Difco Manual of Dehydrated Culture Media and Reagents, 9th edn,
Michigan: Difco Laboratories, 1977.
2. Oxoid Manual, 3rd edn. Baringstoke, R Ananthanarayan, CKJ
Paniker, 6th edn. 2000.
 Chapter
17 Hospital Waste
Management
Chapter Outline
HOSPITAL WASTE DISPOSAL
PLANNING AND ORGANIZATION
INCINERATORS

INTRODUCTION
The following estimates for an average distribution of health
care wastes useful for preliminary planning of waste
management. Eighty percent general health care waste, which
may be dealt by the normal domestic and urban waste
management system:
• Fifteen percent pathological and infectious waste;
• One percent sharps waste;
• Three percent chemical and pharmacological waste.
• Less than one percent special waste, such as radioactive or
cytotoxic waste, pressurized containers or broken
thermometers and used batteries.
The wastes generated by the hospitals add to the
community waste, thereby putting the load on the already
scarce resources. Most of the hospital-generated waste is
potentially infectious and therefore, spreads infections
amongst the community causing a major health problem (Fig.
17.1).

Fig. 17.1: International infectious substance symbol

 Hospital Waste
Type of Hospital Waste
The waste generated by the hospitals is of two types:
1. High-risk waste (which requires special handling)
2. Non-risk waste (general wastes).

The High-risk Waste

Chemical wastes: Which comprises of materials discarded
from diagnostic and experimental works, cleaning,
housekeeping and disinfecting work.
Pathological wastes: Consists of tissues, organic body parts
and human fetuses, which may be infectious.
Highly infectious wastes: Contain pathogens in sufficient
quantity, so that exposure could result in diseases. This
category includes cultures and stocks of infectious agents
from laboratory work, wastes from surgery and autopsies of
patients with infectious diseases, waste from infectious
patients in isolation wards, etc.
Sharp: Include needles, syringes, scalpels, blades, broken
glasses, nails and any other material which can cause
puncture.
Pressurized containers: Include those containers used for
demonstration or instrumental purposes containing innocuous
or inert gas and aerosol cans which may explode, if
incinerated or accidentally punctured.
Laboratory wastes: Include pharmaceutical products, drugs
and chemicals that have been returned from wards, outdated,
contaminated or discarded for any other reason.

General Wastes
General wastes includes domestic wastes, packing material,
noninfectious bleeding from animals, garbage from hospital
kitchens and other waste materials that are not infectious or
hazardous to the human health or environment.
In view of the large number of government hospitals and the
rapidly increasing number of nursing homes and clinics in the
private sector, in the urban as well as in the rural areas,
proper training and awareness is essential for the safe and
efficient management of hospital wastes. It is highly desirable
that the wastes disposed should be free from disease
organisms, the disposal system should prevent re-entry of the
disease organisms in the community, there should be no
contamination of the surface soil, water and a check on air
pollution (including odors).
Getting rid of the hospital wastes in a proper manner plays
a major role in prevention of emergence and re-emergence of
infectious diseases and also other nosocomial infections and
iatrogenic infections.
 266 Essentials of Community Medicine—A Practical Approach
Hazards and Risks from Hospital Waste Exposure

Indiscriminate Disposal of Infectious

Hospital Waste is Hazardous in Many Ways
1. Occupational hazard to persons who are constantly exposed
to these wastes, like patients and hospital workers and
contact personnel such as milkmen, laundry staff, cleaners,
etc.
2. Inappropriately handled waste can be a public health
nuisance as it can spread fatal diseases like Hepatitis B and
C and HIV through injuries caused by contaminated needles
or sharps picked by rag— pickers, children, etc. The people
who visit hospital to see patients also are at risk.
3. Impact of badly disposed infectious hospital waste like
blood soaked bandages, used needles and gloves, syringes
and linen is great. When these wastes are indiscriminately
thrown in backyards of hospitals or into open municipal pits,
they become breeding sources for disease producing
mosquitoes, flies, rodents and microbes. Besides being an
environmental pollutant, this poses additional health risk to
health workers and rag pickers. The ugly sight and stench
of these biomedical wastes can be highly discouraging for
the users of hospital services. Epidemics can result from the
contamination of drinking water and food sources with
these infectious wastes, which can be washed by rains.
Indiscriminate open burning of infectious waste, especially
plastics will result in emission of noxious gases which may
produce cancer.

HOSPITAL WASTE DISPOSAL

Disposal strategies form a critical part of total waste
management in hospitals, as any failure in this aspect will
have hazardous consequences. The basic principle is that
wastes are disposed in most hygienic and cost-effective
manner, by methods which at all stages, minimize risk to
health environment. Any strategy adopted should have a
scientific bases. The Government of India has prescribed strict
procedures and guidelines for each step in waste management
leading to waste disposal in hospitals (Fig. 17.2).
 Hospital Waste

Fig. 17.2: Hospital waste management structure

Categories of Biomedical Waste (Table 17.1)

Table 17.1: Categories of biomedical waste

Category Waste category
I Human anatomical waste
(Human tissues, organs, body parts)
II Animal waste
(Animal tissues, organs, body parts carcasses,
bleeding parts, fluid, blood and experimental animals
used in research, waste generated by veterinary
hospitals colleges, discharge from hospitals, animal
houses)
III Microbiology and biotechnology waste Local auto-
(Wastes from laboratory cultures, stocks or specimens claving/micro-
of microorganisms live or attenuated vaccines, waving/
human and animal cell culture used in research and incineration
infectious agents from research and industrial
laboratories, wastes from production of biological,
toxins, dishes and devices used for transfer of cultures)
Contd...
 268 Essentials of Community Medicine—A Practical Approach
Contd...
IV Waste sharps
(Needles, syringes, scalpels, blades, glass, etc. that
may cause puncture and cuts. This includes both used
and unused sharps)
V Discarded medicines and cytotoxic drugs
(Wastes comprising of outdated, contaminated and
discarded medicines)
VI Solid waste Incineration @
(Items contaminated with blood, and body fluids autoclaving/
including cotton, dressings, solid plaster casts, lines, microwaving
bedding, other material contaminated with blood)
VII Solid waste
(Waste generated from disposal items other than the
waste sharps such as tubings, catheters intravenous
sets, etc.
VIII Liquid waste
(Waste generated from laboratory and washing,
cleaning, house keeping and disinfecting activities)
IX Incineration ash
(Ash from incineration of any biomedical waste)
X Chemical waste
(Chemical used in production of biological, chemicals
used in disinfection, as insecticides, etc.)

Objectives of Plan
The objectives of this plan are:
Immediate Objectives
a. To ensure safe, efficient, cost-effective disposal of hospital
waste by developing a waste disposal plan.
b. To train hospital workers on waste management.

Long-term Objectives
a. To develop strategies for reduction of waste generation in the
hospital.
b. To create awareness among workers about healthy
hospital surroundings.
c. To create community awareness on environment issues in
hospital surrounding.

PLANNING AND ORGANIZATION

The medical officer incharge of the hospital prepares a strategy
on the following aspects.
 Hospital Waste
Organization
Medical officer incharge will be the overall supervisor of the
waste management program, and composes his team as
follows:
• Team leader
– Waste management co-ordinator (Medical officer incharge
of the hospital)
• Members
– The second medical officer
– Senior staff nurse
– FDA
– SDA
– Senior Group ‘D’ worker.

Responsibilities
The team will be responsible for:
1. Implementing effective waste disposal procedures—
collection, transport, storage and final disposal and
continuously monitoring them.
2. Designating Group ‘D’ workers for daily collection of waste,
transport and disposal and monitoring their works.
3. Ensuring that adequate and correct waste containers are
kept and maintained in all strategic areas of the hospital and
used appropriately.
4. Supply and monitor use of protective—clothing, gloves,
footwear, etc. by workers.
5. Arranging training of all staff on waste management
through workshops, demonstrations and talks.
6. Creating environmental awareness among hospital patients,
visitors and community leaders.
7. Developing waste reduction, reuse and recycling strategies.
8. Arranging periodic health check-up of involved personnel
and immunization for all workers.
The team leader will delegate responsibilities to subgroups
within the team to supervise and coordinate all activities.

Staff Appraisal on Hospital Waste Management

The well motivated and committed Medical Officer incharge of
the hospital adopts an effective strategy for proper disposal of
the waste. Entire staff of the hospital will be involved in a
dialogue which will make them understand the mission of the
hospital, present status with regard to hospital waste
generation and implications of improper disposal to patients,
workers and to community at large.
 270 Essentials of Community Medicine—A Practical Approach
Waste Disposal Strategy
Different types of wastes are generated in different quantities
by different sections of the hospital. To achieve the immediate
objective of effective and scientific disposal of hospital waste,
the following strategy will be adopted.

Collection of Waste with Source Segregation

Personnel in each department/section will collect wastes
generated in their areas of responsibility into appropriate
plastic bags kept inside hard, plastic containers which are
coded with suitable colors which indicate nature and type of
waste that should be put inside them, e.g. waste receptacle
coded yellow and labeled as “put infectious wastes only” with
a biohazard sign will receive all infectious waste materials,
blue waste receptacle will receive only sharp waste and
plastic/rubber waste and so on. This process of segregating
wastes into their respective types at the point where they are
generated is called segregation at source. This is a very
critical step in proper waste management as this will facilitate
correct disposal strategy and prevent mixing and cross
contamination which can create a serious health risk. Hence,
it is essential that all hospital workers are trained well on
color coding and collection techniques. The table below gives
details of color coding for different kinds of hospital wastes.
Plastic bags should be collected preferably on a daily basis
to reduce spread of infection by flies or spillage by dongs.
They should be allowed to fill to a maximum of three quarters
of their capacity to prevent the bag from tearing and also to
facilitate the ease of transport by workers.

Storage
Daily hospital waste from different facilities of the hospital
awaiting final disposal are stored in a store-room meant for
the purpose. The store-room should be away from the service
areas and should be dry and well secured to prevent rodent
nuisance.

Transportation
The waste segregated and collected in each point of
generation will be transported daily in a trolley to a central
store-room. The transport will be done in an orderly way
according to stipulated rules:
1. Only designated hospital workers will transport the waste.
2. Only one waste receptacle at a time be transported on a
trolley to the store-room where the plastic bag containing
the waste is left in store and the plastic container washed
with disinfectant brought back and kept in the designated
place.
 Hospital Waste
3. The wastes will be transported at specified time of the day
and through specified routes which the waste management
coordinator will decide and draw.
4. Before removing from the waste receptacle the transported
should ensure that the mouth of the bag is well secured by
tying to prevent pilferage.
5. Waste from white receptacles will be sorted out for
recyclable waste which are bundled and transported to the
store-room separately.

Temporary Storage
The wastes collected daily will be stored in a temporary store-
room which is specially designated for the purpose. The store-
room should be away from all patient care areas and offices
as well as residences and well secured and locked. Recyclable
materials are all stored separately away from other infectious
categories of wastes.

Final Disposal of Waste

Recyclable waste: Waste in white containers which may be
marketed for recycling, e.g. all kinds of papers—typing,
computer prints, drafts, etc. corrugated card board packing
materials, books, news papers, magazines, empty metal cans,
bottles of aerated water are disposed off periodically by
trading for going rates. Hyposolution used for developing films
can also be marketed for its silver content. Mutilated and
treated wastes of category 4 and category 7, viz. used
disposable needles and syringes, blades, broken glassware,
intravenous infusion and blood bags, tubing’s, catheters
collected in blue containers will be transported and stored
until they are disposed to the market for recycling.
Chemical disinfection: Chemical disinfection involves
destruction of most of the pathogenic microorganisms from
inanimate body surface or material by using chemicals.
Instruments and equipment in contact with patients, infected
sharps contaminated floor, beds, etc. may be disinfected by
using neutral disinfectants. Liquid waste from laboratories
may be decontaminated chemically. Bleaching powder,
glutaraldehyde, alcohol’s or quaternary ammonium compounds
may be used. Factors like concentration and stability of
chemicals, surface contact time determines effectiveness of a
chemical disinfectant. The main disadvantage of chemical
disinfectants is that there is no disinfectant which attains the
desirable level III disinfection and there is no easy but
accurate post- treatment test to judge whether the wastes
have been effectively decontaminated. Chemically disinfected
medical wastes should continue to be treated hazardous,
unless bacterial testing shows completed disinfection
(Managing medical wastes in developing countries, WHO,
 272 Essentials of Community Medicine—A Practical Approach
1994). Hence, this type of treatment option may be used only
to decontaminate liquid infection waste from laboratories.
Autoclaves: In autoclaving technology wastes are steam-heated
in a special autoclave meant for waste treatment at specified
temperature and pressure for specific period of time.
Decontamination occurs when steam penetrates the waste.
The equipment requires supply of high temperature and
pressurized steam from a boiler unit. Equipment should
conform to standards, mentioned in rules. A gravity flow
autoclave or a vaccum autoclave which functions within
specified range of internal waste load temperature (121°C-
149°C), pressure (15-51 psi) and residence time (30 to 60
min ) should be used. Vaccum autoclaves are more efficient as
absence of air ensures uniform and total penetration of waste
by steam and thus total disinfection. The equipment should
have computerized recording devices to monitor operational
parameters and should answer specified validation tests such
as spore testing for Bacillus subtilis at concentration of 104
spores/mm. Treated waste from an autoclave remains wet and
disinfected to level III, with no volume change. The emission is
likely to give emits foul odour and may be infectious.
Autoclaves can decontaminate most categories of waste
except biodegradable organic waste and toxic waste.
Autoclaves with superior technology conforming to
regulations of Central Pollution Control Board (CPCB) are
efficient and offer advantages of volume reduction and
odourless and nontoxic emission. But they may cause more
occupational hazard and are not cost-effective, besides,
requiring special elaborate infrastructure.

INCINERATORS
The Central Pollution Control Board has recommended two
types of incinerators:
1. Incinerators for individual hospital/nursing homes/medical
establishments.
2. Common incinerator to handle waste from a number of
hospital/ nursing homes/pathological laboratories, etc.

Site for Incinerator

Incinerators should be installed at appropriate location to
avoid nuisance to patients and neighborhood.

Standards for Incinerators

All incinerators shall meet the following operating and
emission standards:

Operating Standards
• Combustion efficiency (CE) shall be at least 99.0 percent
• The combustion efficiency is computed as follows:
 Hospital Waste

CE 
%  100
CO2
% CO2  %
CO
1. The temperature of the primary chamber shall be 800 +
50°C.
2. The secondary chamber gas residence time shall be at
least 1 (one) second at 1050º + 50ºC, with a minimum %
CO oxygen in the stack gas.
2

Emission Standards
Parameters Concentration mg/Nm 3 at
(12% CO2 correction)
1. Particulate matter 150
2. Nitrogen oxides 450
3. HCI 50
4. Minimum stack height shall be 30 meters above ground
5. Volatile organic compounds in ash shall not be more than 0.01%
Incineration or mass burn technology: The technique of
incineration involves conversion of solids into ash and
harmless gas by subjecting to high temperature. Incineration,
as a simple technique known as burning, has been used to
dispose off all types of wastes from hospitals. When unsorted
waste is burnt in simple kilns incinerators, the high
temperature (1000°C) in them converts the solid waste into
bottom ash (noncombustible matter) and fly ash which may
contain particulate matters and some environmentally
hazardous noxious gases. Adverse publicity has resulted in
innovation of technically superior, state of the art models
equipped with pollution control components such as scrubbers,
gravity settlers, condenses and deodorants that take care of
the possible environmental hazards due to their emissions.
Global/local environmental benefits, consumption of landfull
space, disposal of harmful substances into environment are
factors which are addressed favorably by incinerators.
Incineration offers a direct disposal technology with zero
occupational hazard (from cradle to grave) and a volume
reduction of 85 to 95 percent.
Incinerable hospital waste categories include organic waste
from surgery, autopsy and delivery, blood and body fluids
from dialysis and transfusion, microbial and pathological
waste from laboratories and general wastes like papers,
cardboard, etc. Heavy metals like mercury, cadmium and
chloride based plastics (PVC) cannot be incinerated as at low
temperatures (800°C) they produce hazardous particulate
matter and gases like Hydrogen Chloride dioxins and furons.
Reports on PVC usage in India indicate that hospitals use only
two percent of the total PVC products. Heavy metals are not
 274 Essentials of Community Medicine—A Practical Approach
present in most of the materials used for patient care in
hospitals. Proper source segregation and installing multi-
chambered electrical incinerators with pollution control
technology
 Hospital Waste
are key points to ensure environmental safe use of this
technology. The environment protection agency (EPA)
recommends use of electrical incinerator with adequate
control devices to ensure safe emission standards. Regular
monitoring and recording of flue gas temperature, periodic
checking of emission gases, annual check-up for wear and tear
and importantly ensuring source segregation and recycling of
plastics are EPA guidelines. With these measures taken,
incineration represents the best practical environmental
option (Royal Commission on Environmental Pollution).
As source segregation can identify the actual quantity of
incinerable waste, hospitals can decide on the capacity of the
incinerator they would like to invest in. Incinerators of different
capacities to burn waste beginning with 3 to 40 kg/hr are
available at competitive costs. Incineration as a process
involves waste preparation (segregation) waste charging and
combustion, treatment of emission (through controls) and
handling of incinerator ash. The ash may be collected in thick
puncture proof bags and stored for periodic dumping into a
community landfull. Factors which help the hospital
management to decide on characteristics of their incinerator
system are:
i. Air distribution to combustion chambers (stored excess air
combustion).
ii. Mode of operation (batch/continuous).
iii. Method of removal of ash (batch/continuous).
Microwave: In microwaving technique, the heat generated
inside the equipment during bombardment of electromagnetic
waves into the rotating molecules of the waste, disinfects the
waste. The waste should have some water content to enhance
molecular mobility and thus the heat generated. Shredded
waste is more efficiently disinfected than bully materials,
microwaving attains level III disinfection of all categories of
biomedical waste except those of category 1 and 2, viz. human
body parts and blood-soaked tissues and large metal items.
Any microwave equipment installed must comply with efficacy
tests stipulated under the biomedical rules and have
performance guarantee. At the maximum design capacity,
microwave unit should show total destruction of Bacillus
subtilis spores at a concentration of 104 spores per min. Main
advantage of this treatment technology are high efficiency, 30
to 40 percent volume reduction. Minimal environmental
pollution and occupational risk, compact nature of equipment
and cost-effectiveness. Simple and computerized operation
enable semiskilled hospital staff to operate the equipment.
Microwave system has made good advance years. Available
data on microwave system suggest that it satisfies more
selection criteria for choosing suitable technology for waste
disposal than any other acceptable option.
 276 Essentials of Community Medicine—A Practical Approach
Landfill: Sites are specially constructed areas used as one of
the options for disposal of nonbiodegradable infectious
hospital wastes. Hospitals with large surrounding land may
choose this mode of disposal as it is comparatively simple and
cost-effective. The area chosen should be away from service
areas and residential localities. A hospital with bed strength of
100 may require a landfill site of about 500 to 600 cft. Basic
features of an engineered landfill are:
i. An impermeable clay and pebble base liner to present
uncontrolled release of leachate, a toxic liquid that is
released by decomposition of waste.
ii. Graded base create leachate collection.
iii. Stored earth for covering at the end of each disposal
operation. Essential features of a correct landfill
operation are:
i. That all the waste bags are completely pushed into landfill
without
getting opened up.
ii. Enough earth and hay cover is put to cover the entire
waste so that stray animals do not pick the waste.
iii. Frequent spray of insecticides is done
iv. Personnel use proper protection like boots, gloves, aprons.
Deep burial: Wastes belonging to category 1, 3 and 6 collected
in yellow containers are disposed by deep burial. The waste
coordinator identifies a suitable place for digging a deep pit or
trench within the premises of the hospital but at a fair
distance from the hospital and houses. The place should not
be prone for flooding or erosion and should be away from
shallow wells. The pit may be a 4 feet square with a depth of 6
feet covered with wire mesh to deny access to animals and
prevent accidents. Each time the waste (human tissues—
placenta, amputated parts, blood soaked tissues, etc.) is
disposed into the pit, should be covered completely with a
thick layer of soil to ensure biodegradation.
Land fill: General wastes from white containers and waste
from black containers will be disposed into an ‘engineered
landfill’ (8 ft × 8 ft × 4 ft depth) constructed at a distant
corner of the hospital within its premises. In order to prevent
contamination with subsoil water, the base of the landfill
should be made impermeable by putting a stone masonry.
Scattering by stray animals and rag-pickers should be
prevented by covering with a metallic mesh of the size of the
landfill which is fixed at one margin and can be locked at the
other margin. The medical officer in-charge will liase with the
engineer in-charge of the hospital to construct this landfill.
Disposal of biodegradable kitchen waste: The non-infectious, but
biodegradable waste from kitchen, dining areas and wards such
as food waste, vegetable and fruit peals, etc. will be disposed
into a vermicompost, which will be constructed adjacent to the
land filling site.
 Hospital Waste
Inertization
The process of “inertization” involves mixing waste with
cement and other substances before disposal, in order to
minimize the risk of toxic substances contained in the wastes
migrating into the surface waste or ground water. A typical
proportion of the mixture is: 65 percent pharmaceutical waste,
15 percent lime, 15 percent cement and 5 percent water. A
homogeneous mass is formed and cubes or pellets are
produced on site and then transported to suitable storage
sites.

Legislative Framework
The Government of India has, under Environment Protection
Act (1986), passed the Biomedical Waste (Management and
Handling) Rules in July 1998. The rules define the
Administrative Medical Officers of health care facilities as
biomedical waste ‘generators’ and fix responsibility on them for
developing an effective waste disposal mechanism for the
waste their facilities generate. While the rules spell out
treatment and disposal options for the various categories of
biomedical wastes that are generated in healthcare facilities,
they leave the option of handling the general or domestic type
of waste to the generator. Standards for various treatment and
disposal technologies that may be employed have been
stipulated. The rules have also fixed time scale for
implementing a treatment and disposal technology
(incinerator technology) in hospitals of different bed
strengths. At state level the State Pollution Control Board is
the regulatory body, which monitors the proper implementation
of the rules.
Standards have been fixed for different technology options
giving consideration to international standards accepted by
environment protection agencies in developed countries.

Summary of Biomedical Waste Rules

This notification was issued on 20th July 1998 by the Ministry
of Environ- ment and Forests under Section 6, 8 and 25 of
Environment (Protection) Act, 1986.
1. The rules apply to all persons who generate, collect, receive,
store, transport, treat, dispose and handle biomedical waste
in any form.
2. “Biomedical waste” is any waste generated during diagnosis,
treatment, immunization and research activities involving
human beings and animals.
3. “Authorized person” is an “occupier” or “operator” of any
health care facility who has control over the facility and has
been authorized by the prescribed authority to deal with all
aspects of biomedical waste in accordance with rules.
4. Biomedical waste treatment facility is one where treatment
and disposal of biomedical wastes is carried out.
 278 Essentials of Community Medicine—A Practical Approach
5. Every “generator/occupier” of a health care facility has the
duty to take steps to ensure that waste generated is handled
without any adverse effect on human health and
environment.
6. Biomedical waste shall be segregated from other wastes at
the source, collected in color coded containers and
transported for treatment and disposal within 48 hours of
its generation (Table 17.2).
Table 17.2: Color coding and type of container for
disposal of biomedical wastes
Color Type of container Waste category Treatment options
coding as per schedule
Yellow Plastic bag Cat 1, Cat 2, Cat 3 and Incineration/deep
Cat 6 burial
Red Disinfected container/ Cat 3, Cat 6, and Cat 7 Autoclaving/
plastic bag microwaving/chemical
treatment
Blue/ Plastic bag/puncture Cat 4, Cat 7 Autoclaving/
White proof container Microwaving/Chemical
translu- treatment and
cent destruction/shredding
Black Plastic bag Cat 5, Cat 9 and Disposal in secured
Cat 10 (solid) landfill

What You should Know and Do

Plastics
Plastics are a heterogenous family.
Plastic are polymers of hydrocarbons typically derived from
petroleum of natural gas.
Plastic by not being biodegradable remain in the soil for
more then one thousand years, contaminating the soil and the
surrounding water bodies.
Plastics constitute a major chunk of Health Care Waste.
More so, with the increase in use of disposable items like
syringes, IV bags, blood bags, catheters, etc.
There is four times more plastic in Health Care Waste than
in Municipal Waste.

Problems
Collection and reuse or resale of the single-use (disposable)
products without adequate treatment result in possible spread
of infections.
Infection to the waste handlers, especially the rag-pickers
and pourakarmikas.
Improper burning or sub-standard incineration of these
plastics release toxic gases like—dioxins and furans and also
other harmful gases like— sulphur dioxide, oxides of nitrogen,
hydrochlorides, etc. The dioxins and furans are said to be
potent carcinogens.
 Hospital Waste
Improper landfilling or dumping them results in leaching and
contamina- tion of soil and surrounding water bodies.
Proposed Method for Disinfection of Commonly Used
Articles, Materials/Surfaces in Order of Preference (Table 17.3)
Table 17.3: Proposed method for disinfection of commonly used
articles, materials/surfaces in order of preferences
Material Methods
Ampoules Disinfectant with alcohol/methylated spirit/Iodine (PVI) before cutting.
Skin Handwashing is an effective method for preventing the infection
between health professionals. Some microbial agents are always
present in the skin, which passes from the hands of the health
staff to the patients. Handwashing is a very effective method of
decontamination of hands.
Social handwashing: With soap and water removes microorganisms.
This method should be practiced before handling food, eating and
feeding the patient after visiting the toilet. In this method,
mechanical friction is applied to all the surfaces of the hands
using soap and water for 10 seconds and hands are rinsed under
a stream of water and dried with sterilized paper towel.
Hygienic handwashing: A procedure where an antiseptic
detergent preparation is used for washing or is disinfected with
alcohol. It is performed before any invasive procedure, before and
after use of gloves and after contact with blood products. The
agents used are 4% chlorhexidine gluconate solution, solution
containing 0.75% available chlorine.
Surgical handwashing: A procedure to kill the bacterial flora and
to decrease the organisms present to prevent wound
contamination. This is done before surgical procedures and any
interventions. Only soap is used, but scrubbing of hands, fingers
and nails is very important.
Thermometer Keeping in gluteraldehyde/PVI/Hexachlorophenes/Chlorhexidine
+ cetrimide (salvon) for at least 10 minutes before next use.
Articles/Ware: Wash with warm detergent, disinfect with chlorine releasing
comp- Stainless steel/ ound/PVI/Formaldehyde/Phenolic
compounds/Chloroxylenols/ Enamel plated/ Hexachlorophenes/Chlorhexidine
Plastics, e.g.
Bedpan/urine
bottles/bowls
Surfaces like: Wash with detergent disinfect with chlorine releasing compound/
Floor/walls/ Carbolic acid/PVI/Hexachlorophenes
trolleys/
furnitures/sink/
wash basin

Contd...
 280 Essentials of Community Medicine—A Practical Approach
Contd ...
Material Methods
Humidifiers Fill daily humidifiers with sterile distilled water containing 0.1%
and incubators silver nitrate. Clean and disinfect with chlorine releasing
compounds/activated glutaraldehyde/alcohol or carbolic acid.
Crockery/ Wash with warm detergent solution, keep in boiling water for
Cutlery 10 minutes/expose to steam. No chemical should be used.
disinfectant
Laboratory Phenolic compounds (carbolic acid)/Chlorine releasing
Discarding jar compounds/Chloroxylenols and Hexachlorophenes
Syringes and Chemical disinfectant must not be used for needle and syringes.
needles
Instruments Keep in concentrations recommended for grossly contaminated
Cheatle forceps articles of PVI/Chlorhexidine + cetrimides/Chloroxylenols,
gluteradehyde. Change the disinfectant daily.
Sharp All articles and surfaces to be disinfected must first be cleaned
instruments and washed with warm water preferable containing detergent
—Skin piercing chemical disinfection only as last resort, if sterilization by heat is
and invasive not possible, activated gluteraldehyde/carbolic acid for at least
instruments 10 hours for sterilization.
(not sterilizable
by heat)
Equipment: Chemical disinfection only at last resort, if sterilization by heat is
Catheters, not possible. Immerse in activated solution of gluteraldehyde/
Cystoscope Carbolic acid for 4 to 10 hours or more. Only vegetative bacteria,
Endoscope, fungi and viruses are killed by immersing in surface disinfectants
Laproscope for 30 minutes.

BIBLIOGRAPHY
1. Achary DB, Singh M. The Book of Hospital Waste Management,
2000.
2. Mannual for control of hospital associated infections, NACO,
Ministry of Health and Family Welfare Government of India.
3. Pruss A, Cirouit E, Rushbrook P. Safe management of wastes
from health- care actives, WHO, 1999.
 Hospital Waste
Chapter
National Rural
18 Health Mission
(2005-2012)
Chapter Outline
STRATEGIES
GOALS INSTITUTIONAL MECHANISMS
PLAN OF ACTION ROLE OF STATE GOVERNMENTS UNDER NRHM
TECHNICAL SUPPORT
FOCUS ON THE NORTH EASTERN STATES  ROLE OF PANCHAYATI RAJ INSTITUTIONS
ROLE OF NGOs IN THE MISSION MAINSTREAMING AYUSH
FUNDING ARRANGEMENTS TIMELINES (FOR MAJOR COMPONENTS)
OUTCOMES MONITORING AND EVALUATION
NATIONAL URBAN HEALTH MISSION

INTRODUCTION
Health is fundamental to national progress in any sphere. In
terms of resources for economic development, nothing can be
considered of higher importance than the health of the people.
Recognizing the importance of health in the process of
economic and social development and improving the quality of
life of our citizens, the Government of India has resolved to
launch the National Rural Health Mission (NRHM) to carry our
necessary architectural correction in the basic health care
delivery system.
In India, 12th April 2005 was a historic day, when our
honorable Prime Minister, Dr Manmohan Singh launched “the
National Rural Health Mission.” With a budget outlay of
Rs.6500 crores for 2005 to 2006 and a commitment of the
government to raise public health expenditure from
0.9 to 2-3 percent of GDP, the goal of the Mission is to
improve the availability of and access to quality health care by
people, especially for those residing in rural areas, the poor,
women and children, with initial focus on 18 “high focus”
states.
Any successful development program stands on four pillars,
i.e. political will, financial resources, administrative
infrastructure and scientific leadership.
The National Rural Health Mission seeks to provide
effective health care to the rural population, especially the
disadvantaged groups improving access, enabling community
ownership and demand for services, strengthening public
health systems for efficient service delivery, enhancing equity
and accountability and promoting decentralization.
The National Rural Health Mission subsumes key national
programs, the Reproductive and Child Health II project (RCH
II), the National Disease
 National Rural Health Mission (2005-
Control Programs (NDCP) and the National Disease
Surveillance Project (NDSP). The National Rural Health
Mission will also enable the mainstreaming of AYUSH, i.e.
Ayurvedic, Yoga, Unani, Siddha and Homeopathy Systems of
Health.
The Mission covers the country, with special focus on 18
states where the challenge of strengthening poor public
health systems and there by improve key health indicators is
the greatest. These are Uttar Pradesh, Uttaranchal, Madhya
Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan,
Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal
Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim
and Tripura. NRHM lists a set of core and supplementary
strategies to meet its goals.

GOALS
• Reduction in infant mortality rate (IMR) and maternal
mortality ratio (MMR).
• Universal access to public health services such as Women’s
health, child health, water, sanitation and hygiene,
immunization, and Nutrition.
• Prevention and control of communicable and
noncommunicable disease, including locally endemic
diseases.
• Access to integrated comprehensive primary health care.
• Population stabilization, gender and demographic balance.
• Revitalize local health traditions and mainstream AYUSH.
• Promotion of healthy lifestyles.

STRATEGIES

Core Strategies
• Train and enhance capacity of Panchayati Raj Institutions
(PRIs) to own, control and manage public health services.
• Promote access to improved health care at household level
through the female health activist (ASHA).
• Health plan for each village through Village Health
Committee of the Panchayat.
• Strengthen sub-center through an united fund to enable
local planning and action and more multi-purpose workers
(MPWs).
• Strengthening existing PHCs and CHC per lakh population
for improved curative care to a normative standard (Indian
public Health standards defining personnel, equipment and
management standards).
• Preparation and Implementation of an intersect oral District
Health Plan prepared by the District Health Mission,
including drinking water, sanitation and hygiene and
nutrition.
• Integrating vertical Health and Family Welfare programs at
National, State, block and District levels.
 282 Essentials of Community Medicine—A Practical Approach
• Technical support to National, State, and District Health
Mission, for Public Health Management.
• Strengthening capacities for data collection, assessment
and review for evidence based planning. Monitoring and
supervision.
• Formulation of transport policies for deployment and career
development of human resources for health.
• Developing capacities for preventive health care at all levels
for promoting healthy lifestyles, reduction in consumption of
tobacco and alcohol, etc.
• Promoting nonprofit sector particularly in underserved areas.

Supplementary Strategies
• Regulation of private sector including the informal rural
practioners to ensure availability of quality services to
citizen at reasonable cost.
• Promotion of public private partnerships for achieving
public health goals.
• Mainstreaming AYUSH—revitalizing local health traditions.
• Reorienting medical education to support rural health
issues including regulation of medical care and medical
ethics.
• Effective and viable risk pooling and social health security
to the poor by ensuring accessible, affordable, accountable
and good quality hospital care.

PLAN OF ACTION

Component (A): Accredited Social Health Activists

• Every village/large habitat will have a female Accredited
Social Health Activist (ASHA)—chosen by and accountable
to the panchayat to act as the interface between the
community and the public health system.
• ASHA would act as a bridge between the ANM and the
village and be accountable to the panchayat.
• She will be an honorary volunteer, receiving performance-
based compensation for promoting universal immunization,
referral and escort services for RCH, construction of
household toilets, and other health care delivery programs.
• She will be trained on a pedagogy of public health
developed and mentored through a Standing Mentoring
Group at National level incorporating best practices and
implemented through active involvement of community
health resource organizations.
• She will facilitate preparation and implementation of the
Village Health Plan along with Anganwadi worker, ANM,
functionaries of other Departments, and Self-Help Group
members, under the leadership of the Village Health
Committee of the Panchayat.
 National Rural Health Mission (2005-
• She will be promoted all over the country, with special
emphasis on the 18 high focus States. The government of
India will bear the cost of training. Incentive and medical
kits. The remaining components will be funded under
Financial Envelope given to the States under the program.
• She will be given a drug kit containing generic AYUSH and
allopathic formulations for common ailments. The drug kit
would be replenished from time-to-time.
• Induction training of ASHA to be of 23 days in all, spread over
12 months. On the job training would continue throughout
the year.
• Prototype training material to be developed at national level
subject to state level modifications.
• Cascade model of training proposed through Training of
Trainers including contract plus distance learning model.
• Training would require partnership with NGOs/ICDS
Training Centers and State Health Institutes.

Component (B): Strengthening Sub-Centers

• Each sub-centers will have an united fund for local action @
Rs. 10,000 per annum. This fund will be deposited in a joint
bank account of the ANM and Sarpanch and operated by
the ANM, in consultation with the Village Health
Committee.
• Supply of essential drugs, both allopathic and AYUSH, to the
sub-centers.
• In case of additional outlays, multipurpose workers (Male)
additional ANMs wherever needed, sanction of new sub-
centers as per 2001 population norm, and upgrading
existing sub-centes, including buildings for sub-centers
functioning in rented premise will be considered.

Component (C): Strengthening Primary Health Centers

Mission aims at strengthening PHC for quality preventive,
promotive curative, supervisory and outreach services.
• Adequate and regular supply of essential quality drug and
equipment (including supply of Auto Disabled Syringes for
immunization) to PHCs.
• Provision of 24 hours service in 50 percent PHCs by
addressing shortage of doctors, especially in high focus
states, through mainstreaming AYUSH manpower.
• Observance of standard treatment guidelines and protocols.
• In case of additional outlays, intensification of ongoing
communicable disease control programs, new programs for
control of noncommnuicable disease, upgaradation of 100
percent PHCs for 24 hours referral service, and provision of
2nd. Doctor at PHC level (1 male, 1 female) would be
undertaken on the basis of felt need.
 284 Essentials of Community Medicine—A Practical Approach
Component (D): Strengthening CHCs for First Referral Care
A key strategy of the Mission is:
• Operationalizing 3222 existing Community Health Center
(30-50 beds) as 24 Hours First Referral Units, including of
anesthetist.
• Codification of new Indian Public Health Standards, setting
norms for infrastructure, staff, equipment, management,
etc. for CHCs.
• Promotion of Stakeholder Committees (Rogi Kalyan Samitis)
for hospital management.
• Developing standards of services and costs in hospital care.
• Developing, display and ensure compliance of Citizen’s
Charter at CHC/PHC level.
• In case of additional outlays, creation of new Community
Health Centers (30-50 beds) to meet the population norm as
per Census 2001, and bearing their recurring costs for
Mission period could be considered.
Component (E): District Health Plan
• District Health Plan would be an amalgamation of field
responses through Village Health Plans, State and Notional
priorities for health, water supply, sanitation and nutrition.
• Health Plan would from the core unit of action proposed in
areas like water supply, sanitation, hygiene and nutrition.
Implementing departments would integrate into District
Health Mission for monitoring.
• District becomes core unit of planning, budgeting and
implementation.
• Centrally Sponsored Schemes could be
rationalized/modified accordingly in consulation with
States.
• Concept of “funneling” funds to district for effective
integration of programs.
• All vertical Health and Family Welfare Programs at district
and state level merge into one common—“District Health
Mission (DHM)”at the district level and the “State Health
Mission” at the state level.
• Provision of Project Management Unit for all district,
through contractual engagement.
Component (F): Converging Sanitation and Hygiene under NRHM
• Total Sanitation Campaign (TSC) is presently implemented
in 350 districts, and is proposed to cover all district, and
proposed to cover all district in 10th Plan.
• Components of TSC include IEC activities, rural sanitary
marts, individual household toilets, women sanitary
complex, and School Sanitation Program.
• Similar to the DHM, the TSC is also implemented through
Panchayat Raj Institutions (PRIs)
 National Rural Health Mission (2005-
• The District Health Mission would, therefore, guide
activities of sanitation at district level, and promote joint
IEC for public health, sanitation and hygiene through
Village Health and Sanitation Committee, and promote
household toilets and School Sanitation Program. ASHA
would be incentivized for promoting household toilets by the
mission.
Component (G): Strengthening Disease Control Programs
• National Disease Control Programs for malaria, TB, kala
azar, filaria, Blindness and Iodine Deficiency and Integrated
Disease Surveillance Program shall be integrated under the
Mission, for improved program delivery.
• New Initiative would be launched for control of
Noncommunicable Diseases.
• Disease surveillance system at village level would be
strengthened.
• Supply of generic drugs (both AYUSH and Allopathic) for
common ailments at village, SC, PHC/CHC level.
• Provision of a mobile medical unit at District level for
improved outreach services.
Component (H): Public-Private Partnership for Public Health Goals,
including Regulation of Private Sector
• Since, almost 755 of health services are being currently
provided by the private sector, there is a need to refine
regulation
• Regulation to be transparent and accountable
• Reform to be regulatory bodies/creation where necessary
• District Institutional Mechanism for Mission must have
representation of private sector
• Need to develop guidelines for public-private partnership
(PPP) in health sector. Identifying areas of partnership,
which are need based, thematic and geographic.
• Public sector to play the lead role in defining the framework
and sustaining the partnership
• Management plan for PPP initiatives: At District, State and
National levels.
Component (I): New Health Financing Mechanisms
A Task Group to examine new health financing mechanisms,
including Risk Pooling for Hospital Care as follows:
• Progressively the District Health Mission to move towards
paying hospitals of services by way of reimbursement on the
principal of “money follows the patient.”
• Standardization of services—outpatient, in-patient,
laboratory, surgical interventions and costs will be done
periodically by a committee of experts in each state.
 286 Essentials of Community Medicine—A Practical Approach
• A National Expert Group to monitor theses standards and
give suitable advices and guidance on protocols and cost
comparisons.
• All existing CHCs to have wage component paid on monthly
basis. Other recurrent costs may be reimbursed for services
rendered from District Health Fund. Over the Mission
period, the CHC may move towards all costs, including
wages reimbursed for services rendered.
• A district health accounting system, and an ombudsman to
be created to monitor the District Health Fund
Management, and take corrective action.
• Adequate technical managerial and accounting support to
be provided to DHM in managing risk pooling and health
security.
• Where credible Community Based Health Insurance
Schemes (CBHI) exits/launched, they will be encouraged as
part of the Mission.
• The central government will provide subsidies to cover a
part of the premiums for the poor, and monitor the
schemes.
• The IRDA will be approached to promote such CBHIs, which
will be periodically evaluated for effected delivery.

Component (J): Reorienting Health/Medical Education to support

Rural Health Issues
• While district and tertiary hospitals are necessarily located
in urban centers, they form an integral part of the referral
care chain serving the needs of the rural people.
• Medical and paramedical education facilities need to be
created in states, based on need assessment.
• Suggestion for Commission for Excellence in Health Care
(Medical Grants Commission), National Institution for
Public Health Management, etc.
• Task Group to improve guidelines/details.

INSTITUTIONAL MECHANISMS
• Village Health and Sanitation Samiti (at village level)
consisting of Panchayat Representative/s, ANM/MPW,
Anganwadi worker, teacher, ASHA, community health
volunteers.
• Rogi Kalyan Samiti (or equivalent) for community
management of public hospital.
• District Health Mission, under the leadership of Zila
Parishad with District Health Head as Convener and all
relevant departments, NGOs, private professionals, etc.
represented on it.
• State Health Mission, chaired by Chief Minister and co-
chaired by Health Minister and with the State Health
Secretary as Convener— representation of related
departments, NGOs, private professionals, etc.
• Integration of Departments of Health and Family Welfare, at
National and State level.
 National Rural Health Mission (2005-
• National Mission Steering Group chaired by Union Minister
for Health and Family Welfare with Deputy Chairman,
Planning Commission, Ministers of Panchayat Raj, Rural
Development and Human Resource Development and public
health professionals as members, to provide policy support
and guidance to the Mission.
• Empowered Program Committee chaired by Secretary
HFW, to be the Executive Body of the Mission
• Standing Mentoring Group shall guide and oversee the
implementation of ASHA initiative
• Task Groups for Selected Tasks (time-bound).

TECHNICAL SUPPORT
• To be effective the Mission needs a strong component of
technical support
• This would include reorientation into public health
management
• Reposition existing health resource institutions, like
Population Research Center (PRC), Regional Resource
Center (RRC), State Institute of Health and Family Welfare
(SIHFW)
• Involve NGOs as resource organizations
• Improved Health Information System
• Mission would require two distinct support mechanisms—
Program Management Support Center and Health Trust of
India.

Program Management Support Center

• For strengthening management system—basic program
management, financial systems, infrastructure maintenance,
procurement and logistics systems, Monitoring and
Information System (MIS), non-lapsable health pool, etc.
• For developing manpower system—recruitment (induction
of MBAs/ CAs/MCAs), training and curriculum development
(revitalization of existing institutions and partnerships with
NGO and private sector institutions), motivation and
performance appraisal, etc.
• For improved governance—decentralization and
empowerment of communities, indication of IT based
systems like e-banking, social audit and right to information.
Health Trust of India
• Proposed as a knowledge institution, to be the repository of
innovation
—research and documentation, health information system,
planning, monitoring and evaluation, etc.
• For establishing public accountability systems—external
evaluations, community based feedback mechanisms,
participation of PRIs/NGOs, etc.
• For developing a Framework for pro-poor innovations.
• For reviewing health legislations.
• A base for encouraging experimentation and action research.
 288 Essentials of Community Medicine—A Practical Approach
• For inter- and intra-sector networking with National and
International Organizations.

ROLE OF STATE GOVERNMENTS UNDER NRHM

• The Mission covers the entire country. The 18 high focus
States are Uttar Pradesh, Bihar, Rajasthan, Madhya
Pradesh, Orissa, Uttaranchal, Jharkhand, Chhattisgarh,
Assam, Sikkim, Arunachal Pradesh, Manipur, Meghalaya,
Tripura, Nagaland, Mizoram, Himachal Pradesh and Jammu
and Kashmir. Government of India would provide funding for
key components in these 18 high focus States. Other state
would fund interventions like ASHA, Program Management
Unit (PMU), and upgradation of SC/PHC/CHC through
Integrated Financial Envelope.
• NRHM provides broad conceptual framework. States would
project operational modalities in their State Action Plans, to
be decided in consultation with the Mission Steering Group.
• NRHM would prioritize funding for addressing inter-state
and intradistrict disparities in terms of health infrastructure
disparities in terms of health infrastructure and indicators.
• State would sign Memorandum of Understanding with
Government of India, indicating their commitment to
increase contribution to Public Health Budget (Preferably by
10% each year), increased devolution to Panchyati Raj
Institution as per 73rd Constitution (Amendment) Act, and
performance for release of funds.

FOCUS ON THE NORTH EASTERN STATES

• All 8th North-East States, including Assam, Arunachal
Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim
and Tripura, are among the States selected under the
Mission, for special focus.
• Empowerment to the Mission would mean greater
flexibilities for the 10 percent Committed outaly of the
Ministary of Health and Family Welfare, for North-East
State.
• States shall be supported for creation/upgradation of
Health infrastructure, increased mobility, contractual
engagement, and technical support under the Mission.
• Regional Resource Center is being under supported under
NRHM for the North Eastern States.
• Funding would be available to address local health issues in
a comprehensive manner, through state specific schemes
and initiatives.

ROLE OF PANCHAYATI RAJ INSTITUTIONS

The Mission envisages the following roles for PRIs:
• State to indicate in their Memorandum of Understandings
(MoUs) the Commitment for devolution of funds,
functionaries and programs for health, to PRIs.
 National Rural Health Mission (2005-
• The District Health Mission to be led by the Zila Parishad.
The DHM will control, guide and manage all public health
institutions in the district, Sub-centers, PHCs and CHCs.
• ASHAs would be selected by and be accountable to the
Village Panchayat.
• The Village Health Committee of the Panchayat would
prepare the Village Health Plan, and promote integration.
• Each sub-center will have an United Fund for local action @
Rs. 10,000 per annum. This Fund will be deposited in a joint
Bank Account of the ANM, in consultation with the Village
Health Committee.
• PRI involvement in Rogi Kalyan Samitis for good hospital
management.
• Provision of training to members of PRIs.
• Making available health related databases to all
stakeholders, including Panchayats all levels.

ROLE OF NGOs IN THE MISSION

• Included in institutional arrangement at National, State and
District levels, including Standing Mentoring Group for
ASHA
• Member of Task Groups
• Provision of Training, Technical Support for ASHAs/DHM
• Health Resource Organizations
• Service delivery for identified population groups on selected
themes
• For monitoring, evaluation and social audit

MAINSTREAMING AYUSH
• The Mission seeks to revitalize local health traditions and
mainstream AYUSH infrastructure, including manpower,
and drugs, to strengthen the public health system all level.
• AYUSH medications shall be included in the Drug Kit
provided at village levels to ASHA.
• The additional supply of generic drugs for common ailments
at Sub- center/PHC/CHC levels under the Mission shall also
include AYUSH formulations.
• At the CHC level, two rooms shall be provided for AYUSh
practitioner and pharmacist under the Indian Public Health
System (IPHS) model.
• Single doctor PHCs shall be upgraded to two doctor PHCs
by mainstreaming AYUSH practitioner at that level.

FUNDING ARRANGEMENTS
• The Mission is conceived as an umbrella program
subsuming the existing programs of health and family
welfare, including the RCHII,
 290 Essentials of Community Medicine—A Practical Approach
National Disease Control Programs for Malaria, TB, Kala
Azar, Filaria, Blindness and Iodine Deficiency and
Integrated Disease Surveillance Program.
• The Budget Head For NRHM shall be created in 2006-07 at
National and State levels. Initially, the vertical health and
family welfare programs shall retain their Sub-Budget Head
under the NRHM.
• The outlay of the NRHM for 05 to 06 is in the range of Rs
6700 crores.
• The Mission envisages an additionality of 30 percent over
existing Annual Budgetary outlays, every year, to fulfill the
mandate of the National Common Minimum Program to
raise the outlays for Public Health from 0.9 percent of GDP
to 2 to 3 percent of GDP.
• The outlay for NRHM shall accordingly be determined in
the Annual Budgetary exercise.
• The States are expected to raise their contributions to
Public Health Budget by minimum 10 percent p.a. to
support the Mission activities.
• Funds shall be released to State through SCOVA, largely in
the form of Financial Envelopes, with weightage to 18 high
focus States.

TIMELINES (FOR MAJOR COMPONENTS)

Merger of Multiple Societies June 2005. Constitution of
District/State Mission Provision of additional generic drugs at
SC/PHC/CHC level December 2005, Operational Program
Management Units 2005 to 2006 Preparation of Village Health
Plans 2006, ASHA at village level (with drug kit) 2005-2008.
Upgrading of Rural Hospitals 2005 to 2007, Mobile Medical
Unit at district level 2005 to 2008.

OUTCOMES

National Level
• Infant mortality rate reduced to 30/1000 live births
• Maternal mortality ratio reduced to 100/100,000
• Total fertility reduction rate: 50 percent upto 2.1
• Malaria mortality reduction rate: 50 percent upto 2010 and
sustaining elimination until 2012
• Kala azar mortality reduction rate: 100 percent by 2010 and
sustaining elimination until 2012
• Filaria/Microfilaria reduction rate: 70 percent by 2010, 80
percent by 2012 and elimination by 2015
• Dengue mortality reduction rate: 50 percent by 2010 and
sustaining at that level until 2012
• Japanese encephalitis mortality reduction rate: 50 percent
by 2010 and sustaining at that level until 2012.
• Cataract operation: Increasing to 46 lakhs per year until
2012.
 National Rural Health Mission (2005-
• Leprosy prevalence rate: Reduce from 1.8/10,000 in 2005 to
less than 1/10,000 thereafter
• Tuberculosis DOTS services: Maintain 85 percent cure rate
through entire Mission period.
• Upgrading Community Health Centers to Indian Public
Health Standards
• Increase utilization of First Referral Units from less than 20 to
75 percent
• Engaging 250,000 female Accredited Social Health Activists
(ASHAs) in 10 States.

Community Level
• Availability of trained community level worker at village
level, with a drug kit for generic ailments
• Health Day at Anganwadi level on fixed day/month for
provision of immunization, ante/postnetal checkups and
services related to mother and child health care, including
nutrition.
• Availability of generic drugs for common ailments at
subcenter and hospital level
• Good hospital care through assured availability of doctors,
drugs and quality services at PHC/CHC level
• Improved access to Universal Immunization through induction
of Auto
-Disabled Syringes, alternate vaccine delivery and improved
mobilization services under the program
• Improved facilities for institutional delivery through
provision of referral, transport, escort and improved hospital
care subsidized under the Janani Suraksha Yojana (JSY) for
the Below Poverty Line families.
• Availability of assured health care at reduced financial risk
through pilots of Community Health Insurance under the
Mission
• Provision of household toilets
• Improved outreach services through mobile medical unit at
district level.
MONITORING AND EVALUATION
• Health MIS to be developed upto CHC level, and web-
enabled for citizen scrutiny
• Subcenters to report on performance to Panchayats,
Hospitals to Taluk, Panchayat Rogi Kalyan Samitis and
District Health Mission to Zila Parishad
• The District Health Mission to monitor compliance to
Citizen’s Charter at CHC Level
• Annual District Reports on People’s Health (to be prepared
by Govt/ NGO collaboration)
 292 Essentials of Community Medicine—A Practical Approach
• State and National Reports on people’s Health to be tabled in
assemblies, parliament
• External evaluation/social audit through professional
bodies/NGOs.
• Mid course reviews and appropriate correction.

Is NRHM a New Program of the Government of India?

The NRHM is basically a strategy for integrating ongoing vertical
programs of Health and Family Welfare, and addressing issues
related to the determinants of Health, like sanitation, nutrition
and safe drinking Water. The National Rural Health Mission
seeks to adopt a sector wide approach and aims at systemic
reforms to enable efficiency in health service delivery. NRHM
subsumes key national programs, namely, the Reproductive
and Child Health II project, (RCH II) the National Diseases
Control Program (NDCP) and the Integrated Diseases
surveillance Project (IDSP). NRHM will also enable the
mainstreaming of Ayurvedic, Yoga, Unani, Siddha, and
Homeopathy System of Health (AYUSH).

What is the Institutional Setup at National, State and District Levels?

The Mission Steering Group under the Chairmanship of the Union
Minister for Health and Family Welfare will provide policy
guidance and operational oversight at the National level.
Ministrial/Secretary level representative of Planning
Commission, Rural Development, Panchayati Raj, Human
Resource Development and Health and Family Welfare.

NATIONAL URBAN HEALTH MISSION

As per Census 2001, 28.6 crores people live in urban area.
The urban population is estimated to increase to 35.7 crores in
2011 and to 43.2 crores in 2021. Urban growth has led to rapid
increase in number of urban poor population, many of whom
live in slums and other squatter settlements.
The above situation is reflected in poor health indicators as
per the reanalysis of the NFHS III data as follows:

Urban poor Urban

Under five mortality 72.7 51.9
Number of the children 60% 42%
miss complete immunization
Piped water supply 18.5% 50%
Institutional deliveries 44% 67.5%
 National Rural Health Mission (2005-
Therefore, there is need of the National Urban Health Mission
to address the health economics of the urban poor by
facilitating equitable access to available health facilities by
rationalizing and strengthening of existing capacity of health
care delivery for improving the health status of the urban
poor.

Goal
To improve the health status of the urban poor particularly
the slum dweller and other disadvantaged section.

Core Strategies
1.Improving the efficiency of public health system in the
cities by strengthening, revamping and rationalizing urban
primary health structure
2.Partnership with nongovernment provider for filling up of
health delivery gaps
3.Promotion of access to improved health care at household
level through community based groups; Mahila Arogya
Samiti.
4.Strengthening the public health through preventing and
promotive action
5.Increased access to health care through risk pooling and
community health insurance model
6.IT enabled services (ITES) and e-governance and
monitoring.
7.Capacity building of stakeholders
8.Prioritizing the most vulnerable among the poor.
9.Ensuring quality health care services.

Components of Urban Health Mission (UHM)

1.Planning and mapping
2.Program management
3.Outreach services
4.Primary urban health center
5.Referrals
6.Capacity building, training and orientation
7.Community risk pooling/insurance
8.Public private partnership
9.Monitoring and evaluation
10. Social program for vulnerable groups
11. Support for city level public health action
12. Additional support for National Health Programs
 294 Essentials of Community Medicine—A Practical Approach
Targets
National Urban Health Mission is expected to achieve the
following target in urban areas:
1.IMR reduced to 30/1000 live birth by 2012.
2.Maternal mortality reduced to 100/100,000 live birth by
2012.
3.TFR reduced to 2.1 by 2012
4.Malarial mortality reduction rate—50 percent by 2010
additional 10 percent by 2012
5.Kala-azar mortality reduction rate—100 percent by 2010 and
sustaining elimination thereafter
6.Filarial reduction rate—70 percent by 2010, 80 percent by
2012 and elimination by 2015.
7.Dengue mortality reduction 50 percent by 2010 and
sustaining it at that level till 2012.
8.Japanese encephalitis mortality reduction rate—50 percent
by 2010 and sustaining at that level till 2012.
9.Chikungunya: Reduction in number of outbreaks and
morbidity due to chikungunya by prevention and control
strategy.
10. Leprosy prevalence rate: Reduced from 1.8 per 10,000 in
2005 to less than 1 per 10,000 thereafter.
11. Tuberculosis DOTS Series: Maintain 85 percent cure rate
through the entire Mission period and also sustain
planned case detection rate.
12. Reduce the prevalence of deafness by 25 percent (from
existing level) by 2012.

Urban Health Delivery Model

a. At community level
b. Primary health center level
c. Referral units

At Community Level (Urban Social Health Activist, USHA)

The USHA would preferably be a women resident of the
slummarried/ widowed/divorced, preferably in the age group
of 25 to 45 years.
She should also be a literate women with formal education
upto class eight which may be relaxed only if no suitable person
with this qualification is available.

Essential Service to be Rendered by the USHA

1. Active promoter of good health practices and enjoying
community support.
2. Facilitate awareness on essential RCH services.
 National Rural Health Mission (2005-
3. Facilitate access to health related services available at the
Anganwadi/ Primary Urban Health Center and other
services being provided by state/central government.
4. Formation and promotion of Mahila Arogya Samiti in her
community.
5. Arrange/escort/accompany pregnant women and children
requiring treatment to the nearest primary urban health
center. Secondary/tertiary level health care facility.
6. Reinforcement of community action for immunization,
prevention of water born and other communicable diseases like
TB, malaria, chikungunya and Japanese encephalitis.
7. Carrying out preventive and promotive health activites with
AWW/ Mahila Arogya Samiti
8. Maintenance of necessary information and records about
birth and death, immunization, antinatal services in her
assigned locality.

Performance Based Incentive Package for USHA

Activity Proposed
incentive/month
1. Organization of outreach services Rs 200
2. Organization of monthly meeting of MAS Rs 100
3. Attended monthly meeting at UHC Rs 200
4. Organize Health and National Day in collaboration with AWW
Rs 100
5. Organize community meeting for strengthening
50 per meeting preventive and promotive services
(200 upper limit)
6. Provide support to baseline survey 5 per house
hold and filling up of family health register (once a
year)
7. Maintain records as per the desired 50 per
month norms like household registers.
meeting minutes, outreach camps register.
8. Additional Immunization incentives for 5 per
child achiving complete immunization among the
children in her area of responsibility.

Primary Urban Health Center

• Generally one urban health center is for approximately
50,000 population.
• In slum area, one UHC for 20,000 to 30,000 population.
• In cities, UHC may be established for 75,000 population.
• In areas with very high density, isolated slum clusters or
disadvantage group, one UHC can be established for 5000
to 10,000 population.
Services available under UHC: UHC can provide services
for 4 hours in the morning and 2 hours in the evening. For
provision of certain services evening OPD if required.
The services provided in UHC will include OPD, basic lab
diagnosis, drug and contraceptive dispensing, distribution of
health education
 296 Essentials of Community Medicine—A Practical Approach
material and counseling for all communicable and
noncommunicable disease.

Staffing Pattern
• 1 Docter
• 1 Labtechnician
• 1 Pharmacist
• 2 Staff nurses
• 4 ANMs
• 1 Program manager/Community mobilization officer/Peon/
Sweeper. Financial support: Annual financial support in the
form of Rogi Kalyan Samiti/Hospital Management Committee
fund of Rs. 50,000 per UHC per year.with the amount being
proportional to the population covered @ Re
1.0 per head a PUHC covering 40,000 population will get Rs.
40,000.
Referral units: State government hospitals and medical
colleges, apart from private hospitals will be
empanelled/accredited to act as referral points for different
types of health care services. The referral services will be
cash-free for the beneficiary and will be financed by
community health insurance or voucher scheme as per the PIP
developed for the cities.
 Chapter
19 Sanitation of Camps

Chapter Outline
CAMP SITE ACCOMMODATION AND EQUIPMENT
FOOD AND COOKING ARRANGEMENTS DISPOSAL OF REFUSE AND EXCRETA
DISPOSAL OF STABLE LITTER

INTRODUCTION
In view of the fact that camps and temporary lodgements have
been freely set up all over the country, a description of the
general sanitary control of camps demands special
consideration. For all practical purposes, camps may be
regarded as so many improvised townships where the
different tents or temporary huts represent so many houses.
Although the sanitation of camps is more or less based on the
same principles as of ordinary houses or towns, in practice
certain sanitary rules have to be followed because of their
temporary nature and because very often they are located in
places where sanitary conditions are not ideal. The following
pointes require consideration with reference to camps:
1.Camp site.
2.Accommodation and equipment.
3.Water supply
4.Food and cooking arrangements.
5.Disposal of refuse, excretal matter and waste water.

CAMP SITE
The site should be on a high ground not subject to flooding or
water logging and should have good approach from the main
road. The soil should be porous and physical features suitable
for easy and rapid surface drainage. Irrigated or marshy land or
land with steep slope should be avoided; gentle slope however
facilitates drainage. While the site should not be close to a
bazaar, its accessibility, facility for transport and easy
availability of supplies should be kept in mind.
The ground and its surroundings must be dry and free from
dense vegetation. A high sub-soil water creates dampness and
water-logging. All hollows and other excavations where water
can collect should be filled up to prevent breeding of
mosquitoes. For the same reason, digging or excavating the
soil within the camp area is unwise.
 298 Essentials of Community Medicine—A Practical Approach
Agricultural land, because of its propensity to breed flies,
should be avoided. Wherever possible, there should be
sufficient open land all around the camp area to sever as a
protective boundary.
The most important consideration which should dominate
selection of
a camp site is the facility which exists for obtaining water. This
is specially important in temporary camps. When camp sites
are likely to be occupied for a longer period, the feasibility of
bringing in filtered water by pipe from outside or sinking of
deep tube wells locally may be considered.

ACCOMMODATION AND EQUIPMENT

The lay out of a camp should be properly planned after a
survey of the site. In laying out a camp, the following
particulars should be attended to:
i. The front of the camp should face the prevailing wind.
ii. The sleeping accommodation should be in front, with
kitchens and messing accommodation nearby at one side.
iii. The bathing area and water point should be so at one side,
well away from the conservancy area, and with drainage
so arranged as to prevent the water logging of the camp.
iv. Camp roads should be so arranged that traffic for watering
horses and the delivery of supplies do not cover the
cooking and messing areas with manure-laden dust.
v. Surface drainage of the camp area should be provided.

Water
Supply of safe water is of primary importance and every effort
should be made to see that the water is not only safe but the
chances of accidental contamination are also nil. In camps
where arrangements are made for supply of filtered water or
deep tube well water, no inconvenience is experienced. The
water is delivered from overhead reservoir and stand pipes.
But attention should be paid to see that no contamination
occurs due to defective storing or from other sources. The
delivery taps should be near the kitchen.

FOOD AND COOKING ARRANGEMENTS

With regard to cook and cooking arrangement, attention
should be paid to the following:
i. The kitchen should be located at a distance from latrines,
urine pits and the receptacles for garbage and refuse,
preferably at the opposite end but within easy access of
the water cart. It should be well-lighted and ventilated
preferably fly proofed and provided with a smoke outlet.
 Sanitation of Camps
ii. There should be suitable provision for storage of food.
iii. All sullage water must be made to pass into pits from
which it can drain into suitable dry trenches. In the
alternative, it can be kept in special covered tubs or
reservoirs and removed daily for sanitary disposal.
iv. Provisions should be made for washing cooking utensils,
plates, dishes, etc. It is always convenient to have a special
place allocated for this.
v. There should be provision of ample supply of hot water and
a sufficiency of clean dish-cloths to secure a clean and
wholesome food service.
vi. Everything used for food service namely, utensils, tables,
knives and forks, plates and dishes, tables should be clean.
The practice of using earth. For cleansing cooking utensils,
should be forbidden. Utensils should be cleaned by baked
sand stored in a clean tin. Where ash is used, one should see
that its preparation, collection and storing are sanitary.

DISPOSAL OF REFUSE AND EXCRETA

One of the important duties of the officer-in-charge of the camp
is to ensure that disposal of refuse and excreta is carried out
in such a way as these will be rendered innocuous.
These generally consist of:
a. Dry camp and kitchen refuse.
b. Liquid waste.
c. Feces.

Dry Camp and Kitchen Refuse

Dry camp and kitchen refuse generally consist of bits of papers
and crockery.
These should be collected daily in sand bags or in specially
provided receptacles by men detailed for the purpose.
Dry kitchen refuse consists of scraps of food, remnants of
vegetables, fruits, etc. All these should be collected in covered
metal receptacles and not allowed to scatter in and around the
kitchen.
The solid refuse both from the camp and kitchen, should either
be buried in deep pits at a safe distance or better still burnt in
an incinerator. It may also be disposed of the special type of
dustbins in which refuse can be burnt in the bin itself.

Liquid Waste
This consists of urine (human and animal), kitchen sullage and
ablution water.
 300 Essentials of Community Medicine—A Practical Approach
i. Kitchen sullage, consisting mainly of greasy water, soon
becomes very foul if not properly disposed of. These
should be collected in mental receptacles placed on a
stand fitted with a cover. If allowed to run direct on to the
soil, it makes a greasy quagmire covered with scum which
attracts flies. When its disposal depends on the absorptive
pits filed with hay, straw or coarse brushwood. Here the
grease and other organic solids are entangled allowing the
clear liquid to run away. The hay and straw loaded with
greasy and other fatty matter should be buried or burnt
and replaced by fresh material daily.
ii. Urine is disposed of in soakage pits. The pit may be
combined with urinal. This consists of two parts, the urine
receiving portion on top consisting of either a trough,
funnel or tin; and the disposal portion consisting of the
soakage pit below the ground consisting of the soakage
pit below the ground.

Disposal of Feces
In permanent camps provided with piped water supply and
where water- carriage system prevails, there is no trouble. But
in places where such arrangement cannot be made, one
should have recourse to trench system, earth-pet or service
latrine.
The first principal in any form of trench system is to
construct it in such a way as will not pollute the surrounding
ground. Shallow trenches should be avoided. They should be
regarded as an emergency measure and must not be used for
more than two to three days.
Deep trenches cover less ground and are better suited for
the purpose. These should be made fly-proof. Trenches should be
source of water supply or kitchen. There should always be a
superstructure for protection against inclement weather and
partitions for privacy.
Where convenient, bored-hole, well or pit latrines may be
provided. Boredhole latrines will be found suitable in places
where the sub-soil water in not very high. Generally, one seat
for every 12 persons will be found convenient.
If service latrines are used, the pans or pails should be daily
emptied and the contents quickly removed for final disposal
either by trenching or incineration, whichever will be available
and convenient. After emptying, the pans should be thoroughly
cleansed. Facilities for such cleansing should be available and
convenient. After emptying, the pans should be thoroughly
cleansed. Facilities for such cleansing should be provided with
soakage pits for waster. The cleaned pans should be treated
with crude oil before being replaced under the seats. There
should be a small conservancy staff to look after the
cleanliness of the latrines and urinals and also for removal of
refuse. Washing facilities should be provided and there should
be adequate supply of water for washing purposes. The
approach to the latrines should always be kept clean and
lighted at night.
 Sanitation of Camps
DISPOSAL OF STABLE LITTER
Much nuisance is caused by stable litter which is generally
horse manure or cow dung. Daily collection and complete
removal of these ensure freedom from infestation by flies and
biting insects to a large extent. Arrangements should be made
for their sanitary removal and disposal either by incineration
or by burying in deep pits.
 Chapter
20 Indian Systems
of Medicine
Chapter Outline
AYURVEDA SYSTEM OF MEDICINE SIDDHA SYSTEM OF MEDICINE
UNANI SYSTEM OF MEDICINE HOMEOPATHY
YOGA NATUROPATHY
ALLOPATHY

INTRODUCTION
Indian systems of medicine covers both the systems of which
originated in India and outside but got adopted in India in the
course of time. These systems are Ayurveda, Siddha, Unani,
Homeopathy, Yoga and Naturopathy. These systems have
become a part of the culture and tradition of our country.

AYURVEDA SYSTEM OF MEDICINE

Ayurveda means the "science of life". Ayurveda or the Indian
Science of Life oriented and developed around 1000 BC the
knowledge of Ayurveda was documented by Charaka and
Sushruta.
According to Ayurveda, health is considered a pre-requisite for
achieving the goals of life. Ayurveda takes an integrated view
of the physical and spiritual aspects of man.
The philosophy of Ayurveda is based on the theory of
Panchmahabhutas of which all the objects and living bodies
are composed of these five elements. The combination of these
five elements are represented in the form of tridosha. For
example, vata (Ether+Air), pitta (Fire) and kapha
physiological entities in living beings. The mental-spiritual
attributes are described as satva, rajas and tamas. The
various permutations and combinations of satva, rajas and
tamas constitute human temperament and personality.
Ayurveda considers the human being as a combination of
tridoshas, (Panchmahabhutas) (5 elements), seven body tissue
(Saptadhatu), five senses (Panch-indriyas), mind (Manas),
intellect (Budhi) and soul (Atman).The doctrine of Ayurveda
aims to keep these structural and functional entities in a
functional state of equilibrium which signifies good health.
Any imbalance due to internal or external factors is a disease
and restoring the equilibrium through various techniques,
procedures, regimen, diet and medicine is the treatment.
 Indian Systems of
In Ayurveda, diagnosis is done by questioning and
examination, viz. pulse, urine, feces, tongue, eyes,
visual/sensual examination and inference.
Treatment in Ayurveda has two complements:
a. Preventive measures
b. Curative measures.
Preventive aspects of Ayurveda is called Avasth Vritt and
includes personal hygiene, appropriate social behavior and
Rasayana Sevann, i.e. use of rejuvenate materials/drugs. The
curative treatment consists of three major categories of
procedures:
i. Aushdhi (drug)
ii. Anna (diets)
iii. Vihara (exercises and general mode of life).

SIDDHA SYSTEM OF MEDICINE

Introduction and Origin

Siddha system is one of the oldest systems of medicine in
India. The term 'Siddha' means achievement and 'Siddhas'
were saintly figures who achieved results in medicine through
the practice of Yoga. Eighteen 'Siddha's are said to have
contribute towards the development of this medical system
Siddha literature is in Tamil and it is practiced in Tamil
speaking parts of India. The system is also called Agasthyar
system after its most famous exponent sage Agasthya. A
number of medical works of this system are ascribed to him.
The Siddha system is largely therapeutic in nature.

Basic Concepts
The principles and doctrines of this system, both fundamental
and applied, have a close similarity to Ayurveda.
According to this system the human body is the replica of
the universe and so are the food and drugs irrespective of
their origin. Like Ayurveda, this system believes that all
objects in the universe including human body are composed of
five basic elements namely earth, water, fire, air, sky. The
food which the human body takes and the drugs it uses all
made of these five elements. The proportion of the elements in
the drugs vary and their preponderance or otherwise is
responsible for certain actions and therapeutic results.

Diagnosis and Treatment

The diagnosis of disease involved identifying its cases
identification of causative factors is through the examination
of pulse, urine, eyes, study of voice, color of body, tongue
and status of the digestive system of
 304 Essentials of Community Medicine—A Practical Approach
human body. The system has worked out its color—density,
quantity and oil drop speeding pattern. Diagnosis involves the
study of person, as a whole, as well as his diseases.
The Siddha system of medicine emphasis the medical
treatment is oriented not merely to disease but has to take
into account the patient, his environment, the meteorological
consideration , age, sex, race, habits, mental frame, habitat,
diet, appetite, physical condition, physiological constitution,
etc. This means the treatment has to be individualistic which
ensures lesser chance of committing mistakes in diagnosis or
treatment.

UNANI SYSTEM OF MEDICINE

Origin and Development

Unani system of medicine originated in Greece (460BC-
377BC). It was brought to India by Arabs and Persians. Unani
is the Arabic name for Greece which denotes the origin of the
system. Hippocrates established his philosophy of health on
the word 'Physis' which meant simply 'Organism' and he
postulated that life comprised a reciprocal relationship
between organism and environment. He explained that
disease was a normal process and its symptoms were the
reaction of the body to the disease. The chief function of the
physician was to aid the natural forces of the body. He held
that there exists in the body four humorous that keep up the
balance of it. He also laid emphasis on diet and drugs for cure
of diseases.

Fundamental Principles
The Unani system of medicine is based on the Humoral
Theory, which pre-supposes the presence of four humorous
namely blood (Dam). phlegm (Balgham), yellow bile (Safra)
and black Bile in the body. The humours have specific
temperament and the temperament of a person is expressed
as being sanguine, phlegmatic, choleric and melancholic
according to their preponderance in the body.

Diagnosis and Treatment

The diagnosis of disease and treatment revolves round the
concepts of temperament of 'Mizaj'. Changes in temperament
are related to changes in the balance of humors. Any change
in temperament brings about a change in the health of the
individual. Thus, imbalance in humors and temperament along
with failure of one or more parts of the body to eliminate
pathogenetic waste causes disease.
Treatment is mainly done through drugs of herbal, animal
and mineral origin, which are supposed to have specific
temperament (hot, cold, moist,
 Indian Systems of
dry, etc. in different degree). Use of drugs restores balance of
humors by activating self-preservation mechanism in human
body. The system believes in the presence of some natural
self-prevention mechanism in human body. The drugs are
supposed to stimulate and strengthen the action of defence
mechanism. In other words, drugs not only normalize the
existing imbalance but also minimize chances of future
disease. Thus, the treatment generally is both curative and
preventive.

HOMEOPATHY
Homeopathy is a specialized method of drug therapy of curing
natural diseases by administration of drugs, which have been
experimentally, provide to possess the power of producing
similar artificial symptoms on healthy human beings.
Dr Christian Friedrich Samuel Hahnemann entrained this
observation more thoroughly discovering the fundamental
principles of what was to become Homeopathy. He conducted
experiments upon himself, which went into history as the
famous “Peruvian Bark Trail”. After series of repeated tests,
Hahnemann observed that any substance capable of producing
artificial symptoms on healthy individuals could cure the same
symptoms in natural disease. This forms the basis of the
theory of Homeopathy “Simla Similibus Crenature” or let like
be treated by like. He published his research works in the
classical books—Materia Medica Pura and Organon the Art of
Healing.
Homeopathy is based on the following cardinal principles:
i. The law of similars
ii. The law of direction of cure
iii. The principle of single remedy
iv. The theory of minimum dose
v. The theory of chronic diseases.
The law of similars states that a medicine which can
produce artificial symptoms on healthy human beings can cure
the similar set of symptoms of natural diseases. The direction
of cure states that during cultivate process the symptoms
disappear in the reverse order of its appearance from above
downwards, from more important organs, etc. In the
treatment of chronic diseases Homeopathy generally uses only
a single medicine which has a true similarity of symptoms with
that of the remedy. This process of selecting the correct
remedy done on the basis of individualization. The dose
applied are the minimum possible dose, just sufficient to
correct the diseased state.
Homeopathy does not give much importance to the
nomenclature of disease for treatment. The concept is that the
physical, mental and spiritual expressions of the sick form
the totality of the disease. It is
 306 Essentials of Community Medicine—A Practical Approach
also believed that the external influences such as bacteria,
viruses could not cause sickness unless the vital resistance of
an individual is reduced beyond a certain level.
In treatment, primary emphasis is given to increasing
the defensive mechanism of the individual through
holistic approach of individualization. Here the treatment is
directed in correcting the imbalance in the immune
mechanism and restoring health to the sick. Here two sick
individuals are never considered identical for selection of
medicine, though they may be suffering from the same
disease. Individualization through a detailed and exhaustive
case taking is the most important aspect in homeopathy.
Homeopathy has definite and effective treatment for
individuals with chronic diseases such as diabetes; arthritis;
bronchial asthma; skin, allergic and immunological disorders
and for several other diseases, for which there is less or no
treatment in other system.

YOGA
Yoga is a way of life propounded by Patanjali in a systematic
form. It consists of eight components namely restraint,
observance of austerity. Physical postures, breathing
exercises, restraining of sense organs, contemplation,
meditation and samadhi. These steps in the practice of Yoga
have potential for improvement of social and personal
behavior, improvement of physical health by encouraging
better circulation of oxygenated blood in the body, restraining
the sense organs and thereby the mind and inducing
tranquility and serenity of mind. The practice of Yoga prevents
psychosomatic disorders/diseases and improves individuals
resistance and ability to endure stressful situations.
Meditation, one of the eight components, if regularly
pracused, has the capacity to reduce unwholesome bodily
responses to a bare minimum so that the mind can be directed
to perform more fruitful functions.
A number of physical postures are described in Yogic works to
improve
bodily health, to prevent diseases and to cure illness. The
physical postures are required to be chosen judiciously and
have to be practiced in the right way to drive the benefits of
prevention of diseases, promotion of health and for
therapeutic purposes.
Studies have revealed that the Yogic practices improved
intelligence and memory and help in developing resistance to
endure situations of strain and stress and also to develop an
integrated psychosomatic personality. Meditation is an
exercise which can stabilize emotional changes and prevent
abnormal functions of vital organs of the body. Studies have
shown that meditation not only restrain the sense organs but
also controls the autonomic nervous system.
 Indian Systems of
NATUROPATHY
Naturopathy is not only a system of treatment but also a way
of life. It is often referred to as a drugless treatment of
diseases. It is based mainly on the ancient practice of the
application of the simple laws of Nature. The system is closely
allied to Ayurveda as far as it fundamental principals are
concerned. There are two schools of thought regarding the
approach to Naturopathy. One group believes in the Indian
methods while the other mainly adopts Western methods,
which are more akin to modern physiotherapy.
The advocates of naturopathy pay particular attention to
eating and living habits, adoption of purificatory measures,
use of hydrotherapy, cold packs, mud packs, baths, massage
uses a variety of methods, measures, based on various
innovations.
This system believes that properly boundless organized way
of life and deliver energy, health and happiness. For
prevention of disease, promotion health and to get therapeutic
advantages, it is required to adopt natural means to avoid
distortion of nature.

ALLOPATHY
Allopathy is a method of treating disease with remedies that
produce effects different from those caused by the disease
itself.
The term “allopathy” was invented by German Physician
Samuel Hahnemann he referred it to harsh practices of his
time which included bleeding, purging, vomiting and
administration of highly toxic drugs.
Four humorous theory—attributed diseases to an imbalance
of four humors (i.e. blood, phlegm and black, yellow bile) and
four bodily conditions (i.e. hot, cold, wet and dry) that
corresponded to four elements (earth, air, fire and water).
Physicians follow the Hippocratic tradition attempted to
balance the humors by treating symptoms with 'opposites'
during 18th century, it started to loose ground to several new
and conflicting systems that attempted to several one or two
basic causes for all diseases.
It was well known to the physician that their drugs were
damaging, thus by mid century scientific medicine took a back
seat.

Methods
Methods are used for:
1. Bleeding 8. Puking
2. Blistering 9. Swatting
3. Plastering 10. Fumigation
4. Leaching 11. Purging
5. Blood letting 12. Ointments
6. Cupping 13. Dehydrations.
7. Poulticing
 Chapter
21Adolescent Health
Chapter Outline
PHYSICAL CHANGES DURING ADOLESCENT PUBERTY CHANGES IN ADOLESCENT
EMOTIONAL PROBLEMS EDUCATIONAL PROBLEMS
BENEFICIARIES

INTRODUCTION
The term adolescence is derived from the Latin word
"adolescere" meaning to grow, to mature. It is considered as a
period of transition from childhood to adulthood. They are no
longer children yet not adults. It is characterized by rapid
physical growth, significant physical, emotional, psychological
and spiritual changes. Adolescents constitute
22.8 percent of population of India as on 1st march 2000.
They are not only in large numbers but are the citizens and
workers of tomorrow. The problems of adolescents are multi-
dimensional in nature and require holistic approach.
Adolescent has been defined by WHO as the period of life
spanning between 10 to 19 years and the youth as between 15
to 24 years. Young people, when referred to as such, are those
between 10 to 24 years of age. They are no longer children,
but not yet adults.

Population Profile: Ages 10 to 24 Years in India

Population age: 10 to 24 (yrs) 284.2
millions
10 to 24 years as percent of total population 30
Percentage of males enrolld in secondary 59
school
Percentage of females enrolled in secondary 38
school
Average age at first marrige 20
Total fertility rate 3.4
Percentage of adolescent TFR contributed by 15 to 19 years
9
Percentage of adolescent using contraceptives 7

Characteristics
• A—Aggressive, anemic, abortion
• D—Dynamic, developing, depressed
• O—Overconfident, overindulging, obese
 Adolescent Health
• L—Loud but lonely and lacking information
• E—Enthusiastic, explorative, and experimenting
• S—Social, sexual and spiritual
• C—Courageous, cheerful, and concern
• E—Emotional, eager, emulating
• N—Nervous, never say no to peers
• T—Temperamental, teenage pregnancy.

Early Adolescence (10 to 13 years)

In early adolescent period spurt of growth of development of
secondary sex will take place.

Middle Adolescence (14 to 16 Years)

In middle adolescent period they will have separate identity
from parents, new relationship to peer groups, with opposite
sex and desire for experimentation.

Late Adolescence (17 to 19 Years)

In late adolescent period they will have distinct identity, well
formed opinion and ideas.
The following changes are taking place during adolescent
period:
a. Biological changes—onset of puberty
b. Cognitive changes—emergence of more advanced cognitive
abilities
c. Emotional changes—self-image, intimacy, relation with
adults and peers group
d. Social changes—transition into new roles in the society.
PHYSICAL CHANGES DURING ADOLESCENT
Age group
In girls, physical changes may begin at around 10 years
Reaches their maximum growth by around 14 years
Thereafter, growth continues at slower rate till the age of
18
years Puberty in boys usually appears later than in girls.
During adolescence there is considerable gain in the weight
and height, it accounts for nearly 20 to 25 percent of adult
height and 50 percent of weight. Puberty height spurt begins
at an average age of 12 years for girls and 14 years for boys.
During puberty girls gain 25 cm height and boys 38 cm
height. At the cessation of growth boys are taller than girls by
13 cm.
 310 Essentials of Community Medicine—A Practical Approach
PUBERTY CHANGES IN ADOLESCENT

Puberty in Girls
During this period, in female, subjects the secondary sexual
characteristics appear such as appearance of hair in pubic
area, and breast begin to grow. Other changes include
accelerated growth and development of genital organs.
Ovaries begin to ovulate at around 11 to 14 years once
every 28 days. Menarche is the onset of first menstruation
which occurs in a young girl at around 12 years.

Psychological and Behavioral Changes

1. During this transition phase from childhood to adulthood
due to rapid physical and sexual changes in the body, the
adolescent develops anxiety and apprehension.
2. In case they are not given appropriate information and
education on these normal physical, sexual and
psychological changes they are prone to health risk
behavior such as sex experiments and drug abuse leading
to teenage pregnancy, contracting RTI/STI, HIV/AIDS,
injuries, accidents, violence, rape, homicides, suicides, etc.

Impact of Adolescence
1. Lack of formal or informal education
2. School dropout and childhood labor
3. Malnutrition and anemia
4. Early marriage, teenage pregnancies
5. Habits and behaviors picked up during adolescence
period have lifelong impact
6. Lot of unmet needs regarding nutrition, reproductive
health and mental health
7. They require safe and supportive environment
8. Desire for experimentation
9. Sexual maturity and onset of sexual activity
10. Transition from dependence to relative independence
– Ignorance about sex and sexuality
– Lack of understanding
– Suboptimal support at family level
– Social frustration
– Inadequate school syllabus about adolescent health
– Misdirected peer pressure in absence of adequate
knowledge
– Lack of recreational, creative, and working opportunity.
 Adolescent Health
Adolescent Health Problems
1. Anorexia nervosa
2. Obesity and overweight
3. Adolescent pregnancy
4. Micronutrient deficiency
5. Emotional problems
6. Behavioral problems
7. Substance abuse and injuries
8. Sexually transmitted infection
9. Thinking and studying problems
10. Identity problems
11. Respiratory infection, asthma
12. Goiter
13. Bed wetting
14. Dandruff
15. Alopecia
16. Skin patches
17. Pimples
18. Nutritional problem
19. Menstrual problem.

EMOTIONAL PROBLEMS
1. Lack of freedom: Worry about future and career,
loneliness. Worries regarding love marriage and child
birth, struggle for identity and inferiority complex.
2. Lack of confidence: Failed love affairs, stranger anxiety,
difficulty in adjusting with others, parental expectation,
problems dealing with elders.
3. Lack of emotional stability: Depression, suicide, homicidal
tendencies.

EDUCATIONAL PROBLEMS
1. Lack of proper counseling and guidance.
2. Inferiority complex due to poor performance in studies.
3. Constant nagging of teachers.
4. Lack of opportunities for preferred profession.
5. Difficulty in adjusting with fellow students.
6. Lack of peer acceptance.
7. Difficulty in talking with teachers.
8. Examination fear.
9. Not achieving academic goals like entrance examination.
10. Stage fear.
 312 Essentials of Community Medicine—A Practical Approach
Reasons for Adolescent Reluctant to seek Help
• Fear
• Uncomfortable with of opposite sex health worker
• Poor quality perception
• Lack of privacy
• Confidentiality
• Cumbersome procedure
• Long waiting time
• Parental consent
• Operational barrier
• Lack of information
• Feeling of discomfort.

Prevention
• Health education
• Skill based health education
• Life skill education
• Family life education
• Counseling for emotional stress
• Nutritional counseling
• Early diagnosis and management of medical and behavioral
problem.
Syllabus for Adolescent Health Education
• Development of secondary sexual characters and menarche
• Problems associated with menstrual cycle and menstrual
hygiene
• Body image
• Nutritional needs (micronutrients)
• Managing emotional stress
• Early marriage
• RTI/HIV/AIDS
• Safe sex
• Family life including pregnancy
• Child rearing and responsible parenthood
• Stress management
• Substance abuse.
Inclusion of life skill training in school and college to
empower adolescent in making informed choice to face the
complex life situation.

Life Skills
Decision making: Assessing option and what effects different
decisions may have.
 Adolescent Health
Problem solving: Unresolved problems may cause tension.
Creative thinking: Consequences of both action and non-action,
looking beyond direct experience.
Critical thinking: Factors that influence attitudes and
behavior.
Effective communication: To express not only opinions and
desires but also needs and fears.
Interpersonal skill: To develop and nurture supportive
networks, to be able to end relationships constructively.
Self-awareness: Recognition of our self-positives and
negatives . Coping with emotions and stress.

Adolescent Friendly Health Center Services

• Reproductive health services
• Sexual and reproductive health education
• Contraception
• Pregnancy testing and option
• MTP
• STD/HIV screening counseling and treatment
• Prenatal and postpartum care
• Well baby care
• Nutritional services
• Growth and development monitoring
• Anticipatory guidance about substance abuse and other risk
taking behavior
• Counseling for life skill development
• Screening for various disorders.

Criteria for Adolescent Friendly Health Worker

• Welcoming and friendly nature
• Knowledgeable
• Presentable
• Have good communication skill
• Maintain confidentiality
• Punctuality
• Flexibility
• Understanding
• Good listener
• Nonjudgemental.

Criteria for Adolescent Friendly Health Center

• Good reception
• All facilities
 314 Essentials of Community Medicine—A Practical Approach
• Accessibility
• Quality care service
• Well trained people
• Security
• Easy communication to the outside
• Privacy
• Conducive environment.

Adolescent Girls Scheme

There are two schemes:
• Scheme I: Girl-to-girl approach
• Scheme II: Balika Mandal.

BENEFICIARIES
Scheme I: Girl-to-Girl Approach
This has been designed for adolescent girl (AG) in the age
group 11 to 15 years belonging to families with income level
below Rs. 6400/- per annum and school dropouts in urban and
in the rural areas.
These girls are selected per Anganwadi and attached to
the local Anganwadi center for six months duration for
learning and training. These girls act as resource person for
other girls in their neighborhood.
Intervention focal point of services is an Anganwadi. These
girls are provided supplementary nutrition equivalent to the
entitlement of pregnant/lactating women for six days in a
week.
Simple and practical messages are provided on preventive
health, hygiene, nutrition, working of Anganwadi centers and
family life education. This is provided through initial three
days training program, followed by six continuing education
sessions of one day each, every month. This exercise is aimed
at building confidence and encouraging adolescent girls to
become active participants in the development process.
Anganwadi workers act as role models for these girls.

Scheme II: Balika Mandal

All eligible in the age bracket 11 to 18 years irrespective of
income levels of the family are eligible to receive assistance
in this scheme; preference is given to 11 to 15 years age
group. In each community development block and urban ICDS
areas 10 percent of total Anganwadi centers are selected to
serve as Balika Mandals 20 girls in the age bracket 11 to 18
are identified. These girls are enrolled for a period of 6
months in Balika Mandal. Thus, in a year each Balika Mandal
will reach out to 40 adolescent girls.
 Adolescent Health
Interventions
• These girls are provided supplementary nutrition for six
days in a week to provide 500 calories and 20 g of protein.
• Activities cover the areas of personal hygiene,
environmental sanitation, nutrition, home nursing, first
aids, communicable diseases, vaccine preventable diseases,
family life, child care and development and the impact of
constitutional rights on the quality of life.
• Participate in creative activities and recreation. Learning
through sharing of experiences and discussions on issues
that affect their lives.
• Training in vocational skills/agro-based skills/household
related appropriate technology.
The Anganwadi worker is regular honorary instructor for
the Balika Mandal and provides general education and literacy
to adolescent girls. She is also responsible for overseeing the
work related to skills improvement/upgradation.
Kishori Shakti Yojna (KSY) has much wider scope than the
earlier AG scheme and involves the entire network of
Government of state/union Territory and district as supportive
skills of local self-Government.

Training
Under the AG scheme, a nine days training program has been
designed for selected girls, three days training period is spent
at circle headquarter and remaining six days are devoted for
continuing education, spread over to six months. The training
is conducted by supervisors. There are 10 themes for training-
environmental sanitation, nutrition, home nursing, first aid,
family life education, child development, legal rights of
women, home economics, positive attitudes and motivation.
The National Population Policy 2000, National Health Policy
2002 identifies the adolescent girls as under-served group for
priority intervention. Similarly, National Nutrition Policy
focuses on adolescent girls to improve their nutritional status, to
remove the intergenerational gap.
 C h a p t e r Integrated Disease
22 Surveillance Project (20

CHAPTER OUTLINE
 PROJECT OBJECTIVES
 SPECIFIC OBJECTIVES
 PHASING OF IDSP COVERING THE STATES OF INDIA
 SENTINAL SURVEILLANCE UNDER IDSP
 REGULAR PERIODIC SURVEY
 NATIONAL SURVEILLANCE UNIT
 STATE SURVEILLANCE UNIT
 DISTRICT LEVEL UNIT
 DISTRICT SURVEILLANCE UNIT
 DISTRICT EPIDEMIOLOGICAL CELL
 LEVELS OF RESPONSE TO DIFFERENT TRIGGERS
 SURVEILLANCE OF NONCOMMUNICABLE DISEASES

PROJECT OBJECTIVES
• To establish a decentralized state based system of
surveillance for communicable and noncommunicable
disease, so that timely and effective public health action can
be initiated in response to health challenges in the country
at the state and national level.
• To improve the efficiency of the existing surveillance
activities of disease control programs and facilitate sharing
of relevance information with the health administration,
community and other stakeholders so as to detect disease
trends over time and evaluate control strategies.

SPECIFIC OBJECTIVES
• To integrate, coordinate and decentralize surveillance
activities
• To surveil a limited number of health conditions and risk
factors
• To establish system for quality data collection, reporting,
analysis and feedback using information technology
• To improve laboratory support for disease surveillance
• To develop human resources for disease surveillance
• To involve all stakeholders including private sector and
communities in surveillance.

PHASING OF IDSP COVERING THE STATES OF INDIA

Phase I (commencing from financial year 2004-2005): Andhara
Pradesh, Himachal Pradesh, Karnataka, Madhya Pradesh,
Maharashtra, Uttaranchal, Tamil Nadu, Mizoram and Kerala.
 Integrated Disease Surveillance Project
Phase II (commencing from finacial year 2005-2006):
Chhattisgarh, Goa, Gujarat, Rajasthan, West Bengal, Manipur,
Meghalaya, Orissa, Tripura, Chandigarh, Pondicherry, Delhi
Phase III (commencing from financial year 2006-2007): Uttar
Pradesh, Bihar, Jammu and Kashmir, Jharkhand, Punjab,
Arunachal Pradesh, Assam, Nagaland, Sikkim. Andaman and
Nicobar, Dadra and Nagar Haveli, Daman and Diu,
Lakshadweep.
Project Activities
1. Upgradation of laboratories
• Renovation and furnishing laboratories
• Supply of laboratory equipments
• Laboratory material and supplies
2. Information technology and
communication
• Computer hardware and office
equipment
• Software for surveillance
• Leasing of wide area networking
3. Human resources and development
• Consultant/Contract staff
• Training
• Information education and communication
4. Operational activities and response
5. Monitoring and evaluation.

Diseases and Conditions Covered under IDSP (Table 22.1)

Table 22.1: Diseases and conditions covered under IDSP

Category Disease and condition

Regular surveillance
Vector borne diseases 1. Malaria
Water borne diseases 2. Acute diarrheal disease (Cholera)
3. Typhoid
Respiratory diseases 4. Tuberculosis
Vaccine preventable diseases 5. Measles
Disease under eradication 6. Polio
Other conditions 7. Road traffic accidents
Other international commitments 8. Plague

SENTINAL SURVEILLANCE UNDER IDSP

A. STDs/Blood borne diseases: HIV, HBV,
HCV B. Other conditions: Water quality,
air quality.

REGULAR PERIODIC SURVEY

Noncommunicable risk factors:
Antropometry, BP, pulse, tobacco, blindness, BMI, etc.
 318 Essentials of Community Medicine—A Practical Approach
NATIONAL SURVEILLANCE UNIT
1. Execution of approved annual plan of action.
2. Monitor progress of implementation of project.
3. Obtain reports and expenditure statements from state.
4. Seek reimbursement from world bank.
5. Production of prototype guide lines, manuals, modules.
6. Analysis of data from states and provide feedback on trends
observed.
7. Coordinating with other national organizations.
8. Conduct periodic meetings with state surveillance officers.
9. Organize independent evaluation of various activities.

STATE SURVEILLANCE UNIT

• Chair person: State Secretary for Health
• Analysis of data received by districts and sending it to Central
Surveillance Unit (CSU).
• Formation of rapid response teams and deputing them
• Coordinating with state public health lab, medical colleges,
state level institutes
• Sending regular feedback to districts unit
• Coordinating training activity and meetings of state
surveillance units.

DISTRICT LEVEL UNIT

1. Chair person: DC or district magistrate
2. Data analysis and transmitting it to State Surveillance Unit
(SSU)
3. Constituting rapid response teams
4. Coordinating with other organizations
5. Organizing surveys on infections/noncommunicable
diseases and risk factors
6. Periodic review meetings with State Surveillance Officers.

DISTRICT SURVEILLANCE UNIT (FLOW CHARTS 22.1 TO 22.4)

Functions of the District Surveillance unit

Flow chart 22.1: Chief medical and health officer

 Integrated Disease Surveillance Project
Flow chart 22.2: The role of the district within the surveillance system

Flow chart 22.3: District surveillance committee

 320 Essentials of Community Medicine—A Practical Approach
Flow chart 22.4: District epidemic investigating team (DEIT)

Managerial
• Implement and monitor all project activities
• Coordinate with laboratories, medical colleges,
nongovernmental organizations and private sector
• Organize training and communication activities
• Organize district surveillance committee meetings.

Data Handling
• Centralize data
• Analyze data
• Send regular feedback
• Outbreak response
• Constitute rapid response teams
• Investigate.

DISTRICT EPIDEMIOLOGICAL CELL

• Reports weekly summary data on disease to state
epidemiology center. It collects all data and pass on monthly
summaries to National Institute of Communicable Disease
(NICD).
• This cell has one senior officer not below rank of DHO,
designated as District Epidemiology Officer
• One medical officer and five field workers per two million or
less population
• Cell completes list of all health care institutions, private
medical practitioners in district
• All reports are documented, scanned every day to rule out
clustering of cases, analyzed weekly and is forwarded to
state epidemiology unit
 Integrated Disease Surveillance Project
• District cell is responsible for defining and designing
interventions
• Implements and monitors all project activity in coordination
with labs, private sector and medical colleges
• Conducts training and communication activity
• Organize district surveillance unit meetings
Triggers in the context of the Indian Integrated Disease
Surveillance Program (IDSP) (Flow chart 22.5)
• Threshold for diseases under surveillance that trigger
predetermined actions at various levels
• Based upon the number of cases in weekly report
• Trigger levels depend on:
– Type of disease
– Case fatality (Death/case ratio)
– Number of evolving cases
– Usual trend in the region.
Flow chart 22.5: Structural framework of IDSP

LEVELS OF RESPONSE TO DIFFERENT TRIGGERS (TABLE 22.2)

Table 22.2: Levels of response to different triggers

Trigger significance Levels of response

1. Suspected/limited outbreak • Local response by health worker
and medical officer
2. Outbreak • Local and district response by
district surveillance officer and
rapid response team
3. Confirmed outbreak • Local, district and state
4. Wide spread epidemic • State level response
5. Disaster response • Local, district, state and center
 322 Essentials of Community Medicine—A Practical Approach
Malaria Triggers
Trigger 1
• Single case of smear positive in an area where malaria was
not present for a minimum of three months
• Slide positivity rate doubling over last three months
• Single death from clinically/microscopically proven malaria
• Single falciparum case of indigenous origin in a free region.

Trigger 2
• Two fold rise in malaria in the region over last three months
• More than five cases of falciparum of indigenous origin.

Cholera Triggers
Trigger 1
• A single case of cholera/epidemiologically linked cases of
diarrhea
• A case of severe dehydration/death due to diarrhea in a
patient of >5 years of age
• Clustering of cases in a particular village/urban ward where
more than 10 houses have at least one case of loose stools
irrespective of age per 1000 population.

Trigger 2
More than 20 cases of diarrhea in a village/geographical
area of 1000 population.

Typhoid Fever Triggers

Trigger 1
• More than 30 cases in a week from the entire primary
health center area
• Five or more cases per week from one sub-center of 5,000
population
• More than two cases from a single village/urban ward/1000
population
• Clustering of cases of fever.

Trigger 2
More than 60 cases from a primary health centre or more than
10 cases from a subcenter.

Polio Trigger
One single case.
 Integrated Disease Surveillance Project
Plague Triggers
• Trigger 1
– Rat fall
• Trigger 2
– At least one probable case of plague in community.
Japanese Encephalitis Triggers
• Trigger 1
– Clustering of two or more similar case from a locality in
one week
• Trigger 2
– More than four cases from a PHC (30,000 population) in
one week.
Dengue Triggers
Trigger 1
• Clustering of two similar cases of probable dengue fever in
a village
• Single case of dengue hemorrhagic fever.

Trigger 2
More than four cases of dengue fever in a village with
population of about 1000.
Triggers for Syndromic Surveillance
• Fever
– More than two similar case in the village (1000 population)
• Diarrhea
– See cholera
• Acute flaccid paralysis
– 1 case
• Jaundice
– More than two cases of jaundice in different houses
irrespective of age in a village or 1000 population.

When to Sample?
• Isolation of agent, PCR or antigen:
– At the earliest
– Before antimicrobial administration
• For antibody estimation:
– Ideally two paired specimens
i. At earliest
ii. After 7 to 10 days
– Alternately, one specimen 4 to 5 weeks after onset
 324 Essentials of Community Medicine—A Practical Approach
Whom to Sample During a Classical Outbreak?
• Typical cases
– Should represent the majority of the specimens
• Untreated patients
– Without antibiotics
• Cases likely to carry the pathogen
– Children
• Atypical cases
– Few specimens
• Healthy
contacts
– Few specimens.

Rule of Thumb Regarding the Number of Specimens to take during a

Cholera Outbreak
• 10 specimens to confirm the outbreak
• Five specimens per week during the outbreak
Specimens at the end to confirm that the outbreak
is over.

How many Specimens to take?

• Ensure sufficient number of specimens (At least 20)
– Avoid sampling error
– Obtain reliable results
• Avoid overwhelming the laboratory with excessive
specimens
• Repeat sampling in some case-patients
– Acute and convalescent sera
– Exploration of chronic carriage
– Intermittent shedding (e.g. Stool microscopy for parasites)
– Unknown etiology.

Transport Medium
• Allows organisms to survive under adverse conditions
• Does not allow organisms to proliferate
• Available for bacteria, e.g. Cary Blair
• Available for viruses
• Virus transport media (VTM).

What is a Viral Transport Medium?

• Sterile buffered solution (Pink colored) containing
antibiotics for preservation of viruses
• Used in the collection of specimens for viral isolation and
testing
 Integrated Disease Surveillance Project
• Save the viruses from drying
– Nutrient, glycerol
• Prevents specimen from drying out
• Prevents bacterial and fungus growth
• Prepared in the lab or commercially obtained
• Storage for short periods at 4 to 8°C.

Vacutainers
• Vacuum tube with rubber stopper mounted on a needle
system
• Tubes may be changed for collection of different tubes for
different purposes
• Smooth blood flow, lower risk of hemolysis
• Reduces risk of spillage.

Collecting Blood for Cultures

• Collect within 10 to 30 minutes of fever
• Aseptic technique
• Quantity
• Venous blood for infants—0.5 to 2 ml
• Venous blood for children—2 to 5 ml
• Venous blood for adults—5 to 10 ml
• Take three sets of blood culture when suspecting bacterial
endocarditis.

To Avoiding Hemolysis for Blood Specimens

• Fine needles
• Forced suction of blood with syringe
• Unclean tube (residual detergents)
• Shaking tube vigorously
• Forced expulsion of the blood through needle
• Freezing/thawing of blood
• High speed centrifugation before complete clotting.

Handling and Transporting Blood for Cultures

• Collect in blood culture bottles with infusion broth
– Change the needle to inoculate the broth
• Travel at ambient temperature.

Handling and Transporting Serum

• Transport at 4 to 8°C if transport lasts less than 10 days
• Freeze at –20°C if storage for weeks or months before
processing and shipment to reference laboratory
– Ship frozen
 326 Essentials of Community Medicine—A Practical Approach
• Avoid repeated freeze-thaw cycles
– Destroy IgM (e.g. Measles diagnosis)

Collecting and Handling Cerebrospinal Fluid

• Collection
– Lumbar puncture
i. Aseptic conditions
ii. Trained person
– Sterile tubes
• Handling and transportation
– For bacteria, transport at ambient temperature or
preferably in trans-isolate medium (pre-warmed to 25-
37°C before inoculation)
– For viruses, transport at 4 to 8°C for up to 48 hours or at
–70°C for longer duration.

Collecting a Sputum
• Instruct patient to take a deep breath and cough up sputum
directly into a wide-mouth sterile container
• Avoid saliva or postnasal discharge
• Minimum volume should be about 1 ml.

Handling and Transportation of Respiratory Specimens

• All respiratory specimens except sputum are transported in
appropriate media
– Amie’s or Stuart’s transport medium for bacteria
– Viral transport medium for viruses
• Transport as quickly as possible to the laboratory to reduce
overgrowth by oral flora
• For transit periods up to 24 hours
– Ambient temperature for bacteria
– For viruses 4 to 8°C

Collecting Stool Specimens for Parasites

• Timing
– As soon as possible after onset
• Specimen amount and size
– At least 3 × 5 to 10 ml fresh stool from patients (and
controls)
• Method
– Mixed with 10 percent formalin or polyvinyl chloride, 3
parts of stool to 1 part preservative
– Unpreserved specimens for antigen detection and PCR
• Storage
– Refrigerate at 4°C
– Store at –15°C for antigen detection and PCR
 Integrated Disease Surveillance Project
Transport
• 4°C (Do not freeze)
• Dry ice for antigen detection and PCR.

Collecting stool Specimens for Bacteria

• Timing
– During active phase
• Specimen amount and size
– Fresh specimens and two swabs from patients, controls
and carriers (if indicated)
• Method
– In Cary-Blair medium (+ specimen without transport
medium for antigen detection/PCR)
• Storage
– Refrigerate at 4°C if testing within 48 hours, –70°C if
longer.

Collecting Stool Specimens for Viruses

• Timing
– Within 48 hours of onset
• Specimen amount and
size
– At least 5 to 10 ml fresh stool from patients (and controls)
• Method
– Fresh stool unmixed with urines in clean, dry and sterile
container
• Storage
– Refrigerate at 4°C. Do not freeze
– Store at –15°C for antigen detection and protein chain
reaction (PCR)
• Transport
– 4°C Do not freeze at 4ºC
– Dry ice for antigen detection and PCR.

Rectal Swabs
• Advantage
– Convenient
– Adapted to small children, debilitated patients and other
situation where voided stool specimen collection is not
feasible
• Drawbacks
– No macroscopic assessment possible
– Less materials available
i. Not recommended for viruses.

Collecting and Handling Stool Specimens

• Take freshly passed stool specimen
– Avoid collecting specimen from a bed pan
• Collect specimen in sterile container (if available) or clean
328 Essentials of Community Medicine—A Practical Approach
container (not cleaned with a disinfectant)
 Integrated Disease Surveillance Project
Collecting Serum
• Collect venous blood in a sterile test tube
• Let specimen clot for 30 minutes at ambient temperature
• Place at 4 to 8°C for clot retraction for at least 1 to 2 hours
• Centrifuge at 1500 RPM for 5 to 10 min
• Separate the serum from the clot with pipette/micro-pipette.

Triple-packaging of Specimens: Two Goals

• Protect the environment and the carrier
• Protect the specimen.

Early Warning Signals for an Outbreak (Flow chart 22.6)

• Clustering of cases of deaths
• Increase in cases or deaths
• Single case of disease of epidemic potential
• Acute febrile illness of an unknown etiology
• Two or more linked cases of disease with outbreak potential
– (e.g. measles, cholera, dengue, Japanese encephalitis or
plague)
• Unusual isolate (Cholera O 139)
• Shifting in age distribution of cases (Cholera O 139)
• High vector density
• Natural disasters.

Flow chart 22.6: Components of early warning surveillance

 330 Essentials of Community Medicine—A Practical Approach
Steps in Outbreak Response (Flow chart 22.7)
1. Verifying the outbreak
2. Sending the rapid response team
3. Monitoring the situation
4. Declaring the outbreak over
5. Reviewing the final report.

Step 1: Verifying the Outbreak

• Validate the source of information
– Change in the reporting system
– Change in the population size
– Acute reporting of old, chronic cases
• Check with the concerned medical officer
– Abnormal increase in the number of cases
– Clustering the cases
– Epidemiological link between cases
– Triggering event
– Deaths

Step 2: Sending the Rapid Response Team

• Review if the source and mode of transmission are known
• If not, constitute team with:
Flow chart 22.7: Investigation of an epidemic
 Integrated Disease Surveillance Project
– Medical officer
– Epidemiologist
– Laboratory specialist
• Formulation of hypothesis on basis of the description by
time, place and person (Descriptive epidemiology)
– Does the hypothesis fits the
fact Yes: Propose control
measures No: Conduct
analytical studies.
The rapid response team:
• Composition
– Epidemiologist, clinician and
microbiologist
i. Entomologist when vector-borne disease
– Gathered on ad hoc basis when needed
• Role
– Confirm and investigate outbreaks
• Responsibility
– Assist in the investigation and response
– Primary responsibility rests with local
health staff Monitoring the situation:
• Trends in cases and deaths
• Implementation of containment measures
• Stocks of vaccines and drugs
• Logistics
– Communication
– Vehicles
• Community involvement
• Media response.

Declaring the Outbreak Over

• Role of the district surveillance officer/medical health
officer
• Criteria
– No new case during two incubation periods since onset of
last case
• Implies careful case search to make sure no case are
missed.

Review of the Final Report

• Sent by medical officer of the primary health center to the
district surveillance officer/medical and health officer within
10 days of the outbreak being declared over
• Review by the technical committee
– Identification of system failures
332 Essentials of Community Medicine—A Practical Approach
– Longer term recommendations
 Integrated Disease Surveillance Project
Control Measures for an Outbreak
• General measures
– Till source and route of transmission identified
• Specific measures, based upon the results of the
investigation
– Agent
i. Removing the source
– Environment
i. Interrupting transmission
– Host
i. Protection (e.g. immunization)
ii. Case management.

Sources of Information to detect Outbreaks

• Event-based surveillance
– Rumor register
i. To be kept in standardized format in each institution
ii. Rumours need to be investigated
– Community informants
i. Private and public sector
– Media
i. Important source of information, not to neglect
• Case-based surveillance
i. Review of routine surveillance data and triggers

Outbreaks versus Epidemics

• Occurrence of cases of an illness in excess of expected
numbers
• Scale
– Outbreak
i. Limited to a small area, within one district or few
blocks
– Epidemic
i. Covers larger geographic areas
ii. Linked to control measures in district/state
– No exact precise threshold: Use a word or the other
according to whether you want to generate or deflect
attention
i. Be aware of legal implications of the use of the term
“Epidemic” in India (Epidemic Disease Act, being
revised)
• Endemic versus epidemic
– Endemicity
i. Disease occurring in a population regularly at a usual
level
– Tuberculosis, Malaria
• Epidemics
– Unusual occurrence of the disease in excess of its normal
334 Essentials of Community Medicine—A Practical Approach
expectation
i. In a geographical location
ii. At a given point of time
For example, hepatitis E, measles, cholera
 Integrated Disease Surveillance Project
SURVEILLANCE OF NONCOMMUNICABLE DISEASES

Aims
1. To monitor trends of important risk factors of NCD’s in
community over a period of time.
2. Evolve strategies for intervention of these risk factors so as
to reduce the burden of diseases due to NCD’s.
3. Strengthen NCD surveillance and integrate risk factors
surveillance.

NCD Risk Factors

1. Behavioral: Tobacco, alcohol, diet habits
2. Physical: Levels of inactivity
3. Biochemical: Blood sugar, cholesterol
4. Measurements: Height, weight, pulse, BP, wiast
circumference

Program for Control and Treatment of Occupational Diseases

Major occupational illness are listed based on three criterias:
1. Frequency
2. Severity
3. Potential for prevention.
List
• Occupational injuries
• Occupational lung disorders
• Occupational cancer
• Occupational dermatoses
• Occupational toxicology
• Occupational mental illness.

Etiological Classification of Occupational Disorders

1. Chemical: Dust, gases, acids, alkali, metals.
2. Biological factors
3. Behavioral factors
4. Social occupational factors.
5. Physical: Noise, heat, radiation.

Proposed Projects for Occupational Diseases under National

Program for Control and Treatment of Occupational Diseases
1. Prevention, control, treatment of silicotuberculosis
2. Occupational health problems of tobacco harvestors
 336 Essentials of Community Medicine—A Practical Approach
3. Hazardous process and chemicals database generation,
documentation and information dissemination.
4. Capacity building to promote research, education, training
at National Institute.

Global Strategy of Occupational Health (Fig. 22.1)

• Developing healthy work environment and healthy work
practices to promote health at work.
• Strengthening occupational health services
• Support services for occupational health
• Developing health standards on scientific risk assessment.
• Developing human resources for occupational health
• Strengthening research and developing collaboration in
occupational health services and organizations.
• Strengthening international and national policies.

Monitoring and Evaluation

Monitoring
1. Number and percent of districts providing monthly
surveillance reports on time by state and overall.
2. Number and percent response to disease specific triggers
on time by state and overall.

Fig. 22.1: Recommendations link field epidemiology and program management

 Integrated Disease Surveillance Project
3. Number and percent of labs providing adequate quality of
information by state and center.
4. Number of districts in which private providers are
contributing to disease information
5. Publication by CSU of consolidated annual surveillance
report.

Evaluation
1. Baseline study: Existing quality of lab services and waste
management practice.
2. Sample surveys: Surveys of risk factors of NCDs.
3. Mid-term evaluation: Evaluation of training activities at
various levels.
4. Trends on lab quality assurance and waste management
practices.
5. End line evaluation: Evaluation of training activities at
various levels.
6. Effectiveness information technology in surveillance, cost-
benefit analysis of a project.
 338 Essentials of Community Medicine—A Practical Approach
Chapter
grated Management of Neonatal and Chi
23
Chapter Outline
COMPONENTS OF IMNCI IN INDIA IMNCI STRATEGY IN INDIA

INTRODUCTION
Most illness contributing to under five deaths are preventable.
Only a few, mostly developing countries, account for a large
proportion of child deaths worldwide. Internationally, there has
been a call to reduced burdens contributing to infant, neonate,
child morbidity and mortality such as the world summit for
children (1990) and the Millennium Development Goals
(2001). From this, the Integrated Management of Childhood
Illness (IMCI) strategy was developed by WHO, UNICEF and
other agencies, institution and individuals to address issues
related to morbidity among children under five years of age.

Problem Statement
• In India 2.1 million children die before reaching the age of
5 years
• India accounts for one-fifth of the global child morbidity
burden
• IMR—60 to 7 per 1000 live births of which two-third are
neonates.
• NMR—40 to 45 per 1000 live births.
• National Goals of India by 2015
– IMR—27 and NMR—20.

COMPONENTS OF IMNCI IN INDIA

1. Care of newborns and young infants (<2 months)
2. Care of infants and children (2 months to 5 years)
3. Home visits
4. Skill based training
5. Strengthening the Health Systems and Referral
6. Improvements of family and community practices
7. Collaboration with other departments, PRIs, SHGs, MSS.

IMNCI STRATEGY IN INDIA

Implementation of Integrated Management of Neonatal and
Childhood Illness, in the district is a component of the Child
Health Strategy under
 336 Essentials of Community Medicine—A Practical Approach
the National Rural Health Mission/Reproductive and Child
Health Program Phase II. The IMNCI strategy has been
developed by child health researchers, academicians, the
Indian Academics of Pediatrics (IAP) and National
Neonatology Forums (NNFs). According to operational
guidelines developed by the Indian Ministry of Health and
Family Welfare, Governments of India, the IMNCI package
includes the following components:
I. Care of newborns and young infants (under-two months):
• Keeping the baby warm
• Initiation of breastfeeding immediately after birth and
counseling for exclusive breastfeeding and non-use of
prelacteal feeds
• Cord, skin and eye care
• Recognition of illness in newborn and management
and/or referral
• Immunization
• Home visits in postnatal period.
II. Care of infants (2 months and 5 years):
• Management of diarrhea, acute respiratory infections
(pneumonia), malaria, measles, acute ear infection,
malnutrition and anemia
• Recognition of illness, risk conditions and their
management and referral
• Prevention and management of iron and vitamin A
deficiency
• Counseling on feeding for malnourished children
between two to five years
• Immunization.
III. Home visits: Home visits made by ANMs, ASHAs and link
volunteers are integral part of this intervention which help
mothers and families to understand and provide essential
newborn care at home.
IV. Training: IMNCI involves two categories of skill based
training. One for medical officers and a second for front
Line functionaries including ANMs and AWWs. For ASHA
and link volunteers if any a separate package focusing on
home care of newborn and children is being prepared.
V. Improvements to health systems: Essential elements
include:
• Ensuring availability of essential drugs
• Improves referral to identified referral health facility
• Referral mechanism to ensure that an identified sick
infant or child can be swiftly transferred to a higher
level of care
• Functioning referral centers, especially where health
care systems are weak, referral institutions need to be
reinforced or private/ public need to be established
• Ensuring availability of health workers/providers at all
levels.
 Integrated Management of Neonatal and Childhood
Illnesses 337

• Ensuring supervision and monitoring follow-up visits by

trained supervisors.
VI. Improvements of family and community practices:
Counseling of families and creating awareness among
community on healthy behaviors through IEC campaigns
and counseling of caregivers and families as part of
management of the sick child.
VII. Collaboration/Community Medicine coordination with
other departments, PRIs, Self-Help Groups, MSS, etc.
Globally
Integrated Management of Childhood Illness (IMCI)

India
Integrated Management of Neonatal and Childhood Illness
(IMNCI) (Table 23.1)
Table 23.1: Integrated management of neonatal and childhood illness

Feature Generic IMCI Indian IMNCI

Coverage of 0-6 days No Yes
(early new born period)
Basic health worker module No Yes
Home visit module by provider for care No Yes
of new born and young infants
Home based training No Yes
Duration of training on newborn/ 2 of 11 days 4 of 8 days
young infant
Sequence of training Child first then Newborn/young
young infant infant then children

Timeline of IMNCI
1. Instrument Development (July-Sep, 2006)
2. Program Managers Meeting (August, 2006)
3. International Advisory Board meeting (September, 2006)
4. National Orientation and Protocol Finalization Workshop
(September, 2006)
5. Second International Advisory Board meeting (November,
2006)
6. Regional Training Workshops (February-March, 2007)
7. Data Collection (March-May, 2007)
8. Data Analysis (ongoing)
9. Draft Report Writing (ongoing)
10. Dissemination of Results (July, 2009)
11. Final Report (August, 2009).
 338 Essentials of Community Medicine—A Practical Approach
The IMNCI-PLUS
• The objective of IMNCI-PLUS strategy in RCH II are to
implement by 2010, a comprehensive newborn and child
health package at the level of all subcenters (through
ANMs). Primary health centers (through medical officers,
nurse and LHVs) and first referral units (through medical
officers and nurses).
• Implement by 2010 a comprehensive newborn and child
health package at household level in 250 districts (through
AWWs).
 Chapter
Community-based
24 Rehabilitation
Chapter Outline
HARD FACTS NEED OF REHABILITATION SERVICE

INTRODUCTION
Community-based Rehabilitation (CBR) strategy was
developed by the WHO after 1978. Alma Ata declaration,
which stated that comprehensive primary health care, should
include promotive, preventive, curative and rehabilitative
care. The major objective of CBR is to ensure that people with
disabilities (PWD) are able to maximize their physical and
mental abilities, have access to regular services and
opportunities and achieve full social integration within their
communities. CBR is a comprehensive approach, which
encompasses disability prevention and rehabilitation in
primary health care activities and integration of disabled
children in ordinary school and provision of opportunities for
the gainful economic activities for disabled adults.
Community-based Rehabilitation (CBR) may be defined,
according
to three United Nation Agencies, ILO, UNESCO, and the
WHO, as a strategy within community development for the
rehabilitation, equalization of opportunities, and social
integration of all people with disabilities. CBR is implemented
through the combined efforts of disabled people themselves,
their families and communities, and the appropriate health,
education, vocational and social services.

HARD FACTS
• One billion population distributed over 27 states and 7 union
territories that are further divided into 557 administrative
units called districts.
• About five percent persons with disabilities.
• Seventy eight percent population lives in rural areas.
• Fifteen percent people who live in urban areas have access
to some kind of rehabilitation service whereas in rural areas
it is only one percent.
• On average 5 to 10 percent person with disabilities has
access to basic rehabilitation services.
 340 Essentials of Community Medicine—A Practical Approach
NEED OF REHABILITATION SERVICE
Only 15 percent people living in urban areas and three
percent people living in rural areas can avail rehabilitation
service in India, total coverage according Ministry of Social
Justice and Empowerment is only 5.7 percent

Seven National Levels Institutes

• National Institute for the Visually Handicapped, Dehradun
• National Institute for the Hearing Handicapped, Mumbai
• National Institute for the Mentally Handicapped,
Secunderabad
• National Institute for the Orthopedically Handicapped,
Kolkata
• National Institute of Rehabilitation Training and Research,
Cuttack
• Institute for the Physically Handicapped, New Delhi
• National Institute for the Empowerment with Persons with
Multiple Disabilities, Chennai

Government Rehabilitation Services

The Ministry of Social Justice and Empowerment is the nodal
agency of the Central Government that promotes services for
the people with disabilities through its various schemes.

Objectives
The primary object is to promote services for people with
disabilities through government and non government
organizations, so that they are encouraged to become
functionally independent and productive members of the
nation through opportunities of education, vocational training,
medical rehabilitation, and socioeconomic rehabilitation.
Emphasis is also placed on coordination of services
particularly those related to health, nutrition, education, science
and technology, employment, sports, cultural, art and craft and
welfare programs of various government and nongovernment
organizations.
• District Rehabilitation Center (DRC) Project
• Regional Rehabilitation Training Center (RRTC)
• National Information Center on Disability and Rehabilitation
(NICDR)
• National Council for Handicapped Welfare
• National Handicapped Finance and Development
Corporation
• Assistance through Overseas Development Administration,
UK
• Training in the UK under the Colombo Plan
• UNICEF Assistance in collaboration with the Government
of India National Awards.
 Community-based
District Rehabilitation Center (DRC) Project
The District Rehabilitation Center scheme was launched in
early 1985 to provide comprehensive rehabilitation services
to the rural disabled.
 342 Essentials of Community Medicine—A Practical Approach
This was done in collaboration with the National Institute of
Disability and Rehabilitation Research (NIDRR), Washington,
USA. A Central Administrative and Coordinaiton Unit (CACU)
for coordinating and administering the activities of DRC was
setup.
The aims and objectives of the DRCs include surveys of
disabled population, prevention, early detection and medical
intervention and surgical correction, fitting of artificial aids
and appliances, therapeutic services—physiotherapy,
occupational therapy and speech therapy, provision of
educational services in special and integrated schools,
provision of vocational training, job placement in local
industries and trades, self-employment opportunities,
awareness generation for the involvement of community and
family to create a cadre of multi- disciplinary professionals to
take care of major categories of disabled in the district. At
present, 11 DRCs function in 10 states in India.

Regional Rehabilitation Training Center (RRTC)

Four Regional Rehabilitation Centers have been functioning
under the DRCs scheme at Mumbai, Chennai, Cuttack and
Lucknow since 1985 for the training of village level
functionaries, training of DRCs professionals, orientation and
training of State Government officials, research in service
delivery and low cost aids, etc. Apart from developing training
material and manuals for actual field use, RRTCs also produce
material for creating community awareness through the
medium of folders, posters, audio- visuals, films and
traditional forms.

National Information Center on Disability and Rehabilitation (NICDR)

A National Information Center on Disability and Rehabilitation
was set up under CACU in 1987 to provide a database for
comprehensive information on all facilities and welfare
services for the disabled within the country. It also acts as a
nodal agency for awareness creation, preparation/collection
and dissemination of materials/information on disability relief
and rehabilitation. The computerized data so far collected
relates to institutions/professionals working for the disabled,
aids and appliances, scholarships, national awards and
physical/financial performance of DRCs/RRTCs. It publishes
the Indian Journal of Disability and Rehabilitation.
The Media Cell is responsible for the publication of
awareness- generation material/journals, hold
seminars/workshops, organization of film festival/exhibitions,
production of films, etc. UNICEF assistance is obtained for
different activities on awareness creation.

Proposed Program for Rehabilitation of the Disabled in the Ninth

Five-year Plan
• At the Gram Panchayat level the local panchayat
committee will manage the CBR program. Preferably, two
CBR workers—one male
 Community-based
and one female, for about 5,000 population, may be
employed and suitably trained at the Gram Panchayat level.
• At the PHC level 2 multirehabilitation workers (MRWs) for
about 30,000 population will be responsible to provide
services to the persons with disabilities. They will provide
information to community leaders, to the persons with
disabilities and their families about disability. They will also
provide services and opportunities using already available
resources. The MRW will cooperate with PHC, education,
labor, NGOs and other persons, which will make services
available and open opportunities for PWDs. They will also
make appropriate referral of cases to the District
Rehabilitation Center (DRC).
• At the district level DRC will be headed by District
Rehabilitation Officer who will monitor and guide the work
carried out at peripheral levels. Functionaries of the
department of rural development, social welfare, labor and
employment and women and child development will also
provide specialist services at the district level.
• At the state level, an apex level institution will be set up to
serve as resource center in the field of disability prevention
and rehabilitation. This institute will train the functionaries
of DRCs, PHCs and CHCs. The institute will also undertake
long and short term training program to develop the
manpower required in the state for the delivery of
rehabilitation services. It will also establish linkages with
the existing medical professionals, training and employment
infrastructure and also promote and conduct research in the
area of disability prevention and rehabilitation.
• At the national level, it is proposed that there should be a
national center for disability rehabilitation under the
national program of rehabilitation.

Role of Primary Health Centers for Disability Rehabilitation

Various services for persons with disabilities in India are very
short in supply and do not cover more than even one percent
of the entire disabled population. In order to face the
challenges of increased population and the lack of proper
services to match the needs and expectations of the persons
with disability, their family members and the society as a
whole, a suitable framework having wide coverage has to be
developed in the country for effective management of the
disabled. It is in view of these primary and basic needs, the
primary health center (PHC) network in India assumes great
importance. A PHC is the only existing minimum necessary
infrastructure to provide various disability prevention and
rehabilitation services. By sensitizing the medical officers and
health teams in PHCs on some of the important aspects of
disability prevention, early identification, referral and
rehabilitation, valuable services could be rendered to people
with disabilities in the rural areas.
 344 Essentials of Community Medicine—A Practical Approach
Primary health care in India is provided by a network of
primary health centers and its subcenters in rural areas and
health posts in urban areas. Health workers at subcenters get
help from village health guides (VHGs), traditional birth
attendants (TBAs) and Anganwadi workers in their
functioning. This huge manpower can help in identification of
disabled along with CBR workers and community level
functionaries of DRC with the help of training packages
developed by WHO.
Multi-rehabilitation workers (MRWs) at PHC with the help
of Medical Officer will attend to referred disabled and help in
training of personnel engaged at subcenter and village level.
Vocational rehabilitation centers will provide support in
relation to generating various occupational opportunities for
disabled along with NGOs and other concerned personnel at
district level.

Model Method of Implementation of CBR Using Primary Health Centers

Community level functionaries (CLF) at village and subcenter
level for a population of 5000. The village rehabilitation
committee (VRC) of the Panchayat members will manage the
activities.

Manpower
• Person with disabilities
• Family trainee
• Community rehabilitation worker
• MPHW male and female
• VHG, TBA and Anganwadi worker
• NGOs, teachers and volunteers.
Functions
• Micromanagement
• Community preparation
• Resources
• Monitoring.
Tasks
• Locate and identify PWD
• Referral
• Assess functions and activities
• Select training material and trainees
• Teach and motivate family training
• Increased acceptance by family
• Facilitate school admission
• Refer to social and vocational organization
 Community-based
• Assess record and report results to VRC
• Stimulate awareness of community about disability.
• Continuing education for CLF and teach them about health
care needs of disabled persons.
At PHC and CHC level for a population of 30,000 to 1
lakh. The Medical Officer-in-charge of PHC and CHC will
manage the activities.

Manpower
• Multirehabilitation worker (MRW)
• Health assistant male and female.

Functions
• Provide technical training, supervision and support of CBR
program
• Report on effectiveness of CBR center
• Provide first level referral advice and refer to higher level if
required
• Interact with middle level personnel in other sectors like
social, education and labor and coordinate supports to
community.

Orientation of Medical Officers Working in

Primary Health Centers to Disability Management
Rehabilitation Council of India has launched the National
Program on Orientation of Medical Officers working in
Primary Health Centers to Disability Management on 15th July
1999, with a view that the Medical Officers of PHCs could be
trained in various disability issues, PHC is the only health
infrastructure, which is spread over the country. Training the
Medical Officers in Disability Prevention and Rehabilitation
can bring significant benefits to the persons with disabilities.
Most of the disable people live in the rural areas with very
poor infrastructure for providing rehabilitation services. In
view of such gross neglect of rural areas, this program has
been designed for rural disabled.
The program is being implemented in two stages. In the
first stage, a master training program is imparted in each
state to a team of medical practitioners/rehabilitation
professionals working in the institutions selected to conduct
the master training program. In the second stage, the trained
Master Trainer's Services are utilized for taking up the training
of the Medical Officers working in the PHCs. The ingenuity of
program is the utilization of the rehabilitation professionals
taken from all the disability areas for the training of Medical
Officers. This has been consciously done with a view to add
thrust to program by way of transferring the rich knowledge
and experience of these professionals to the Medical Officers
regarding various intricate disability issues. Another notable
feature of the program is the selection of institutions, which
have rich experience and possess laboratories in one or
more
 346 Essentials of Community Medicine—A Practical Approach
areas of disability. This not only gives an opportunity to the
doctors to observe themselves the various facets of disability
and also allow them to gain practical insight into managing
the problems in the locality covered under their PHCs.

Expected Benefits of the Program

1. The program is expected to generate in the country, the
following benefits in the short as well as in the long run.
2. Large scale direct benefit of various services like
prevention, early identification, referral and rehabilitation
to the rural population.
3. Wide and improved service network for the persons with
disabilities even in the remotest corners of the country.
4. Decrease in the severity and extent of disability in millions
of cases.
5. Increase in the GDP, as the impact of disability prevalence
will be less.
6. Awareness generation among the Health Workers through
the PHC Medical Officers which will percolate to the lowest
level as the lower level health workers function within the
community.
7. Social and economic empowerment of the persons with
disability.
8. Leadership building in the PHC Medical Officers to help
create better sensitization at the grass root level which will
ultimately ensure better implementation of the Persons with
Disabilities Act, 1995.

BIBLIOGRAPHY
1. Disability Prevention and Rehabilitation in primary health care—
a guide for district health and rehabilitation managers.
Rehabilitation, WHO, 1995.
2. National programme on orientation of medical officers working in
primary health centres to disability management-status of
implementation 2001, Rehabilitation Council of India.
3. Proceedings of workshop on Community-based Rehabilitation
WHO sponsored—department of Physical Medicine and
Rehabilitation, Safdarjang Hospital, New Delhi, 1997.
4. The Persons with Disabilities (equal opportunities, protection of
rights and full participation) Act 1995—Ministry of Law, Justice
and Company affairs.
 Community-based
Chapter
25 Social Security

Chapter Outline
WORKFORCE IN INDIA
FUNCTIONS OF SOCIAL SECURITY DIVISION

INTRODUCTION
Social security protects not just the subscriber but also
his/her entire family by giving benefit packages in financial
security and health care. Social security schemes are
designed to guarantee at least long-term sustenance to
families when the earning member retires, dies or suffers a
disability. Thus, the main strength of the social security
system is that it acts as a facilitator—it helps people to plan
their own future through insurance and assistance. The
success of social security schemes, however, requires the
active support and involvement of employees and employers.
In the Indian context, social security is a comprehensive
approach designed to prevent deprivation, assure the
individual of a basic minimum income for himself and his
dependents and to protect the individual from any
uncertainties. The state bears the primary responsibility for
developing appropriate system for providing protection and
assistance to its workforce. Social security is increasingly
viewed as an integral part of the development process. It
helps to create a more positive attitude to the challenge of
globalization and the consequent structural and technological
changes.

WORKFORCE IN INDIA
The dimensions and complexities of the problem in India can
be better appreciated by taking into consideration the extent
of the labor force in the organized and unorganized sectors.

Organized and Unorganized Sectors

The organized sector includes primarily those establishments
which are covered by the Factories Act, 1948, the Shops and
Commercial Establishments Acts of State Governments, the
Industrial Employment Standing Orders Act, 1946, etc. This
sector already has a structure through which social security
benefits are extended to workers covered under these
legislations.
 Social Security
The unorganized sector on the other hand, is characterized
by the lack of labor law coverage, seasonal and temporary
nature of occupations, high labor mobility, dispersed
functioning of operations, casualization of labor, lack of
organizational support, low bargaining power, etc. all of
which make it vulnerable to socioeconomic hardships. The
nature of work in the unorganized sector varies between
regions and also between the rural areas and the urban areas,
which may include the remote rural areas as well as
sometimes the most inhospitable urban concentrations. In the
rural areas it comprises of landless agricultural laborers,
small and marginal farmers, share croppers, persons engaged
in animal husbandry, fishing, horticulture, bee-keeping, toddy
tapping, forest workers, rural artisans, etc. where as in the
urban areas, it comprises mainly of manual laborers in
construction, carpentry, trade, transport, communication, etc.
and also includes street vendors, hawkers, head load workers,
cobblers, tin smiths, garment makers, etc.

FUNCTIONS OF SOCIAL SECURITY DIVISION

List of Subjects
• Matters concerning framing of social security policy
especially for the organized sector of workers.
• Administration of Employees' State Insurance Act, 1948.
• Administration of the Employees' Provident Funds and
Miscellaneous Provisions Act, 1952 and three schemes
framed there under, namely:
– The Employees' Provident Fund Scheme, 1952
– The Employees' Pension scheme, 1995
– The Employees' Deposit linked Insurance Scheme, 1976.
• Workmen's Compensation Act, 1923.
• Maternity Benefits Act, 1961.
• Payment of Gratuity, Act, 1972.
• Establishment matters relating to the Employees' State
Insurance Corporation—Constitution of ESI Corporation,
Standing Committee and Medical Benefit Council of ESIC as
also Regional Board.
• Administrative matters of ESI Corporation including
implementation of ESI Scheme in New Geographical Areas,
opening of Sub-Regional Offices of ESIC and up-gradation of
medical facilities.
• Annual report, budget and accounts, and matters connected
with auditing of accounts of the ESIC and EPFO
• Issues relating to International Social Security Association
(ISSA); and other International Social Security
Organizations. Processing of ILO Conventions relating to
social security.
• All parliamentary matters and MP/VIP References in
relation to the above as also legislative matters/amendment
in respect of the aforesaid Acts.
348 Essentials of Community Medicine—A Practical Approach

• Vigilance matters/Disciplinary proceedings relating to

officers of EPFO and ESIC.
• Representations from employees of ESIC and EPFO, and
general public grievances on ESIC/EPFO/Social Security
measures in India.
• All matters relating to setting up of EPF Appellate
Tribunal- establishment matters and appointment of staff.
• Constitution of the Central Board of Trustees and
Regional Committees, EPFO.
• All matters relating to:
– Pattern of investment of provident fund money.
– Declaration of rate of interest on the provident fund.
– Enhancement of the rate of provident fund contributions.
– Budget of the EDLI Scheme and EPS;
– Payment of central government contribution and
administrative charges for Family Pension Scheme,
Deposit Linked Insurance under the EPF Act as well as the
Assam Tea Plantation Provident Fund Act.
– References relating to recovery of EPF/ESI
dues/exemptions and Exclusions from the EPF and MP
Act and also the ESI Act.

EPFO Programs at a Glance (Table 25.1)

Table 25.1: EPFO programs at a glance

Program name Program type Financing Coverage
Employees Mandatory • Employer: 1.67–3.67% Firms with + 20
provident fund • Employee: 10–12% employees
• Government: None
Employees Mandatory • Employer: 8.33% Firms with + 20
pension • Employee: None employees
scheme (EPS) • Government: 1.16%
Employees deposit Mandatory • Employer: 0.5% Firms with+20
linked insurance • Employeees: None employees
Scheme (EDLI) • Government: None

ESI contribution rates

• Employees: 1.75 percent of wages
• Employers: 4.75 percent of wages
• State Govts.: 1/8th share of expenditure.
A few examples of other retirement programs giving social
security (Table 25.2).
(Information on extent of coverage of the labor force
under these programs is not available).
 Social Security
Table 25.2: Retirement programms in social security

Program name Program type Financing Coverage

Civil service Mandatory State or central Civil servants at state and
pension scheme Government central government level
Government Mandatory Employee Civil servants at state and
provident fund contribution central government level
Special provident Mandatory Employer and Applies to worker in
particular funds employee sectors: Coal, mines, tea
contributions plantation, Jammu and
Kashmir seamen, etc.
Public provident Voluntary Contributions All individuals are eligible to
fund apply
Personal pension Voluntary Contributions Employees as decided by
respective establishments
Personal pension Voluntary Purchase of All individuals
annuity type
products
State level social Government State Varies by state and type of
assistance sponsored Government scheme
social
assistance
National old age Government Central Poor persons above age 65
pension scheme sponsored Government
social
assistance

New Initiative in Social Security

Varishtha Pension Bima Yojana (VPBY): This scheme proposed
in the 2003- 04 budget by the Ministry of Finance is to be
administered by the Life Insurance Corporation of India (LIC).
Its main features are summarized below:
• Under VPBY, any citizen above 55 years of age could apy a
lump-sum and get a monthly pensions are pegged at Rs. 250
and Rs. 2000 per month respectively. These amounts are
not indexed to inflation.
• There is a guaranteed return of nine percent per annum for
this scheme.
• The difference between the actual yield by the LIC under
this scheme and the 9 percent will be made up by the
central government.
• The EPF and MP Act is proposed to be amended suitably to
allow EPF subscribes to invest in the VBPY.
 Chapter
26 Swine Flu

Chapter Outline
TRANSMISSION SIGNS AND SYMPTOMS

INTRODUCTION
Swine influenza was first proposed to be a disease related to
human influenza during the 1918 flu pandemic. When pig
became sick at the same time as human. The first
identification of an influenza virus as a cause of disease in pigs
occurred about ten years later, in 1930. For the following 60
years, swine influenza strain were almost exclusively H1N1.
Then, between 1997 and 2002, new strain of three different
subtype and five different genotype emerged as cause of
influenza among pigs in North America. In 1997 to 1998,
H3N2 strain emerged. These strain, which include genes
derived by reassortment from human, swine and avian virus,
have become a major cause of swine influenza in North
America.

Outbreak in Human, 2009

The H1N1 viral strain implicated in 2009 flu pandemic among
human often is called “swine flu” because initial testing
showed many of genes in the virus were similar to influenza
viruses normally occurring in North American swine.

TRANSMISSION
The main route of transmission is through direct contact
between infected and uninfected animals. These close
contacts are particularly common during transport. Intensive
farming may also increase the risk of transmission, as the pigs
are raised in very close proximity to each other. The direct
transfer of the virus probably occurs either by pigs touching
noses or through dried mucus. Airborn transmission through
the aerosols produced by pigs coughing or sneezing are also
an important means of infection. The virus usually spread
quickly through a herd, infect all the pigs within a few days.
Transmission may also occur through wild animals, such as:

Transmission to Human
People who work with poultry and swine, especially people
with intense exposures, are at increased risk of zoonotic
infection with influenza virus
 Swine Flu 351

endemic in these animal and constitute a population of human

host in which zoonosis and reassortment can co-occur.

SIGNS AND SYMPTOMS

The symptoms of swine flu H1N1 virus are similar to those of
influenza and of influenza like illness in general. Symptoms
include fever, cough, sore throat, body aches, headache,
chills, and fatigue. The 2009 outbreak has shown an increased
percentage of patient reporting diarrhea and vomiting.

Cause of Death
Common cause of death is respiratory failure. Other cause of
death are pneumonia (leading to sepsis) high fever (leading to
neurological problem), dehydration (excessive diarrhea and
vomiting) and electrolyte imbalance. Fatality are more likely
in young children and the elderly.

Prevention
i. Prevention in swine
ii. Prevention of transmission to human
iii. Prevention of its spread among humans.

Prevention in Swine
i. Facility management
ii. Herd management
iii. Vaccination.

Facility Management
Facility management includes using disinfectant and ambient
temperature to control virus in environment.

Herd Management
Herd management includes not adding pigs carrying influenza
to herds that have not been exposed to the virus. The virus
survives in healthy carrier pigs for upto three months.
Prevention of human-to-human transmission: Frequent
washing of hands with soap and water or with alcohol-based
hand sanitizers, especially after being out in public.
Social distancing is another tactic. It means staying away
from other people who might be infected and can include
avoiding large gatherings, spreading out a little at work or
perhaps staying home and lying low if an infection is
spreading in a community.
 352 Essentials of Community Medicine—A Practical Approach
Treatment in human being: If the person become sick with
swine flu, antiviral drugs can make illness milder and make the
patient feel better faster. They may also prevent serious flu
complications. For treatment antiviral drugs work best if
started soon after getting sick (within 2 days of symptoms).
Beside antivirals, supportive care at home or in hospital,
focuses on controling fevers, relieving pain and maintaining
fluid balance, as well as indentifying and treating any
secondary infections or other medical problems. The US
Centers for Disease Control and Prevention recommends the
use of Tamiflu (oseltamivir) or Relenza (zanamivir) for the
treatment and prevention of infection with swine influenza
viruses; however, the majority of people infected with the
virus make a full recovery without requiring medical attention
or antiviral drugs. The virus isolates in the 2009 outbreak
have been found resistant to amantadine and rimantadine.
 Chapter
27Hospital Statistics
Chapter Outline
DAILY ANALYSIS MONTHLY REPORTS
CENSUS DEATH RATE

DAILY ANALYSIS
• Daily census of admissions, births, transfer in, transfers out
and death complied by ward and by specialty.
• Daily discharge analysis.

MONTHLY REPORTS
• Summary of outpatient visits (first and repeat).
• Summary of inpatient activity speciality wise: number of
admissions, discharges, death, hospital days, mean length of
stay, bed turnover ratio, occupancy rate, mortality rate,
operations, infections, specialized procedures.

CENSUS
• Inpatient bed occupancy ratio:
Total inpatient service days for a period × 100
Total inpatient bed count × number of days for a period
• Average daily newborn inpatient service days for a
period. Total number of days in the period.

DEATH RATE
• Hospital death rate (Gross death rate):
No.
= of inpatient deaths in a period 
No. of discharges (including deaths) in the same
100
period
• Postoperative death rate:
Total no. of deaths within 10 days postoperative for
 a period Total no.of patients operated upon for  100
the period
• Anesthesia death rate:
Total number of deaths due to anesthetic agents for a
 period Total no. of patients administered anesthesia
 100
for the period
 354 Essentials of Community Medicine—A Practical Approach
• Maternal death rate (Maternal mortality rate):

 Total no.of direct maternal deaths for a period

No. of obstetric discharges (incl. deaths) for
 100
the period
• Neonatal death rate

 Total number of newborn deaths for a period


No of newborn infant discharges (incl. deaths) for
100
the period
• Perinatal mortality rate:
Intermediate (20-28 weeks gestation or 500-1000 gm weight)
and late fetal (after 28 weeks) deaths + neonatal

 Deaths (less than 28 days)


Births and fetal deaths for the
100
period
• Hospital admission rate
Hospital admission rate denotes the number of hospital
admissions per 1000 population per year. Hospital
admission rate
Total admissions during the year
 Midyear population
 100
• Per capita hospitalization rate
Per capita hospitalization rate is the per capita days of
hospital care given per 1000 population for a particular
geographical area. During a particular period. It expresses
the volume of hospitalizations in terms of number of
hospitalization days per person per year.
Total number of days inpatient care
 Midyear population
 100
The rang varies from 0.3 to 1.5 in India, it is approximately
0.3.
• Bed turnover rate (BTR)
Bed turnover rate gives the number of discharges per
hospital bed over a given period, i.e. how many times a bed
was “turned over” during the period, say a year. It is
directly related to the average length of stay (ALS) and bed
turnover interval (BTI).
No. of discharges for a given period of time
Bed turnover
rate: Average bed count for that period of time

Average length of Total patient days during a given

stay = period Total discharges (including
deaths) during the same period
 Hospital Statistics 355

• Average length of stay (ALS)

Average length of stay (ALS) is the average period in
hospital (in days) per patient admitted, i.e. the average
number of days of service rendered to each inpatient
Number of inpatient days care (excluding) healthy newborn
during the year
ALS = Total number of discharges and deaths.

Other Statistics
• Autopsy rate
This relates to autopsies carried out on patients who died in
hospital Therefore, it excludes stillbirths. Dead on
arrival/brought in dead. and medicolegal cases.
Autopsy rate No of autopsies
=  100
No of deaths in
hospital
• Consultation (written only) rate
No. of patients receiving consultations
No. of patients discharged (and
 100
dead)

Cesarean Section Rate

 Total no. of cesarean sections in a period


No. of deliveries (incl. cesarean sections) in the
100
period

Infection Rates
Hospital infection
rate:
Total no. of nosocomial infections in the hospital
(or specific clinical unit) for a period
 Total no. of discharges (incl. deaths) in the  100
hospital (or specific clinical unit) for the
period
• Postoperative infection rate:
No. of infections in clean surgical cases for
 a period Number of clean surgical  100
operations for the period
 Chapter
28 Biostatistics

Chapter Outline
COLLECTION AND PRESENTATION OF DATA
GRAPHICAL REPRESENTATION OF DATA
CENTERING CONSTANTS (MEASURES OF CENTRAL TENDENCY)
MEASURES OF VARIATION
INTERNATIONAL DEATH CERTIFICATE—CAUSE OF DEATH

INTRODUCTION

Definitions of Statistics
The word “statistics” used in plural means ‘figures’ but while
used in singular it implies “science of figures” such as
collection, presentation, analysis and interpretation of data.

Quantitative Medicine
Since, every thing in medicine be it research, diagnosis, or
treatment depends on measurement and counting the medical
biostatistics is defined as quantitative medicine.

Science of Variation
For defining normal health and prescribing the normal limits
for health, the variations in the characteristics like pulse rate,
blood pressure, height, weight, etc. are noted and studied. In
this sense it is defined as science of variation.

Science of Averages
Many types of averages are computed in course of the analysis
of a statistical data to arrive at an inference or interpretation.
In this connection it is also defined as the science of averages.
Biostatistics in the real sense means “Science of figures
about any life”.
The three important branches of biostatistics are: (a) Health
statistics,
(b) Medical statistics, and (c) Vital statistics.
a. The Health Statistics are collected in connection with the
assessment of health and for prescribing the normal limits
of health.
 Biostatistics
b. The medical statistics deal with the study of injury defect
and disease. The efficiency of various drug. Seraline of
treatment are also tested statistically in this branch.
c. Vital statistics deal with the figures of births deaths and
marriages in populations.

Use of Biostatistics
1. Interpretation of observation
2. Assessment of patient/situation/problem
3. Management of patient/situation/problem
4. Evaluation of patient/situation/problem.

COLLECTION AND PRESENTATION OF DATA

The data collected in respect of any characteristics will be full
of figures and lies in a haphazard manner. It conveys no
meaning unless the figures are sorted out properly and
presented systematically.
The following are the principles of presentation:
1. To arrange the data in such a way that it should create
interest in the reader’s mind at the first sight.
2. To present the information in a compact and concise form
without losing important details.
3. To present the data in a simple form so as to draw the
conclusion directly by viewing at the data.
4. To help in the further statistical analysis.

Presentation of Data (Flow chart 28.1)

Flow chart 28.1: Presentation of data

 358 Essentials of Community Medicine—A Practical Approach
Frequency Table
It is a table showing the frequency with which the values are
distributed in different groups or classes with some defined
characteristic.

Construction of a Frequency Table

Rules: Rules to be followed in the construction of a frequency
table.
a. The class interval should not be too large or too small.
b. The number of classes to be framed more than 8 and less
than 15.
c. Class interval should be equal and uniform throughout the
classification. d. After the construction of the table, proper
and clear heading should
be given to it.
e. The base or source of a data should be mentioned with the
pattern of analysis in a footnote at the end of the table.
f. If some observations are omitted or missing the details of
exclusion of such observations should be mentioned.

GRAPHICAL REPRESENTATION OF DATA

Graphs
1. The data is presented diagramatically.
2. It gives better grasp than the table.
3. Interpretation is done by rough translation of the points into
the actual figures as a change in the scale will give different
patterns.
4. Graphs should never be substituted for statistical table
because the graphs cannot have the mathematical
treatment whereas table can be treated mathematically.
5. Whenever comparing graphs note the difference in the scale
if any.

Bar Diagram (Fig. 28.1)

It is used for representing discrete or discontinuous data.
Data is presented in form of rectangular bars of equal
breadth. Each bar
 Biostatistics
Fig. 28.1: Bar diagram—prevalence of reproductive tract infection
 360 Essentials of Community Medicine—A Practical Approach
represents one attribute/variate. The width of the bar and the
gaps between the bars should be the same throughout. Scale
must from zero if not it may be indicated by broken bar.
1. Breadth of all bars is equal.
2. Length of each bar is proportional to the frequency of the
characteristic it is representing.
3. Distance between the bars is smaller than the breadth of
each bar.
4. Scale has been indicated.
5. Scale starts from zero.
6. Available space is used.

Proportional Bar Diagram (Fig. 28.2)

The bar is colored differently to show various proportions.
Gynecological morbidity
Age Vaginitis Cervicitis Cervical Genital
Pelvic Firm bulley
group erosion prolapse
inflamma- uterul
years tory disease
No% No% No% No% No% No% No% No% No% No% No% No%
15-25 12 18.2 34 31.7 21 20.6 4 10 11 31.4 02 14.3
26-35 37 56.1 57 53.3 61 59.8 10 25 18 51.4 08 57.1
36-45 16 24.2 11 10.3 18 17.6 20 50 5 14.3 02 14.3
46+ 01 1.5 05 4.7 02 2.0 6 15 01 2.9 02 14.3
Total 66 100 107 100 102 100 40 100 35 100 14 100

Fig. 28.2: Proportional bar diagram—age-wise distribution

of gynecological morbidity on clinical examination

Histogram (Fig. 28.3)

1. This method is useful for presenting frequency of
quantitative continuous variate.
2. It is an area diagram composed of a series of adjacent
rectangles. The area of each rectangle is proportional to the
frequency of that group or class.
 Biostatistics

Fig. 28.3: Histogram with frequency polygon

3. The width of the rectangles is equal.

4. Histogram is useful to represent the mode graphically.
5. The only disadvantage of this graph is that it varies
accordingly to the class intervals.

Frequency Polygon
Frequency polygon is an area diagram of frequency
distribution developed over a histogram.
It is a linear representation of a frequency table and
histogram. Frequency is plotted at the central point of a
group. It is used when two or more frequency distributions
are to be compared.

Pie Diagram (Fig. 28.4)

This is used for showing proportions of the total areas of
sectors of a circle each sector represents an attribute/variate.
It is used for presenting qualitative data and quantitative
discrete data.

The Ogive
The ogive is graph of the cumulative relative frequency
distribution.
This is curve plotted on X- and Y-axis with the
corresponding cumulative frequency of each class or group.
This curve is useful to find the median and the quartiles
graphically.
 362 Essentials of Community Medicine—A Practical Approach

Fig. 28.4: Pie diagram—gynecological morbidity on clinical examination

CENTERING CONSTANTS
(MEASURES OF CENTRAL TENDENCY)
Measures of central tendency is measurement of variate
which represents a group of individual measurement in a
simple and precise manner.
After collecting and presenting the data in frequency
distribution, it is essential to calculate certain values which
may be used as descriptive characteristic of that distribution.
With the help of these values it is possible to make the
comparisons between two series of observations as they
represent the entire data. A majority of the observations are
very close to this value.
There are three measures of central tendency.
There are helpful in measuring closeness of each
observation to the central value and to understand the
homogenicity of the information collected.
a. Mean b. Median c. Mode

Arithmetic Mean
It is the sum of observations divided by the total number of
observations and is noted by x .
By Definition
x
f
i. x = (for unclassified data) ii. x
(for classified
x
n = data)
N
The arithmetic mean is used usually when the data is
quantitative.
 Biostatistics
Median
i. Median is the middle most item when the observations are
arranged either in ascending or in descending order of
magnitude (for unclassified data).
N c
ii. Median   2   (for classified data)
l   i
f
Where l = Lower limit of the median class N= Total
frequency
f = Frequency of the median class i = Class interval
c = Cumulative frequency of the class preceeding to
the median class. Median is usually preferred in
case if the data is quantitative type.

Mode
Mode is that value of variate for which the frequency is
maximum.
It is calculated if median and mean are known by using the
relation.
Mode = 3 (Median) – 2 (Mean)
In case of normal distribution, Mean = Median
= Mode
Mode is generally used in the field of industrial statistics to
control the quality of the products produced.

MEASURES OF VARIATION
Measures of variation are computed to know the degree of
scatteredness of each value from the central value. The
important measures of variation are larger scatteredness
indicate not normal condition while less or no scatteredness
suggest to the normal conditions.
• Range
• Mean deviation
• Standard deviation
• Coefficient of variation
• Quartile deviation
• Inter-quartile range
• Percentile.

Range
It is the difference between the maximum and minimum value
of the observation. It quantities the variation in one number.
The nature of variation between the observations is not taken
into account.
Range = X –X
max
min
 364 Essentials of Community Medicine—A Practical Approach
Mean Deviation (MD)
It is arithmetic average of each observations from the mean
neglecting the sign of the deviation. It measures the absolute
distance of each observation from the central value as an
average.

Mean deviation |(X  x)|

(MD) = (for unclassified data)
n
f |(X  x
Or (for classified data)
)| N
=

Standard Deviation (SD)

It is defined as ‘Root-Means—Square-Deviation’.
(x  x)2
SD = n  1 for n < 30

If the number of observation is less than 30, then the sum of

squares of deviation is divided by (n – 1) instead of n. It is the
most sensitive measures of variation lesser SD reveals smaller
variation and a bigger SD suggests the deviation from normal
condition.
(x  x)2
SD = n for large size

Coefficient of Variation (CV)

It is a relative measure of dispersion defined as the ratio of
SD to the mean and expressed in percentage.
SD
CV = × 100%
Mean
If the CV is small then observations are considered to be
more consistent as it reveals little variation from the normal
value higher value of CV. Suggests uncomfortable situation.

Quartile Deviation (QD)

It is obtained by dividing the range between the lower and
upper Quartiles by 2.

QD =
Q3 – Q1
2 ,
where = lower Quartile = upper Quartile
Q and Q
1 3
 Biostatistics

Coefficient of Q3 –
QD = Q1 Q3
 Q1

Percentile
In inter-quartile range, we divide the set of observations into
four parts. If the series is divided into 10 equal parts then
each part is called as ‘decile’ if it is divided into 100 equal
parts, each part is called “percentile”.

Tests of Statistical Comparison of Two Groups

Tests of statistical comparison of two groups where the cause
effect relationship is to be established for a certain factor
under consideration.

Tests of Statistical Significance (Flow chart 28.2)

Flow chart 28.2: Tests of statistical significance

• Chance: Something unexpected

• Probability: May be defined as possible chances of
occurrence. With which an event is expected to occur on an
average, such as of giving birth to a boy in the first
pregnancy.
• Null hypothesis: Assumption is made that external factor
plays no role in the condition under study. Such an
assumption is called Null Hypothesis (Ho). This hypothesis
nullifies the claim that the experimental result is different
from or better than the one observed already.

Test of Significance (for Large Size)

Standard Error of Mean

Definition: Standard error (SE) of any statistical value is a
measure of variability that would occur merely by chance in
the repeated samples of the same size drawn from the same
population. The standard error
 366 Essentials of Community Medicine—A Practical Approach

of mean is given SD
by SE  , i.e. the SE varies directly with
x n
SD and
inversely as square root of the size the sample.

Uses of SE of Mean
1. To find the confidence limits of population mean if the
standard deviation of the sample is known.
2. To tell whether a sample is drawn. From the same
population or not.
3. To test the significant difference between two sample means.
4. To calculate the approximate size of a sample in order to
have the desired confidence limits.
5. It measures variation due to chance (or biological factors).

Standard Error of difference between Two Means

Definition: If repeatedly independent random samples are
drawn in pairs from the same population and each time the
difference between two means of each pair is calculated. There
will be a series of difference between means. It is shown
mathematically that these differences are also normally
distributed around the population mean. The standard
deviation of difference is called as standard error of difference
between two means.
Whenever we want to test the significance of the observed
difference between two given means the standard error is
applied directly by making use of the individual standard
deviation. In case the observed difference is more than 1.96
times the standard error, then it is said to be statistically
significant at 95 percent confidence limits.

Formulae

Let X1 and X2 be the means of the first and the second

samples
respectively.
Next the steps involved in the calculation of standard
error of difference between two means are:
i. |X1  X2 |

ii. SED = SD2

SD2 2  11   1  1 
1 2 SD    = SD  
= n1n2  n1n2   n1n2 

iii. |X1  X2 |
SE
D
Note: > 1.96 the difference is significant.
The Ho is rejected (Variation is due to external factors)
< 1.96 the difference is not significant.
 Biostatistics
The Ho is accepted (Variation is due to chance).
Where Ho is null hypothesis Ho is a tentative statement
related to the population and always stated negatively, e.g.
there is no difference in the birth weight of babies born in two
different hospitals.
Or
There is no difference in growth rate of babies belonging to
two different socioeconomic groups.

Test of Significance (for Small Sample Size)

t-Distribution
If we have to test the difference between two sample means of
small size (usually less then 30) the sample standard deviation
will not be the accurate estimate of the population SD.
Secondary it has been shown mathematically that the ratio of
difference between two means to their SD will not be
following the normal distribution. But it will follow a slightly
different distribution known as “Students t-distribution”. The
tests based on this distribution are known as t-tests. There
are two t-tests.
i. t-tests for unpaired data
ii. t-tests for paired data.

Criteria for Applying t-test

1. Random samples
2. Quantitative data
3. Variable normally distributed
4. Sample size less than 30.

t-tests for Unpaired Data

This test is used when two types of observation one on
controlled group and the other on experimental group are
available to test the significance of difference between means
of the two groups.
Steps involved in the test: Suppose X and Y are two series of
observations.
1. Make the null hypothesis that there is no difference
between the two sample means.
2. Calculate the difference between the two sample means.
3. Calculate combined standard deviation.
(X  X )   (Y  Y )2
CSD = n1  n2  2
 368 Essentials of Community Medicine—A Practical Approach
Standard Error of Difference
Standard error of difference is then calculated as
1  1
SED = CSD
n1n2

tc = (X  Y)
SED
Note: > t 0.05 for df (n1 + n2 – 2) the difference is
significant Ho is rejected (Variation is due to
external factors)
< t 0.05 for df (n1 + n2 – 2) the difference is not
significant
Ho is accepted (Variation is due to chance for biological
variation)

t-tests for Paired Data

The paired t-test is used when paired observations are
available. This is when:
i. Observation are made on the same individual before
and after exposure to some factor (or treatment) under
study.
ii. The same sample is tested by two methods.
Before proceeding with the test we first frame the null
hypothesis that there is no real difference between the two sets
of observations.

Steps for Paired t-test

1. Calculate the difference in each set of observations ( x
– y = z). This will form the new set of observation (z
series).
2. Find out the mean of this series (Z).
3. Compute the SEz by the formula.
2
2 Z
Z  
i. SDz  n  SD Z
= n 1 ii. SE2 2 iii. t
SE2
= n =

t=
Z > t 0.05 for df (n – 1) the difference is
SE2 significant.
< t 0.05 for df (n – 1) the difference is not
significant. Ho is accepted.

Standard Error of Proportion (Large Sample Size)

Whenever the statistical value is of qualitative type it is the
customary to express it in proportion of percentages.
The SE of proportions is computed to know the variation in
proportions of different samples drawn from the same
 Biostatistics
population due to chance it is given by:
 370 Essentials of Community Medicine—A Practical Approach
Pqn
SEP =

p = Sample proportion (expressed in percentage)

q = 1 – p (expressed in percentage)
When p is the percentage of individuals belonging to one
category and q is the percentage of the individuals belonging
to the other category and n is the number of individuals in the
sample. Since, all sample proportions p and q follow the
normal distribution the confidence limits can be calculated to
find the range for p the population percentage.
As a convention we take 1.96 times. SE as a criteria. If the
difference exceeds 1.96 (SE) the difference is said to be
significant statistically. This rule applies for a large sample
size (>30) taken from the same population. For small sample
this does not hold good. Since, the distribution of proportion
follows the normal distribution the CL can also be computed.
P ± 1. SEp Contains 68.27 percent of sample
proportions P ± 2. SEp Contains 95.45 percent of
sample proportions P ± 3. SEp Contains 99.73
percent of sample proportions

Standard Error of Difference between

Two Proportions (Large Sample)
As we have tested the standard error of difference between
two means in case of quantitative data, we can similarly test
the difference between two proportion in case of qualitative
data by using SE of proportions.
The difference between proportions in a pair samples will
vary from pair to pair and from even sample to sample though
they are drawn from the same population or universe.
The object of the test is to determine the size of difference
that is likely to occur by chance in samples of given size and
how far it can deviated by chance. In reasonably large sample
the SE of difference may be taken as the sum of square root
of the two individual standard errors of values in two samples.

Steps for Calculation

1. Compute the difference between – P )|
proportion |(P 2
1

p1 q1  p2 q2 n1n2
2. S
( p1  p2 ) =
E

|P1  P2|
3. Z SE(  p2 )
= p1
 Biostatistics
Probability of a Larger Value of ‘t’ (Table 28.1)
Table 28.1: Probability (P)
df 0.10 005 001 0.001
1 6.31 12.71 63.66 636.62
2 2.92 4.30 9.39 31.60
3 2.35 3.18 5.84 12.94
4 2.13 2.78 4.60 8.61
5 2.02 2.57 4.03 6.89
6 1.94 2.47 3.71 5.96
7 1.90 2.37 3.50 5.41
8 1.86 2.31 3.36 5.04
9 1.83 2.26 3.25 4.78
10 1.81 2.23 3.17 4.59
11 1.80 2.20 3.11 4.44
12 1.78 2.18 3.06 4.32
13 1.77 2.16 3.01 4.22
14 1.76 2.15 2.98 4.14
15 1.75 2.13 2.95 4.07
16 1.75 2.12 2.92 4.02
17 1.74 2.11 2.90 3.97
18 1.73 2.10 2.88 3.92
19 1.73 2.09 2.86 3.88
20 1.73 2.09 2.85 3.85
21 1.72 2.08 2.83 3.82
22 1.72 2.07 2.82 3.79
23 1.71 2.07 2.81 3.77
24 1.71 2.06 2.80 3.75
25 1.71 2.06 2.79 3.73
26 1.71 2.06 2.78 3.71
27 1.70 2.05 2.77 3.69
28 1.70 2.05 2.76 3.67
29 1.70 2.05 2.76 3.66
30 1.70 2.04 2.75 3.65
35 1.69 2.03 2.72 —
40 1.68 2.02 2.71 3.55
45 1.68 2.02 2.69 —
50 1.68 2.01 2.68 —
100 1.66 1.98 2.63 3.37
— 1.64 1.96 2.58 3.29
P = Probability of getting a larger value of ‘t’ than indicated in the column by mere
chance
df = Degrees of freedom
 372 Essentials of Community Medicine—A Practical Approach
Note: > 1.96 the difference is
significant Ho is rejected
< 1.96 the difference is not
significant Ho is accepted
If the sample is small, then it follows t-test with prescribed
degrees of freedom.

Normal Distribution
If we take large number of observations of a characteristic
and if the observations are arranged in a frequency
distribution with small class interval, the frequencies will be
very small in the beginning and at the end, while the largest
frequency is found to have concentrated somewhere in the
middle class. The frequency curve drawn of such data will
give us a smooth symmetric curve. This curve is normal curve.
This is a curve of great importance in statistics theory as it is
the basis of all statistical tests of significance. It is useful:
1. To estimate the population value based on a small sample.
2. To study whether two samples are drawn from the same
population.
3. To know whether two samples values differ significantly or
not.

Normal Curve
The normal curve is as shown in Figure 28.5.

Fig. 28.5: Normal curve

Characteristics of the Normal Curve

The normal curve has the following characteristics—it is bell
shaped curve.
1. The mean, median and the mode all coincide.
2. It is smooth symmetrical curve. The smoothness is due to
small and equal class intervals. Symmetry means that the
curve has one peak and its skewness is zero.
3. The whole area under the curve is unity.
4. By knowing the sample mean and standard deviation we can
calculate
 Biostatistics
Table of the Unit Normal Distribution (Table 28.2)

Table 28.2: The normal distribution with mean zero and

standard deviation unity
The normal Proportion of Normal variate Proportion of
variate with individuals who with mean = 0 individuals who do
and standard do not exceed not exceed the
deviation unity the value (Z) value (Z)
1 2 3 4
0.0 0.50000 2.3 0.98928
0.1 0.53983 2.4 0.99180
0.2 0.57926 2.5 0.99379
0.3 0.61791 2.6 0.99534
0.4 0.65542 2.7 0.99653
0.5 0.69146 2.8 0.99744
0.6 0.72575 2.9 0.99813
0.7 0.75804 …. ….
0.8 0.78814 3.0 0.99865
0.9 0.81594 3.1 0.99903
…. …. 3.2 0.99931
1.0 0.81434 3.3 0.99952
1.1 0.86433 3.4 0.99966
1.2 0.88493 3.5 0.99977
1.3 0.90320 3.6 0.99984
1.4 0.91924 3.7 0.99989
1.5 0.93319 3.8 0.99993
1.6 0.64520 3.9 0.99995
1.7 0.95543 …. ….
1.8 0.96407 4.0 0.99997
1.9 0.97128 4.1 0.99998
…. …. 4.2 0.99999
2.0 0.97725 4.3 0.99999
2.1 0.99214 4.4 0.99999
2.2 0.98610 …. ….

the number of observations falling on both sides of mean

at any multiple of SD by the help of this curve.
a. X ± 1  contains 68.27 (68.3) percent of observations
b. X ± 2  contains 95.45 (95.4) percent of observations
c. X ± 3  contains 99.73 (99.7) percent of observations
We thus find that the values that differ from the mean by
more than twice the SD(s) are fairly large (5%) and that differ
more than three times the SD(s) are very few (0.27) in normal
distribution.
If mean height X is 160 cms, SD () = 4 cms and height X is
166 cms. Z

will X– 166 – 160 corresponding we find 0.93 out

be X =
 1.5 Z1.5 of
 4
 374 Essentials of Community Medicine—A Practical Approach
one 93 percent height do not exceed 160 cms only seven
percent of the subjects will be taller. To find proportion for
negative values of Z subtract the corresponding proportion
from one.

Chi-square Test ( 2-Test)

Chi-square (): Test offers an alternate method of testing the
significance of difference between two proportions. It can also
be used when more than two groups are to compared.
It was developed by Karl Pearson and has got the
following three common but very important application in
medical statistics as test of:
1. Proportion
2. Association
3. Goodness of fit.
The test is usefull to know whether the observed
frequencies in the distribution differ significantly from the
expected frequencies calculated according to same assumed
hypothesis like the other tests of significance it only shows the
probability of chance operation.
a. Chi-square-test (2-test) is done with the actual
observations.

Table of Chi-square (Table 28.3)

Table 28.3: Probability (P)
d.f. .50 .10 .05 .02 .01 005 .001
1 0.45 2.71 3.84 5.41 66.3 7.88 10.83
2 1.39 4.61 5.99 7.82 9.21 10.60 13.82
3 2.37 6.25 7.82 9.84 11.34 12.84 16.27
4 3.35 7.78 9.46 11.67 13.38 14.86 18.47
5 4.35 9.24 11.07 13.39 16.09 16.75 20.52
6 4.35 10.64 12.59 5.03 16.81 18.55 22.46
7 6.35 12.02 14.07 16.62 18.48 20.28 24.32
8 7.31 13.36 15.51 18.17 20.09 21.96 26.13
9 8.34 14.68 16.92 19.68 21.67 23.59 27.88
10 9.34 15.99 18.31 21.16 23.21 25.19 29.59
11 10.34 17.28 19.68 22.62 24.72 26.70 31.26
12 11.34 18.55 21.03 21.05 26.22 28.30 31.91
chi-square
P = Probability of getting a larger value of 2 by chance alone
df = Degrees of freedom

b. Degrees of freedom (df) are not related to the actual

number of observations but on the number of columns and
rows in the table, i.e.
d.f = ( c – 1) (r – 1), c for columns, and r for rows
c. Yate’s correction is to be applied to the 2 × 2 contingency
tables if any of the frequency in the cells is less than 5.
 Biostatistics
d. If the expected frequency in any group is less than five, it is
to be clubed with the frequency of the previous group so
that the total frequency is greater than five.

Formula

1. x2 = (O  E)2
 E

where O = observed frequency and E = expected frequency

2. x2 (ab  bc)2 N
= ,
(a  b) (c  d) (a  c) (b  d)
where N = a + b + c + d and r = row c = columns

|ab  bc|
2
N  N
 
Yates correction –  2 
x2 = (a  b) (c  d) (a  c) (b  d)

(|O  E| 0.5) 2

2
x = E
Reject Ho if x2 > x2 0.05 for df = (c – 1) (r
c
– 1) Accept Ho if x2 < x2 0.05 for df = (c –
c
1) (r – 1)

Fallacies in Biostatistics
1. Comparison of dissimilar groups.
2. Use of different standard for classification.
3. Generalization from not representative sample.
4. Conclusions based on biased sample.
5. Conclusions from the relative values or proportion rates
without considering absolute values or population.
6. Mixture of noncomparable records.
7. Consideration of association direct or indirect as the cause
and effect.
8. Conclusion based on statistical significance alone without
other important practical consideration.

Causes
1. Personal
error
– Interviewee
– Interviewer
2. Institutional errors
376 Essentials of Community Medicine—A Practical Approach
– Records
 Biostatistics
– Selection of the facts for reporting
3. Spurious correlation
4. Correlation of unusual situations.

Vital Statistics

Definition
Data which gives quantitative information on vital events
occurring in life, i.e. births, deaths, marriages, etc.

Measures of Population
Mid-year population
Arithmetical progression
method
Pt = + rt
Po
where t is the period in years after the last census.
P = Population at the required time, i.e. t years after the last
census.
t

P = Population of last census

r o= Annual increase rate.

Geometrical Progression Method

P = Po (1 + r)t where P = Population of any census years
t o
and r =
Annual increase per person in intercensal years. P =
t
Population after t
years

Measures of Vital Statistics

Measures of Fertility
1. Crude birth rate (CBR)
Number of live births which occurred among the population
of a given geographical area during a given year
= ×
1000
Mid-year population of the same geographical area
during same year
2. General fertility rate (GFR)
Number of live births in one
= year Number of women aged × 1000
15-49 years

3. Age specific fertility rate (ASFR)

Number of live births to mothers of a specified
= age group Mid-year female population of the × 1000
same age group
 378 Essentials of Community Medicine—A Practical Approach
4. Gross reproduction rate (GRR)
Total number of female children

= born to women in the cohort sample

Total number of women in the same cohort
sample
5. Net reproduction rate (NRR)

Number of girls survived after the mortality

= experience Number of cohort women survived at
the end of reproductive period as per their
mortality experience
6. Sex ratio at birth
Number of female live
= births Number of male × 1000
live birth

Measures of Mortality
1. Crude death rate (CDR)
Number of death which occurred among the population
of a given geographical area during a given × 1000
= year

Mid-year population of the same geographical

area during same year
D
CDR = × 1000, where D = Total death and P = Total
population
P

2. Age specific death rate (ASDR)

Number of deaths in the specified age

= group Mid-year population of the × 1000
same age group

3. Infant mortality rate (IMR)

Number of deaths under one year

= of age Number of live × 1000
births

4. Still or late fetal death rate

Fetal deaths of after 28 weeks of

= gestation Live births + still × 1000
births
 Biostatistics
5. Perinatal mortality rate (PMR)

Late fetal deaths (after 28 weeks or more)+ deaths under 1

week
= ×
Live births + still births
1000

6. Neonatal mortality rate (NMR)

Number of deaths up to 28 days of life

= Number of live births 
1000

7. Post-neonatal mortality or late infant mortality rate

Deaths after 28 days of life up to

=
one year × 1000
Live births
8. Cause specific mortality rate (CSMR)

Number of deaths in a year due to

=
some cause × 100000
Mid-year population

9. Case fatality rate (CFR)

Number of deaths due to a particular

= disease Number of cases of the × 100
same disease

10. Proportional mortality rate (PMR)

Number of deaths from the specific disease

= in a year Total deaths from all causes in × 100
that year

Morbidity Statistics

1. Incidence rate (IR)

Number of persons becoming sick in a specified

= period of time Number of exposed to risk at ×
the same period 1000

2. Period prevalence rate (PPR)

Number of person sick (Old + New) within a

= specific of time Number exposed to risk at ×
the same period 1000
 380 Essentials of Community Medicine—A Practical Approach
3. Point prevalence rate (PPR)

Number of person sick (Old + New) at a specified point of

time
=
× 1000
Number of exposed to risk at the point of time

4. Average duration of sickness

Point prevalence
= rate Incidence
rate

INTERNATIONAL DEATH CERTIFICATE—

CAUSE OF DEATH (TABLE 28.4)

Table 28.4: International death certificate—cause of death

Name of patients: Approximate interval

between onset and death
Address:

Part 1
Disease or condition directly leading to death (a)
Antecedent cause: Morbid condition if any:
Giving rise to the above
(b) Cause stating the underlying condition last (c)

Part 2
Other significant condition contributing to the death
but not related to the death or condition causing
it.

Signature

BIBLIOGRAPHY
1. Kulkarni AP, Baride JP. Textbook of community medicine, 2nd
edn, 2002.
2. Mahajan BK. Methods in Biostatics, 6th edn, 1997.
3. Park’s Textbook of PSM, 16th edn, 2000.
 Biostatistics
Chapter
29 Problems

Chapter Outline
ENVIRONMENTAL PROBLEMS BIOSTATISTICS
CORRELATION AND REGRESSION DEMOGRAPHY
EPIDEMIOLOGICAL AND NUTRITIONAL EXERCISES

ENVIRONMENTAL PROBLEMS
1. 1 cubic feet = 6.25 gallons of water
2. 1 cubic meter = 1000 liters of water .
3. 1 gallon of water = 4.55 liters.
4. If blue color appears in I, II, and III up of Horrock’s
apparatus the required amount of bleaching powder to
disinfect the well is 2,4, 6 gm for 100 gallons of water.
5. Standard bleaching powder contains 33 percent of available
chlorine.
6. If available chlorine is 25 percent, i.e. ¼ for 1 gm, it is
taken as inverse proportion and while calculating, multiply
1000 liter of water 5×4. This will give you required amount
of bleaching powder to disinfect 1000 liters of water. If
available chlorine in given sample of

water is 20 percent
1 of 1 gram multiply by 2.
in
5
7. If the well is circular and measurement is in feet, calculate
the total amount of water by using the formula 5D2h.
Where D = diameter of well , h = depth of water
8. If the measurements are in meters, then:
2 22 2 2

r h or r h or 3.14 r h
7
where r = radius of well, h = depth of water
9. If the well is rectangular well then:
L × b × h × 6.25 which gives, gallons of water.
10. If measurements are in
meters, then:
L × b × h × 1000 gives liters of
water.

Problems
1. Calculate the amount of bleaching powder required to
disinfect a circular well having a diameter of 6 m and
depth of water is 12 m. The Horrock’s test shows blue
color in 4th cup.
 Problems
Sol. Given D = 6 m, R = 3 m, H = 12 m
– The given data for circular well is in meters, so
= 3.14 2 h
r
= 3.14 × 32 × 12
= 3.14 × 9 × 12
= 3.14 × 108
= 339.12 m
– 1 cubic meter = 1000 liters of water
– 339.12 meter = ?
339.12 × 1000 = 339120 liters of water
– 4.55 liters = 1 gallon of water
– 339.120 liter = ?
– 339120/4.55 = 74531.868 gallons
– 100 gallons = 8 gm of bleaching powder
– 74531.868 = ?
– 74531.868 × 8/ 100 = 5962.5 gm
2. Calculate the amount of bleaching powder required to
disinfect a circular well where D = 5 feet and depth of
water is 10 feet. Available chlorine is 33 percent in
bleaching powder.
Sol. Given D = 5 feet and h = 10 feet
– The given data for circular well is in
feet, so 5 D2 h = 5 × 5 2 × 10
= 5 × 25 × 10 = 1250 feet
– 1 cubic feet = 6.25 gallons of
water 1250 feet = ?
1250 × 6.25 = 7812.5 gallons of water.
– 1 gallon of water = 4.55
liters 7812.5 gallons of
water = ?
7812.5 × 4.55 = 35546.87 liters
– 1000 liters – 2.5 gm of bleaching
powder 35546.85 liters = ?
35546.85 × 2.5/1000 = 88867.18/1000
= 88.867 gm of bleaching powder.
3. A well measuring 10 m in diameter having depth of water
20 m. Available chlorine is 25 percent in bleaching
powder. Calculate the amount of bleaching powder
required.
Sol. Given D = 10 m, H = 20 m, R = 5 m
The given data for circular well is in meters, so
= 3.14 r2 h
= 3.14 × 52 × 20
= 3.14 × 25 × 20
 380 Essentials of Community Medicine—A Practical Approach
= 3.14 × 500
= 1570 m
Available chlorine is 25 percent, i.e. ¼ of gm =
0.25 gm Hence,
= 1570 × 0.25 × 4
= 1570 × 1 = 1570 gm
= 1.57 kg.
4. Calculate the amount of bleaching powder required if L =
6 feet, B= 8 feet, D = 25 feet Horrock’s apparatus shows
blue color in 12th cup.
Sol. The given data for rectangular well is in feet, so
= L × b × h × 6.25
= 6 × 8 × 25 × 6.25
= 48 × 156.25
= 7500 gallons of water
– 100 gallons = 24 gm of bleaching powder,
then: 7500 gallons = ?
7500 × 24 = 1800 gm
= 1.8 kg
5. An annual fair has been organized in summer season in a
village on the bank of river. What arrangements you shall
make for the safe drinking water for the fair?
Sol. • The survey should be done by Medical Officer (MO).
The fair consists of a large number of people.
• Gathered at one place it is the site for the spread of many
diseases.
Arrangements:
• The site should be surveyed by Medical Officer.
• As the fair is to be conducted on the bank of rivers, all
the precautions should be taken to prevent
contamination of water.
• Fencing of river should be done, to prevent people
going in for wash.
• Safe drinking water should be provided by
constructing reserviours tanks separately away from
the gathering place, which should be provided with
taps to prevent contamination.
• The surrounding should be kept clean or platform
should be constructed so that there is no stagnation of
water.
• Water should be changed regularly one for two days.
• Health education to the people regarding water-borne
disease.
6. There is an NCC camp of 100 students in the outskirts of
the city. What type of sanitary measures you suggest?
Sol. Arrangements:
• The site should be surveyed by Medical Officer.
• It should be selected in such a way that it should be
clean, free from endemic diseases.
 Problems
• It should be free from mosquito and fly-breeding sites.
• Trench latrine should be provided for some days,
shallow latrines, for weeks and for months deep trench
latrine.
• Disposal of refuse should be done by controlled tipping.
• Safe water should be provided by boiling and cooling
the water and chlorine tablets.
• All the students should be advised to have separate
beds, towels, to prevent communicable diseases.
BIOSTATISTICS
1. Following are the respiratory rates of 10 infants suspected
to be suffering from acute respiratory infection.
53, 52, 55, 48, 54, 59, 46, 58, 49 and 60.
Find the measures of central tendency.
Sol
.
 xni
i. Mean i  1 = 534 = 53.4
= n 10
th
n 1
ii. Median =   value in the arranged series.
 2 
Arranging the data in ascending
order: 46, 48, 49, 52, 53, 54, 55,
58, 59, 60
th
 10  1 
=   value
 2 

th
=  11  value = 5.5th
 2
i.e. Average of 5th and 6th value
53 
=
54 = 53.5.
2
iii. Mode: Mode does not exist.
Mode is most repeated value or the value which
possesses the highest frequency. Here, in this problem
not any value repeats,
i.e. it indicates mode does not exist in this distribution.
2. During the MCH clinic at Devarayasamudra RHTC, the
Hb% of 10 ANC and 10 PNC women were recorded as
follows:
ANC (gm%) : 12, 11, 10, 12, 12, 11, 08, 06, 09, 08
PNC (gm%) : 11, 09, 10, 11, 10, 11, 07, 08, 05, 07
Calculate the measures of dispersion and compare the
coefficient of variation.
382 Essentials of Community Medicine—A Practical Approach
Sol. i. Take ANC group. Write the data in ascending
order: 6, 08, 08, 09, 10, 11, 11, 12, 12, 12
Range = H – L
= 12 – 6
=6
n
|(x
i  x)|
Mean deviation = i1
(from n
Mean)
17.2 = 1.72
=
10

X x |(x – x )| (x – x 2
i
)
i

1 2.1 4.41
2
1 1.1 1.21
1
1 0.1 0.01
0
1 2.1 4.41
2
1 9.9 2.1 4.41
2
1 1.1 1.21
1
0 1.9 3.61
8
0 3.9 15.21
6
0 0.9 0.81
9
0 1.9 3.61
8
17.20 38.90
(for n < 30)
(x
n i  x)2
Standard i 1
deviation = n1
38.9
= 9
= 4.3222
SD = 2.0790 = 

Coefficient of 
variation = × 100
xn
 
  xi 99 
where mean ( x )  i1   9.9
 Problems
 n 10 
 
2.0790
CV = 9.9 × 100 = 0.2100 × 100
CV for ANC group = 21
384 Essentials of Community Medicine—A Practical Approach
ii. Take PNC group:
Write the data in ascending
order: 05, 07, 07, 08, 09, 10,
10, 11, 11,11
Range = 11 – 05 = 6
Range = 6
n

Mean
|x
i 1
i  x|
deviation = n
x1 x |(xi1 – x )| (xi1 – x )2
11 2.1 4.41
09 0.1 0.01
10 1.1 1.21
11 2.1 4.41
10 8.9 1.1 1.21
11 2.1 4.41
07 1.9 3.61
08 0.9 0.81
05 3.9 15.2
1
07 1.9 3.69
17.2 38.9

 x
n
i
89 
 Mean  i1
  8.9 
 n 10 
 
 

 xi  x 
n

Mean deviation i 1

= n
17.2
= 10 = 1.72
n
 (x i
 x)2
Standard deviation = i 1
n1
38.9
= 9
= 4.3222
SD = 2.0790
 Problems

 CV 
2.0790 × 100
× 100 =
=
x 8.9
= 0.2336 ×
100
= 23.36
CV of ANC group is less than CV of PNC group
3. The following data represents the total weight gain in kg
of 15 women at the end of 9th month of pregnancy:
06, 08, 07, 10, 06, 07, 07, 08, 09, 11, 10, 10, 12, 14, 12.
Calculate the measures of central tendency and discuss
the limitations of the mean.

x n
i13
Sol. i. Mean = x i  1 = 9.1333
7
= 
n 1
5
ii. Median is the middle most value in the arranged
series: 06, 06, 07, 07, 07, 08, 08, 09, 10, 10,
10, 11, 12, 12, 14.
th
n 1
Median =   value
 2 
th
15  1 
=   value
 2 
th
=  16  value = 8th value
 2
Median = 9
iii. Mode = Most repeated value
In this problem 07 and 10 repeat three times.
Therefore, this is a
“Bimodel”distribution. Both 7 and 10 are the modes.

Limitations of the Mean

• It is unduly influenced by an abnormal value in the
distribution.
• It cannot be easily calculated in the case of distributions
containing open-end class-interval.
• If one of value of the items is missing, the arithmetic mean
cannot be calculated.
• Sometimes it gives fallacious conclusions.
• It has an upward bias. It gives less importance to smaller
items and more importance to larger items in the data, i.e. a
large item in the series can push-up the value of arithmetic
mean considerably, but a small item cannot pull down the
value of it to the same extent.
 384 Essentials of Community Medicine—A Practical Approach
4. In a series of boys during admission to a college the mean
height was 160 cm and the standard deviation was 10 cm.
In the same series, the mean weight was 55 kg and the
standard deviation was 5 kg. Find which of the above two
characters show greater variation.

Sol. CV of 1st × 100
character = x

 CV =
10 × 100

160
and CV = 6.25%

CV of IInd 
character = × 100
x
 CV =
5 × 100

55
CV = 9.09%
Thus, we find that the 2nd character shows greater
variation.
5. The systolic BP of male and female interns posted to UHC,
Gulpet, is as follows:
Males : 130, 120, 126, 128, 122, 142, 116 and 160
Females : 110, 120, 100, 114, 108, 102, 110 and 110
Calculate arithmetic mean and standard
deviation. Comment on the above data.
Sol. For males:
X1 x |(x i – x )| (x – x 2
) i
130 0.5 0.25
120 10.5 110.25
126 4.5 20.25
128 2.5 6.25
122 130. 8.5 72.25
5
142 11.5 132.25
116 14.5 210.25
160 29.5 870.25
1044 1422
Arithmetic mean for males = x
1044
= 8 = 13.05.
x
n
 (xi  x)2
i 1
Standard deviation =
n1
 Problems

1422 1422
= =
81 7
 SD =203.1428
SD = 14.25
For
females:
x1 x |(xi – x )| (xi – x )2
110 0.75 0.56
120 10.75 115.56
100 9.25 85.56
114 4.75 22.56
108 109.25 1.25 1.56
102 7.25 52.56
110 0.75 0.56
110 0.75 0.56
874 279.48

x n
i 87
Arithmetic mean for i 1 = 109.25
4
females = 
n 8

n
 (x i  x)2
Standard deviation = i 1
n1
279.48 279.48
= 81 
7
 SD = 39.9257
SD = 6.3186
Comments: On comparing the SD values for males and
females, it is concluded that:
(SD value for male = 14.25
and SD value for female =
6.31)
The deviation of values from mean in the male is greater
than the female values.
6. The respiratory rate in 10 persons
was as follows: 20, 21, 22, 16, 19, 18,
19, 17, 20 and 18.
Calculate the range, mean deviation, standard deviation
and coefficient of variation.
Sol. Range = H – L = 22
– 16 Range = 4
 386 Essentials of Community Medicine—A Practical Approach
xi x (x x ) (x x 2
– – )
i i

20 1 1
21 2 4
22 3 9
16 3 9
19 0 0
18 1 1 1
9
19 0 0
17 2 4
20 1 1
18 1 1
190 14 3
0

|(x n
i  x)|
Mean deviation = 1.4
= 14
i 1
=
n 10
n
 (x i
 x)2
i 1
Standard deviation =
n1
30
= 9

 SD = 3.3333
SD = 1.8257

CV = 
× 100
x
1.82
= 19 × 100
= 0.0957 × 100
CV = 9.57

CORRELATION AND REGRESSION

1. Here the variables are non-correlated. Because the points
spread all over the graph.
 388 Essentials of Community Medicine—A Practical Approach
2. The variables are positively correlated. Because the points
cluster around a line with positive slope. (It is also called
partially positive correlation)
(Moderately + ve correlation)

3. The variables are positively and perfectly correlated.

Because the points form a line with positive slope.

4. There is a curvilinear relation between the variables.

5. The variables are negatively very correlated. Because the

points cluster around a line with negative slope (It is also
called partially negative correlation)
(Moderately –ve correlation)

6. This diagram indicates curvilinear relation between the

variables.
 Problems
7. The variables are perfect –ve correlation. Because the
points form a line with –ve slope

8. The variables are perfectly –vely correlated.

Problems
1. Find the value ‘r’ for the
following data: X—48, 52, 60,
45, 65, 72, 80, 50 Y—50, 55,
72, 50, 60, 60, 78, 55.
Sol. Karl Pearson’s coefficient of correlation between two
variables X and Y is:

rxy = Covariance (x, y) Cov (x, y)


var (x)  var (y)
x y

rxy =
(x  x)(y  y)
(x  x)2  (y  y)2
X Y (x– x ) (y– ) (x– x ) (y– ) (x – )2 (y– )2
y y x
i y
48 5 –11 –10 110 121 100
0
52 5 –7 –5 35 49 25
5
60 7 1 12 12 1 44
2
45 5 –14 –10 140 196 100
0
65 6 6 0 0 36 0
0
72 6 13 0 0 169 0
0
80 7 21 18 378 441 324
8
50 5 –9 –5 45 81 25
5
390 Essentials of Community Medicine—A Practical Approach
720 109 718
4
 Problems

(x  x)(y  y)
 r =
x (x  x)2 (y  y)2

[ ]
When means are not known, we can use:
n  xy   x   y 
r = 22
 n  y 2   y 2 
 n  x   x    

 n

xi 472 = 59 and

x =
i 1 8
n

 n

yi 480
 = 60.
j 1
y
= 8 8
From the table,

= 720  720
1094  718 785492

720
=886.2815 = 0.8123 = = 0.8
0.8 = r x
i.e. the variables are +vely correlated.
2. Find the regression coefficients for:
X : 10, 15, 16, 20, 21, 17, 12, 13, 18 and 8
Y : 7, 16, 20, 18, 19, 21, 10, 14, 19, 6
Sol. The regression coefficients are:

(x  x)(y  y)
=
xy
(x  x)2

and b = (x  x)(y  if means are known.

(yy) y)2
y

If the means are not known, then we can use

392 Essentials of Community Medicine—A Practical Approach
bxy = r   n xy  x y 
x

 n y2  y2 
y

and b r  y n xy  (x)(y)
= 
n x2  (x2 )
yx
x
 Problems
Applying the first formulae for b and b
xy yx
x y (x– ) (y– ) (x– x ) (y– ) (xi– 2
(y– )2
x y y x y
1 7 –5 –8 40 25 64
0
1 16 0 1 0 0 1
5
1 20 1 5 5 1 25
6
2 18 5 3 15 25 09
0
2 19 6 4 24 36 16
1
1 21 2 6 12 4 36
7
1 10 –3 –5 15 9 25
2
1 14 –2 –1 2 4 1
3
1 19 3 4 12 9 16
8
8 6 –7 –9 63 49 81
Total=15 150 188 162 274
0

x 150
x =  = 15
n 10

y 150
y =  = 15
n 10

bxy = (x  x)(y 
188
y) (x  =
162
x )2
 b = 1.16
x
(x  x)(y 
y) 188
 b
yx = = 274
(y  y )2
 byx = 0.6861
3. For the following data calculate correlation coefficient to
determine association if any between fluoride content of
drinking water and community fluorosis index:
Drinkin water lev mg/L Communi fluoros index
g fluoride el ty is
394 Essentials of Community Medicine—A Practical Approach
0.8 0.1
1.3 0.4
1.5 0.9
1.9 0.6
2.3 0.7
2.4 1.1
2.6 0.8
3.5 1.1
 Problems
Sol. Karl Pearson’s correlation
coefficient ‘r’
Cov (x, y)
Cov (x,
y)
rxy = var (x)  var (y) 
x y

(x  x) (y  y)
r
xy (x  x)2 (y  y)2
(x– x ) (y– ) (x– x ) (y– y
2
X y (x– x ) (y– )
y y )2
1.8 0. – 0.36 – 0. 0.216 0.1296 0.36
1 6
1.3 0. – 0.86 – 0. 0.258 0.7396 0.09
4 3
1.5 0. – 0.66 0. – 0.066 0.4356 0.01
8 1
1.9 0. – 0.26 – 0. + 0.026 0.0676 0.01
6 1
2.3 0. 0.14 0 0.000 0.0196 0
7
2.4 1. 0.24 0. 0.096 0.0576 0.16
1 4
2.6 0. 0.44 0. 0.044 0.1936 0.01
8 1
3.5 1. 1.34 0. 0.536 1.7956 0.16
1 4
Total: 5. 1.11 3.4388 0.8
17.3 6
x

17.3 = 2.16
x = i

ny 8
= 0.7
y = i
n 
5.6
8

rxy =  (x  x ) ( y  y )
(x  x)2 (y  y)2
= 1.11 1.11 1.11
3.4388  0.8  2.7510 1.65

rxy = 1.11
= 0.6692 = 0.7.
1.65
86
r x

This indicates there is +ve correlation between these two

variables.
 396 Essentials of Community Medicine—A Practical Approach
DEMOGRAPHY
1. The census population of Kolar town.
1981 : 75,000
1982 : 87,000
No. of live births in 1988 : 1250
Total no. of deaths in 1988 : 750
No. of infant deaths :
70 Deaths of infants within 1 month of
births : 30
a. Calculate all vital statistics rates for 1988
b. Compare with current national rates and comment.
 Problems
Sol. a. For the calculation of 1988 vital rates,
CBR = (Total births/Mid year population of 1988)
× 1000 Mid year population (MYP) of 1988
Pt = P + rt
MYP of 1988 = 75000 + rt
Increase in 10 years
= 87000 – 75000
= 12000
Average increase per year = 12000/10 =
1200 MYP of 1988 = 75000 + (1200 × 7)
+ (1200 × 1/3)
= 75000 + 8400 + 400
= 83800
b. i. CBR = (Total births/Mid year population of 1988 )
× 1000
= (1250/83800 ) × 1000
= 0.0149 × 1000
CBR = 14.9
ii. CDR = (No. of deaths registered during a year in an
area/Mid year population of 1988) × 1000
= (750/83800 ) × 1000
= 8.9498
iii. IMR = (Number of deaths under one year of age or
infants/ No. of live births ) × 1000
= (70/1250 ) × 1000
IMR = 7000/125 = 56
iv. NMR = Neonatal mortality rate
= (No. of deaths up to 28 days
of life/ No. of live births) ×
1000
NMR = (30/1250) × 1000 = 3000/125 = 24
2. The following vital events are recorded in Kolar district for
1991:
MYP of 1991 :
22,00000
Total no. of deaths in 1991 : 20,000
Total no. of live birth in : 40,000
1991
Newly diagnosed TB cases : 220
Old cases of TB : 880
No. of deaths due to TB : 140
Calculate all vital indices for 1991 [comment on the
growth rate of the district with reference to the current
year].
Sol. CBR = (No. of live births/Mid year population of 1991)
× 1000
= ( 40000/2200000 ) × 1000
= 18.1818
CDR = (No. of deaths/MYP of 1991) × 1000
= (20000/2200000 ) × 1000
398 Essentials of Community Medicine—A Practical Approach
CDR = 200/22 = 9.0909
 Problems
3. The following is the data of DSRM. PHC area for 1997:
Midyear popn : 70000
Total deaths : 1050
Total birth : 2500
Total infant deaths : 300
No. of maternal deaths : 15
No. of death with in 28 days :
120
Calculate all vital rates of the PHC area for 1997. Compare
with the goal for
2000 AD.
Sol. i. CBR = (No. of live births/Mid year population of 1997)
× 1000
= (2500/70000) × 1000
CBR = 250/7 = 35.742
ii. CDR = (Total no. of deaths/MYP of 1997) × 1000
= (1050/70000) × 1000
CDR = 105/7 = 15
iii. Infant mortality rate
= (Total infant deaths/No of live
births) × 1000 IMR = (300/2500) × 1000
= 3000/25
 IMR = 120
iv. Maternal mortality rate
MMR = (No. of maternal deaths/Total of live births)
× 1000
= (15/2500) × 1000
= 150/25 = 6
MMR = 6
v. Neonatal mortality rate
= (No. of deaths with 28 days of
life No. of live births) × 1000
NMR = (120/2500) × 1000
= 1200/25
= 48
4. The MYP of Kolar town in 1998 was 90,000 and the
following vital indices were reported:
CBR = 24/1000
MYP CDR =
10/1000 MYP
IMR = 80/1000
LB MMR =
3/1000 LB
Calculate :
i. No. of births
ii. No. of deaths
iii. Infant deaths
iv. Maternal deaths
v. Growth rate for 1998.
 400 Essentials of Community Medicine—A Practical Approach
Sol. i. CBR = (No. of births/MYP of Kolar) ×
1000
 No. of births = (CBR × MYP)/1000
= (24 × 90,000)/1000 = 2160
 No. of births = 2160
Similarly
ii. No. of deaths = (CDR × MYP)/1000
= (10 × 90,000)/1000
 No. of deaths = 900
iii. IMR = (No. of infant deaths/Total no. of live births) ×
1000
 No. of infant deaths = (80 × 2160)/1000
= 1728/10 =172.8
 Infant deaths = 172.8
iv. MMR = (No. of maternal deaths/No. of live
births) × 1000 Maternal deaths = (3 ×
2160)/1000
= 6480/1000 = 6.48
 Maternal deaths = 6.48
v. Growth rate for 1998 = Birth rate – Death rate
= 24 –10
 GR = 14/1000 MYP
5. The MYP of PHU is 35,000. The age wise population of
women and live births is given below :
Age group No. of women No. of births
live
15-25 3500 300
25-35 5500 600
35-45 3000 200
Total 1200 110
0 0
Calcula
te i .
CBR
ii. Age specific fertility rate
iii. Total fertility rate
iv. Comment on the results.
Sol. i. CBR = (Total births/Mid year population) ×
1000
= (1100/35000) × 1000
 CBR = 31.4285
ii. Age specific fertility rate
In the first group, i.e. for 15 to 25 age group
ASFR = (No. of live births reported at 15-25 age
group/ No. of mothers at the same age
group) × 1000
ASFR = (300/3500) × 1000
 Problems
= 3000/35
= 85.71
 402 Essentials of Community Medicine—A Practical Approach
ASFR for the age-group 25 to
35 i.e. ASFR =
(600/5500) × 1000
= 6000/55 =109.0909
= 109.1
and ASFR for the age group 35 to 45
ASFR = (200/3000) × 1000
ASFR = 2000/30 = 66.66
iii. Total
Fertility rate = Addition of the ASFR gives
us TFR TFR = 85.71 + 109.1 + 66.66
= 261.47
6. The following is the data related to Mulbagal town for
1996:
MYP : 6400
0
No. of live births : 1856
No. of deaths : 704
No. of fetal deaths > 1000 gms : 40
No. of deaths age < 1 week : 20
No. of deaths aged < 4 weeks : 120
No. of infant deaths : 160
No. of maternal deaths between 28 weeks
of 8
pregnancy and 42nd day of delivery :
Calculate CDR, CBR, MMR, perinatal mortality rate, NMR,
IMR, GR. Sol. i. CDR = (No. of deaths registered during
a year in an area/
Mid year population) × 1000
= (704/64000) × 1000
CDR = 11
ii. CBR = (No. of live births/Mid year population) ×
1000
1856
=  1000 = 0.029 × 1000 = 29
64000
iii. MMR = (No. of female deaths registered during a
year due to pregnancy and its
complication/No. of live births during that
year) × 1000
 MMR = (8/1856) × 1000
 MMR = 4.3103
iv. Perinatal mortality rate
= PMR = [Late fetal deaths (after 28 weeks
or more) + deaths under one week/Total
births (live + still)] × 1000
= [(40 + 20)/1856] × 1000
= (60/1856) × 1000
= 60000/1856
 Problems
 PMR = 32.32
404 Essentials of Community Medicine—A Practical Approach
v. NMR = Neonatal mortality rate
= (Number of deaths upto 28 days of
life/ Number of live births) × 1000
= (120/1856) × 1000
= 0.0646 × 1000 = 64.6
vi. IMR (Infant mortality rate)
IMR = (Number of deaths under one year
of age/ Number of live births) ×
1000
= (160/1856 ) × 1000
= 0.0862 × 1000
 IMR = 86.2
7. The census population of a district in 1981 and 1991 was
20,00,000 and 26,00,000 respectively calculate:
Mid Year population of 1989
What is the present growth rate of India
So
l: Using arithmetical progression method
Population of a district in 1981 = 20,00,000
Population of a district in 1991 =
26,00,000 Increase in 10 years = 26,00,000 –
20,00,000 = 600,000
 Average increase per year = 60,000
 Mid year population in 1989 = Pt = Po+rt (from AP)
= 20,00,000 + 60000 × 8 + 60000 ×
1/3
(1/3 Means 1st March to June 30th)
= 20,00,000 + 480,000 + 20,000
= 25,00,000
8. In an estimated MYP of 100,000 there were 1500 live
births and 850 deaths in 1995.
No. of abortions reported :
300 No. of fetal deaths (1000 gm) :
50 Deaths 0-7 days :
50
Deaths 8 day to 1 month : 25
Deaths 1 month to 1 year : 50
Woman in the child bearing age group constituted 20
percent of the population 400 deaths occurred in the age
group of 45 years and above. These were:
Heart disease : 200
Chronic lung disease : 50
Neoplasms : 80
Suicides : 20
Others : 50
 Problems
Calculate
a.General fertility rate
b.IMR
c. PMR
d.Proportional mortality of deaths overs 45 years due to
heart disease.
Sol. a. General fertility rate :
GFR = (No. of live births in one year/ No. of women
aged 15-49 years ) × 1000
GFR = (1500/20000) × 1000 = 75
(20% of the population are women in the child
bearing age group).
b. IMR = (Number of deaths under one year of age/No.
of live births) × 1000
 IMR = (50 + 25 + 50/1500) × 1000
= (125/1500) × 1000
= 0.0833 × 1000
 IMR = 83.3
c. PMR = (Late fetal deaths (after 28 weeks or more)
+ deaths under one week/Total births) ×
1000
= (50 + 50/1500) × 1000
 PMR = (100/1500) × 1000 = 66.66
d. Proportional mortality of deaths over 45 years due to
heart disease. Proportional mortality rate
= (No. of deaths due to specific cause/Total
deaths)
× 100
PMR = (200/400) × 100
(Deaths, due to heart disease =
200) PMR = 50%
9. Estimate the midyear population in the year 1985 given
1971 census population 548.1 million and 1981 census
population 685.2 million.
Sol. Population in the year 1981 = 685.2 million
Population in year 1971 = 548.1 million
Population growth in 10 years = 137.1
million Annual rate of growth = (Pt – P0)/P0 ×
1/10
= (137.1/548.1) × 1/10
= 0.025
It is assumed that ‘r’ remains contant
approximately. Then by geometric growth
model
Pt = P0 (1 + r)t
Log Pt = LogP0 + tlog (1+ r)
= log 685.2 + (4 + 1/3) log (1 + 2.5/100)
= log 685.2 + 13/3 log 1.025
= 2.8358 + 4.33 × 0.0107
 406 Essentials of Community Medicine—A Practical Approach
= 2.8358 + 0.0463
 logPt = 2.8821
 Pt = Antilog (2.8821)
= 762.3 million.

EPIDEMIOLOGICAL AND NUTRITIONAL EXERCISES

1. In a boarding house inhabited by 100 children all below
10 years, on 1/3/88, 10 cases of measles occurred. On the
11th a second batch of 35 cases were detected.
Interrogation of those who had not contracted the disease
revealed that 15 of them were previously immunized
against measles. Determine the serial interval and the
secondary attack rate of measles.
Sol. Serial interval
= Gap between the onset of primary and
secondary case.
= Gap between 1st and 11th March = 10 days.
Secondary attack rate
= No. of exposed persons developing
diseases/Total no. of exposed/susceptible
contacts × 100
Total no. exposed are 100 – 10 = 90
Out of these 15 who were immunized are not
susceptible. So no. susceptible are 90 – 15 = 75
 Secondary attack rate = 35/75 × 100
= 46.66%
2. The 1994 MYP of a place was 5,000. There were 750
children below 5 years, and 500 from 5 to 10 years.
A lameness survey revealed that 4 of the children 5 to 10
years were lame. Determine the annual incidence of:
a. Paralytic and
b.All cases of poliomyelities in the total
population. Sol. Prevalence of polio in
children of 5 to 10 years:
= Polio cases in 5-10 age group/Population of 5-
10 age
group × 1000
= 4/500 × 1000 = 8 per 1000
Correction for those cases not involving lower
extremities:
= Prevalence of polio in 5-10 years group × 1.25
= 8 × 1.25 = 10 per 1000
Average annual incidence rate of 0-4 years:
= Corrected prevalence/No. of years of risk =
10/5 = 2 per 1000
a. Annual paralytic incidence for whole population:
= Average incidence of 0-4 years ×
proportion of 0-4 population
= 2 × 750/5000 = 0.3 per 1000
 Problems
b. Incidence of all cases of poliomyelitis:
= Annual incidence × 1.33
= 0.3 × 1.33 = 0.399 per 1000
3. The average daily calorie consumption of a weighing 60 kg
person is 2770, and the protein intake 60 G. Determine his
percent protein calories and comment.
He is currently taking 100 G. Eggs daily and no
groundnuts. He wishes to replace eggs with groundnuts.
How much of the latter he must eat so that it furnishes
him the same amount of absorbed protein as 100 G of
eggs ? If the cost of egg is 2.50 per 100 G and of
groundnuts, 25 per kg, how much less/ more he have to
spend ?
Sol. a. Percent protein calories
= Energy given by protein/Total energy × 100
= 60 × 4.1/2770 × 100 = 8.88%
This is within the required range of 7 to 12 percent
b. Net protein utilization of egg is 96
percent 100 G of eggs have 13.3 G
of Protein
of this 96/100 × 13.3 or 12.77 G is net protein
utilization Net protein utilization of groundnut
is 55 percent
To get 55 G of protein utilization in this body 100 G of
nut protein have to be consumed.
So to get 12.77————?
(12.77/55) × 100 = 23.22 G of Groundnut protein.
The percentage of protein is 25 percent so 23.22 G of
Groundnut protein will be obtained from 23.22 ×
100/1000 = 93 G
So, 100 G of egg costing 2.50 rupees should be
replaced by 93 G of groundnut costing 93 × 25/1000 =
2.33 rupees.
Therefore, he will be saving 2.50 – 2.33 = 0.17 rupees.
4. The estimated MYP of place for 1994 was 9,000. Its CBR
was 30/1000 population IMR, 80/1000 live births and
under 1 to 3 mortality 10/1000 children below three years.
a. How many packets of ORS and how many tablets of
septran with 20 mg. Methoprim and 100 mg,
Sulphamethoxazole will be required for the treatment
of episodes of acute diarrheal and respiratory diseases,
respectively ? No change in the incidence is expected.
b. A mass polio-immunization camp is planned for January
and another for February 1995 in which all children
below three years would be given polio vaccine
irrespective of previous history of vaccination.
Determine the vials of oral polio vaccine that will be
required. How many vaccine carriers will be needed to
carry the vaccine to different immunization centers?
c. The place is being brought under CSSM Program in
1995. How many bottles of vitamin A concentrate will
be required for carrying out vitamin A prophylaxis
408 Essentials of Community Medicine—A Practical Approach
among infant during 1995?
 Problems
Sol. a. i. Under 5 population is 15 percent
 Under 5 population = 15 percent of 9000 =
1,350 Average incidence of diarrhea is
2.5/epiosde/year/child.
 Total episodes of diarrhea in under fives:
= 1,350 × 2.5 = 3,375
Only 10 percent require ORS packets.
That is 337.5 or 338 children require ORS
packets. Two packets per episodes with
wastage of 30 percent
 ORS packets required = 338 × 2 + 30 wastage
= 676 + 203
= 879 packets of ORS.
ii. Incidence of respiratory diseases under 5 is 3
episodes/year/ child.
 No. of episodes in 1350 children = 1350 × 3 =
4,050
Fifteen percent episodes or moderate or severe which
need drug.
 15% of 4050 = 608 episode need drug.
Each episode needs 2 tablets bd for 5 days, that is 20
Tablets per episodes.
 Total No. of Tablets = 608 × 20 = 12,160
b. To find the estimated population of Under 3, the
following formula is used.
Estimated under 3 population:
= 3 MYP × Birth rate as decimal
× (1-3 Death rate under 3 as decimal)
= 3 × 900 × 0.03 × (1-3 × 0.01) = 785.7 or 786
 Total doses of OPV required to immunize 786 under 3
children for second rounds:
2 × no. of children × WMF = 2 × 786 × 2 = 3144
1 OPV vial has 20 doses.
 OPV vials required = 3144/20 = 157.2 or 158
So, for 1st round 79 vials and second round also 79
and each vaccine carrier accommodates 15 vials.
 Vaccine carriers need = 79/15 = 5.2 or 6
Six vaccine carriers will sufficient for both round.
c. Estimated infants under one year:
= MYP × Birth rate as decimal × (1-IMR as
decimal)
= 9000 × 0.03 × 0.92 = 248.4 or 249.
One lakh IU of vitamin A for 1 baby Under 1 years is
required: So, for 249 babies 249 lakh IU of vitamin A is
required:
One bottle of vitamin A = 100
Ml Each 1 ml = 1 lakh IU of
vitamin A
Therefore, for 1 lakh IU we require 1 ml
For 249 lakh IU we require 249 ml, bottles are
410 Essentials of Community Medicine—A Practical Approach
therefore – 3
 Problems
5. a. 50,000 liters of water with fluorine concentration of 0.4
mg/L have to be fluoridated so as to bring the
concentration to 1 mg/L determine the quantity of
sodium fluoride required.
b. During 1994, in an industry employing 1,000 workers,
200 remained absent. Of the later 10 were absent each
for one day only; 20 for 2 days each; 30 for 4 days each,
40 for 6 days each; 60 for 12 days each and the remaining
for 14 days each. Calculate the absenteeism rate of this
industry for 1994.
Sol. a. Fluorine concentration is 0.4 mg/liter.
Therefore, to get concentration of 1 PPM add 0.6 mg of
fluorine per liters water.
Sodium fluoride contains 45 percent fluorine ions.
That is 1 mg Sodium fluorine gives 0.45 mg of fluorine.
Therefore, to get 0.6 mg fluorine sodium fluoride added
is:
= 0.6/0.45 = 1.33 mg
Therefore, to get 1 PPM fluorine level, add 1.33
mg/liter of Sodium fluoride.
Required Sodium fluoride for 50,000 liters of water:
= 1.33 × 50,000 mg
= 66,500 mg = 66.5 gm.
No o day absent No o workers Tot no. days of
. f s . f al of absenteeism
10 1 10
20 2 40
30 4 120
40 6 240
60 12 720
40 14 560
Tota 1690
l
b. Absenteeism rate
= Total no. of days of absenteeism/Total no. of
workers
= 1690/1000 = 1.69 days/head/year
6. In June 1989, an epidemic of acute gastroenteritis
occurred in a village. There were 160 cases of which 20
died. There are two wells in the village. Well ‘A’ is in the
north which is used by 600 persons; 120 cases were noted
among them. Well ‘B’ in the south is the source of water
for the remaining 1000 persons among whom 40 cases
were recorded.
The age and sex-distribution of the population of the
village along with the cases and deaths in each age sex
group is shown below.
 412 Essentials of Community Medicine—A Practical Approach
Age Males Females
group Pop. Cases Deaths Pop. Cases
Deaths
0 130 30 12 120 20 8
5 200 40 0 180 20 0
15 270 25 0 300 15 0
35 150 10 0 100 0 0
55 and 70 0 0 80 0 0
above
Total 820 10 12 780 55 8
5
a. Analyze and interpret the above data.
b. What further information is necessary to elucidate the
epidemiology of the epidemic?
Sol. a. Analysis and interpretation:
i. Attach rate = 160/1600 × 1000 = 100/1000
population.
ii. Case fatality rate = Deaths/Cases × 100
20
= 100 × 100 = 12.5%
iii. CFR under 5 = Deaths < 5/Cases < 5 × 100
= 20/50 × 100 = 40%
Comment: All the deaths under five years. None in
older children. This may be due to complicity of
malnutrition in under fives.
iv. Attack rate in males = 105/820 × 1000 =
128/1000 males. Attack rate in Females = 55/780
× 1000 = 70.5/1000 females
Comment: The disease is 128/70.5 or 1.8 time more
in males.
v. Attack rate in different age groups:
Cases in that age group/Total persons in that age
group × 1000
a. 50/250 × 1000 = 200/1000, children below 5
b. 60/380 × 1000 = 157.9/1000 children 5 -< 15
c. 40/570 × 1000 = 70.2/1000 persons
15 - <
35 d. 10/250 × 1000 = 40/1000 adults
35 - <
55
e. 0/150 × 1000 = Zero after 55
years age
group
Comment: There is steady decline in the attack rate
with rise in age up to 54 years. After 55 there are
no cases. ‘A’
vi. Well ‘A’/Attack rate = 120/600 ×
100 = 20% Well ‘B’ attack rate =
40/1000 × 100 = 4% Is this
 Problems
difference statistically significant.
Ho: There is no difference in the attack rates.
|P1  P2 |
Test criteria is Z =
SE(P1  P2 )
 414 Essentials of Community Medicine—A Practical Approach
p1q1  p2 q2 n1n2
= SE(P1  P2
) =
 SE(P1  = 1.75
20  80  4  96
P2 ) =
600 1000
20 
4
 Z = = 9.14
1.75
Here Z = 9.14 > 1.96 
reject Ho Therefore p.001
Therefore, rejected null hypothesis = 1.75
Comment: This epidemic is due to contamination of
the water of well ‘A’.

Miscellaneous Problems

1. 2000 smokers and 1000 matched non-smokers were

followed-up. Lung cancer developed in 120 smokers and 20
nonsmokers. Find the absolute risk, relatives risk,
attributable risk of lung cancer in smokers and comment
on them.
Persons with Persons Total
lung cancer without
lung cancer
Smokers 120(a) 1880 (b) 2000 (a+b)
Non-smokers 20 (c) 980 (d) 1000 (c+
d)
Sol. Absolute Risk = Incidence of disease among smokers.
= a/a + b = 120/2000 = 0.06 or 6%
Relative risk
= Ratio of incidence of lung cancer between smokers and
nonsmokers
a/a  b a (c  d) 120  1000
= c/c  d c (a  b) 20  2000 3
Attributable risk
= incidence (risk) of disease that is attributed to
smoking
a c

ab cd
a  100
=
ab
0.06  0.02
= 0.06  100
0.04
=  100  66.6%
0.06
 Problems
Comments:
• Lung cancer is three times commoner in smokers than
non- smokers.
• Lung cancer among 66.6 percent smoker is due to
smoking, the rest due to background effect.
• Results of other studies in other part of world should be
considering before concluding there is casual
relationship between smoking and lung cancer.
2. According to past records the hookworm prevalence rate
in a community is 25/1000 population. It is decided to conduct
a fresh hookworm survey. Determine the size of the sample
for this survey, allowing an error of 10 percent with a
confidence limit of 95 percent.
The formula to calculate the sample size with 95 percent
confidence limit with d percent error is true prevalence
‘p’ of disease is:
4pq
n  2 , where q = 1 – p
d
Sol. Given information:
Prevalence of hookworm = p = 25/1000 = 0.025
q = 1 – p = 0.975
Error allowed = d = 10% of p = 10% of 0.025
= 0.0025
4 pq 4 × 0.025 × 0.975

Required sample size n  4  0.025 

4pq 0.975
=
(0.0025
d2 )2

0.0975
 15600
= 0.000000625

3. The 1993 estimated mid-year population of a town was

200,000. The numbers of registered vehicles during the
year were 5,000. Of these 100 were not driven during
1993 at all. The average number of KMS per day run by
the remaining vehicles is given below:
1,900 vehicles 10
2,500 vehicles 50
500 vehicles 100
The numbers of persons killed in motor vehicular accident
in 1993 were 500, of which 400 were the occupants of
vehicles. Calculate all possible accident fatality rates.
 416 Essentials of Community Medicine—A Practical Approach
Sol. 1. Accident death rate per 100,000 population
Deaths due to accidents
Mid-year 
= 100000
population
= (500 × 100,000)/200000= 250/100000 population.
2. Death rate per 1000 registered vehicles = 500 ×
1000/5000
= 100/1000 registered vehicles.
3. Total vehicle kilometers are
= (1900 × 10) + (2500 × 50) + (500 × 100) × 365
= (19000 + 125000 + 50000) × 365
= 70,810,000
Death rate per 100,000 Vehicle kilometers
= 500 × 100,000/70,810,000
= 0.7/100,000 vehicle kilometer
Death rate of vehicle occupants per 1000 vehicles per
year
= 400 × 1000/5000 = 80/1000 vehicle occupants.
4. A new screening test for a certain disease was
administered to 490 persons, 60 of whom are known to
have the disease. The test was positive in 50 of the persons
with the disease, as well as in 20 persons without the disease.
Calculate the following:
a. Sensitivity of the test
b.Specificity of the test.
c. Percentage of false positive
d.Percentage of false negatives
e. Prevalence of disease
f. Predictive value of a positive test
g.Predictive value of a negative test.

Screening Diagnosis Total

test results Diseased Non-
diseased
Positive 50 (a) 20 (b) 70 (a + b)
Negative 10 (c) 400 (d) 410 (c + d)
Total 60 (a + c) 420 (b + 480
d)
Sol. a. Sensitivity of screening test = a/(a + c) × 100
= 50/60 × 100 = 83.33%
b. Specificity of screening test = d/(b + d) × 100
= 400/420 × 100 = 95.24%
c. Percentage of false positives = b/(b + d) × 100
= 20/420 × 100 = 4.76%
 Problems
d. Percentage of false negatives = c/(a + c) × 100
= 10/60 × 100 =17.67%
 418 Essentials of Community Medicine—A Practical Approach
e. Prevalence of disease = a + c/(a+ b+ c+ d) × 100
= 60/480 × 100 =12.5%
f. Predictive value of positive test = a/(a+b) × 100
= 50/70 × 100 = 71.43%
g. Predictive value of negative test = d/(c + d) × 100
= 400/410 × 100 = 97.56%
5. In a clinical trial, 240 patients suffering from depression
were included. These matched groups were made. The
first was put on drug ‘A’ second on drug ‘B’ and third on a
placebo. The results of the trial are shown below:
Drug/ No. felt No. felt No. Total
place better worse unchang
bo ed
‘A’ 47 6 29 82
‘B’ 52 3 22 77
Placebo 32 16 33 81
Determine if drug ‘A’ is statistically more effective than ‘B’
Sol. To compare efficacy of drug A with B, exclude placebo
results from analysis. Also club the results ‘not felt worse’
and ‘number unchanged’ as ‘not felt better’. The results
can be tabulated as:
Drug No. felt No. felt Total
better worse
‘A’ 47 (a) 35 (b) 82 (a+ b)
‘B’ 52 (c) 25 (d) 77 (c+ d)
Total 99 (a+ c) 60 (b+ d) 159 (N)
Null hypothesis: Drug ‘A’ and ‘B’ are equally
effective Use Chi-Square test. 2 for 2 × 2 table
is:
2 = (ad – bc)2 × N/(a+b) (c + d) (a + c) (b + d)
= (645)2 × 159/99 × 60 × 82 × 77
= 66147975/37505160= 1.763
Degree of freedom = (r – 1) (c – 1) = (2 – 1) (2 – 1) = 1
For one degree of freedom, 2 value at 0.05 level of
significance is
3.84. The calculated 2 is less than critical value of 2.
Therefore, accept null hypothesis. Therefore, drug ‘A’ is
not more effective than drug ‘B’.
 408 Essentials of Community Medicine—A Problems
Chapter
30 Visits
CHAPTER OUTLINE
NTEGRATED COUNSELING AND TESTING CENTER (ICTC)
VISIT TO BLIND SCHOOL
A VISIT TO DEAF AND DUMB SCHOOL
VISIT TO DISTRICT HEALTH LABORATORY
VISIT TO PRIMARY HEALTH CENTER (PHC)
POSTPARTUM CENTER
DELIVERY OF INTEGRATED SERVICES FOR MATERNAL AND CHILD HEALTH, FAMILY PLANNING, NUTRITION AND IMMUNIZA
THE BABY FRIENDLY HOSPITAL INITIATIVE
WORLD BREASTFEEDING WEEK
ANGANWADI
NTEGRATED CHILD DEVELOPMENT SCHEME
VISIT TO DISTRICT TUBERCULOSIS CENTER
VISIT TO DISTRICT REHABILITATION CENTER
VISIT TO PLACES OF NATURAL CALAMITIES
SCHOOL HEALTH SERVICE
VISIT TO DISTRICT LEPROSY CENTER

INTEGRATED COUNSELING AND TESTING CENTER (ICTC)

An Integrated Counseling and Testing Center (ICTC) is a place
where person is counseled and tested for HIV, on his own or
advised by a medical provider. This common facility will remove
fear, stigma and discrimination among the clients. The ICTCs
have common televise and video-based health education
material that are screened continuous in the waiting area. The
main functions of ICTC include:
1. Early diction of HIV
2. Provision of basic information on modes of transmission
and prevention of HIV/AIDS for promoting behavioral
change and reducing vulnerability.
3. Link people with other HIV prevention, care and treatment
services.
Strategies adopted in ICTCs for HIV testing:
• “Opt out” and “opt in” strategy
• “Opt out” strategy.
Provider-initiated counseling and testing—“opt out”: There are
three varieties of patients who are offered provider counseling
and testing:
a. Patients who present at a health facility with symptoms
suggestive of HIV infection (pneumonia, TB and persistent
diarrhea).
b. Patients with STI/RTI.
c. Pregnant women who register at antenatal clinic.
 Visits
In such cases the client in given basic information on HIV,
and educated about testing for HIV. The counselor will ask
each client, “Do you wish to test for HIV or not?” The client
can “opt out” or choose not to test for HIV. If a client does not
“opt out” then he/she is tested for HIV.
Client initiated counseling and testing “opt in “ or Direct
walk in client. These clients who present themselves at the
ICTC of their own free will based on their individual risk
behavior or information and advice received from a friend,
sexual partner, or outreach worker or peer educator. Here the
client is counseled for HIV and then “opts in“ or actively
aggress to be tested for HIV. Written consent has to be
obtained from such clients before testing.
ICTC can be located in the Obstetric and Gynecology
Department for pregnant women, or with tuberculosis
microscopy center for TB patients at work place, on national
highways and on universities.
There are two typed of ICTCs:
1. Fixed facility ICTC
2. Mobile ICTCs.
A fixed facility ICTC can be two types:
• “Stand alone” ICTC having full time counselor and a
laboratory technician located in medical colleges and
district and in some sub- district hospitals. It is envisaged
under NACP-III to have such ICTCs established up to the
level of CHC.
• “Facility-integrated” ICTC which does not have full time
staff and provides HIV counseling and testing as a service
along with other services. Such center canters to small
number of clients.

VISIT TO BLIND SCHOOL

In India, there are 140 blind schools of which 4 are in
Karnataka in Hubli, Davangere, Mysore and Gulbarga; Blind
School at Davangere is exclusively for girls.

Admission Criteria
Students are admitted in the month of June-July every year the
students should be blind and should produce a certificate from
an ophthalmologist. He should also produce an age certificate,
a caste certificate in case of a SC, ST student, also three
passport size photos. Age group for admission into 1st Std is 6
to 10 years. In case of an orphan a certificate from the
magistrate is needed. There is no admission fees.

Government Authority
The school is government school under the directorate of
disabled welfare which looks after the blind, physically
handicapped, deaf and dumb, mentally handicapped and those
suffering from cerebral palsy.
 410 Essentials of Community Medicine—A Practical Approach
Everything is provided free of cost. Besides education the
other facilities for blind are:
1. KSRTC has completely exempted the travelling charges for
blind people in ordinary buses.
2. In the Indian Railways, the blind persons has to pay only 25
percent of the fare. For travel of the person needs an
escort, the escort also has to pay only 25 percent of the
fare.
3. They are given Rs 125/- month as disabling allowance.
4. The blind students get a reader’s allowance of Rs 50 per
month.

Syllabus for the Blind

There is no exemption in the syllabus for the blind up to VII
Std but after VII Std instead of mathematics and science, they
can study economics, political science, music and history (
choose any two subjects). The special script for blind is called
Braille script. Invented by Louis Braille (divine life for blind).

Staffing Pattern
Consists of 24 members. In which are included the
superintendent, teachers with physical director to look after the
affairs of the school. There is also one visiting medical officer.

Specific Program for Prevention of Blindness

1. Vitamin A prophylaxis program
2. Trachoma control program
3. School age health services.

National and International Agencies

1. National Association for Blind (NAB) established in 1962.
2. Royal Common Wealth Society for Blind (1950).
3. International Agency for Prevention of Blindness.
4. Danish International Development Association (DANIDA).

A VISIT TO DEAF AND DUMB SCHOOL

There are four government schools in Karnataka:
1. Mysore upto SSLC
2. Gulbarga upto 7th Standard
3. Bellary upto 7th Standard
4. Belgaum upto 7th Standard
The Belgaum school is only for girls, rest all are only for
boys.
 Visits
Staffing Pattern
1. Gazetted post—Superintendent.
2. Two FDA (1st division assistant).
3. Two SDA (2nd division assistant). They look after the
administration and other problems individually.
4. Matron: Food, clothing, bedding are provided
by him. To assist them more in cooking staff
two cooking posts.
5. Four graduate assistants who teach upto high school.
6. One primary school teacher undergraduate.
7. One tailoring instructor.
8. Two weaving assistants.
9. Night watchman.

Rules and Regulations

Boys and girls 6 to 10 years are admitted along with their
records.
1. Birth certificate from municipality corporation, panchayat.
2. Income certificate and caste certificate from Tahsildar.
3. Photographs—four.
The capacity of student accommodation is 100 in each school.
The govern- ment is providing training facilities to all
teachers. Teachers training institute are formed for this
purpose now it is at Bangalore.
There are two categories:
1. Institute for oral training
2. Institute for sign training.

VISIT TO DISTRICT HEALTH LABORATORY

In each district there is one district health laboratory.

Staffing Pattern
1. Medical Officer 1
2. Senior Laboratory 4
Technician
3. Attender 4
4. Peon 2
5. Sweeper 1

Functions
1. Preparation of stain for all PHCs.
2. Conducting malaria clinics.
3. Surveillance: (a) Active surveillance, (b) Passive surveillance.
4. Training for paramedical staff.
5. Examination of malaria slides from all PHCs and rural sub-
centers.
6. Routine laboratory work: Total count, differential count,
ESR, Hb%, VDRL, pregnancy test.
 412 Essentials of Community Medicine—A Practical Approach
Urine Test: Bile salts, bile pigment, sugar, albumin and
microscopic examination. Stool examination for ova and cyst.
Staining Procedure for Malarial Smear
The stain used for this is JSB stain (Jaswant Singh
Bhattacharya). Two solutions of JSB are used—JSB1 solution
and JSB2 solution. After dehemoglobinization of the smear, dip
the smear in JSB2 solution for 30 to 40 seconds which contains
eosin. Wash it with buffer water containing KPO4 and disodium
hydrogen phosphate. Then dip in JSB1 solution for
30 to 40 seconds and again wash with buffer water. Dry it and
examine under oil immersion lens using liquid paraffin. JSB 1
solution contain methylene blue, water, etc.
VISIT TO PRIMARY HEALTH CENTER (PHC)
The National Health Plan (1983) proposed reorganization of
primary health centers on the basis of one PHC for every
30,000 rural population in the plains, and one PHC for every
20,000 population in hilly, tribal and backward areas for more
effective coverage. As on 30th June 1999, 22807 primary
health centers have been established in the country against
the total requirement of about 23,000.

Functions of the PHC

1.Medical care
2.MCH including family planning
3.Safe water supply and basic sanitation
4.Prevention and control of locally endemic diseases
5.Collection and reporting of vital statistics
6.Education about health
7.National Health Programs—as relevant
8.Referral services
9.Training of health guides, health workers, local dais and health
assistants
10. Basic laboratory services.

Staffing Pattern
At present in each community development block, there are
one or more PHCs each of which covers 30,000 rural
population. In the new set-up each PHC will have the
following staff:

At the PHC Level

Medical Officer 1
Pharmacist 1
Nurse midwife 1
 Visits
Health worker (Female) ANM 1
Block extension educator 1
Health assistant (Male) 1
Health assistant (Female)/LHV 1
UDC 1
LDC 1
Laboratory technician 1
Driver (subject to availability of 1
vehicle)
Class IV 4
15
At the Sub-center Level
Health worker (female)/ANH 1
Health worker (male) 1
Voluntary worker
(Paid Rs 50 per month as 1
honorarium)
3
POSTPARTUM CENTER

Introduction
The history of postpartum concept dates back to the year
1966 when the Population Council, New York, developed an
International Program to test the idea that the post delivery
(or postpartum) period is the point of highest motivation for
family planning and therefore the best occasion for providing
information and service. Government of India launched the All
India Hospitals Postpartum Program in 1969.
The postpartum program has been defined as “A maternity
centered hospital based approach to Family Welfare Program
to motivate women with in the reproductive age group (15-44
years) or their husbands for adopting small family norms
through education and motivation particularly during prenatal
and postnatal period”.
Over a period of years the concept of postpartum program
has undergone a change. The service of the postpartum
center now include MCH and Family Planning Services. The
postpartum centers function as referral centres for peripheral
institution.
It ensures effective Obstetric Services leading to decline in
maternal and infant mortality and better acceptance of family
planning methods (Table 30.1).
 414 Essentials of Community Medicine—A Practical Approach
Table 30.1: Staff pattern of the postpartum center attached to medical college
1. Assistant Professor in OBG 1
2. Lecturer in Health Education and FP 1
3. Lecturer in Statistics and Demography/ 1
Lecturer in Social Preventive Medicine
4. Lecturer in Pediatrics 1
5. Anesthetist (Asst. Surgeon Gr.I) 1
6. Projectionist-cum-Mechanic 1
7. Medical Officer (1 Male and 1 female) 2
8. Public Health Nurse/LHV 1
9. Auxilliary Nurse Mid-wife 2
10. Family Welfare Worker (M) 1
11. Store Keeper cum/Clerk 1
12. Steno-typist 1
13. LDC 1
14. Driver 1
15. Attendant 1
16. Cytotechnician 1

Functions of Postpartum Unit

The Postpartum Unit as a whole is responsible for carrying out
the following functions.
A. To provide contraceptive advice and services primarily to
obstetric and abortion cases attending the Department of
Obstetrics and Gynecology and various other Departments,
knowledge regarding available methods and follow-up of
acceptors, in addition to this, advice/service treatment of
infertility for both male and female recanalization.
B. To provide out reach services and extend material and
Child Health Family Welfare Hospital. This all should cover
at least a population of 50,000 or the whole town if the
population is less than 50,000.
C. Immunization of all children delivered at the Postpartum
Center and those attending hospital Outpatient Department.
To provide nutritional education to women during antenatal,
correct methodology of weaning of the child. Health
education on prevention of anemia, protein malnutrition
and vitamin ‘A’ deficiency in addition to other diseases also
needs to be imparted. The above services shall also be
provided to the community of the field area.
D. To involve all the departments and staff of the hospital in
addition to the Department of Obstetrics and Gynecology in
the Family Welfare Program.
E. To detect early cases of cervical cancer among users and
not-users of family welfare methods through Postpartum
Pap Smear test facilities wherever such facility is provided
under the Postpartum Program.
F. To conduct teaching and training program in family welfare
for under graduate and postgraduate medical and
paramedical students.
 Visits
G. To develop an over all plan for distribution of conventional
contra- ceptives and identify depot holders to meet the
demand of the people in the area served by the Center.
H. To participate in the State Level Seminar and suggest
methods for improving the Program and removing the
bottleneck if any.
Department of Obstetrics and Gynecology
Shares the major responsibility of implementing the program
while the other departments viz. Pediatrics, Surgery and
Preventive and Social Medicine supplement the efforts of the
Department of Obstetrics and Gynecology. In the case of non-
teaching hospitals, the Medical Superintendent or Civil Surgeon
acts as Program Director and Senior Medical Officer as
Project
Officer.
Monitoring and Evaluation Aspects
Program monitoring is considered as one of the most essential
tools for the successful implementing of the program. It helps
in studying day-to- day developments to the program.

Institutional Level Monitoring and Evaluation

At institutional Level the program is monitored by way of
maintaining proper records like eligible couple survey register
of field area population served, acceptors motivated at various
intervals of time, etc. and evaluated by Coordination
Committee constituted in every Institution as per the norms
suggested by Government of India.

Guidelines for Constitution of Coordination Committee

In order to evaluate and review the working of the program
and to bring about further improvement in effective
functioning of the program, Coordination Committees are
formed in all the Medical Institutions Hospital/covered under
the program. The composition of the Co-ordination Committee
may be as follows (Table 30.2).
Table 30.2: Composition of the coordination committee
1. Program Director—Principal/Dean in case of Medical Chairman
College/Teaching Institution Medical Superintendent/Civil
Surgeon in case of nonteaching Hospital/Institution
2. Project Director—Head of the Department of Obstetrics of Member
Gynecology
3. Head of the Department of Pediatrics Member
4. Head of the Department of Preventive and Social Medicine Member
5. Head of the Department of Surgery Member
6. Regional Director (H and FW, Government of India) Member
if available
7. State Family Welfare Officer/District, Family Welfare Officer Member
or any person outside the Medical College
May be co-opted as Member at the discretion of the
Chairman if necessary
 416 Essentials of Community Medicine—A Practical Approach
In those Postpartum Units where Pap Smear Test Facility
has been sanctioned, Professor of Pathology/Cytopathologist
may be co-opted as member of coordination Committee.

Broad Functions
The broad functions of the committee in an institution are:
I. To evaluate and review the progress of the postpartum
program.
II. To adopt corrective measures for improvement of the
program.
III.To meet at least once in three months.
IV. To apprise State Government of the development taking
place in the field.

DELIVERY OF INTEGRATED SERVICES FOR MATERNAL AND

CHILD HEALTH, FAMILY PLANNING, NUTRITION AND
IMMUNIZATION
The health of the mother and child are interviewed so that the
services of maternal and child health, family planning,
nutrition and immunization are closely and required to be
delivered as an integrated package of family health care. This
is indicated in Figure 30.1.

Fig. 30.1: Integrated family health care

 Visits
THE BABY FRIENDLY HOSPITAL INITIATIVE

What is BFHI?
This is global program aimed at giving quality care to mothers
and children and to ensure that every newborn baby gets the
best start in its life. The program commits itself to protecting,
supporting, and promoting breastfeeding.
Why this Program?
It is generally felt that all mothers in this part of the world
breastfeed their babies anyway. So why worry about such a
program?
If we think for a moment and apply our mind to this
situation, we all know that there are many mothers who
deliver a baby for the first time, many more mothers are
delivered by cesarean section (this figure is on the increase
especially among urban mothers), one-third of the babies born
in our state are low-birth weight and nearly 12 to 15 percent
are preterm babies Mothers delivering with episiotomy wound
and forceps extraction are also quite a few. These are
situations found by each one of us wherein newborn babies
and mothers have breastfeeding difficulties.
Studies conducted from 222 villages of Central Karnataka
has shown that rural mothers delay the first feed, administer
prelacteal feeds, quite a few discard colostrum considering
that it is unsuitable to the child and exclusive breastfeeding is
not optimally practised. Quite a few mothers bottle-feed their
babies.
Taking all these points into consideration, we have to
conclude that where ever there is a maternity service and
where ever there are lactating mothers there must be high
level of expertise available among MCH care staff to deal
appropriately with any lactation management difficulty.
Hence, this program is very relevant to us.
What is New About it?
• Lactation management focuses its attention on
understanding the physiology of the newborn and parturient
mothers and critically looks at factors that govern initation
and establishment of lactation.
• The dynamics of breast milk transfer is now understood in
proper perspective. We now know that baby should attach
in a good position and its tongue should remove all the milk
from the lactiferous sinuses (the reservoirs of milk).
Complete emptying results in more production of breast
milk.
 418 Essentials of Community Medicine—A Practical Approach
• Early initiation results in practical disappearance of breast
engorgement
• Sore nipples, fissures, cracks and pain experienced by the
mother while breastfeeding are the result of nipple feeding.
• The art of manual expression of breast milk tries to mimic
the action of baby at the mothers breast.

What is this Program All About?

Can it be Simply Described in a Few Words?
Yes, the program comprises of:
A. Ten simple steps that should be implemented in a maternity
service.
B. Learning five basic skills by all the MCH care staff.

The Ten Steps

1.Have a written breastfeeding policy that is routinely
communicated to all health care staff.
2.Train all health care staff in skills necessary to implement
this policy.
3.Inform all pregnant women about the benefits and
management of breastfeeding.
4.Help mothers initiate breastfeeding within half an hour of
birth.
5.Show mothers how to breastfeed and how to maintain
lactation even if they should be separated from their
infants.
6.Give newborn infants no food or drink other than breast
milk unless medically indicated.
7.Practice “rooming-in” allowing mothers and infants to
remain together 24 hours a day.
8.Encourage breast-feeding on demand.
9.Give no artificial teats or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups.

The Five Basic Skills

1. To learn the skill of initiating breastfeeding and to assure
that baby is placed in a good position at the mothers breast.
2. To learn the skill of manual expression of breast milk.
3. To learn how to prevent and treat insufficient milk supply.
4. To learn how to prevent and treat sore nipples.
5. To learn how to prevent and treat breast engorgement.

What are the Benefits of Making

My Hospital Baby Friendly?
There are many benefits of making my hospital baby friendly:
1. Firstly you will have the satisfaction of providing scientific
and updated information and technical help to lactating
mothers.
2. Infant mortality will come down.
 Visits
3. Your hospital staff will work as a cohesive team and will
derive pride in their work.
4. Your hospital will get National and International recognition.
5. This program will place us on a global forefront.

What are the Investments Needed and

What is the Cost Involved?
Nothing. There is no financial involvement. However, you will
have to spend lots of time training your MCH care staff.

What should I do to get My Hospital

Recognized as Baby Friendly Hospital?
The steps are three folds:
1. Obtain self-assessment form.
2. Complete the form, Xerox two copies and send to
coordinator baby friendly hospital initiative for Karnataka
State (Retain one copy with you).
3. Train your health care staff and await inspection.

WORLD BREASTFEEDING WEEK

Each year we have been observing “ World Breastfeeding
Week” from 1st to 7th August every year. We all know that
exclusive breastfeeding for the first six months and continued
breastfeeding for two years along with home made semi
solids, is the best way of bringing up a child.
• Most mothers in our country want to breastfeed their
children.
• Though 90 percent of mothers are successful in
breastfeeding their children, primi mothers, mothers
delivering by LSCS and mothers having preterm and low-
birth weight children more often have breastfeeding
difficulties.

What are Our Problems?

Delayed Start
Mothers usually delay the first feed for three days and offer
cows milk, honey, sugar water using cloth or cotton wisp.
These pre-lacteal feeds are unnecessary and can introduce
infection in the baby. They also interfere with the physiology
of lactation and delay establishment of breast milk, They can
cause breast engorgement by 4th or 5th postnatal day.
Hence, we have to spread an important message that “
babies should be put to breast in first half an hour of birth”.
During this period, the neonate is awake, alert and all his
neonatal reflexes such as rooting, sucking and swallowing are
very sharp. This is the right time when we should initiate
breastfeeding.
 420 Essentials of Community Medicine—A Practical Approach
Mothers delivering by LSCS: Such mothers have lot of pain
and difficulty looking after themselves. Such mothers need
the help of trained nursing staff who are able to support and
assist them with breastfeeding. The number of LSCS
deliveries are increasing. Hence, we have to create adequate
expertise in all maternity facilities.
Primi mothers: For these mothers, all said and done, it is their
first experience. Mothers have many doubts and fears about
breastfeeding and carrying for their young ones. They need to
be adequately supported and helped. Most difficulties are in
the first few days after birth.
Working mothers: Mothers who have to return to work are
constantly under stress as to how to manage feeding once they
return to work. Usually such mothers end up bottle feeding
their young ones inviting risks and hazards of artificial
feeding. There is explosion in knowledge and technical
expertise in helping such mothers.
Common breastfeeding problems: Sore nipples, mastitis,
engorgement, difficulty in positioning and breast refusal are
some of the common problems seen. These problems can be
easily prevented by simple measures because of better
understanding of physiology of lactation and breast milk
transfer.

What can We do for the World Breastfeeding Week (WBW)?

There is tremendous amount of responsibility with each one of
us to ensure that no mothers will have any difficulty with
breastfeeding their young ones.
At individual level:
1. Every newborn baby that you come across, please make
sure that the baby is sucking in proper position.
2. Ensure that breastfeeding is initiated early and baby fed on
demand as frequently as needed.
3. Train Nurses to assist mothers delivering by LSCS with
breastfeeding.
4. Help mothers in manual expression of breast milk in
situation like- baby very small or preterm, mother who has
to return to work.
5. Create supporting environment for the mother.
6. Congratulate every mother who is doing well with
breastfeeding.
7. Encourage every mother to exclusive breastfeed for six
months.
8. Each one of us involved in neonatal care can contribute to
better lactation management in our day to day work,
involving nurses and mothers.
At community level:
1. Organize talks and meetings with Pediatricians,
Obstetricians, IMA members and Medical Practitioners.
Include all nursing staff in such meetings.
 Visits
2. Hold public meetings with Lions Club, Rotary Club and
other such Voluntary Organizations.
3. Organize meetings with Mahila Mandals and Womens
organizations.
4. Give radio talks and TV talks.
5. Write in daily newspapers, magazines and other print media.

Promote BFHI Concept

The Baby Friendly Hospital Initiative aims at promoting,
protecting and supporting breastfeeding in the community.
Let us rededicate our efforts to help all mothers in attaining
their best in their role of child rearing. Please note that these
activities are not limited to just the week alone but should
become a part and way of life.
Please plan your activities along with your District Branch
President and Secretary.

ANGANWADI
The focal point for the operation of the ICDS at the village
level, is an Anganwadi. It covers a population of about 1000 in
urban and rural areas and 700 in tribal areas. The worker who
coordinates and offers the services is the Anganwadi Worker
(AWW).
Some of the important tasks to be performed by the AWW are
as follows:
1. To survey the community and identify child and mother
beneficiaries.
2. To monitor the growth of children using weight for age and
identify children suffering from malnourishment.
3. To maintain growth charts and records of attendance,
immunisation, births, deaths, etc. at the Anganwadi.
4. To provide supplementary feeding to children.
5. Assist the LHV in distributing Vitamin A to children and iron
and folic acid supplements to pregnant and lactating
women; and refer patients to local health services.
6. To teach nonformal preschool education to three to six years
old children and functional literacy classes for adult women.
7. To make home visits in order to enlist community and
beneficiary to supports various activities.
8. To organize women’s clubs (Mahila Mandals) for health and
nutrition education and centers for income-generating
activities.

INTEGRATED CHILD DEVELOPMENT SCHEME

A majority of India’s children live in impoverished economic,
social and environmental conditions which impede their
physical and mental development. As a response to the unmet
needs of this vast and vulnerable population, the Government
of India introduced in 1975 its most ambitious
 422 Essentials of Community Medicine—A Practical Approach
and comprehensive plan to increase child survival rates among
the poorest and enhance the health, nutrition and learning
opportunities of pre-school children and their mothers.
Drawing upon experience called from twenty years of planned
social development, the Integrated Child Development
Scheme (ICDS) is designed both as a preventive and
developmental effort. If extends beyond the existing health
and education systems to reach children and their mothers in
villages and slums and delivers to them an integrated package
of services.

Objectives
Its major objectives are to:
i. Reduce malnutrition, morbidity and mortality of children in
the age group 0 to 6 years
ii. Improve their health and nutritional status
iii. Provide the environmental conditions necessary for their
psychological social and physical development
iv. Enhance the ability of mothers to provide proper care to
their children
v. Achieve effective coordination among various departments
providing developmental services to children.

Package of Services
To achieve these goals a package of services consisting of the
following was introduced:
a. Supplementary feeding (Details given in Table 30.3).
b. Immunization
c. Health check-up
d. Referral services
e. Nutrition and health education
f. Pre-school education and
g. Non-formal education for women.
Table 30.3: Nutritional supplements
Recipients Calories Grams of protein
1. Child up to 6 years 300 8-10
2. Adolescent girls 500 20-25
3. Pregnant and nursing mothers 500 20-25
4 Malnourished children Double the daily supplement provided to
the other children (600) and/or special on
medical recommendation

Organizational Set-up
The Ministry of Social Welfare is responsible for the budgetary
control and administration of the scheme forms the center and
coordinates activities with the Ministries of Education, Health
Family Welfare and Rural Development.
 Visits

Fig. 30.2: Convergence of ICDS services

At the State level, the Department of Social Welfare is mainly

responsible, although in some states, other Departments (e.g.
Tribal Welfare, Women and Child Welfare, Health or Rural
Development) may take primary responsibility for
implementation.
At the block level, the Block Development Officer (BDO)
exercises overall responsibility for the project, co-
ordinating activities with the main ICDS functionary, the
Child Development Officer (CDPO) (Fig. 30.2).
Anganwadi Worker
Anganwadi worker is a part-time trained voluntary worker and
receives an honorarium of Rs. 700 per month. She is assisted
by a helper who is also a local women and paid an
honorarium.
Mukhya Sevika (MS)
Mukhya Sevika is a full-time worker who supervises the work
of 20, 25 and 17 Anganwadi workers in urban, rural and tribal
projects respectively. She visits each Anganwadi at least once
a month, and liaise with lady health visitor in nutritional and
health activities.

Child Development Project Officer

For one project there is one Child Development Project Officer
(CDPO) who cover one community development block having
a population of
 424 Essentials of Community Medicine—A Practical Approach
80,000 to 120,000. He or she supervises, co-ordinates and
guides the work of entire ICDS project as an in-charge and
provide supervision to four to five Mukhya Sevika. He is
assisted by one assistant CDPO.

Achievements
New ICDS is effective in 5171 community development blocks
and major urban slums throughout the country. As against
2.27 crore beneficiaries until March 1997, there were 3.4
crore beneficiaries in April 2001. Today the scheme reached
out to about 54 lakh expectant and nursing mothers and 288
lakh children under six years of age belonging to the
disadvantage groups.
The type of services to be provided for target groups are
given in Table 30.4.

Scheme for Adolescent Girls (Kishori Shakti Yojna)

There was a gap in between women and child age group
which was not covered by any health and social welfare
program whereas girls in this crucial groups need special
attention. On one side they need appropriate nutrition,
education, health education, training for adulthood, training
for acquiring skills as the base for earning an independent
livelihood, training for motherhood, etc. Similarly on the other
side their potential to be a good community leader has to be
realized. A scheme for adolescent girls in ICDS was launched
by the Department of Women and Child Development,
Ministry of Human Resource Development in 1991.

Table 30.4: Type of services to be provided for target groups

Beneficiary Service
1. Expectant and nursing mothers i. Health check-up
ii. Immunization of
expectant mothers
against tetanus
iii. Supplementary nutrition
iv. Functional literacy
2.Other women 25-45 years i. Nutrition and health education
ii. Functional literacy
3. Children less than 3 years i. Supplementary nutrition
ii. Immunization
iii. Health check-up
iv. Referral services
4. Children between 3-6 years i. Supplementary nutrition
ii. Immunization
iii. Health check-up
iv. Referral services
v. Nonformal preschool education
 Visits
Common services: All adolescents girls in the age group of 11
to 18 years (70%) receive the following common services:
1. Watch over menarche
2. Immunization
3. General health check-ups once in every six months
4. Training for minor ailments
5. Deworming
6. Prophylactic measures against anemia, goiter, vitamin
deficiency, etc. and
7. Referral to PHC/District hospital in case of acute need.
This scheme for adolescent is extended to 3.51 lakh
adolescent girls in 507 ICDS blocks covering all states and
union territories. It is proposed to extend the scheme in 2000
community development blocks during ninth plan covering
12.8 lakh adolescent girls.

VISIT TO DISTRICT TUBERCULOSIS CENTER

National Tuberculosis Program (NTP)

National Tuberculosis Program (NTP) has been in operation
since 1962 NTP operates through the District Tuberculosis
Program (DTP) which is the backbone of the NTP. Over 600
TB clinics have been set up in the country, of which 390 have
been upgraded todate as District TB Centres (DTC) to
undertake districtwise TB control in association with general
health and medical institutions.

Organization
A District Tuberculosis Program consists of one District
Tuberculosis Center (DTC) and on an average 50 peripheral
health institutions comprising of PHCs, general hospitals,
rural dispensaries, etc.
To implement the program, a specially trained team of key
program personnel (Trained at the National Tuberculosis
Institute, Bangalore for a period of 13 weeks) is posted at
each DTC. The team consists of:
• One District Tuberculosis Officer (DTO)
• One Second Medical Officer
• Two Laboratory Technicians
• Two Treatment Organzer/Health Visitor
• One X-ray Technician
• One Non-medical Team Leader
• One Statistical Assistant
• One Pharmacist.
The program is integrated with primary health care system
( general health services) and is brought within the ambit of
the District Health Organization. The District Health Officer is
made directly responsible for the DTP, with the DTO as a
specialized staff officer to assist him in the
 426 Essentials of Community Medicine—A Practical Approach
management of DTP. Not only the peripheral health
institutions, but also the caders of health workers and MPWs
are all involved in the program of case detection and
treatment.

VISIT TO DISTRICT REHABILITATION CENTER

The Government of India launched District Rehabilitation
Center (DRC) scheme in early 1985, for providing a package
of model comprehensive rehabilitation services to the rural
disabled. The scheme, at present is operated in 11 different
places of the country. The scheme covered:
(1) Locomotor handicap, (2) Speech and hearing impaired, (3)
Visually impaired, (4) Mentally handicapped, and (5) Multiple
handicaps.

Services Provided
1. Preventive and early detection
2. Medical intervention and surgical correction
3. Fitment of artificial aids and appliances
4. Therapeutic services such as physiotherapy, speech
therapy, and occupational therapy
5. Provision of educational services in special and integrated
school
6. Provision of training, for acquisition of skills through
vocational training, job placement in local industries and trade
with proper linkages with on going training and employment
programs
7. Provision of self employment opportunities and bank loans
8. Establishing a meaningful linkage with existing government
scheme such as disability/old age pension, scholarship, etc.
9. Creating of awareness movement of community and family
counseling.

At Village Level
Anganwadi worker, teacher, health workers, etc. undertake
the work of prevention, detection, and referral to
PHC/CHC/District Hospital or voluntary organizations.

At PHC/CHC Level
Medical officers and paramedical staff are trained and oriented
to prevent, detect, and appropriate intervention at their level
and timely referral to highest centers.

DRC Level
District unit:
1. Provide service to handicaps
2.Act as referral center to PHC/CHC and for village level staff
3. Organizing camps
 Visits
4. Education, vocational training, coordinating work with
voluntary agencies and other departments.
Regional Rehabilitation Training Center were set up in
Lucknow, Chennai, Cuttack, Mumbai to provide technical
support to the DRCs.

National Program for Rehabilitation of

Persons with Disabilities
National Sample Survey Organization of 1991 indicated 1.8
percent of the population in the country as disabled which is
now 1.9 percent and 2-2.5 percent has mental retardation.
The prevalence rate of disability is 22.7 per 1000 males and
16.9 per 1000 females. Disability was more in rural than
urban areas and above national average in states of AP, HP,
MP, Karnataka, Orissa, Punjab, and Tamil Nadu.

Objectives
1. To create services delivery system at state/district block/gram
panchayat level so as to provide comprehensive based
rehabilitation services.
2. Prevention, early intervention and information dissemination.

VISIT TO PLACES OF NATURAL CALAMITIES

WHO defines disaster as “Any occurrence that causes
damage, ecological disruption, loss of human life,
deterioration of health and health services, on a scale
sufficient to warrant an extraordinary response from outside
the affected community or area.”

Disasters
Disasters are classified in various ways, e.g. natural versus
manmade disasters or sudden versus slow-onset disasters.

Phases of a Disaster (Fig. 30.3)

Predisaster phase: The phase before a disaster strikes is the
pre-disaster phase.
Alert phase: This phase refers to the period when a disaster is
developing and when it has not yet hit the community.
Impact phase: There is no well-defined impact phase for
gradual onset disasters, and sudden onset disasters are
unpredictable in every way.
Post impact phase: This is the phase following the actual
impact of the disaster.
Reconstruction and rehabilitation phase: This is a long-term
phase. It aims at getting the community back to where it was
before the emergency and to strengthen its ability to prevent
and/or mitigate other diseases.
 428 Essentials of Community Medicine—A Practical Approach

Fig. 30.3: Prototype acute disaster cycle

Effect of Disasters on Health (Table 30.5)

Objectives of health disaster preparedness:

The objectives of disaster preparedness and response activities in
the health sector may be expressed as follows:
a. To prevent excess mortality due to the disaster, which may
be caused by the direct impact of the disaster, by delays in
rescue and relief activities, by lack of appropriate and
timely health care, by the disruption of the normal health
care and breakdown of preventive measures, and sometimes
by malnutrition.
b. To provide appropriate and timely care for casualties due to
the disaster. These include injuries, trauma and burns in
natural disasters; malnutrition in situations of food shortage;
acute cases of communicable disease in epidemic outbreaks,
etc.
c. To prevent exposure to adverse climatic and environmental
conditions including lack of food, water, sanitation, shelter,
clothing, chemical or nuclear exposure, etc.
d. To prevent short-term and long-term disaster related
morbidity: Outbreaks of communicable disease usually due
to changes in the local ecological conditions, disruption of
health services, interruption of control measures, lack of
sanitation, overcrowding;
Increase in morbidity and mortality due to destruction of
health infrastructure and to the provision of basic health
services; Introduction of new diseases due to resettlement or
imported by external relief workers;
Occurrence of wide-spread malnutrition/under-nutrition.
 Visits
Table 30.5: Effect of disasters on health

Effect Earthquake High wind Tidal waves/ Flood Drought

(without flash flood
floodings)
Deaths Many Few Many Few Moderate
Severe Overwhelming Moderate Few Few Moderate
injuries
requiring
extensive
care
Increase risk of Potential risk following all
major communicable diseases natural disasters
(Probability rising with overcrowding and deteriorating sanitation)
Food Rare (May Rare Common Common Common
scarcity occur due
to factors
other than food
shortage)
Major Rare (May Rare Common Common Common
population occur in
move- heavily
ments damaged
urban areas)
Under- Occasional Rare Occasional Moderate Common
nutrition/
Famine
e. To re-establish health services to or above pre-disaster
levels, with special attention to:
– Reconstruction and repair of damaged health facilities;
– Renovation of health facilities to adequate and appropriate
level;
– Reorganization of health services based on Primary Health
Care.
Examples of Some Disasters
A few examples of disasters which are still fresh in the
memory of living generations are as under:
Atom bombing of Hiroshima (6 August 1945) and Nagasaki (9
August 1945): During the second world war is regarded as the
worst manmade disaster of the century with estimated
casualties of 120,000 and 75,000 respectively.
Guatemala earthquake (1976): In which 92 percent lost their
homes, about 76,000 sustained injuries and some 23,000 got
killed. A sample survey of victims of this disaster brought out
such startling findings as:
– Eighty-four percent of the victims had no social security
in the form of insurance.
– Forty-six percent were dissatisfied with the medical care
received by them.
– Thirteen percent could not return to their former
employment because of their injury, i.e. they needed
vocational rehabilitation.
 430 Essentials of Community Medicine—A Practical Approach
– Twelve percent had to wait 2-3 days and 16 percent for
one week before admission into a hospital.
– Even for first-aid, 13 percent had to wait for 2-4 hours, 12
percent for four to eight hours and 21 percent for two to
three days.
Bhopal gas tragedy (1984): It is regarded as the worst air
pollution disaster so far and was due to accidental leakage of
methylisocynate (MIC) from its plant. It affected about two
lakh people and claimed 1,754 lives, according to one
published report.

SCHOOL HEALTH SERVICE

School health is an important branch of community health.
According to modern concepts, school health service is an
economical and powerful means of raising community health.

Benefits of School Health Programs

School health programs have a beneficial impact on students,
family, nation and all people at large:
1. Investment in school health programs is the most efficient
and cost effective way to improve students health, and
consequently their academic performance. Beside the
students, teachers and other staff also get health benefits.
2.It has been estimated that 1.3 years of schooling to the
mother reduces child mortality by about 15 percent. More
years of education a female receives, the more likely it is
that her children will survive the first 5 years of life (World
Development Report, 1993).
3. School food programs also have a marked effect on
attendance and school performance.
4. Carefully designed and implemented comprehensive health
education curricula can prevent certain adverse behaviors,
including tobacco use, illicit drug use, unhealthy dietary
practices, unsafe sexual behavior, and physical inactivity.
5. Schools setting provides an efficient means of improving young
people’s health, self-esteem, life skills (abilities related to
effective decision- making, communication, understanding
emotions, critical thinking, coping with stress, etc.) and
behavior. School can also provide the setting to introduce
health information and technologies to the community and
can lead the community by advocating policies and services
that promote health.
6. Schools can reach about one billion students worldwide
everyday and, through them, their families and communities
that is the world broadest and deepest channel for putting
information at the disposal of its citizens (UNICEF 1988).
 Visits
Objectives of School Health Service
The objectives of the program of a school health service are as
follows:
1. The promotion of positive health
2. The prevention of diseases
3. Early diagnosis, treatment and follow-up of defects
4. Awakening health consciousness in children
5. The provision of healthful environment.
School Health Program in India
Formal school health program is nonexistence in India.
However, school medical inspection was started first in Baroda
city in 1909. In the succeeding years practically every province
in British India introduced some form of school health
program particularly in middle and high schools. But after
independence there was not much progress made in school
health program. At the government level, a School Health
Committee was set up in 1960 to review the program at
national level. The committee recommended that in the first
phase (1962-66) school health services should be developed in
an area close to primary health unit to cover 40 primary
schools and in cities all primary school children in slums must
be covered. In the second phase (1966-71) these services
should be extended to all primary schools in both rural and
urban area (GOI 1960-61). Again the progress in this direction
has been rather very slow (Lal 1998).
It is suggested by the School Health Committee that
primary health centers should also cover schools in their
jurisdiction for health care delivery including inspection. One
PHC is responsible for more than 5000 students per year. In
urban area school health service schemes are run by
corporation or nongovernmental organization.
Aspects of School Health Service
The tasks of a school health service are manifold, and vary
according to local priorities. Where resources are plentiful,
special school health services may be developed. Some aspects
of a school health service are as follows:
1.Health appraisal of school children and school personnel
2.Remedial measures and follow-up
3.Prevention of communicable diseases
4.Health school environment
5.Nutritional services
6.First aid and emergency care
7.Mental health
8.Dental health
9.Eye health
10. Health education
 432 Essentials of Community Medicine—A Practical Approach
11. Education of handicapped children
12. Proper maintenance and use of school health records.
VISIT TO DISTRICT LEPROSY CENTER
The distribution of leprosy within districts is quite uneven and
equally the services available in the districts for leprosy control
vary considerably. There are many reasons for this including
the availability of number of staff, difficult terrain, lack of
logistic support and limited participation of general health
staff and community in program activities.
A district level leprosy elimination cell under the
chairmanship of CDMO with ADMO (PH), skin and orthopedic
specialists of HQ hospital, one LCU medical officer, MO
incharge and one PHC medical officer as members of the
district leprosy cell could do the planning and monitoring of
leprosy elimination activities in the district. The district
leprosy elimination plan to be comprehensive should include
all core activities for leprosy elimination and take care to see
that leprosy services reach every patient in every village. The
plan should be placed before the DLES and sent to JDHS (Lep)
for their information and approval.

District Infrastructure (Table 30.6)

Main Activities
The main activities are to be focused at the district level are:
• To expand MDT services to all health facilities.
• To treat all leprosy patients with MDT given free of cost.
• To detect all leprosy cases undetected in the district and
treat them with MDT.
• Capacity building at local level.
• To inform and impart health education to community on
leprosy and seek their support.
• Referral services for leprosy patients.
• The prevention of disability (POD).
• Monitoring, supervision and evaluation.
• To promote health system research (HSR).
Table 30.6: District infrastructure according to endemicity level
District classification by prevalence levelssanctioned
Infrastructure at the start
of phase-1-218 high endemic • Leprosy Control Units ( LCU): 1 per 4.5 lakh rural population
districts (PR>50/10000) A LCU is manned by one Medical Officer (MO) 4 Non-medical S
Modified LCUs: Rural areas
Urban Leprosy Centers (ULCs):1 per 50,000 population 1 PMW
•
•

Contd...
 Visits
Contd...
• Temporary Hospitalization Wards (THWs): To provide specialize
2 Mobile Leprosy Treatment Units (MLTU) for each moderately e
MLTU for leprosy patients at drug delivery with the help of gener
sanctioned in the country
SET Centers: Survey Education and Treatment Centers attached
ULCs in urban endemic pockets
79 Moderately endemic districts

193 Low-endemic districts •

Goal of National Health Policy 2002

“Elimination of Leprosy by 2005”

Project Phase II 2000 Onward

The Project Implementation Plan (PIP) for the NLEP Phase II.
• Part A: National plan setting out the project design for the
country.
• Part B: Plan for eight high endemic states (Madhya Pradesh,
Orissa, Bihar,Uttar Pradesh and West Bengal, Uttaranchal,
Chhattisgarh, Jharkhand)
• Part C: Plan for the remaining 27 states and Union
Territories

Project Phase II Objectives

1. To achieve elimination of leprosy at national level by the
end of the project.
2. To accomplish integration of leprosy services with the
general health care system in the 27 low endemic
states/UTs—union territories.
3. To proceed with integration of services as rapidly as
possible in the eight high endemic states.

Project Phase II Components

1. Decentralization and institutional development
2. Strengthening and integration of service delivery
3. Disability care and prevention
4. Information, education and communication
5. Training.
 434 Essentials of Community Medicine—A Practical Approach
BIBLIOGRAPHY
1. J Kishore, National Health Programmes of India, 4th edn, 2002.
2. Karnataka Paediatric Journal. April-Sept 2000;14:243
3. Park’s Textbook of Preventive and Social Medicine, 16th edn, Nov,
2000.
4. Should disaster strike—Be prepared—Central Health Bureau
Directorate, General of Health Services, Government of India.
5. Swasth Hind, Annual Report 1999-2000.
 Appendix

Appendix

GOALS TO BE ACHIEVED BY 2000-2015

Year Goals to be achieved
2003 : Enactment of legislation for regulating
minimum standard in Clinical
Establishment/Medical Institutions
2005 : Eradicate poliomyelitis and yaws
: Eliminate leprosy
: Establish an integrated system of surveillance,
National Health Accounts and Health Statistics
: Increase State Sector Health spending from 5.5
to 7 percent of the budget
: One percent of the total health budget for
Medical Research
: Decentralization of implementation of public
health programs.
2007 : Achieve zero level growth of
HIV/AIDS 2010 : Eliminate kala-azar
: Reduce Mortality by 50 percent on account of TB,
Malaria and other Vector and Water-borne
diseases
: Reduce prevalence of blindness to 0.5 percent
: Reduce IMR to 30/1000 And MMR to 100/Lakh
: Increase utilization of public health facilities from
current level of <20 to >75 percent
: Increase health expenditure by government
from the existing 0.9 to 2.0 percent of GDP.
: Two percent of the total health budget for Medical
Research
: Increase share of Central grants to constitute at
least 25 percent of total health spending
: Further increase of State Sector Health spending
to eight percent
2015 : Eliminate lymphatic filariasis
 436 Essentials of Community Medicine—A Practical Approach
THEMES OF THE WORLD NO TOBACCO DAYS
• “A World No Smoking Day”, April 7, 1988
• World No Tobacco Day, May 31
On 31 May of each year, WHO celebrates World No Tobacco
Day, highlighting the health risks associated with tobacco use
and advocating for effective policies to reduce consumption.
Tobacco use is the second cause of death globally (after
Hypertension) and is currently responsible for killing one in
10 adults worldwide.
The World Health Assembly created World No Tobacco Day
in 1987 to draw global attention to the tobacco epidemic and
its lethal effects. It provides an opportunity to highlight
specific tobacco control messages and to promote adherence
to the WHO framework convention on tobacco control.
Tobacco use is the number one preventable epidemic the
health community faces.

Year Themes
1988 : Tobacco or Health—choose health
1989 : Women and tobacco—the female smoker—at added
risk 1990 : Childhood and youth without tobacco—growing
up without
tobacco
1991 : Public places and transport—better be tobacco
free
1992 : Tobacco free workplaces—safer and healthier
1993 : Health services—our windows to a tobacco-free
world
1994 : Media and tobacco—get the message across
1995 : Tobacco costs more than you think
1996 : Sport and art without tobacco—play it tobacco
free
1997 : United for a tobacco-free world
1998 : Growing up without tobacco
1999 : Leave the pack behind
2000 : Tobacco kills, don’t be duped
2001 : Second-hand smoke kills
2002 : Tobacco-free sports
2003 : Tobacco-free film, tobacco free fashion
2004 : Tobacco and poverty, a vicious circle
2005 : Health professionals against tobacco
2006 : Tobacco—deadly in any form or disguise
2007 : Smoke free inside
2008 : Tobacco-free youth
2009 : Tobacco health warnings
2010 : Gender and tobacco with an emphasis on marketing to
women
 Appendix
World Diabetes Day
In recent years, World Diabetes Day has focused particularly
on raising awareness of the complications of diabetes affecting
the heart, eyes, kidneys, and feet.
The following themes have been addressed since World
Diabetes Day began in 1991:
1991 : Diabetes Goes Public
1992 : Diabetes—A Problem of All Ages in All
Countries 1993 : Growing up with Diabetes
1994 : Diabetes and Growing
Older 1995 : The Price of Ignorance
1996 : Insulin for Life!
1997 : Global Awareness—Our Key to a
Better Life 1998 : Diabetes and Human Rights
1999 : The Costs of Diabetes
2000 : Diabetes and Lifestyle in the New
Millennium 2001 : Diabetes and Cardiovascular
Disease
2002 : Your Eyes and
Diabetes 2003 : Diabetes
and Kidneys 2004 : Diabetes
and Obesity 2005 : Diabetes
and Foot Care
2006 : Diabetes and the Disadvantaged and
Vulnerable 2007 : Diabetes in Children and
Adolescents
2009–2013 : Diabetes Education and Prevention

INTERNATIONAL DECADES
2011–2020 : Decade of Action for Road Safety.
2008–2017 : Second United Nations Decade for the
Eradication of Poverty.
2006–2016 : Decade of Recovery and Sustainable
Development of the Affected Regions (third
decade after the Chernobyl disaster).
2005–2015 : International Decade for Action, “Water for Life”.
2005–2014 : United Nations Decade of Education for
Sustainable
Development.
Second International Decade of the World’s
Indigenous People.
2003–2012 : United Nations Literacy Decade—Education for
All. 2001–2010 : International Decade for a Culture of Peace
and Non-violence
for the Children of the World.
Decade to Roll Back Malaria in Developing
Countries, Particularly in Africa.
 438 Essentials of Community Medicine—A Practical Approach
Second International Decade for the
Eradication of Colonialism.
1997–2006 : Decade for the Eradication for
Poverty. 1995–2004 : Decade for Human Rights
Education.
1994–2004 : Decade of the World’s Indigenous People.
1993–2003 : Third Decade to Combat Racism and Racial
Discrimination. 1991–2000 : Second Industrial Development
Decade for Africa.
Second Transport and Communications Decade in
Africa. United Nations Decade Against Drug Abuse.
Fourth United Nations Development Decade.
1990–2000 : International Decade for the Eradification of
Colonialism. 1990–1999 : United Nations Decade of
International Law.
: International Decade for Natural Disaster
Reduction.
1990s : Third Disarmament Decade.
1988–1997 : World Decade for Cultural Development.
1983–1993 : Second Decade to Combat Racism and Racial
Discrimination. 1983–1992 : United Nations Decade for
Disabled Persons.
1981–1990 : International Drinking Water Supply and Sanitation
Decade.
Third United Nations Development Decade.
1980–1990 : Second Disarmament Decade.
1980S : Industrial Development Decade for Africa.
1978–1988 : Transport and Communications Decade
for Africa.
1976–1985 : United Nations Decade for Women—Equality,
Development and Peace.
1973–1983 : Decade to Combat Racism and Racial
Discrimination. 1971–1980 : Second United Nations
Development Decade.
1970s : Disarmament Decade.
1960–1970 : United Nations Development Decade.

IMPORTANT ACTS RELATED TO HEALTH

Acts
• The Indian Medical Council Act, 1956 and Regulations, 2002
• The Indian Nursing Council Act, 1947
• The Dentists Act, 1948
• The Pharmacy Act, 1948
• The Rehabilitation Council of India Act, 1992
• The Indian Medicine Central Council Act, 1970
• The Homeopathy Central Council Act, 1973
• The Consumer Protection Act (CPA), 1986
• The Registration of Births and Deaths Act, 1969
• The Epidemic Diseases Act, 1897
• The Transplantation of Human Organ Act, 1994
 Appendix
• The Prevention of Food Adulteration Act, 1954
• The International Health Regulation
• The Medical Termination of Pregnancy (MTP) Act, 1971
• The Maternity Benefit Act, 1961
• The Dowry Probihition Act, 1961
• The Immoral Traffic (Prevention) Act, 1956
• The Prenatal Diagnostic Techniques (Regulation and
Prevention of Misuse) Act, 1994
• The Infant Milk Substitutes, Feeding Bottlers and
Infant Foods (Regulation of Production, Supply and
Distribution) Act, 1992
• The Juvenile Justice (Care and Prevention of Children) Act,
2001
• The Child Labor (Prohibition and Regulation) Act, 1986
• The Child Marriage Restraint Act, 1929
• The Persons with Disabilities (Equal Opportunity, Protection
of Rights and Full Participation) Act, 1995
• The Mental Health Act, 1987
• The SCs and the STs (Prevention of Atrocities) Act, 1989
• The Narcotic Drugs and Psychotropic Substances Act, 1985
• The Drugs and Cosmetics Act, 1940
• The Drugs (Control) Act, 1948
• The Drugs and Magic Remedies (Objectionable Adverstiments)
Act, 1954
• The Minimum Wages Act, 1948
• The Dangerous Machine (Regulation) Act, 1983
• The Plantation Labor, Act, 1951
• The Factories Act, 1948
• The Mines Act, 1952
• The Employees State Insurance (ESI) Act, 1948
• The Workmen’s Compensation Act, 1923
• The Bonded Labor System (Abolition Act)
• The Environment (Protection) Act, 1986
• The Biomedical Waste (Management and Handling) Rules,
1998
• The Municipal Solid Waste (Management and Handling)
Rules, 2000
• The Hazardous Waste (Management and Handling)
Rules,1989
• The National Environmental Tribunal Act, 1995
• The Air (Prevention and Control of Pollution) Act, 1981
• The Water (Prevention and Control of Pollution) Act, 1974
• The Insecticides Act, 1988
• The Motor Vehicles Act, 1988
• Red Cross Society Act, 1936
 440 Essentials of Community Medicine—A Practical Approach
YEARS OF LAUNCHING NATIONAL HEALTH PROGRAMS
National program Year
Sexual Transmitted Diseases Program 1949
BCG Vaccination Program 1951
Community Development Program 1952
National Malaria Control Program 1953
National Family Planning Program 1953
Contributory Health Service Scheme 1954
National Water Supply and Sanitation Program 1954
National Leprosy Control Program 1955
National Filaria Control Program 1955
National Malaria Eradication Program 1958
National Small Pox Eradication Program 1962
School Health Program 1962
National Goiter Control Program 1962
District Tuberculosis Program 1962
Applied Nutritional Program 1963
National Trachoma Control Program 1963
Contributory Health Services renamed as 1963
Central Government Health Scheme
Expanded Family Planning Program 1963
National Trachoma Control Program 1968
All India Hospital (Postpartum) PP Program 1969
Accelerated Rural Water Supply Program 1972
National Program of Minimum Needs 1973
National Program for Prevention of
Visual Impairment and Control of Blindness 1976
Rural Health Scheme 1977
Re-oriented Medical Education (ROME) 1977
Modified Plan of Operation (MPO) 1977
Expanded Program on Immunization (EPI) 1978
National Guineaworm Eradication Program 1979
National Mental Health Program 1982
National Leprosy Eradication Program 1983
National Health Policy 1983
Universal Immunization Program (UIP) 1985
New 20 Point Program 1987
National Diabetes Control Program 1987
National AIDS Control Program 1987
Blood Safety Program 1989
Child Survival and Safe Motherhood Program 1992
Reproductive and Child Health Program 1994
Integrated Disease Surveillance Project (IDSP) 2004
Contd...
 Appendix
Contd...
National program Year
Reproductive and Child Health Program II 2005
(RCH II)
Integrated Management of Childhood Illness 2007-2010
(IMCI)
Integrated Management of Neonatal and
Childhood Illness 2010
National Rural Health Mission 2005-2012
National Urban Health Mission 2008-2012

WORLD HEALTH DAY

What is the World Health Day?

The seventh of April each year is celebrated as the World
Health Day and it marks the date 1948 when sufficient
countries had ratified their signature to bring the Constitution
of the World Health Organization into force. Ever since 1950,
a theme related to international public health has been chosen
for the World Health Day, with an appropriate slogan. Thus in
1955, the slogan was “Clean Water Means Better Health”. In
1962, “Preserve Sight—Prevent Blindness” and in 1980,
“Smoking Health— the Choice is Yours’’.
All over the world, governments, WHO national commities,
United Nations association and Nongovernmental
Organizations help to arrange events related to the theme.
Over the years, the World Health Day events have attracted
more and more coverage by media—whether newspapers or
radio and television. And the impetus does cease when the day
is over—the them is regarded as valid for the rest of the
year.

LIST OF WORLD HEALTH DAY THEMES

1950 : Know Your Own Health Services
1951 : Healthy for Your Child and the World’s
Children 1952 : Healthy Surrounding Make
Healthy people
1953 : Health is Wealth
1954 : The Nurse, Pioneer of
Health 1955 : Clean Water Means
Better Health 1956 : Destroy,
Disease Carrying Insects 1957 :
Food for Health
1958 : Ten Years of Health Progress
1959 : Mental Illness and Mental Health in the World
Today 1960 : Malaria Eradication—A Word Challenge
1961 : Accidents need not Happen
1962 : Preserve Sight—Prevent
Blindness 1963 : Hunger, Disease of
Millions
 442 Essentials of Community Medicine—A Practical Approach
1964 : No Truce for Tuberculosis
 Appendix
1965 : Smallpox—Constant
Alert 1966 : Man and His
Cities
1967 : Partners in Health
1968 : Health in the World of
Tomorrow 1969 : Health, Labor and
Productivity
1970 : Early Detection of Cancer Saves
Lives 1971 : A Full Life Despite
Diabetes
1972 : Your Heart is Your
Health 1973 : Health Begins
at Home
1974 : Better Food for a Healthier
World 1975 : Smallpox—Point of No
Return 1976 : Foresight Prevent
Blindness
1977 : Immunize and Protect your
Child 1978 : Down with High Blood
Pressure 1979 : A Healthy Child, A
Sure Future
1980 : Smoking or Health—The Choice is
Yours 1981 : Health for All by the Year
2000
1982 : Add Life to Years
1983 : Health for All by the Year 2000—The Count down has
Begun 1984 : Children’s Health—Tomorrow’s Wealth
1985 : Healthy Youth—Our Best
Resource 1986 : Healthy Living—
Everyone a Winner
1987 : Immunization—A Change for Every
Child 1988 : Health for All—All for Health
1989 : Let Us Talk Health
1990 : Our planet, our health—think globally act
locally 1991 : Should disaster strike—Be
prepared
1992 : Heart beat—The rhythm of health
1993 : Handle Life with Care—Prevent Violence and
Negligence. 1994 : Oral Health for a Healthy Living
1995 : Target 2000—A World without
Polio 1996 : Healthy City for Better
Living
1997 : Emerging Diseases—Global alert, Global
response 1998 : Pregnancy is Precious “Let us
make it safe”
1999 : Active Ageing Makes Difference
2000 : Safe blood starts with me, blood
saves life. 2001 : STOP Exclusion dare to
care
2002 : Move for Health
2003 : Shape the Future of Life—Healthy Environments for
Children. 2004 : Road Safety.
2005 : Make every mother and child
 444 Essentials of Community Medicine—A Practical Approach
count. 2006 : Working together for
health.
 Appendix
2007 : International Health Security.
2008 : Protecting health from the adverse effects of
climate change. 2009 : Save lives, Make Hospitals Safe in
Emergencies.
2010 : 1000 cities, 1000 lives.

IMPORTANT INTERNATIONAL EVENTS AND DAYS

9th January Cancer Day
30th January Anti-Leprosy Day
1st February Deaf and Dumb
Day
8th March International Women’s Day
15th March World Consumer Rights Day + World
Disabled Day 16th March Measles Day
20th March World Forestry Day
24th March World TB Day
7th April World Health Day
26th April Anniversary of Chernobyl
disaster 30th AprilChild Labor Day
1st May World Labor Day
8th May World Red Cross Day
12th May Red Cross Day
13th May Mothers Day
24th May Dr Olle Hansson Day
31st May World No Tobacco Day
5th June World Environment Day
26th June International Day against Drug Abuse and
Illicit Trafficking
1st July Doctors Day (India)
1st August World Breastfeeding Day World
breastfeeding week 5th August World Breastfeeding Practice
Day
6th August Hiroshima Day
9th August Nagasaki Day
20th August World Mosquito Day
1st October World Voluntary Blood Donation
Day 1-7th September National Nutrition Week
8th September International Literacy
Day 20th September International
Peace Day 3rd October Habitat Day
10th October World Mental Health
Day 11th October National No Tobacco
Day 13th October Anti-National Disaster
Day 14th October World Standards Day
16th October World Food Day
 446 Essentials of Community Medicine—A Practical Approach
24th October United Nations
Day 15th November World
Diabetes Day 18th November
World Epilepsy Day
1st December International Pollution and Prevention Day +
World AIDS Day
2nd December National Pollution and Prevention
Day 3rd December Bhopal Gas Tragedy Day
8th December National Day for the Mentally
Retarded 10th December World Human Rights Day
11th December UNICEF Day.

POLICIES
National Policies Related to Health
1.National Health Policy 2002
2.National Population Policy 2000
3.National AIDS Prevention and Control Policy 2002
4.National Blood Policy 2002
5. National Policy for the Empowerment of Women (2001)
6.National Policiy and Charter for Children Draft
7.National Policy for Old Person 1999
8.National Nutrition Policy 1993
9.National Health Research Policy Draft
10. National Policy on Education
11. National Water Policy
12. National Conservation Strategy and Policy Statement on
Environment and Development 1992
13. Census of India 2001.

ACRONYMS
AFP Acute Flaccid Paralysis
AIDS Acquired Immunodeficiency
Syndrome ANM Auxiliary Nurse-Midwife
ARI Acute Respiratory Infection
BFHI Baby Friendly Hospital Initiatives
CBO Community Based Organization
CBR Crude Birth Rate
CHC Community Health Center
CIDA Canadian International Development
Agency CMO Chief Medical Officer
CPA Consumer Protection Act
CPR Couple Protection Rate
CSSM Child Survival and Safe
Motherhood DALY Disability Adjusted Life
Year Lost
 Appendix
DGHS Director General of Health
Services DHO/DMO District
Health/Medical Officer DHS Directorate
of Health Services
DOTS Directly Observed Therapy Short-
course DPT Diphtheria, Pertussis, and Tetanus
Vaccine EPI Expanded Program on Immunization
FAO Food and Agriculture Organization
FWP Family Welfare Program
GBD Global Burden of Disease
GDP Gross Domestic Product
GNP Gross Net Product
GOI Government of India
HIV Human Immunodeficiency Virus
ICCIDD International Council for Control of Iodine
Deficiency Disorders
ICDS Integrated Child Development Service
IEC Information, Education and
Communication IFA Iron and Folic Acid
ILO International Labor Organization
IMA Indian Medical Association
IMR Infant Mortality Rate
ISM Indian System of Medicine
IUD Intrauterine Device
LHV Lady Health Visitor
MCH Maternal and Child Health
MDR Multi-Drugs Resistance
Tuberculosis MDT Mutli-Drugs Therapy of
Leprosy
MMR Maternal Mortality Rate
MOHFW Ministry of Health and Family
Welfare MPW Multipurpose Worker
MS Medical Superintendent
 Index

Page numbers followed by f refer to figure and t refer to table

A Arthropods 215
Accredited social health activists Ascariasis 224
282 Action plan of MLEC 51, 51t treatment 224t
Active and passive immunization Aspects of school health service
182 Acute flaccid paralysis 171 431
Adolescent Aspergillus flavus
friendly health center services 195 Assessment of
313 girls scheme 314 dehydration 61
health 308, 311 energy requirement for family
Advantages of 191 nutritional status 190
MVA 152 obesity 83
syndromic case management Atom bombing of Hiroshima 429
73 Adverse effects of vaccine Autoclaving 230
177 Aflatoxin 195 Average weight of vegetables 204
AFP case Ayurveda system of medicine 302
investigation
172
B
case notification 172
Albert stain 256 Baby friendly hospital initiative
417 Bacteria in milk 253
All India Consumer’s Price Index
Bacterial index 41
12 Allopathy 307
Bacteriological
Amount of ORS solution 61
Ancylostoma duodenale 226 examination 40, 253
treatment 226t of water 247
Anganwadi 421 quality of drinking water 249t
worker 423 Bacteriology of
Angina 78 milk 253
Angioneurotic edema 184 water 247
Antibiotics used in treatment of Balanced diet 188, 200,
cholera 62t 200t for children 201,
Anti-fertility vaccines 141 201t
Anti-larval measures 220 Bar diagram 358
Antileprosy drugs 45t BCG 166
Anti-nutritional factors 193 Benefits of School Health
Anti-rabies vaccine 182 Programs 430 Bhopal gas tragedy
430
Antiseptic 228
Bleaching powder 232, 271
Antisera 179 Blind school 409
Anti-snake venom 184 Body
Arachnida 217 mass index 84
Arm tapes 128f
measurement techniques 124
Breastfeeding 132
Broca’s index 83
 448 Essentials of Community Medicine—A Practical Approach
Burden of
disease Chlorhexidine 231
52 Chlorinometer 238
leprosy 33 Chloroscope 238
occupational diseases and Choice of contraceptives 153t
injuries 3 tuberculosis 23t Cholera 56
triggers 322
C Chronic noncommunicable
Calculation of diseases and conditions 2
effective couple protection rate Classification of
152 expected blood pressure
height of child 132 80t leprosy 37t
weight of child 131 occupational disorders 332
pediatrics doses 132 PEM 120
Calorie deficiency classification Classifying types of leprosy 43t
120 Cancer 96 Clinical
registration 97, 98 classification of diabetes mellitus
Candidate vaccines 92 features of obesity 85
48 Carcinoma of Clostridium tetani 261
breast 99 Coefficient of variation
lung 100 363 Cohort cure rate
MB/PB 35 Coliform test
Case finding tools 20 249 Collecting
Categories of biomedical waste and handling
267 Causes of cerebrospinal fluid
cancer 98 326
death 351 stool specimens
diarrhea 56, 56t 327 blood for
maternal death 101 cultures 325
Cell culture vaccine serum 328
183 Centering sputum 326
constants 361 stool specimens
Central Pollution Control Board for bacteria
272 Cesarean section rate 355 327
Cetrimide 232 parasites 326
Characteristics of viruses 327
insecta 216f Collection of waste with source
mosquitoes 218f segregation 270
normal curve 370 Color coding and type of
Chemical container for disposal of
disinfection biomedical wastes
271
277t
wastes 265
Combined
Chemoprophylaxis 21
oral contraceptive 144
Chemotherapy 54
vaccine 178
Chickenpox vaccine 185
Common breastfeeding problems
Chief medical and health officer 420 Communicable disease 2, 16,
318 Child 17 Community
development project officer
423 survival elements 104 based rehabilitation 339
Childhood illnesses 335 health centers 3
Chi-square test 371 level 291
Completion of treatment and cure
46 Complex media 257
 Index
Complicated manifestations of
disease 187 Crustacea 217
Complications of myocardial Cubic space 11
infarction 78 Cyclops 224
Components of
IMNCI in India
335 RCH 103 D
Urban Health Mission 293 Deaf and dumb school
Composition of 410 Death rate 353
coordination committee Definition of
415t DPT vaccines 179 infection 16
Conceptual framework of safe RCH 103
motherhood 102 statistics 356
Concurrent disinfection 229 Deformities occurring in leprosy
Conditioning influences 118 43t Delivery of
Confirmation of existence of chlorine solution into well
epidemic 64 251 integrated services for
Construction of frequency table maternal and child health
358 Contact period 251 416
Contraceptive failure rate 134 Dengue triggers 323
Control measures for Department of Obstetrics
cyclops 224 and
houseflies 222 Gynecology 415
itch mite 224 Detection of
lice 223 coliform bacteria and E. coli
ratflea 224 248 fecal streptococci 250
Determination of total hardness
sandfly 223 246 Development of immunity
ticks 221 168 Diabetes mellitus 92
Control of Diagram of human body 41f
cholera 58 Diarrhea
scabies 68 and dysentery 55
Conventional
Control Program 56
contraceptive 134
regimens 21 Diarrheal disease 55
Convergence of ICDs services Control Program 63
423f Converging sanitation Dichloro-diphenyl-
and hygiene trichloroethane 235
under NRHM 284 Difference in National
Coronary heart disease Tuberculosis Program and
76 Corpulence index 84 Revised NTCP 29, 29t
Corynebacterium diphtheriae Diphtheria immunization 178
261 Directly observed therapy
Cresol emulsions 231 short- course 27
Criteria for adolescent Disease burden 1
friendly health Disinfection 62, 228
center 313 of sputum 30
worker 313 Disposal of
Crude biodegradable kitchen waste
birth rate 4 276 feces 300
death rate 4 refuse and excreta
299 stable litter 301
phenol 231 Dissolve bleaching powder in
water 251
 450 Essentials of Community Medicine—A Practical Approach
District
Cancer Control Program 99 number of contacts 156
epidemic investigating team requirements of
320 epidemiological cell 320 immunization cards 162
health sterilization equipment 159
laboratory 411 syringes and needles 158
vaccine
plan 284 needs
immunization officer 171 159
infrastructure 432 requirements 162
leprosy center 432 Ethylene oxide
rehabilitation center 426 233 Examination
project 340 for
surveillance Clostridium perfringens 250
committee 319 specific pathogens 254
unit 318 Expanded program of
tuberculosis immunization 157
center 425
officer 28 F
Dosage schedule for MDT Failure of
45t DOTS-plus strategy OPV 169
30 three dose regimen 169
Dr Udani’s classification Failure rate of contraceptives 135t
120 Dry Families of medical importance
and wet bulb thermometer 220 Family
238 camp and kitchen refuse cycle 8
299 planning
Durham’s tubes 249 insurance scheme 148
methods 136
E Fat fold thickness
Economic burden of 84 Fermentation
tuberculosis 18 Eijkman’s test 193
249 Filariasis 52
Elements of intensified program Final disposal of waste
52 Eligibility criteria for 271 Flag sign 120
beneficiaries Floor space accepted standard
under scheme 112 11 Formaldehyde 233
Elimination of gas 233
leprosy 51 Formulation of hypotheses 66
neonatal tetanus 182 Frequency
Emergency contraceptives 141 polygon 360
Emerging oral contraception table
142 Endocrine disorders 83 358
Enterobius vermicularis Functions
225 treatment 225t of
Enumerate eligibles 162 District Surveillance Unit
Epidemiological and nutritional 318 PHC 412
exercises 399 postpartum unit 414
Epidemiology of malnutrition social security division 347
122 ESI contribution rates
348 Essential indicators for G
leprosy 34 Estimation of
cold chain requirements 160 Gastroenteritis 55
Genital ulcers 74
Geometrical progression method
374
 Index
Germination 193
Giddiness 183 Homeopathy 305
Global Hospital waste
Leprosy Elimination Program disposal 266
52 Strategy of Occupational management 264
Health 333 structure 267f
Globe thermometer 240 Houseflies 221
Glutaraldehyde 271 Hypertension 80
Gomez’s classification 120
Government rehabilitation I
services
Immunization 155
340 of pregnant woman
Gram stain 255 155 Immunoglobulin
Green Light Committee Initiative 178 IMNCI
32 plus 338
strategy in India 335
H Impact of adolescence
Handling and 310 Important
facts about contraceptives
transportation of respiratory
specimens 326 153 features of JSY 110
international events and days
transporting 443 Incinerators 272
blood for cultures Indian systems of medicine
325 serum 325 302 Infant
Harward’s classification 121 feeding formula 115, 115t
Head and chest circumference mortality rate 4
129 Headache 183 Infection 118
Health
care rates 355
indicators 4 Influenza vaccines 186
infrastructure 3 Injectable contraceptives 145,
services for beneficiaries 146t Insecticides 234
under scheme 112 Insomnia 183
Integrated
education 48
Child Development Scheme
regarding danger 421 counseling and testing
signals 99 facilities in
center 408 disease
India 3t promotion 131
surveillance 316
status in India
management of neonatal and
4t trust of India
287 childhood illness 337t
Hepatitis B vaccines 186 Integration of PPTCT within
Hexachlorphane 231 postnatal MCH services 114
Highly infectious wastes Intensive pulse polio
265 High-risk immunization
infants 117 175
screening 94 International
waste 265 Death Certificate 377, 377t
Histamine test 42, decades 437
42t infectious substance symbol 264f
Histogram with frequency Intravenous rehydration 61
polygon 360f Investigation of epidemic 63, 329
HIV
infection 32
vaccine 185
 452 Essentials of Community Medicine—A Practical Approach
J
Maternit
Janani Suraksha Yojana 109
Japanese encephalitis triggers y
323 Jellyfish classification and child health 101
121 emergency care 102f
Maximum and
Joint family 8
minimum
Jones criteria for diagnosis of
acute rheumatic fever 87t thermometer 239
Mean deviation 363
Measles
K mumps and rubella vaccine 186
Kata thermometer 240 vaccine 176
Kishori Shakti Yojna 424 Measurement burden of disease
Kuppuswamy’s method 77 Measures of
12 central tendency 361
Kwashiorkor 120, 197t fertility 374
mortality 375
L population 374
Laboratory wastes 265 variation 362
Late adolescence 309 vital statistics 374
Lathyrism 193 Measuring child’s height 126f,
Legislative framework 276 127f Medical methods of
Lepromatous leprosy 37 abortion 149 Membrane
filtration method 249
Lepromin test 43 Meningococcal vaccines 187
Leprosy 33 Mental health 88
Control Programs 48 Methods of
educational messages 48 family planning 136
Organizations in India 49 social classification 11
vaccine 185
study 8
Leptospira 262 uterine evacuation 150
Liquid waste 299 Methylene blue reduction test
List of World Health Day Themes 253 Methylisocynate 430
441 Lorentz’s formula 84 Microscopic slides 258
Lymphatic filariasis 53 Midarm circumference 128
Middle adolescence 309
M Mifepristone 149
Maintain Milestones in vaccination 166t
equipment Mineral oil 236
165 Misoprostol 149
vaccines 164 Mixed vaccines 178
Maintenance therapy 61, 61t Mode of transmission
Malaria 36
triggers 322 Modified leprosy elimination
vaccines 187 campaigns 50
Mamta scheme 111 Morbidity statistics 376
Manual vacuum aspiration 150 Morphological index
Marasmus 119, 197 42 Mosquito
Maternal borne diseases 217, 219
and child health 3, 108 control measures 220
mortality ratio 4 Mukhya sevika 423
Multibacillary rate 35
Multiple tube technique
248
 Index
Mycobacterium
leprae 35, Nurse population ratio 4
259 Nutrient requirements
tuberculosis 259 during
Myocardial infarction 78 pregnancy 196
Nutritional
deficiencies 2
N supplements 422t
National
Cancer Control Program O
99 Diabetes Control Obesity 82
Program 95 Filaria Objectives
Control Program 54 of
Health Policy 55
antenatal visit 107
Immunization
health disaster preparedness
days 170, 171 428 NTCP 30
schedule 155, 157, 168
plan 268
information center on
disability and rehabilitation postnatal care 116
341 school health service
431
Leprosy Eradication Program
50 Mental Health Program 91 Oral
polio surveillance unit 173 glucose tolerance test
program for rehabilitation of 94t polio vaccine 168,
persons with disabilities 173 rehydration therapy
427 Rural Health Mission 280 62t
STD Control Program 75 Orthotolidine arsenite test 252
Subcommittee of Indian
Academy P
of Pediatric 121 Package of services
Surveillance unit 422 Passive
318 TB Control immunization 181
Program 29 Pearl index 153
Tuberculosis Program Pediatric
425 Urban Health Mission DOTS 25
292 tuberculosis 25
Neisseria Pellagra
gonorrhoeae 192 Per
261 capita
meningitidis 260 income 10
Neuraminidase specific vaccine
186 Neuroparalysis 184 monthly income 12
Percentage of major causes of all
New deaths in developing countries 3t
health financing mechanisms Percutaneous transluminal
285 initiative in social coronary angioplasty 78
security 349
Perinatal vaccine 185
Newer
Pesticides 234
contraceptives 136
Phosphatase test 254
vaccines 185
No scalpel vasectomy 141 Pie diagram 360, 361
Normal Places of natural calamities
427 Plague triggers 323
curve 370, 370f
Point prevalence rate 34
distribution 368 Polio trigger 322
with mean zero and Polyandrous type 7
standard deviation unity
371t Polygamous type of nuclear family
Notifiable diseases 5 7
 454 Essentials of Community Medicine—A Practical Approach
Ponderal index 84
Population strategy 79
Q
Postnatal care 116 Qualities of good contraceptives
Postpartum center 134 Quartile deviation 363
413 Poverty Quaternary ammonia compounds
cycle 122 232
line 10
Prasad’s R
classification 12t Rapid sand filter 245
method 11 RCH-II and family planning 108
Precurrent disinfection 229 Recombinant vaccine 186
Pre-exposure prophylaxis 183 Recommended dietary
Pregnancy rate 136 allowances for
Prenatal Indians 207
advice 107 Rectal swabs 327
services 107 Recyclable waste
Pressurized containers 265 Reference index 13t
Presumptive coliform count 248 Regional rehabilitation training
Prevalence of reproductive tract center 341
infection 359f Regular periodic survey
Prevention of 317 Rehydration therapy
blindness 410 58 Relief of pain 78
parent to child transmission of Reproductive
HIV infection 112 and Child Health Program 103
Preventive vaccine health elements 104
185 Primary Retirement Programms in Social
health center 3, 412 Security 349t
urban health center Rheumatic heart
295 disease 86 Risk of
Primi mothers 420 tuberculosis 32 Role
of
Principles in calculating
balanced diet 200 district within surveillance
system 319
Probability of larger value of T
369 Process of AFP surveillance NGOs in mission 289
173 Program Panchayati Raj institutions
288 primary health centers
implementation plan 109
management support center for
287 disability rehabilitation
342 state governments under
Proportion of single skin lesion
case rate 35 NRHM
Proportional bar diagram 358f, 288
359 Protection against mosquito Routes of
bites 220 Protein energy administration
malnutrition 119 Prototype acute 167
disaster cycle 428f Puberty transmission 222
changes in adolescent Routine immunization 170
310 in girls 310 Rubella vaccine 185, 186
Public health importance of ticks
221 Pulmonary TB 166 S
Pulse Polio Immunization Sanitation of camps 297
Program 170 Scabies 67
Schedule of national
immunization 157t
Scheme for adolescent girls 424
 Index
School Health
Program in India 431 Sweat test 42, 43t
service 430 Swine flu 350
Sentinal Surveillance under Symptoms of ascariasis 225
IDSP 317 Seven National Levels
Institutes 340 Sexually T
transmitted diseases 69 Short-
Table of
course chemotherapy regimens
22t chi-square 372
Sickness unit normal distribution
17 371 Ten leading causes of
Siddha system of medicine 303 burden of
Side effects of anti-leprosy drugs disease 1t
46, 46t Skin fold thickness 84 Terminal disinfection 229
Sling psychrometer Test for coliform bacteria
241 Slow sand filter 253 Testing of
244 Sodium hypotheses 67
hypochlorite 232 Tests of statistical significance
Split-virus vaccine 186 364 Tetanus
Spread of diseases 222, spores 233
223 Stage of toxoid 180
disintegration 9 Themes of World No Tobacco
formation 9 Days 436
growth 9 Tick sign 120
Staining procedure for malarial Transmission 350
smear 412 Transport medium 324
Standard Treatment for
deviation 363 cancer 99
error of
most common STD associated
mean 364 syndromes 73
proportion 367
State Treatment of
Surveillance Unit 318 ENL reaction 46
tuberculosis officer hypertension 82
28 Steps for lower abdominal pain in female
calculation 368 75 mild dehydration 61
paired T-test 367 reversal reaction 45
Steps in well disinfection 250 severe dehydration 61
Strategies for polio eradication urethral discharge 73
170 Strengthening vaginal discharge 74
disease control programs 285 Treatment plan for
primary health centers 283 rehydration
Strongyloides stercoralis 227 therapy 61t
treatment 227t Treponema pallidum
Structural framework of IDSP 259
321 Structure of RNTCP 28 Trichuris trichiura
Sub-virion vaccine 186 225 treatment
Summary of biomedical waste 225t
rules 276 Surveillance Triggers for syndromic
medical officer 171 surveillance 323
of acute flaccid paralysis 171 Tubercle Bacillus 254
of noncommunicable diseases Tubercular meningitis 167
332 Tuberculosis 18, 198t
unit 28
Turbidity test 254
 456 Essentials of Community Medicine—A Practical Approach
Types of
bacteria in milk 253 Varishtha Pension Bima Yojana
disinfection 229 349 Viral transport medium 324
family 7 Virological classification scheme
172
hospital waste 265
media 257 W
non-sporing bacteria 233
PEM 119 Warm chain 117
Waste disposal strategy 270
vaccine 167 Waterlow’s classification 121
vacuum aspiration 151
Weighing procedure 124
Typhoid fever triggers 322
WHO prototype growth chart
130f World
U
breastfeeding week 419
Unani system of medicine diabetes day 437
304 Under RCH Program
106 health day 441
Universal Immunization Program Wuchereria bancrofti 226
157 Urban treatment 226t
health delivery model 294
measles campaign 178 Y
Uses of Years of launching National
hanging spring balance Health Programs 440
for weighing infants Yoga 306
125f MVA equipment
152 Z
Ziehl-Neelsen stain 256
V
Vaccine 166
vial monitoring 176