PARK’S TEXTBOOK

OF

PREVENTIVE AND
SOCIAL MEDICINE

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K. PARK
M.B.B.S., M.S.

TWENTY-SEVENTH EDITION

M/s BANARSIDAS BHANOT

PUBLISHERS

JABALPUR PUNE
1167, Prem Nagar, 703, Konark Icon,
Jabalpur - 482 001 S.No. 134/1D/2, Hadapsar,
Madhya Pradesh Magarpatta Road, Pune - 411 036

2023

by R△J
 M/s BANARSIDAS BHANOT
PUBLISHERS

JABALPUR PUNE
1167, Prem Nagar, 703, Konark Icon,
Jabalpur-482 001 (M.P.) S.No. 134/1D/2, Hadapsar,
Tel: 4-91-761 2424246, 94251 54030, 94251 52894 Magarpatta Road, Pune - 411 036
E-mail: [email protected] Tel: +91-20 48606788
All rights reserved. This book
© 2023 K. PARK or parts thereof, not to be reproduced
without prior written permission of the Author.

ISBN No. 978-93-82219-19-4

1st Edition July, 1970

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2nd Edition Nov, 1971
3rd Edition Sept, 1972
4th Edition April, 1974
5th Edition March, 1976
6th Edition July, 1977
yth Edition March, 1979 NOTICE
8th Edition Sept, 1980
gth The author and the publisher of this work have checked with
Edition June, 1983 sources believed to be reliable in their efforts to provide information
10th Edition Jan, 1985 that is complete and generally in accord with the standards accepted
11th Edition Nov, 1986 at the time of publication. However, in view of the possibility of
human error or changes in medical sciences, neither the author nor
12th Edition Sept, 1989 the publisher warrants that the information contained herein is in
13th Edition Dec, 1991 every respect accurate or complete, and they disclaim all
14th Edition responsibility for any errors or omissions or for the results obtained
Dec, 1994
from use of the information contained in this work. Readers are
15th Edition Sept, 1997 advised to confirm the information contained herein with other
16th Edition Nov, 2000 sources. In particular, readers are advised to check the product
information sheet included in the package of each drug they plan to
17th Edition Nov, 2002 administer to be certain that the information contained in this work is
18th Edition Jan, 2005 accurate and that changes have not been made in the recommended
19th Edition Feb, 2007 dose or in the contraindications for administration.
20th Edition Feb, 2009
21st Edition Feb, 2011
22nd Edition Feb, 2013
23rd Edition Jan, 2015
24th Edition Jan, 2017
25th Edition Feb, 2019
26th Edition Mar, 2021
27th Edition Feb, 2023

The twelfth edition was published under the title

“Textbook of Preventive and Social Medicine”

PRICE Rs. 1700/

by R△J
 CONTENTS

Chapter Page

1. MAN AND MEDICINE : TOWARDS HEALTH FOR ALL 1

2. CONCEPT OF HEALTH AND DISEASE 13

3. PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS 60

Aims of Epidemiology..................... 61 Infectious disease epidemiology........ 100

Epidemiological approach................ 62 Disease transmission.......................... 102
Measurement of mortality.................64 Immunity............................................ 109
Rates and ratios.................................65 Immunizing agents............................. 111
Measurement of morbidity................68 Cold chain.......................................... 116
Epidemiologic methods.................... 70 Open Vial Policy................................ 121
Descriptive epidemiology.................71 Adverse events after immunization 123
Analytical epidemiology...................78 Disease prevention and control.......... 131
Cohort study..................................... 83 Immunization schedule...................... 135
Experimental epidemiology..............88 Disinfection........................................ 140
Association and causation.................95 Investigation of an epidemic............. 147
Uses of epidemiology....................... 99
4. SCREENING FOR DISEASE 151
Sensitivity and specificity..................................... 155

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Concept of screening...................... 151
Uses of screening........................... 152 Problems of the borderline................... ................157
Criteria for screening..................... 153
5. EPIDEMIOLOGY OF COMMUNICABLE DISEASES 159
I. Respiratory infections
Smallpox......................................... 159 Whooping cough.................................................. 181
Chickenpox.................................... 161 Meningococcal meningitis................................... 183
Measles.......................................... 164 Acute respiratory infections................................. 185
Rubella............................................ 168 SARS....................................................................191
Mumps............................................ 170 COVID-19............................................................192
Influenza........................................ 172 Tuberculosis......................................................... 207
Diphtheria...................................... 178
II. Intestinal infections
Poliomyelitis................................... 240 Food poisoning.....................................................280
Viral hepatitis..................................248 Amoebiasis...........................................................283
Acute diarrhoeal diseases............... 263 Ascariasis............................................................. 285
Cholera............................................270 Hookworm infection............................................ 285
Typhoid fever..................................276 Dracunculiasis...................................................... 288

III. Arthropod-borne infections

Dengue syndrome........................... 288 Lymphatic Filariasis............................................. 315
Malaria............................................ 299^- Zika Virus Disease................................................321

IV. Zoonoses
Viral Bacterial
Rabies............................................. 322 Chikungunya fever...............................................335
Yellow fever................................... 327 Brucellosis............................................................337
Nipah virus infection..................... 330, Leptospirosis........................................................ 338
Japanese encephalitis...................... 331' Plague...................................................................339
KFD................................................ 334 Human salmonellosis............../......i..................... 345
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 Rickettsial diseases Parasitic zoonoses
Rickettsial zoonoses.... .................346 Taeniasis............................................. ..................349
Scrub typhus.................. .................347 Hydatid disease.................................. ..................350
Murine typhus............... .................347 Leishmaniasis.................................... ..................351
Tick typhus.................... .................347
Q Fever......................... .................348

V. Surface infections
Trachoma...................... .................356 STD.................................................... ..................379
Tetanus.......................... .................358 Yaws................................................... ..................390
Leprosy......................... .................362 AIDS.................................................. ..................392

$ VI. Emerging and re-emerging infectious diseases 406

VII. Hospital acquired infections 410

6. EPIDEMIOLOGY OF CHRONIC NON-COMMUNICABLE 413

DISEASES AND CONDITIONS
Cardiovascular diseases.......... ...... 417 Diabetes............................................ ....................446
Coronary heart disease............ ...... 419 Obesity............................................. ....................451
Hypertension........................... ...... 425 Blindness.......................................... ....................456
Stroke...................................... ...... 430 Oral diseases.................................... ....................460
Rheumatic heart disease.......... ...... 431 Accidents and Injuries...................... ....................462
Cancer..................................... ...... 434

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7. HEALTH PROGRAMMES IN INDIA 472
8. DEMOGRAPHY AND FAMILY PLANNING 554
9. PREVENTIVE MEDICINE IN OBSTETRICS, 596
PAEDIATRICS AND GERIATRICS
10. HEALTH CARE OF THE COMMUNITY 692
11. NUTRITION AND HEALTH 723
12. MEDICINE AND SOCIAL SCIENCES 783
13. TRIBAL HEALTH IN INDIA 820
14. SUSTAINABLE DEVELOPMENT GOALS 824
15. ENVIRONMENT AND HEALTH 832
16. HOSPITAL WASTE MANAGEMENT 915
17. DISASTER MANAGEMENT 921
18. OCCUPATIONAL HEALTH^ 930
19. GENETICS AND HEALTH 947
20. MENTAL HEALTH 957
21. HEALTH INFORMATION AND BASIC MEDICAL STATISTICS 967
22. COMMUNICATION FOR HEALTH EDUCATION 982
23. HEALTH PLANNING AND MANAGEMENT 996
24. ESSENTIAL MEDICINES AND COUNTERFEIT MEDICINES 1012
25. INTERNATIONAL HEALTH 1025
ABBREVIATIONS 1033
INDEX

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 Man and Medicine :
Towards Health for All

□ “Those who fail to read history are destined to suffer the repetition of its mistakes”

rom time immemorial man has been interested in trying dominated by magical and religious beliefs which were an
to control disease. The medicine man, the priest, the integral part of ancient cultures and civilizations. Henry
herbalist and the magician, all undertook in various ways to Siegerist, the medical historian has stated that every culture
cure man’s disease and/or to bring relief to the sick. In an had developed a system of medicine, and medical history is
almost complete absence of scientific medical knowledge, it but one aspect of the history of culture (1). Dubos goes one
would not be fair to say that the early practitioners of step further and says that ancient medicine was the mother of
medicine contributed nothing to the alleviation of man’s sciences and played a large role in the integration of early
suffering from disease. Medical knowledge in fact has been cultures (2). (Since there is an organic relationship between
derived, to a very great degree, from the intuitive and medicine andTiuman advancement, any account of medicine
observational propositions and cumulative experiences at a given period should be viewed against the civilization
gleaned from others. A history of medicine thus contributes and human advancement at that time, i.e. philosophy,
religion, economic conditions, form of government,

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a review of accomplishments and errors, false theories and
misinformation and mistaken interpretations. It is also a education, science and aspirations of the people. >
study of the evolution of man and of human knowledge
down the ages; of the biographies of eminent individuals Primitive medicine
who developed medicine; of the discoveries and inventions It has been truly said that medicine was conceived in
in different historical periods; and of the ever-changing sympathy and born out of necessity; and that the first doctor
concepts, goals and objectives of medicine. In the course of was the first man, and the first woman, the first nurse. The
its evolution, which proceeded by stages, with advances and prehistoric man, motivated by feelings of sympathy and
halts, medicine has drawn richly from the traditional cultures kindness, was always at the behest of his kindred, trying to
of which it is a part, and later from biological and natural provide relief, in times of sickness and suffering.
sciences and more recently from social and behavioural Since his knowledge was limited, the primitive man
sciences. Medicine is thus built on the best of the past. In the attributed disease, and in fact all human suffering and other
crucible of time, medicine has evolved itself into a social calamities, to the wrath of gods, the invasion of body by
system heavily bureaucratized and politicized. The “evil spirits” and the malevolent influence of stars and
“explosion” of knowledge during the 20th century has made planets. The concept of disease in which the ancient man
medicine more complex, and treatment more costly, but the believed is known as the ^supernatural theory of disease^
benefits of modern medicine have not yet penetrated the As a logical sequence, the medicine he practised consisted in
social periphery in many countries Ajhe glaring contrasts' in appeasing gods by prayers, rituals and sacrifices, driving out
the state of health between the developed and developing “evil spirits” from the human body by witchcraft and other
countries, between the rural and urban areas, and between crude means and using charms and amulets to protect
the rich and poor have attracted worldwide criticism as himself against the influence of evil spirits. The
“social injustice”?'. The commitment ot all countries, under administration of certain herbs or drugs whose effect is
t ,e banner o! the World Health Organization, is to wipe out doubtful or nil, but hopefully harmless, may also.be likened
the inequalities in the distribution of health resources and to a kind of magic ritual associated with the need to “do
services, and attain the Millenium Development Goals/ something”. (There is also evidence that prehistoric man
Sustainable Development Goals, frhe goal of modern improvised stone and flint instruments with which he
medicine is no longer merely treatment of sickness. The performed circumcisions, amputations and trephining of
other and more important goals which have emerged are skullf. It is thus obvious that medicine in the prehistoric
prevention of disease, promotion of health and times (about 5000 B.C.) was intermingled with superstition,
improvement of the quality of life of individuals and groups religion, magic and witchcraft.
or communities. In other words, the scope of medicine has
considerably broadened during recent years. It is also Primitive medicine is timeless. If we look around the
regarded as an {essential component of socio-economic world, we find that the rudiments of primitive medicine still
development. ' persist in many parts of the world - in Asia, Africa, South
America, Australia and the Pacific islands. The supernatural
I. MEDICINE IN ANTIQUITY theory of disease in which the primitive man believed is as
new as today. For example, in India, one may still hear the
In ancient times, health and illness were interpreted in a talk of curing snake bites by “mantras”. Diseases such as
cosmological and anthropological perspective. Medicine was leprosy are interpreted as being punishment for one’s past
by R△J
 MAN AND MEDICINE : TOWARDS HEALTH FOR ALL

sins in some cultures. Although primitive man may be ( Hygiene was given an important place_in ancient Indian
extinct, his progeny - the so-called “traditional healers” are medicine. The laws of Manu were a code of personal
found everywhere. They live close to the people and their hygiene. Archaeological excavations at Mohenjo-daro and
treatments are based on various combinations of religion, Harappa in the Indus valley uncovered cities of over two
magic and empiricism. thousand years old which revealed rather advanced
knowledge of sanitation, water supply and engineerinaJThe
Indian medicine (3) golden age of Indian medicine was between 800 B.C. and
The medical systems that are truly Indian in origin and 600 A.D. During the Moghul period and subsequent years,
development are the Ayurveda and the Siddha systems. Ayurveda declined due to lack of State support. \
Ayurveda is practisedTHroughout India, but the Siddha Medical historians admit that Indian medicine has played
system is practised in the Tamil-speaking areas of South in Asia the same role as the Greek medicine in the west, for
India. These systems differ very little both in theory and it has spread in Indochina, Indonesia, Tibet, Central Asia,
practice (4). Ayurveda by definition implies the ^knowledge and as far as Japan, exactly as the Greek medicine has done
of life” or the knowledge by which life may be prolonged. Its in Europe and Arab countries (7).
origin is traced far back to the Vedic times, about 5000 B.C.
During this period, medical history was associated with Mention must be made of the other indigenous systems of
mythological figures, sages and seers. CDhanvantarL the medicine namely Unani-Tibb and Homoeopathy, which are
Hindu god of medicine is said to have been born as a result not of Indian origin. The Unani-Tibb system of medicine,
of the churning of the oceans during a ‘tug of war’ between whose origin is traced to the ancient Greekmedicine, was
go s and demons. According to some authorities^ tha introduced into India by the Muslim rulers about the 10th
medical knowledge in the Atharvaveda (one of the four century A.D. By the 13th century, the Unani system of
Vedas) gradually developed into the science of Ayurveda J medicine was firmly entrenched in certain towns and cities
notably Delhi, Aligarh, Lucknow and Hyderabad (5). It
In ancient India, the celebrated authorities in Ayurvedic
medicine were (Atreya, Charaka. Sushruta and Vaghbhatt. enjoyed State support under successive Muslim rulers in
(fAtreya (about 800 B.C.) is acknowledged as the first great India, till the advent of the British in the 18th century,
Indiarf physician and teacher. He lived in the ancient homoeopathy, which was propounded by Samuel
university of Takshashila, about 20 miles west of modern Hahnemann (1755-1843) of Germany gained foothold in
Rawalpindi (5). Ayurveda witnessed tremendous growth and India during 1810 and 1839 (9). It is a system of pharmaco­

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development during the Buddhist times. King Ashoka dynamics based on “treatment of disease by the use of small
(226 B.C.) and the other Buddhist kings patronized amounts of a drug "that, in healthy persons, produces
Ayurveda as State medicine and established schools of symptoms similar to those of the disease being treated” (10).
medicine and public hospitals.[Charaka (200 A.D.), the most Homoeopathy is practised in several countries, but India
popular name in Ayurvedic medicine? was a court physician claims to have the largest number of practitioners of this
to the Buddhist king Kanishka. Based on the teachings of system in the world 19).
Atreya, Charaka compiled his”famous treatise on medicine, The Indian systems of medicine including Unani-Tibb and
the “Charaka Samhita”. Charaka mentions some 500 drugs. Homoeopathy are very much alive in India even today. In
The Indian snakeroot (rauwolfia) was employed for fact, they have become part of Indian culture, and they
centuries by the Indian physicians, before reserpine was continue to be an important source of medical relief to the
extracted from the root and found spectacularly effective in rural population.
the treatment of hypertension. J
Among the many distinguished names in Hindu Chinese medicine
medicine, that of Susruta, the “father of Indian surgery” Chinese medicine claims to be the world’s first organized
stands out in prominence. He compiled the surgical body of medical knowledge dating back to 2700 BLC. (11). It
knowledge of his time in his classic “Sushruta Samhita”. It is is based on two principles - the yang and the yinbThe yang
believed that this classic was compiled between 800 B.C. is believed to be an active masculine principle andthe-yin^a.
and 400 A.D. Though this work is mainly devoted to negative feminine principle. The balance of these two
surgery, it also includes medicine, pathology, anatomy,
opposing forces meant good health. Qjygiene, dietetics,
midwifery, ophthalmology, hygiene and bedside manners.
hydrotherapy, massage, drugs were all used by the Chinese
The early Indians set fractures, performed amputations,
physicians. \
excised tumours, repaired hernias and excelled in cataract
operations and plastic surgery (6) .(It is stated that the British (The Chinese were early pioneers of immunization. They
physicians learned the art of rhinoplasty from TndiarF practised variolation to prevent smallpox. To a Chinese, “the
surgeons in the days of East India Company (7) L However, great doctor is one who treats not someone who is already ill
during Buddhist times, Indian surgery suffered a setback but someone not yet ill”. The Chinese have greaFfaith in
because of the doctrine of ahimsa (non-violence). their traditional medicine, which is fully integrated with
Of significance in Ayurveda is the “tridosha theory of modern medicinefThe Chinese system of “barefoot doctors”
disease”. The doshas or humors are: uata'(wind), pitta (gall) and accupuncture have attracted worldwide attention in
and kapha (mucus). Disease was explained as a disturbance recent years (12).
in the equilibrium of the three humors; when these were in
perfect balance and harmony, a person is said to be healthy Egyptian medicine
(8). This theory of disease is strikingly similar to the^theorv Egypt had one of the oldest civilizations in about
of four humors” in Greek medicine. Medical historians admit 2000 B.C. A lot is known about ancient Egypt because they
that there was free exchange of thought and experience invented picture writing and recorded their doings on
between the Hindu, Arab, Persian, Greek and Jewish papyrus. In Egyptian times, the art of medicine was mingled
scholars. The Samhitas of Charaka and Susruta were with religion. Egyptian physicians were co-equals of priests,
translated into Persian and Arabic in about 800 A.D trained in schools within the temples. They often helped

by R△J
 priests care for the sick who were brought to the temples for
MEDICINE IN ANCIENT TIMES
5
proposed therapy proved wrong, ran the risk of being killed.
1
treatment. There were no practical demonstrations in Laws relating to medical practice, including fees payable to
anatomy, for Egyptian religion enjoined strict preservation physicians for satisfactory services and penalties for harmful
of the human body. Egyptian medicine reached its peak in therapy are contained in the Babylonian Code of
the days of Imhotep (2800 B.C.) who was famous as a Hammurabi, the very first codification of medical practice.
statesman, architect, builder of the step pyramid at While the code of Hammurabi reflected a high degree of
Saqqarah and physician. The Egyptians worshipped many social organization, the medicine of his time was devoid of
gods. Clmhotep was considered both a doctor and divinity. any scientific foundation.
Specialization prevailed in Egyptian times. There were eye
doctors, head doctors and tooth doctors. All these doctors Greek medicine
were officials paid by the State. Homer speaking of the The classic period of Greek medicine was the year
doctors of the ancient world considered the Egyptians to be 460-136 B.C. The Greeks enjoyed the reputation - the
the “the best of all” (13). civilizers of the ancient world. They taught men to think in
Egyptian medicine was far from primitive. They believed terms of ‘why’ and ‘how’. An early leader in Greek medicine
that disease was due to absorption from the intestine of was Aesculapius (1200 B.C.). Aesculapius bore two
harmful substances which gave rise to putrefaction of blood daughters - Hygiea and Panacea. The medical historian,
arid formation of pus. They believed that the pulse was “the Douglas Guthrie (17) has reminded us of the legend that
speech of the heart”. Diseases were treated with cathartics, Hygiea was worshipped as the goddess of health, and Panacea
ehema, blood-letting and a wide range of drugs. The best as the goddess of medicine. Panacea and Hygiea gave rise to
known medical manuscripts belonging to the Egyptian times dynasties of healers (curative medicine) and hygienists
are the^Edwin Smith papyrus (3000-2500 B.C.), and the (preventive medicine) with different philosophies. Thus the
Ebers papyrus (1150 B.C.). The Edwin Smith papyrus, the dichotomy between curative medicine and preventive
oldest treatise on surgery, accurately describes partial medicine began early and we know it remains true today.
paralysis following cerebral lesions in skull fractures. The (HygieaJ (prevention) is at present fashionable among the
Ebers papyrus which was found with a mummy on the banks intellectuals; but Panacea (cure) gets the cash. Aesculapius is
of the Nile, is a unique record of some 800 prescriptions based still cherished in medical circles - his staff, entwined by a
on some 700 drugs. Castor oil, tannic acid, opium, turpentine, serpent, continues to be the symbol of medicine. '
gentian, senna, minerals and root drugs were all used by the By far the greatest physician in Greek medicine was

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Egyptian physicians.^A great number of diseases are reported Hippocrates (460-370 B.C.) who is often called the “Father
in the papyri such as worms, eye diseases, diabetes, of Medicine”. He was born on the little island of Cos, in the
rheumatism, polio and schistosomiasis. Unfortunately, these Aegean sea, about 460 B.C. He studied and classified
ailments are still present in modern Egypt (7). diseases based on observation and reasoning.fae challenged
In the realm of public health also, the Egyptians excelled. the tradition of magic in medicine, and initiated a radically
They built planned cities, public baths and underground new approach to medicine i.e., application of clinical
drains which even the modern might envy. They had also methods in medicine. Hippocrate’s lectures and writings, as
some knowledge of inoculation against smallpox, the value compiled later by Alexandrian scholars into the “Corpus
of mosquito nets and the association of plague with_rats. Hippocraticum”, encompassed all branches of medicine. This
CTheir god of health was Horus. Egyptian medicine occupied 72 volume work contains the first scientific clinical case
a dominant place in the ancient world for about 2,500 years histories. Some of the sayings of Hippocrates later became
when it was replaced by Greek medicine. favourites with physicians, such as “Life is short, the art (of
medicine) long, opportunity fleeting, experience treacherous
Mesopotamian medicine and judgement difficult”. and ^‘where there is love for
mankind, there is love for the art of healing”,/His famous
Contemporary with ancient Egyptian civilization, there oath, the “Hippocratic oath” has become the keystone of
existed another civilization in the land which lies between the medical ethics. It sets a high moral standard for the medical
Euphrates and Tigris rivers, Mesopotamia (now part of Iraq), profession and demands absolute integrity of doctors.
often called thet‘Cradle of Civilization), as long as 6,000 years Hippocrates will always be regarded as pne of the masters of
ago. the medical art.
In ancient Mesopotamia, the basic concepts of medicine Hippocrates was also an epidemiologist. Since he
were religious, and taught and practised by herb doctors, distinguished between diseases which were epidemic and
knife doctors and spell doctors - a classification that roughly those which were endemic, he was, in factTthe first true
parallels our own internists, surgeons and psychiatrists. epidemiologist. He was constantly seeking the causes of
Mesopotamia was the cradle of magic and necromancy. disease. He studied such things as climate, water, clothing,
Medical students were busy in classifying “demons”, the diet, habits of eating and drinking and the_effect thevTScT in
causes of diseases. Geomancy, the interpretation of dreams, producing disease. His book? Airs, Water and Places'’ is
and hepatoscopic divination (the liver was considered the consiaered’a treatise on social medicine and hygiene. The
seat_nf_Jife) are characteristic- of their medical lore. Hippocratic concept of health and disease stressed the
Sumerians, Babylonians and Assyrians were the authors of a relation between man and his environment.
medical astrology which flourished in the whole of Eurasia. In short, the Greeks gave a new direction to medical
^Prescriptions were written on tablets, in cuneiform writing. thought. [They rejected the supernatural theory of disease
The oldest medical prescription comes to us from and looked upon disease as a natural process, not a
Mesopotamia, dating back to 2100 B.C. visitation from a god of immolation. The Greeks believed
^Hammurabi, a great king of Babylon who lived around that matter was made up of four elements -j^arth, air, firg.
2000 B.C. formulated a set of drastic laws known as the and water. These elements had the corresponding qualities
Code of Hammurabi that governed the conduct of physicians of being cold, dry, hot and moist and were represented in
and provided for health practices (14). Doctors whose the body by the four humors - phlegm, yellow bile, hlood_________

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 MAN AND MEDICINE : TOWARDS HEALTH FOR ALL

and black bile - similar to the “tridosha theory” in known as “Middle Aggs”. With the fall of the Roman empire,
Ayurveda. The Greeks postulated that health prevailed the medical schools established in Roman times also
when the four~Kum~ors were in equilibrium and jwheir the disappeared. Europe was ravaged by disease and pestilence:
balance was disturbed, disease was the result. The human plague, smallpox, leprosy and tuberculosis. The practice of
body was assumed to have powers of restoration of humoral medicine reverted back to primitive medicine dominated by
equilibrium, and it was the physician’s primary role to assist superstition and dogma. Rejection of the body and
in this healing process. While the humoral theory of glorification of the spirit became the accepted pattern of
Hippocrates was based on incorrect foundations, the behaviour. It was regarded as immoral to see one’s body;
concept of the innate capacity of the body of responding to consequently, people seldom bathed. Dissection of the
disturbances in the equilibrium that constitutes health is human body was prohibited. Consequently there was no
highly relevant to modern medicine (15). progress of medicine.(The medieval period is therefore called
Outstanding amongst post-Hippocratic medical centres the n?ark Ages of Medicine - a time of great strife, of socio-
was Alexandria’s huge museum, the first University in the political change, of regression and progression (7).
world which sheltered a library containing over 70,000 When Europe was passing through the Dark Ages, the
books. To this house of learning came eminent men. Arabs stole a march over the rest of the civilization. They
Between 300 B.C. and 30 B.C., thousands of pupils translated the Graeco-Roman medical literature into Arabic
matriculated in the school of Alexandria, which replaced and helped preserve the ancient knowledge. Borrowing
Athens as the world’s centre of learning. In short, the largely from the Greeks and Romans, they developed their
Hippocratic school inspired in turn the Alexandria school, own system of medicine known as the Unani system of
and the Arabo-Persian medicine. QTie Hippocratic school medicine. They founded schools of medicine and hospitals
changed the destiny of medicine by separating it from magic in Baghdad, Damascus, Cairo and other Muslim capitals.
and raising it_io the status of a science. They had scientific The Arabs lit a brilliant torch from Greecian lamps, said
method, although not scientific knowledge. The glorious OsIen Leaders in Arabic medicine were the Persians, Abu
Greek civilization fell into decay and was succeeded by the Beer (865-925) also known as Rhazes; and lbn Sina
Roman civilization. (980-1037) known as Avicenna to the western world.
Rhazes was a director of a large hospital in Baghdad and a
Roman medicine court physician as well. Noted for keen observation and

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By the first Century B.C., the centre of civilization shifted inventiveness, he was the first to observe pupillary reaction
to Rome. (The Romans borrowed their medicine largely from to light; to use mercurial purgatives; and to publish the first
the Greeks_whom they had conquered. While the politics of known book on Children’s diseasesjf7). However, the work
the world became Roman, medicine remained Greek. In the most highly regarded today is his book on smallpox and
political philosophy of the Romans, the State and not the measles which he distinguished clinically.VAvicenna was an
individual was supreme. intellectual prodigy. He compiled a 21 volume
The Romans were a more practical-minded people than encyclopaedia, the “Canon of Medicine^, which was to
the Greeks. They had a keen sense of sanitation. Public leave its mark on medical theory and practice. He was
health was born in Rome with the development of baths, responsible for elevating Islamic medicine to its zenith in the
sewers and ^aqueducts. The Romans made fine roads middle ages./The greatest contribution of Arabs, in general,
throughout their empire, brought pure water to~aTl their cities was in the fie! i o p armacology. Seeking the “elixir of life”,
through aqueducts, drained marshes to combat malaria, they "developed pharmaceutical chemistry, introducing a
built sewerage systems and established hospitals for the sick. large _number of drugs, herbal and chemical. Pioneers in
An outstanding figure among Roman medical teachers pharmacology, they invented the art of writing prescriptions,
was Galen (130-205 A.D.) who was born in the Greek city of an art inherited Ey our modern pharmacists. They
Pergamon in Asia Minor (now Turkey). He was physician to introduced a wide range of syrups, oils, poultices, plasters,
the Roman emperor, Marcus Aurelius. -His important pills, powders, alcoholates and aromatic waters. The words
contributions were in the field of comparative anatomy and drug, alcohol, syrup and sugar are all Arabian (17). The
experimental physiology. Galen was far ahead of his time in golden age of Arabic medicine was between 800-1300 A.D.
his views about health and disease. About health he stated: During the turbulent middle ages, Christianity exerted a
“Since both in importance and in time, health precedes wholesome influence. ^Ehe_spread of ChristianityJecLlcuthe
disease, so we ought to consider first how health may be establishment of hospitals. Early medieval hospitals rarely
preserved, and then how one may best cure disease” (16). specialized in treatment of the sick. (Usually the sick were
About disease, Galen observed that disease is due to three received for the purpose of supplying their bodily wants and
factors - predisposing, exciting and environmental factors, a catering to their spiritual needs. The first hospital on record
truly modern idea. The doctrines of Hippocrates and Galen in England was built in York in 937 A.D. With the growth of
were often in conflict since their approaches were so different medicine, a chain of hospitals sprang up from Persia to
- one is synthetic, the other analytic. The author of some 500 Spain- there were more than 60 in Baghdad and 33 in
treatises on medical subjects, Galen was literally a “medical Cairo.(^bme hospitals, like Cairo’s Al Mansur had separate
dictator” in his time, and also for a long time thereafter. His departments for various diseases, wards for both sexes,
writings influenced European medicine. They were accepted fountains to cool fever patients, libraries, musicians and
as standard textbooks in medicine for 14 centuries, till his story tellers for the sleepless.
teachings and views were challenged by the anatomist, L During the middle ages, religious institutions known as
Vesalius in 1543, and the physiologist, William Harvey in “monasteries” headed by monks, saints and abbotts also
1628, almost 1500 years after his death. came up. These monasteries admitted men and women from
all ranks including kings and queens. They not only helped
Middle ages preserve the ancient knowledge but also rendered active
The period between |500 and 1500 A.D. is generally medical and nursing care to the sick- '

by R△J
 DAWN OF SCIENTIFIC MEDICINE

II. DAWN OF SCIENTIFIC MEDICINE • , 22 years for the working class, in 1842 (14). Add to this, the
frequent visitations of cholera compounded the misery of the
The period following 1500 A.D. was marked by people. (The great cholera epidemic of _1832 led Edwin
revolutions - political, industrial, religious and medical. Chadwick (1800-1890), a lawyer in England to investigate
Political revolutions took place in France and America, the health of the inhabitants of the large towns with a view to
people claiming their just rights. CThe lndusirial_iavolution in improve the conditions under which they lived (18).
the West brought great benefits leading to an improvement Chadwick’s report on “The Sanitary-Conditions of the
in the standard of living among people. With advancing Labouring Population in Great Britain” , a landmark in the
degrees of civilization, medicine also evolved. history of public health, set London and other cities slowly
on the way to improve housing and working conditions.
Revival of medicine Chadwick’s report focussed the attention of the people and
For many historians, the revival of medicine encompasses government on the urgent need to improve public health.
the period from 1453-1600 A.D. It was an age of individual Filth was recognized as man’s greatest enem and with_this
scientific endeavour. The distinguished personalities during began an anti-filth cn .de, t e “great sanitar awakening”
this period were: Paracelsus (1493-1541) who revived which led to the enactment of the Public Health Acfof 1848
medicine. He was born at a time “when Europe stretched in England. A new thinking began to take shape i.e., the
her limbs after a sleep of a thousand years in a bed of State has a direct responsibility for the health of the people. :
darkness”. Labelled genius by some and quack by others,
Swiss-born Paracelsus publicly burnt the works of Galen and Rise of public health
Avicenna and attacked superstition and dogma and helped The above events led to the birth of public health concept
turn medicine towards rational research, f Fracastorius in England around 1840. Earlier, Johanna Peter Frank
(1483-1553), an Italian physician enunciated the “theory of (1745-1821) a health philosopher of his time, conceived
contagion”. He envisaged the transfer of infection uia public health as good health laws enforced by the police and
minute invisible particles and explained the cause of enunciated the principle that the State is responsible for the
epidemics. Fracastorius recognized that syphilis was health of its people. The Public Health Act of 1848 was a
transmitted from person to person durin sexual relations. fulfilment of his dream about the State’s responsibility for the
health of its people.
(1514-1564) of Brussels did lot of dissections on the human

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Cholera which is often called the “father of public health”
body and demonstrated some of Galen’s errors.(He raised appeared time and again in the western world during the
the_study of anatomy to a science, and has been called “the 19th century. An English epidemiologist________ John Snow,
first man of modern science”. Vesalius’ great work Fabrica studied the epidemiology of cholera in London from 1848 to
became a classic text in medical education. What Vesalius 1854. and established the role of polluted drinking water in
did Tor anatomy, Ambroise Pare (1510-1590), a French the spread of cholera. In 1856, William Budd, another
Army surgeon did for surgery and earned the title, “father of pioneer, by careful observations of an outbreak of typhoid
surgery”. Pare advanced the art of surgery, but John Hunter fever in the rural north of England concluded that the spread
(1728-1793) taught the science of it. In 1540, the United was by drinking water, not by miasma and sewer gas. These
Company of Barber Surgeons was established in England, two discoveries were all the more remarkable when one
which later became the Royal College of Surgeons. Another considers that the causative agents of cholera and typhoid
great name in clinical medicine is that of Thomas Sydenham fever were not identified. Then came the demand from
(1624-1689), the English Hippocrates wTo set the example people for clean water. At that time the Thames was both a
of the true clinical method. He made a differential diagnosis source of drinking water and the depository for sewage. A
of scarlet fever, malaria, dysentery and cholera. Sydenham comprehensive piece of legislation was brought into force in
is also regarded as the first distinguished epidemiologists England, the\Public Health Act _of_1875 for the control of
The 17th and 18th centuries were full of even more man’s physical environment. The torch was already lit by
exciting discoveries, e.g., I Harvey’s discovery of the Chadwick, but the man who was actually responsible more
circulation of blood (1628), Leeuwenhoek’s microscope than any other for sanitary reforms was
(1670) and Jenner’s vaccination against smallpox (1796). y Sir John Simon (1816-1904), the first jnedical officer of
However, the progress in medicine as well as surgery, during health of London. He built up a system of public health in
the 19th century would not have been possible but for I ngland which became the admiration o: t e rest of the
Morgagni (1682-1771) who founded a new branch of workLHS). This early phase~oTpublic-Health (1880-1920) is
medical science, pathologic anatomy] often called the “disease control phase”. Efforts were
directed entirely towards general cleanliness, garbage and_
Sanitary awakening refuse disposal. Quarantine conventions were held to
Another historic milestone in the evolution of medicine is contain disease^
the ^great sanitary awakening” twhich took place in^Englandj The development of the public health movement in
in the mid-nineteenth century and gradually spread to other Amercia follows closely the English pattern. In 1850, Lemuel
countries. It had_ a tremendous impact in modifying the Shattuck (1793-1859), a bookseller and publisher,
behaviour of people and ushering an era ofpublicTiealth. published his report on the health conditions in
(^he industrial revolution of The T8fH~ century sparked off Massachusetts. Like Chadwick’s report it stirred the
numerous problems - creation of slums, overcrowding with conscience of the American people to the improvement of
all its ijl-effects, accumulation of filth in cities and towns, high public health. France, Spain, Australia, Germany, Italy,
sickness and death rates especially among women and Belgium and the Scandinavian countries all developed their
children, infectious diseases like tuberculosis, industrial and public health. By thejbeginning of the 20th century^jhe
social problems - which leteriorated the health of the people Abroad foundations of public health - clean water, clean
tolhe lowest ebb A The mean age at death in London was surroundings, wholesome condition of houses, _contro o
reported to be 44 years for the gentry and professionals, and offensive trades, etc were laid in all the countries of the
by R△J
 MAN AND MEDICINE : TOWARDS HEALTH FOR ALL

western world. After the First World War, there were three Aedes mosquito. With the knowledge derived from
particular newcomers to the public health scene - bacteriology, it became possible to control disease by
Yugoslavia, Turkey and Russia (19). These three countries in specific measures such as blocking: the channels of
1920 presented the typical picture of the underdeveloped transmission, e.g., quarantine, water _purification,
world. Today they are quite advanced in public health j pasteurization of milk, protection of foods, proper disposal
(While public health made ra_pid strides in the western of sewage, destruction of insects and disinfection. The
world, its progress has been slow in the developing countries development of laboratory methods for the early detection
such as India where the main health problems continue to of disease was a further advance. In its early years,
be those faced by the western world about 100 years ago. preventive medicine was equated with the control of
The establishment of the WHO providing a Health Charter infectious diseases. The modern concepts of primary,
for all people provided a great fillip to the public health secondary and tertiary prevention were not known.
movement in these countries.
III. MODERN MEDICINE
Germ theory of disease The dichotomy of medicine into two major branches
For long, man was groping in darkness about the namely curative medicine, and public health/preventive
causation of disease. Several theories were advanced from medicine _was evident at the close of the 19th century. After
time to time to explain disease causation such as the 1900, medicine moved faster towards specialization, and a
supernatural theory of disease, the theory of humors by rational, scientific approach to disease. The pattern of
Greeks and Indians, the theory_of contagion, the miasmatic disease began to change. With the control of acute infectious
theory which attributed disease to noxious air and vapours, diseases, the so-called modern diseases such as cancer,
the theory of spontaneous generation, etc. The diabetes, cardiovascular disease, mental illness and
breakthrough came in 18UT when the French bacteriologist accidents came into prominence and have become the
Louis Pasteur (1822-1895) de_monstrated the presence of leading causes of death in industrialized countries. (These
bacteria in air. He disproved the theory of “spontaneous diseases could not be explained on the basis of the germ
generati n”. In 1873, Pasteur advanced the “germ theor . of theory of disease, nor treated with “magic bullets”j The
disease In 1877, Robert Koch (1843-1910fshowed that realization began to dawn that there are other factors or
anthrax was caused by a bacteria. The discoveries of Pasteur causes in the^aetiology of diseases, namely social, economic,

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and Koch confirmed the germ theory of disease. It was the genetic, environmental and psychological factors which are
golden age of bacteriology. Microbe after microbe was equallyTmpQitant. Most of these factors are linked to man’s
discovered in quick succession - gonococcus in 1847; lifestyle and behaviour. (The germ Theory of disease gave
typhoid-bacillus, pneurnococcus in 1880; tubercle bacillus in place to a newer concept of disease - “multifactorial
1882; cholera vihrio in 1883; diphtheria bacillus in 1884, causation^ In fact, it was Pettenkofer of Munich (1819-
and so on. These discoveries and a host of others at the turn 19"0T) who first mooted the concept of multifactorial
of the century marked a turning point in our aetiological causation of disease but his ideas were lost Fn the
concepts. ^\11 attention was focussed on microbes and their bacteriological era. The concept of multifactorial causation
role in disease causationjjhe germ theory of disease came was revived by epidemiologists who have contributed
to the forefront, supplanting ihe earlier theories of disease significantly to our present-day understanding______________ of
causation. (Medicine finally shed the rags of dogma and multifactorial causation of disease and “risk-factors” in the
superstition_and put on the robes of scientific knowledge^ aetiology of disease. The developments in modern medicine
may be reviewed broadly under the following heads:
Birth of preventive medicine
Preventive medicine really dates back jto the 18th 1. Curative medicine
century. It developed as a branch of medicine distinct from Although curative medicine is thousands of years old,
public health. Curiously, it came into existence even before modern medicine, as we know today, is hardly 100 years
the causative agents of disease were known. James Lind old. It< primary objective is the removal of disease from the
(1716-1794), a naval surgeon advocated theintake_Qf fresh patient (rather than from the mass). It employs various
fruit and vegetables for the prevention of scurvy in 1753. modalities to accomplish this objective, e.g., diagnostic
Edward Jenner (1749-1823) of Great Britain, a pupil of techniques, treatment. Over the years, the tools of diagnosis
John Hunterf discovered vaccination against smallpox in have become refined, sophisticated and numerous; the
1796. These two discoveries marked the beginning of a new armamentarium for treatment more specific and potent. In
era,The era of disease prevention by specific measures./ the middle of the 20th century a profound revolution was
(^Preventive medicine got a firm foundation only after the brought in “allopathic medicine” which has been defined as
discovery of causative agents of disease and the “treatment of disease by the use of a drug which produces a
establishment of the germ theory of diseaseTThe latter part reaction that itself neutralizes the disease” (10), by the
of the 19th century was marked by such discoveries in introduction of antibacterial and antibiotic agents. These
preventive medicine as Pasteur’s antLrabies treatment discoveries, if they were to be recorded, would fill volumes.
(1883), cholera vaccine (18 2), diphtheria antitoxin (1894), Suffice it to say that curative medicine, over the years, has
anti-typhoid vaccine (1898), antiseptics and disinfectants accumulated a vast body of scientific knowledge, technical
(1827-1912), etc. A further advance was the elucidation of skills, medicaments and machinery - highly organized - not
the modes of disease transmission. For example, in 1896, merely to treat disease but to preserve life itself as far as it
Bruce, a British Army surgeon, demonstrated that the could be possible.
African sleeping sickness was transmitted by tsetse flyy In QnReviewing the history of medicine during the past 100
1898, Ross demonstrated that malaria was transmitted by years, one cannot fail to note the tremendous growth of
the Anopheles. In 1900, Walter Reed and his colleagues specialization that has taken place in response to advances
demonstrated that yellow fever was transmitted by the in medical technology due to changes in the nature and
by R△J
 ;MODERN MEDICINE 7
distribution of health and disease pattern in the community, treatment have become important tools of preventive
and to the changing emphasis placed by society upon age medicine. The pattern of disease in the community began to
and sex groups. Some specialities have emerged, based on change with improved control of infectious diseases through
clearly defined skills such as surgery, radiology, and both prevention and treatment, and people are now living
anaesthesia; some based on parts of the body such as ENT, for_longer years, especially those in developing countries.
ophthalmology, cardiology, gynaecology; and, some based A new concept - concept of disease eradication - began
on particular age or sex groups such as paediatrics, geriatrics to take shape. This concept found ready application in the
and obstetrics. Again, within each speciality, there has been eradication of smallpox.' Eradication of certain other
a growth of sub-specialities, as for example, neonatology, diseases (e.g., measles, tetanus, guineaworm and endemic
perinatology, paediatric cardiology, paediatric neurology goitre) are on the anvil.
ancTpaediatric surgery - all in paediatrics. One wonders
Another notable development in the 20th century is the
whether such microspecialization is needed.
development of “screening” for the diagnosis of disease in
C Specialization has no doubt raised the standards of its presymptomatic stags (21). In the 1930s, the two most
medical care, but it has escalated the cost of medical care commonly used tests were the serologic blood test for
and placed specialist medical care beyond the means of an syphilis, and the chest X-ray for tuberculosis. As the number
average citizen, without outside aid or charity. It has of screening tests increased, the concept of screening for
infringed upon the basic tenets of socialism (i.e., the greatest individual diseases entered the multiphasic epoch in early
good of the greatest number) and paved the way to varying 1950s. In spite of the fact that the utility of screening has
degrees of social control over medicine. Specialization has been increasingly debated in recent years, screening for
also contributed to the decline of general practice and the disease among apparently healthy people has remained an
isolation of medical practitioners at the periphery of the important part of preventive medicine. An offshoot of the
medical care system (20). screening is screening for “risk-factors” of disease and
identification of “high-risk groups”. Since we do not have
2. Preventive medicine specific weapons against chronic diseases, screening and
Preventive medicine developed as a branch of medicine regular health checkups have acquired an important place in
distinct'from public health. By definition, preventive the early detection of cancer, diabetes, rheumatism and
medicine is applied to “healthy” people, customarily by cardiovascular disease, the so-called V^diseases of

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actions affecting large numbers or populations. Its primary civilization”.
objective is_prevention of disease and promotion of health. Preventive medicine is currently faced with the problem of
The early triumphs of preventive medicine were in the “population explosion” in developing countries where
field of bacterial vaccines and antisera at the turn of the population overgrowth is causing social, economic, political
century which led to the conquest of a wide spectrum of and environmental problems. Thisis another kind of
specific diseases. (Declines took place in the morbidity and prevention - prevention of a problem that demands a mass
mortality from diphtheria, tetanus, typhoid fever and others. attack, if its benefits are to accrue in the present and
Later, the introduction of tissue culture of viruses led to the succeeding generations. (Consequently, research in human
development of anti-viral vaccines, e.g., polio vaccines fertility and contraceptive technology has gained momentum.
(1955, 1960). The eradication of smallpox (the last case of ^Genetic counselling is another aspect of the population
smallpox occurred in Somalia in 1977) is one of the greatest problem that is receiving attention.
triumphs of preventive medicine in recent times. The search (Preventive medicine has become a growing point in
for better and newer vaccines (e.g., against malaria, leprosy, medicine (.21). Advances in the field of treatment in no way
syphilis and other parasitic diseases and even cancer) has diminished the need for preventive care nor its
continues. usefulness. (Preventive measures are already being applied
(^Preventive medicine did not confine itself to vaccination not only to the chronic, degenerative and hereditary
and quarantine. Discoveries in the field of nutrition have diseases but also to the special problems of old age. In fact,
added a new dimension to preventive medicine. New as medical science advances, it will become more and more
strategies have been developed for combating specific preventive medical practice in nature. ^The emergence of
deficiencies as for example, nutritional blindness and iodine preventive paediatrics, geriatrics and preventive cardiology
deficiency disorders. The recognition of the role of vitamins, reflect newer trends in the scope of preventive medicine]
minerals, proteins and other nutrients, and more recently Scientific advances, improved living standards and fuller
dietary fibre emphasize the nutrition component of education of the public have opened up a number of new
preventive medicine.} avenues to prevention. Three levels of prevention are now
Another glorious chapter in the history of preventive recognized: primary, intended to prevent disease among
medicine is the discovery of synthetic insecticides such as healthy people; secondary, directed towards those in whom
DDT,_HCH, malathion and others. They have brought about the disease has already developed; and tertiary, to reduce
fundamental changes in the strategy in the control of vector- the prevalence of chronic disability consequent to disease,
borne diseases (e.g., malaria, leishmaniasis, plague, preventive medicine ranges far beyond the medical field in
rickettsial diseases) which have been among the most the narrow sense of the word. ^Besides communicable
important world-wide health problems for many years. diseases, it is concerned with the environmental, social,
(Despite insecticide resistance and environmental pollution economic and more general aspects of prevention. Modern
mishaps (e.g., Bhopal tragedy in India in 1984), some of the preventive medicine has been defined as “the art a.nd
chemical insecticides such as DDT still remain unchallenged scignce of healih_Diomotion, disease__pxev£ntion, disability
in the control of disease. . limitation and rehabilitation”. It implies a more personal
The discovery of sulpha drugs, anti-malarials, antibiotics, encounter between the individual and health professional
anti-tubercular and anti-leprosy drugs have all enriched than public health. In sum, preventive medicine is a kind of
preventive medicine. Chemoprophylaxis and mass drug anticipatory medicine (22).
by R△J
8 MAN AND MEDICINE : TOWARDS HEALTH FOR ALL

3. Social medicine the control of man’s physical environment, e.g., water

Social medicine has been primarily a European speciality. supply, sewage disposal, etc. Clearly these measures were
The_seedsJhatmedicine is a social science were sown late in not aimed at the control of any specific disease, for want of
the 19th century by pioneers such as Neumann (1847) and the needed technical knowledge. However, these measures
Virchow (1848). But their ideas were far too ahead of their vastly improved the health of the people due to disease and
time. The germ theory of disease and discoveries in death control.
microbiology checked the development of these ideas. b. Health promotional phase (l_920-1960)
In 1911, the concept of social medicine was revived by At the beginning of the 20th century, a new concept, the
Alfred Grotjahiv (1869-1931) of Berlin who stressed the concept of “health promotion” began to take shape. Jt was
importance of social factors in the aetiology of disease, realized that public health had neglected the citizen as an
which he called '•‘‘social pathology?. Others called it individual, and that the State had a direct responsibility for
geographical pathology and population pathology. In 1912 the health of the individual. Consequently, in addition to
Rene Sand had founded the Belgian Social Medicine disease control activities, one more goal was added to public
Association. Developments in the field of social sciences health, that is, health promotion of individuals. It was
(e.g., sociology, psychology, anthropology) rediscovered initiated as personal health services such as mother and
that man is not only a biological animal, but also a social child health services, school health services, industrial health
being, and disease has social causes, social consequences services, mental health and rehabilitation services. Public
and social therapy. The ideas of social medicine spread to healtFTnursing was a direct offshoot of this concept. Public
other countries. John Ryle and his group in England were health departments began expanding their programmes
influenced by these ideas and visualized social medicine as towards health promotional activities. C.E.A. Winslow, one
an evolution of medicine. They promoted the concept of of the leading figures in the history of public health, in 1920,
social medicine in England. A Chair of social medicine was defined public health as “the science and art of preventing
set up at Oxford in 1942 followed by similar others in other disease, prolonging life and promoting health and efficiency
Universities in England. tfirough organized community effort”. This definition
Social medicine has varying meanings attached to its label. summarizes the philosophy of public health, which remains
By derivation, social medicine is the study of man as a social largely true even today.

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being in his totaLenvironment. Its focus is on the health of the Since the State had assumed direct responsibility for the
community as^whole. Professor Crew (23) had ably stated health of the individual, two great movements were initiated
that social medicine stands on two pillars - medicine and for human development during the first half of the present
sociology. Others stated that the maiden sociology married century, namely (a) f provision of “basic health services”
public health and became social medicine (24). McKeown through the medium of primary health centres and
(25) has this to say: ‘Jin contemporary usage social medicine su cen res or rural and urban areas. The evolution of health
has two meanings, one broad and ill-defined, the other more centres is an important development in the history of public
restricted and precise. In the broad sense, social medicine is health (28). (The concept of the health centre was first
an expression of the humanitarian tradition in medicine and mooted in 1920 by Lord Dawson in England. In 1931, the
people read into it any interpretation consistent with their League of Nations Health Organization called for the
own aspirations and interests. Thus it may be identified with establishment of health centres. The Bhore Committee
care of patients, prevention of disease, administration of (1946) in India had also recommended the establishment of
medical services; indeed with almost any subject in the health centres for providing integrated curatjyeL—and
extensive field__of health and welfare. But in the more preventive services. Many developing countries have given
restricted sense, social medicine is concerned with a body of the highest priority to the establishment of health centres for
knowledge embodied in epidemiology and the study of the providing basic health services, (b) The second great
medical needs or medical care_of society”. In short, social movement was the Community Development Programme to
medicine is not a new branch of medicine but rather a new promote village development through the active
orientation of medicine to the changing needs of man and participation of the whole community and on the initiative of
society. It emphasizes the strong relationship between the community. This programme tried to do too much too
medicine and social sciences. The pre-eminent concern of quickly with inadequate resources. It was a great opportunity
social medicine has unquestionably been the development of lost, because it failed to survive. However, the establishment
epidemiological methods and their application to the of primary health centres and subcentres provided the much-
investigation of disease. It has entered into a productive needed infrastructure of health services, especially in the
relationship with social sciences and statistics to be able to rural areas (29).
elucidate the role of social factors in disease aetiology (26).
/These developments represent a forceful bid for the c. Social engineering-phase (1960-1980)
expanding concept of medicine. Mdowever, social medicine (With the advances in preventive medicine and practice of
was criticized because it was virtually isolated from the public health, the pattern of disease began to change in the
service world and confined mostly to academic study of developed world. Many of the acute illness problems have
health services and chronic diseasej(27A been brought under control. However, as old problems were
solved, new health problems in the form of chronic diseases
Changing concepts in public health began to emerge, e.g., cancer, diabetes, cardiovascular
In the history of public health, four distinct phases may diseases, alcoholism and drug addiction etc. especially in the
be demarcated: affluent societies. These problems could not be tackled by the
traditional approaches to public health such as isolation,
a^Disease control phase (1880-1920) immunization and disinfection nor could these be explained
Public health during the 19th century was largely a on the basis of the germ theory of disease. A new concept, the
matter of sanitary legislation and sanitary reforms aimed at concept of “risk factors” as determinants of these diseases
by R△J
 MEDICAL REVOLUTION 9
came into existence. The consequences of these diseases, has become highly technical. It has acquired new
unlike the swift death brought by the acute infectious capabilities to modify and perhaps control_the_capacities
diseases, was to place a chronic burden on the society that and_activities„_ of men by direct intervention into and
created them. These problems brought new challenges to manipulation of their bodies and minds, viz. genetic
public health which needed reorientation more towards counselling, genetic engineering, prenatal diagnosis of sex,
sociaTobjectives. Public health entered a new phase in the prenatal diagnosis of genetic diseases, in vitro fertilization,
1960s, described as^ the “social engineering” phase (14). the prospect of cloning (the asexual reproduction of
[Social and behavioural aspects of disease and health were unlimited number of genetically identical individuals from a
given a new priority. Public health moved into the preventive single parent), organ transplantation, the use of artificial
and rehabilitative aspects of chronic diseases and kidney machine, the development of an artificial heart, the
behavioural problems. In this process, the goals of public practice of psychosurgery, etc. The data presented show that
health _and preventive medicine which had already modern medicine has entered a new evolutionary sjage with
considerable overlapping became identical, namely the promise of continued improvements in medical
prevention of disease, promotion of health and prolongation capabilities to preserve life, if not merely to solve problems
of life. In short, although thelerm “public health” is still used, of sickness..__ ‘
its original meaning has changed. In view of its changed
meaning and scope, the term “community health” has been Social control of medicine
preferred by some leaders in public health. Community When Virchow wrote in 1849 that\“Medicine is a social
health incorporates services to the population at large as science and politics is medicine on a large scale”, he
opposed to preventive or social medicine. anticipated probably the social (political) control of
medicine. Indeed, as medicine advanced, it became a highly
d. “Health for All” phase (1981 -2000 A.D.) personalized and institutionalized service. This generated a
As the centuries have unfolded, the glaring contrasts in feeling that medicine was not rendering its full service to
the picture of health in the developed and developing humanity. As the cost of medical care increased, two kinds of
countries came into a sharper focus, despite advances in medical care came into existence - one for the rich and the
medicine.(Most people in the developed countries, and the other for the poor. The gap was bridged to a small extent by
elite of the developing countries, enjoy all the determinants charitable, and voluntary agencies providing free medical
of good health - adequate income, nutrition, education, care to the poor. An attitude developed that charity was

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sanitation, safe drinking water and comprehensive health worthy of man and that the benefits of modern medicine
care. In contrast, only 10 to 20 per cent of the population in should be available to all people A A solution was to be found
"developing countries enjoy ready access to health services of - it was “socialization of medicine”.
any__kind (30). [Death claims 60-250 of every 1000 live
births within the first year of life, and the life expectancy is Social medicine should not be confused with state
30 per cent lower than in the developed countries (30). John medicine or socialized medicine. State medicine implies
Bryant in the introduction to his book: “Health and the provision of free medical service to the people at
Developing World” presented a gloomy picture and a government expense. Sociajized medicine envisages
challenge of inequalities in health by saying: “Large provision of medical service and professional education by
numbers of the world’s people, perhaps more than half, the State as in state medicine, but the programme is
have no access to health care at all, and_for many of the rest, operated and regulated by professional groups rather than
the care they receive does not answer the problems they by the government. 1
have”. CChe jlobal conscience was stirred leading to a new Germany led the way by instituting compulsory sickness
awakening that the health gap between rich and poor within insurance in 1883. Other countries followed suit - England
countries and between countries should be narrowed and in 1911, France in 1928 and so on. Great Britain
ultimately eliminated] It was conceded that the neglected nationalized its health services in 1946. c A. few other
80 per cent of the world’s population too have an equal countries notably the socialist nations in Europe, New
claim to health care, to protection from the killer diseases of Zealand and Cuba took steps to socialize their health
childhood, to primary health care for mothers and children, services. (However, Russia was the first country to socialize
to treatment for those ills that mankind has long ago learnt medicine completely and to givejts citizens a constitutional
to control, if not to cure (31). Against this background, in right to all health services. From a private ownership,
1981, the members of the WHO pledged themselves to an medicine became a social institution, one more link in the
ambitious target to provide (^Health for All” by the year chain of welfare institutions (33).
2000, that is attainment of a level of health that will permit
(^Socialization is a noble idea. It eliminates the competition
all people “to lead a socially and economically productive
among physicians in search of clients. It ensures social
life— (32). The public health, along with other medical equity, that is universal coverage by health services.Medical
sciences and other health-related sectors are engaged in this care becomes free for the patient, which is supported by the
broad field of effort, j State.. However, the varying degrees of social control over
medicine, has resulted in a variety of health systems, each
IV. MEDICAL REVOLUTION system having its own merits and demerits. It is now
recognized that mere socialization was not sufficient to
State of the art ensure utilization of health services. What is required is
Medicine has moved from the' organism to organ, and “community participation”, which, as envisaged by WHO
from the organ to the-cell, and from the cell to molecular and UNICEF is “the process by which individuals and
properties. The discovery of the biological role of nucleic families assume responsibility for their own health^ and
acids the uncovering of the genetic code and its role in welfare and for those of the community, and develop the
regulating life processes are marvellous discoveries in recent capacity to contribute to their and the community s
years. Medicine has acquired a vast body of knowledge and development^(32). It also implies community participation in

by R△J
BliEII MAN AND MEDICINE : TOWARDS HEALTH FOR ALL

the planning, organization and management of their own and conflict about roles, tasks and professional identities in
healtHIsenzices. This is called simply ‘‘Health by the People” the service as well as the academic worlds of community
(34). This is what Virchow had prophesied_that medicine is medicine (27).
nothing but politics on a large scale J
V. HEALTH CARE REVOLUTION
Family and community medicine
Way back in 1923, (_Dr. Francis Peabody, professor of Background
medicine at Harvard, commented that specialization in
It was recognized that in both developed and developing
medicine had already reached its apex and that modern
countries, the standard of health services the public
medicine had fragmented the health care delivery system to
expected was not being provided (38). The services do not
too great a degree. (He called for a rapid return of the
cover the whole population. There is lack of services in some
general physician (family physician) who would give
areas and unnecessary duplication in others. A very high
comprehensive and personalized care. In 1966, two reports proportion of the population in many developing countries,
(i.e., Millis Commission Report, Willard Committee Report) and especially in rural areas does not have ready access to
in United States made similar recommendations. In 1971,
health services. The health services favoured only the
the American Academy of General Practice (which began in privileged few and urban dwellers. Although there was the
1947) changed its name tok^American Academy of Family recognition that health is a fundamental human right, there
Physicians” to place increased emphasis upon family- is a denial of this right to millions of people who are caught
oriented health care and to gain academic acceptance for in the vicious circle of poverty and illhealth. There are
the new speciality^ marked differences in health status between people in
Cfhe .emergence of Family and Community Medicine different countries as well as between different groups in the
represents a counterforce to the direction which medical same country; the cost of health care is rising without much
science has taken lately. The field of specialization of family improvement in their quality. In short, there has been a
and community medicine is neither an organ system nor a growing dissatisfaction with the existing health services and
disease syndrome, but rather in both instances, a designation a clear demand for better health care. '
of social categories namely family and community. Family
and community medicine overlap and’strengthen each other. Health for All

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The spate of new ideas and concepts, e.g., increasing
Family medicine importance given to social justice and equity, recognition of
The emergence of family medicine has been hailed as a the crucial role of community participation, changing ideas
rediscovery of the human, social and cultural aspects of about the nature of health and development, the importance
health and disease, and of the recognition of family, as a of political will called for new approaches to make medicine
focal point of health care and thejright place for integrating in the service of humanity more effective.
preventive, promotive and curative services. Family Against the above background, the 30th World Health
medicine has been defined as (‘a field of specialization in Assembly.resolved in May 1977, that “the main social target
medicine which is neither disease nor organ oriented. It is of governments and WHO in the coming decades should be
family oriented medicine or health care centred on the the attainment by all citizens of the world by the year 2000
family as the unit - from first conta_ct to the ongoing care^of of a level of health that will permit them to lead a socially
chronic problems (from prevention to rehabilitation). When and economically productive life.” This culminated in the
family medicine is applied to the_care of patients and their international objective of HEALTH FOR ALL by the year
families, it becomes the speciality of family practice) eFamily 2000 as the social goal of aj£ governments!
practice is a horizontal speciality, which, like paediatrics and
The goal of Health for All has two perspectives. Viewed in
internal medicine, shares large areas of content with other
the long-term context, it simply means the realization of the
clinical disciplines. CThe speciality of family^ practice is
WHO’s objective of “attainment by all peoples of the highest
specially designed to deliver “primary care” (35).
possible level of health”. But, what is of immediate
Community medicine relevance is the meaning that, as a minimum, all people in
all countries should have at least such a level of health that
Like family medicine, community medicine is a
they are capable of working productively and of
newcomer. It is the successor of what was previously known
participating actively in the social life of the community in
as public health, community health, preventive and social
which they live. .1
medicine. All these share common ground, i.e., prevention
of disease and promotion of health. The appearance of Health for All means that health is to be brought within
community medicine has caused confusion. (The Faculty of the reach of every one in a given community. It implies the
Community Medicine of the Royal College of Physicians has removal of obstacles to health - that is to say,Jhe_elimination
defined community medicine as {that speciality which deals of malnutrition, ignorance, disease, contaminated water
with populations.........and comprises those doctors who try"to supply, unhygienic housing, etc. It depends on continued
measure the needs of the population, both sick and well, progress in medicine and public health.
who plan and administer services to meet thoseneeds, and Health for All was a holistic concept calling for efforts in
those who are engaged in research and teaching in the fiekELJ agriculture, industry, education, housing . and
(27). Besides this, there are at least four other definitions of communications, just as much as in medicine and public
community medicine (36). To make matters worse, a WHO health. The attainment of Health for All by 2000 A.D. was
study group (37) stated that since health problems vary from the central issue and official target of WHO and its member
country to country, each country should formulate its own countries. It symbolized the determination of the countries
definition of community medicine in the light of its of the world to provide an acceptable level_o£Jiea_lth_ to_all
traditions, geography and resources. There is still confusion people /Health for All has been described as a revolutionary
by R△J
 HEALTH CARE REVOLUTION J1
concept and a historic movement — a movement in terms of The Millennium Development Goals
its own evolutionary process. In September 2000, representatives from 189 countries
Primary health care (39) met at the Millennium Summit in New York to adopt the
United Nations Millennium Declaration. The leaders made
With increasing recognition of the failure of existing health specific commitments in seven areas ( peace, security and
services to provide health care, alternative ideas and disarmament; development, and poverty eradication:
methods to provide health care have been considered and protecting our common environment, human rights,
tried (34,40). . Discussing fhese issues at the JomCWtLO- democracy and good^governance; protecting the vulnerable:
UNICEFL international conference ii m meeting the special needs of Africa; and strengthening the
(USSR), the governments of 134 countries and many United Nations. The Road Map established goals and targets
voluntary agencies called for a revolutionary approach to to be reached by the year 2O15.irteach of seven areas. The
health care. Declaring that “The existing gross inequality in goals in the area of developm.ent._and poverty eradication
the health status of people particularly between developed are now widely referred to as “Millennium Development
and developing countries as well as within countries is Goals” (41, 42).
politically, socially and economically unacceptable”, the The Millennium Development Goals, place health at the
Alma-Ata conference called for acceptance of the WHO goal heart of development and represent commitments by
of Health for All by 2000 A.D. and proclaimed primary governments throughout the world to do more to reduce
health care as way to achieving “Health for All”. poverty and hunger, and to tackle ill-health, gender
^Primary health care is a new approach to health care, which inequality, lack of education, access to clean water; and
integrates at the community level all the factors required for environmental degradation AJhus three of the eight goals are
improving the health status of the population.' It consists of at directly health related and all of other goals have important
?ast eight elements (see page 37) described as “essential indirect effects on health;1 three of the 8 goals, 8 of the
health care”. This presupposes services that are both simple 18 targets required to achieve these goals, and 18 of the
and efficient with regard to cost, techniques, and organization, 48 indicators of progress, are health related. /
that are readily accessible to those concerned, and that
contribute to improving the living conditions of individuals, Sustainable Development Goals
families and the community as a whole .'Primary health care is In September _ 2015, the United Nations General

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available to all people at the first level of health care. It is based Assembly adopted the new .development__________ agenda :
on principles of equity, wider coverage, individual and Transforming our world : the 2030 agenda for sustainable
community involvement and intersectoral coordination. development. Comprising 17 Sustainable Development
Viewed in these terms, primary health care is a radical Goals (SDGs), the 2030 Agenda integrates all three
departure from the conventional health care systems of the dimensions of sustainable development (economic, social
past. While it integrates promotive, preventive and curative and environmental) around the themes of people, planet,
services, it is also conceived as an integral part of the country's prosperity, peace and partnership. The SDGs recognize that
plan for socio-economic development. eradicating poverty and inequality, creating economic
C.The Ahna-Ata Declaration called on all governments to growth and preserving the planet are inextricably linked not
formulate national policies, strategies and plans of action to only to each other, but also to population health. |
launch and sustain primary health care as part of a national Health is centrally positioned within the 2030 Agenda,
neat s stem. It is left to each country to innovate, with one comprehensive goal - SDG 3 : “Ensure hea't! y
according to its own circumstances to provide primary lives and promote well-being for all at all ages”; and explicit
health care. This was followed by the formulation and links to many of the other goals. SDG 3 includes JJLiargets
adoption of the Global strategy for Health for All by the covering all major health priorites, including four targe_ts_on
34th World Health Assembly in 1981. Primary health care the unfinished and expanded Millennium Development Goal
got off to a good start in many countries with the theme agenda, four targets to address non-communicable diseases,
“Health for All by 2000 A.D.”. It presented a challenge so mental health, injuries and environmental issues, and four
formidable that its implications boggle the bravest minds. “means of implementation” targets. The target for universal
’ The challenge brought us face-to-face with the Declaration health coverage is key to the achievemenFoTall other targets
of Alma-Ata. and the development of strong resilient health system. It will
require an integrated approach to the provision of health
Deprofessionalization of medicine services that minimize the fragmentation (43).
vThe practice of primary health care involves a good deal
of “deprofessionalizaion” of medicine. Laymen have come Conclusion
to play a prominent role in the delivery of health care. While CContemporary medicine is no longer solely an art, and
the physician still holds his unique position in the field of science for the diagnosis and treatment of diseases. lt_is also
health care in general, the participation of a new cadre of the science for the prevention of disease and the promotion
health workers (e.g., community health workers, anganwadi of health. The scope of medicine has expanded during the
workers, multipurpose workers, practitioners of indigenous last few decades to include not only health problems of
medicine, social workers) with relatively little training and individuals, but those of communities as well. This
support have been considered and tried to provide health expansion of the scope of medicine has required a
cape. They now comprise part of the ‘^health teams”L The reformulation of its goals and objectives. Systems should
medical man can no longer restrict himself to his traditional integrate health promotion and disease prevention on the
role as diagnoser of ailments, prescriber of pills and potions, one hand, and treatment for acute illness and chronic care
and exciser of lumps. He has acquired new roles - being an on the .other. This should be done across all levels of the
edycatgr, case-finder, preventer, counsellor and an agent of health care system, with the aim of delivering—quality
social changeA services equitably and efficiently to the whole population.

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12 MAN AND MEDICINE : TOWARDS HEALTH FOR ALL

The real progress in health depends vitally on stronger 21. Norton Alan (1969). The New Dimensions of Medicine, 20th
health system based on primary health care. Century Studies, London, Hodder & Stoughton.
22. Clark Duncan, W and B. MacMahon (1981). Preventive and
/"It is left to the posterity to review our errors and Community Medicine, 2nd ed. Boston, Little, Brown & Co.
accomplishments. This is how medicine has evolved down 23. Crew. F.A.E. (1960). Med. Edu. Bull, No.2, WHO, SEARO, New
the centuries. Medicine will continue to evolve so long as Delhi.
man’s quest for better health continues. 24. Stieglitz, Edward J. (1949). In: Social Medicine, Its Derivatives and
Objectives, Ed.Iago Galdstone, New York, The Commonwealth
Fund.
References 25. Mckeown, T. and C.R. Lowe (1974). An Introduction to Social
1. Siegerist Henry (1951). A History of Medicine, Vol I Oxford Medicine, 2nd ed., Blackwell, Oxford.
University Press, London. 26. Martin, F.M. (1977). Lancet, 2, 1336.
2. Dubos, R.J. (1969). Man, Medicine and Environment, New 27. Acheson, R.M. (1978). Lancet, 2, 1737.
American Library, New York. 28. Roemer, M.I. (1972). Public Health Papers, No.48 Geneva, WHO.
3. Jaggi, O.P. (1973). Indian System of Medicine, Atma Ram and Sons. 29. Fendall, R. (1984). World Health Forum, 5,300.
4. Gokhale, B.V. (1960). Swasth Hind, 4, 165. 30. Morley, David, et al (1984). Practising Health for All, Oxford
5. Banerjee, J.N. (1966). Ind. J. Med. Edu., 5,79. University Press.
6. Bhatia, S.L. (1957). Ind. J. Hist. Med., 2,70. 31. Mahler, H. (1977). World Health, Nov. 1977.
7. Parke-Davis (1961). Great Moments in Medicine. A History- of 32. WHO-UN1CEF (1978). Health For All, Sr.No.l.
Medicine in pictures, Parke-Davis & Co. 33. Siegerist, (1947). Medicine and Health in the Soviet Union, Jaico
8. Kutumbiah, P (1956). Ind.J.Hist.Med., 2,6. Publishing House, Bombay.
9. Kishore, Jugal (1974). Swasth Hind, 18,36. 34. Newell, K.W. et al (1975). Health by the People, WHO, Geneva.
10. WHO (1984) . World Health, July 1984. 35. Rakel, R.E. (1977). Principles of Family Medicine, Saunders.
11. Smith, A.J. (1974). Brit.Med.J., 2, 367. 36. Last, J.M. ed (1983) A Dictionary of Epidemiology, Oxford
12. Diamond, E.G. (1971). JAMA 218, 1558. University Press.
13. WHO (1970). World Health, May 1970. 37. WHO (1972). Report on the Regional Seminar on Community
Medicine of Medical teachers, WHO/SEA/Med.Edu/187, 7 Sept.
14. Anderson, C.L. et al (1978). Community Health, C.V. Mosby.
38. WHO (1976). WHO Chronicle, 30 (1).8.
15. Kark, S.L. (1974). Epidemiology and Community Medicine,
Appleton Century Crofts. 39. WHO (1978). Health for All Sr.No.l.
16. Reiser, S.L. (1980). World Health Forum, 1, 103. 40. Djukanovic, V. and Mach, E.P. (1975). Alternative approaches to
meeting basic health needs in developing countries, A joint UNICEF/

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17. Guthrie Douglas (1947). A History of Medicine, Thomas Nelson & WHO study, WHO, Geneva.
Sons, London. 41. WHO (2003), The World Health Report 2003, Shaping the future.
18. Hobson, W. (1965). World Health and History, Oxford University 42. UNDP, Human Development Report 2003, Millennium Development
Press, London. Goals : A compact among nations to end human poverty, Oxford
19. Brockington, C.F. (1967). World Health, Churchill, London. University Press.
20. Noble, John (1976). Primary Care and the Practice of Medicine, 43. WHO (2016), World Health Statistics 2016, Monitoring Health for
Boston, Little, Brown & Co. the SDGs.

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 2 Concept of Health
and Disease
"Health is NOT mainly an issue of doctors, social services and hospitals. It is an issue of social justice."
CONCEPT OF HEALTH
Health is a common theme in most cultures. In fact, all 1. Biomedical concept
communities have their concepts of health, as part of their Traditionally, health has been viewed as an “absence of
culture. Among definitions still used, probably the oldest is disease”, and if one was free from disease, then the person
that health is the ^‘absence of disease,”. In some cultures, was considered healthy. Cjhis concept, known as the
health and harmony are considered equivalent, fharmony “biomedical concept” has the basis in thej‘germ theory of
being defined as '.‘being at peace with the self, the. community, diseasgLwhich dominated medical thought at the turn of the
god and cosmos”. The ancient Indians and Greeks shared this 20th century. /The medical profession viewed_the human
concept and attributed disease to disturbances in bodily body as a machine, disease as a consequence of the
equilibrium of what they called “humors”. breakdown of the machine and one of the doctor’s task as
Modern medicine is often accused for its preoccupation repair of the machine (3). Thus health, in this narrow view,

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with the study of disease, and neglect of the study of health. became the ultimate goal of medicine.
Consequently, our ignorance about health continues to be The criticism that is levelled against the biomedical
profound, as for example, the determinants of health are not concept is that it has f minimized the role of the
yet clear; the current definitions of health are elusive; and environmental, social, psychological and cultural
there is no single yardstick for measuring health. There is thus determinants of health. The biomedical model, for all its
a great scope for the study of the “epidemiology” of health. spectacular success in treating disease, was found
However, during the past few decades, there has been a inadequate to solve some of the major health problems of
reawakening that health is a fundamental human right and a mankind (e.g., malnutrition, chronic diseases, accidents,
worldwide social goal; that it is essential to the satisfaction of drug abuse, mental illness, environmental ^pollution,
basic human needs and to an improved quality of life; and, population explosion) by elaborating the medical
that it is to be attained by all people. In 1977, the 30th technologies.(Developments in medical and social sciences
World Health Assembly decided that the main social target led to the conclusion that the biomedical concept of health
of governments and WHO in the coming decades should be was inadequate.
“the attainment by all citizens of the world by the year 2000
of a level of health that will permit them to lead a socially 2. Ecological concept
and economically productive life”, for brevity, called “Health Deficiencies in the biomedical concept gave rise to other
for All” (1). With the adoption of health as an integral part concepts. The ecologists put forward an attractive
of socio-economic development by the United Nations in hypothesis which viewed health as a dynamic equilibrium
1979 (2), health, while being an end in itself, has also between man and his environment, and disease a
become a major instrument of overall socio-economic maladjustment of the human organism to environment.
development and the creation of a new social order. In the Dubos (4) defined health saying : ^Health implies the
year 2000, the Millennium Development Goals, and more relative absence of pain and discomfort and a continuous
recently in the year 2015, the Sustainable Development adaptation and adjustment to the environment to ensure
Goals kept health centrally positioned to ensure healthy lives optimal function”. Human, ecological and ^cultural
andpromote well-being Jor all at all ages.j adaptations do determine not only the occurrence of disease
but also the availability of food and the population
CHANGING CONCEPTS explosion. The ecological concept raises two issues, viz.
An understanding of health is the basis of all health care. imperfect man and imperfect environment. History!argues
Health is not perceived the same way by all members of a strongly that improvement in human adaptation to natural
community including various professional groups (e.g., environments can lead to longer life expectancies and a
biomedical scientists, social science specialists, health better quality of life - even in the absence of modern health
administrators, ecologists, etc) giving rise to confusion about delivery services (5).
the concept of health. In a world of continuous change, new
concepts are bound to emerge based on new patterns of 3. Psychosocial concept
thought. Health has evolved over the centuries as a concept Contemporary developments in social sciences revealed
from an individual concern to a worldwide social goal and that health is not only a biomedical phenomenon, but one
encompasses the whole quality of life. A brief account of the which is influenced by social, psychological, cultural,
“hanging concepts of health is given below economic and political factors of thejgeople concerned (5)
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14 CONCEPT OF HEALTH AND DISEASE

These factors must be taken into consideration in defining criteria generally accepted for one’s age, sex, community,
and measuring health. Thus health is both a biological and and geographic region; and (b) the several organs of the
social phenomenon. body are functioning adequately fn~fhemselves and in
relation to one another, which implies a kind of equilibrium
4. Holistic concept or homeostasis - a condition relatively stable but which may
The holistic model is a synthesis of all the above vary as human beings adapt to internal and external stimuli.
concepts. It recognizes the strength of social, economfc,
political and environmental influences on health. It has been New philosophy of health
variously described as a unified or multidimensional process In recent years, we have acquired a new philosophy of
involving the well-being of the whole person in the context health, which may be stated as below :
of his environment. This view corresponds to the view held - health is a fundamental human right
by the ancients that health implies a sound mind, in a sound - health isthe essence of productive life, and not the
body, in a sound family, in a sound environment. The result of ever increasing expenditure on medical care
holistic approach implies that all sectors of society have an - health is intersectoral
effect on health, in particular, agriculture, animal husbandry, - health is an integral part of development
food, industry, education, housing, public—_works, - health is central to the concept of quality of life
communications and other sectors (6). The emphasis is on
- health involves individuals, state and international
the promotion and protection of health.
responsibility j
- (health and its maintenance is a major social
DEFINITION OF HEALTH investment
“Health” is one of those terms which most people find it - \health is a worldwide social goal'^
difficult to define, although they are confident of its
meaning. Therefore, many definitions of health have been DIMENSIONS OF HEALTH
offered from time to time.
Health is multidimensional. The WHO definition
WHO definition x envisages three specific dimensions - the physical, the
mental and the social. Many more may be cited, viz.

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The widely accepted definition of health is that given by spiritual, emotional, vocational and political dimensions. As
the World Health Organization (1948) in the preamble to its the knowledge base grows, the list may be expanding.
constitution, which is as follows : Although these dimensions function and interact with one
(^Health is a state of complete .physical, mental and another, each has its own nature, and for descriptive
social ivell-being and not merely an absence of disease purposes will be treated separately.
or infirmity”
1. Physical dimension
In recent years, this statement has been amplified to The physical dimension of health is probably the easiest
include the ability to lead a “socially and economically to understand. The state of physical health implies the
productive life” (6). notion of “perfect functioning” of the body. It conceptualizes
The WHO definition of health has been criticized as being health biologically as a state in which every cell and every
too broad. Some argue that health cannot be defined as a organ is functioning at optimum capacity and in perfect
“stated at all, but must be seen as a process of continuous harmony with the rest of the body. However, the term
adjustment to the changing demands of living and of the “optimum” is not definable.
changing meanings we give to life. It is a dynamic concept. It The signs of physical health in an individual are: “a good
helps people live well, work well and enjoy themselves. complexion, a clean skin, bright eyes, lustrous hair with a
Inspite of the above limitations, the concept of health as body well clothed with firm_flesh, not too fat, a sweet breath,
defined by WHO is broad and positive in its implications; it a good appetite, sound sleep, regular activity oTbowels and
sets out the standard, the standard of “positive” health. Jt bladder and smooth, easy? coordinatedTodily movements.
symbolizes the aspirations of people and represents__an Air the organs of the body are of unexceptional size and
overall objective or goal towards which__nations should function normally; all the special senses are intact; the
strive. resting pulse_rate. blood pressure and exercise tolerance are
all within the range of “normality” for the individual’s age
Operational definition of health and_seKx In the young and growing individual there is a
The WHO definition of health is not an “operational” steady gain in weight and in the future this weight remains
definition, i.e., it does not lend itself to direct measurement. more or less constant at a point about 5 lbs (2.3 kg) more or
Studies of epidemiology of health have been hampered less than the individual’s weight at the age of 25 years (8).
because of our inability to measure health and well-being This state of normality has fairly wide limits. These limits are
directly. In this connection an “operational definition” has set by observation of a large number of “normal” people,
been devised by a WHO study group (7). In this definition, who are free from evident disease.
the concept of health is viewed as being of two orders. In a
broad sense, health can be seen as£a_condition or quality of Evaluation of physical health
the human organism expressing the adequate functioning of Modern medicine has evolved tools and techniques
the organism in given conditions, genetic or environmental”. which may be used in various combinations for the
In a narrow sense - more useful for measuring purposes - assessment of physical health. They include :
health means: (a) there is no obvious evidence of disease, - self assessment of overall health
and that a person is functioning normally, i.e., conforming - inquiry into symptoms of ill-health and risk factors
within normal limits of variation to the standards of health - inquiry into medications
by R△J
 DIMENSIONS OF HEALTH
__15
- inquiry into levels of activity (e.g., number of days of well-being is also made. The most basic decision to be made
restricted activity within a specified time, degree of in assessing mental health is whether to assess mental
fitness) functioning, i.e., the extent to which cognitive or affective
- inquiry into use of medical services (e.g., the number impairments impede role performance and subjective life
of visits to a physician, number of hospitalizations) in quality, or psychiatric diagnosis (10).
the recent past One of the keys to good health is a positive mental
- (standardized questionnaires for cardiovascular health”. Unfortunately, our knowledge about mental health is
diseases— faFfrom complete.
- ^standardized questionnaires for respiratory diseases
- clinicalexaminaiion 3. Social dimension
- (nutrition and dietary assessment, and Social well-being implies harmony and integration within
- biochemical and laboratory investigations. the individual, between each individual and other members
of society and between individuals^ and the world in which
At the community level, the state of health may be theyJive (11). It has been defined as the ^‘quantity and
assessed by such indicators as death rate, infant mortality quality of an individual’s interpersonal ties and the extentof
rate and expectation of life. Ideally, each piece of involvement with the community” (12).
information should be individually useful and when ■->
combined should permit a more complete health profile of The social dimension of health includes the levels of social
individuals and communities. skills one possesses, social functioning and the ability to see
oneself as a member of a larger society. In general, social health
2. Mental dimension takes into account that every individual is part of a family and
of wider community and focuses on social and economic
CMental health is not mere absence of mental illness. Good
coriditions-ancLwell-being of the “wholeperson” in the context
mental health is the ability to respond to the many varied
of his social network. Social health is rooted in “positive
experiences of life with flexibility and a sense of purpose. In
material environment” (focussing on financial and residential
the recent past, mental health has been defined as “ajtate
matters), and “positive human environment” which is
of balance between the individual and the surrounding
world, a state of harmony between oneself and others, a concerned with the social network of the individual (10).
coexistence between the realities of the self and that of other 4. Spiritual dimension

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people and that of the environment” (9).
Proponents of holistic health believe that the time has
Some decades ago, the mind and body were considered come to give serious consideration to the spiritual dimension
independent entities. However, researchers have discovered and to the role this plays in health and disease. Spiritual
that (psychological factors can induce all kinds of illness, not health in this context, refers to that part of the individual
simply mental ones. They include conditions such as which reaches out and strives for meaning and purpose in
essential hypertension, peptic ulcer and bronchial asthma. life. ' It is the intangible “something” that transcends-
Some major mental illnesses such as depressionZand physiology and psychology. As a relatively new concept, it
schizophrenia have a biological component. The underlying seems to defy concrete definition. Qt_includes_integrity,
inference is that there is a behavioural, psychological or principles and ethics, the purpose in life, commitment to
bjological disfunction and that the disturbance in the mental some higher being and belief in concepts that are not subject
equilibrium is not merely in the relationshipi Jjetween the to “state of the art” explanation (13).
individual and the society (10).
Although mental health is an essential component of 5. Emotional dimension
health, the scientific foundations of mental health are not yet Qdistorically the mental and emotional dimensions have
clear. Therefore, we do not have precise tools to assess the been seen as one element or as two closely related elements.
state of mental health unlike physical health. Psychologists However, as more research becomes available a definite
have mentioned the following characteristics as attributes of difference is emerging. (Mental health can be seen as
a mentally healthy person: “knowing” or “cognition” while emotional health relates to
a. (^a mentally healthy person is free from__________ internal “feeling”? Experts in psychobiology have been relatively
conflicts; he is not at “war”jvith himself. successful in isolating these two separate dimensions. With
b. y he is well-adjusted, i.e., he is able to get along well with this new data, the mental and emotional aspects of
others. He accepts criticism and is not easily upset. humanness may have to be viewed as two separate
c. he searches for identity. dimensions of human health (13).
d. he has a strong sense of self-esteem. 6. Vocational dimension
e. he knows himself: his needs, problems and goals (this The vocational aspect of life is a new dimension. It is part
is known as self-actualization).
of human existence. When work is fully adapted to human
f. he has _good self-control-balances rationality and goals, capacities and limitations, work often plays a role in
emotionality. promoting both physical and mental health. Physical work is
g. 'Jnejaces.problems and tries to solve them intelligently, usually associated with an improvement in physical capacity,
i.e., coping with stress and anxiety. while goal achievement and self-realization in work are a
Assessment of mental health at the population level may source of satisfaction and enhanced self-esteem (14).
be made by administering mental status questionnaires by The importance of this dimension is exposed when
trained interviewers. The most commonly used individuals suddenly lose their jobs or are _faced_with
questionnaires seek to determine the presence and extent of mandatory retirement. For many individuals, the vocational
“organic disease” and of symptoms that could indicate dimension may be merely a source of income. To others, this
psychiatric disorder; some personal assessment of mental dimension represents the culmination of the efforts of other

by R△J
16 CONCEPT OF HEALTH AND DISEASE

dimensions as they function together to produce what the compared to 3.5 kg in the developed countries, and yet
individual considers life “success” (13). compares favourably in health. The height and weight
standards vary from country to country, and also between
7. Others socio-economic groups. Many normal people show heart
A few other dimensions have also been suggested such murmurs, enlarged tonsils and X-ray shadows in the chest
as (15): and yet do not show signs of ill-health. Thus health is a
relative concept (7) and health standards vary among
- philosophical dimension,, cultures, social classes and age-groups. This implies that
- cultural dimension health in any society should be defined in terms of
- socio-economic dimension prevailing ecological conditions. That is, instead of setting
- environmental dimension universal health standards, each country will decide on its
- educational dimension own norms for a given set of prevailing conditions and then
- nutritional dimension look into ways to achieve that level (19).
- curative dimension
- preventive dimension.
CONCEPT OF WELL-BEING
A glance at the above dimensions shows that there are
( Well-being is in general a term used to describe a
many “non-medical” dimensions of health, e.g., social,
condition of an individual or a group, with reference to
cultural, educational, etc. These symbolize a huge range of
social, economic, psychological, spiritual or medical
factors to which other sectors besides health must contribute if
attention.
all people are indeed to attain a level of health that will permit
them to lead a socially and economically productive life. Psychologists have pointed out that the “well-being” of an
individual or group_ of individuals have objective and
POSITIVE HEALTH subjective components. The objective components relate to
such concerns as are generally known by the term “standard of
C Health in the broad sense of the world does not merely living” or “level of living”. The subjective component of well­
mean the absence of disease or provision of diagnostic, being (as expressed by each individual) is referred to as
curative and preventive services. It also includes as “quality of life” (20). Let us consider these concepts separately.
embodied inlheWHO definition, a state of physical, mental

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and social well-being. The harmonious balance of this state 1. Standard of living
of the human individual integrated into his environment, C The term “standard of living” refers to the usual scale of
constitutes health, as defined by WHO. our expenditure, the goods we consume and the services we
The state of positive health implies the notion of “perfect enjoy. It includes the level of education, employment status,
functioning” of the body and_mind. It conceptualizes health food^ dress, house, amusements and comforts of modern
biologically, as a state in which ever cell and every organ is living (20).
functioning at optimum capacity and in perfect harmony with A similar definition, corresponding to the above, was
the rest of the body; psychologically, as a state in which the proposed by WHO: “Income and occupation standards of
individual feels a sense of perfect well-being and of mastery
housing, sanitation and nutrition, the level of provision of
over his environment, and socially, as a state in which the
health, educational, recreational and other services may all
individual’s capacities for participation in the social system
be used individually as measures of socio-economic status,
are optimal (16). These ideas were widely ventilated some
and collectively as an index of the “standard of living” (21).
years ago but now appear slightly ridiculous (17).
There are vast inequalities in the standards of living of the
Dubos (4) said, “The concept of perfect positive health
people in different countries o£ the world. (. The extent of
cannot become a reality because man will never be so
these differences are usually measured through The
perfectly adapted to his environment_that his life will not
comparison of per capita GNP on which the standard .of
involve struggles, failures and sufferings”. Positive health
living primarily depends.
will, therefore, always remain a mirage, because everything
in our life is subject to change. Health in this context has
2. Level of living
been described as a potentiality - the ability of an individual
or a social group to modify himself or itself continually, in the The parallel term for standard of living used in United
face of changing conditions of life.Qn working for positive Nations documents is “level of living” (22). It consists of
health the doctor and the community health expert are in the nine components: health, food consumption, education,
same position as the gardener or farmer faced with insects, occupation and working conditions, housing, social security,
moulds and weeds. Their work is never done (18). clothing, recreation and leisure, and human rights. These
A broader concept of health has been emerging - that of objective characteristics are believed to influence human
improving the quality of life of which health is an essential well-being. It is considered that health is the most important
component. This at once brings to focus that positive health component of the level of living because its impairment
depends not only on medical action, but on all the other always means impairment of the level of living.
economic, cultural and social factors operating in the
community. 3. Quality of life
Much has been said and written on the quality of life in
HEALTH - A RELATIVE CONCEPT recent years. It is the “subjective” component of well-being.
“Quality of life” was defined by WHO (23) as: “the
An alternative approach to positive health conceptualizes condition of life resulting from the combination of the effects
health not as an ideal state, but as a biologically “normal” of the complete range of factors such as those determining
state, based on statistical averages (3). For example, a health, happiness (including comfort in the physical
newborn baby in India weighs 2.8 kg on an average environment and a satisfying occupation), education, social
by R△J
 CONCEPT OF WELL-BEING
—17
and intellectual attainments, freedom of action, justice and East with high per capita incomes have in fact not very high
freedom of expression” J PQLIs. At the other extreme, Sri Lanka and Kerala state in
A recent definition of quality of life by WHO is as follows: India have low per capita incomes with high PQLIs. In short
“the product of the interplay between social, health, PQLI does not measure economic growth; it measures the
economic, and environmental conditions which affect human results of social, economic and political policies. It is
and social development. It is a broad-ranging concept; intended to complement, not .replace GNP (25). The
ultimate objective is to attain a PQLI of 100.
incorporating a person’s physical health, psychological state,
level of independence, social relationships, personaL belief
Human Development Index (HDI) (26)
and relationship to salient features in the environment” (24).
Human development index (HDI) is defined as “a
Thus, a distinction is drawn between the concept of “level
composite index focusing on three basic dimensions of
of living” consisting of objective criteria and of “quality of
human development : to lead a long and healthy life
life” comprising the individual’s own subjective evaluation
measured by life expectancy at birth; the ability to acquire
of these. The quality of life can be evaluated by assessing a
knowledge, measured by mean years of schooling and
person’s subjective feelings of happiness or unhappiness
expected years of schooling; and the ability to achieve a
about the various life concerns, .
decent standard of living, measured by gross national
People are now demanding a better quality of life. income per capita in PPP US $. Fig. 1 summarizes how the
Therefore, governments all over the world are increasingly human development index is constructed.
concerned about improving the quality of life of their people by
Thus the concept of HDLreflects achievements in the
reducing morbidity and mortality, providing primary health
most basic human capabilities, viz, leading a long life, being
caie_andjenhancing physical,_mental and social well-being. It is
conceded that a rise in the standard of living of the people is not knowledgeable and enjoying a decent standard of living.
enough to achieve satisfaction or happiness. Improvement of Hence, these three variables have been chosen to represent
quality of life must also be added, and this means increased those dimensions. The HDI is a more comprehensive
emphasis on social policy and on reformulation of societal measure than per capita income. Income is only a means to
goals to make life more liveable for all. human development, not an end. Nor is it a sum total of
human lives. Thus by focussing on areas beyond income
Physical quality of life index (PQLI) and treating income as a proxy for a decent standard of

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living, the HDI provides a more comprehensive picture of
As things stand at present, this important concept of quality human life than income does. \
of life is difficult to define and even more difficult to measure.
Various attempts have been made to reach one composite The HDI values range between 0 to 1 The HDI value for
index from a number of health indicators. The “Physical a country shows the distance that it lias already travelled
qualityj^fJifeJndex” is one such index. It consolidates three towards maximum possible value to 1. and also allows
indicators, viz. infant mortality, life expectancy at age one, comparisons with other countries.
and literacy. These three components measure the results STEPS TO ESTIMATE THE HUMAN DEVELOPMENT
rather than inputs. As such they lend themselves to
INDEX (27)
international and national comparison.
For each component, the performance of individual There are two steps to calculating the HDI.
countries is placed on a scale of 0 to 100, where 0 represents Step 1. Creating the dimension indices
an absolutely defined “worst” performance, and—100 Minimum and maximum values (goalposts) are set in
represents an absolutely defined “best” performance. The order to transform the indicators into indices between 0
com osite index is calculated by averaging the three and 1. The maximums are the highest observed values in
indicators, giving equal weight to each of them. The the time series (1980-2011). The minimum values can be
resulting PQLI thus also is scaled 0 to 100. appropriately conceived of as subsistence values. The
It may be mentioned that PQLI has not taken per capita minimum values are set at 20 years for expectancy, at
GNP into consideration, showing thereby that “money is not 0 years for both education variables and at $100 for per
everything”. For example, the oil-rich countries of Middle capita gross national income (GNI).

DIMENSIONS Long and A decent standard

healthy life Knowledge of living
INDICATORS Life expectancy Mean years of Expected years of GNI per capita
at birth schooling schooling (PPP US$)

DIMENSION Education index GNI index

INDEX
I
Human development index (HDI)

FIG. 1
Calculating the Human Development Index
Source : (28)

by R△J
18 CONCEPT OF HEALTH AND DISEASE

Goalposts for the Human Development Index For the year 2019, Norway, Ireland and Switzerland are
at the top of HDI ranking, Niger and Central African
DIMENSION OBSERVED MAXIMUM MINIMUM
Republic,~are at the bottom. India comes in the medium
Life expectancy 85 20.0 human development category, ranking at number 131 (29).
Mean years of schooling 15 0 Disparities between regions can be significant with some
Expected years of schooling 18 T regions having more ground to cover jn making the shortfall
Per capita income (PPP $) 75,000 100 than others. The linkbetween the economic prosperity and
human development is neither automatic nor obvious. Two
Having defined the minimum and maximum values, the countries with similar income per capita can have very
subindices are calculated as follows: different HDI values, and countries having similar HDI can
. , Actual value — Minimum value have very different income levels.
tension index = ------------------------------------------

E
(1)
SPECTRUM OF HEALTH
For education, equation Maximum value — to
1 is applied Minimum value
each of the^two
Health and disease lie along a continuum, and there is no
subcomponents, then a geometric mean of the resulting
single cut-off point. The lowest point on the health-disease
indices is created and finally, equation 1 is reapplied to the
spectrum is death and the highest point corresponds to the
geometric mean of the indices using 0 as the minimum and
WHO definition of positive health (Fig. 2). It is thus obvious
the highest geometric mean of the resulting indices for the
that health fluctuates within a range of optimum well-being
time period under consideration, as the maximum. This is
equivalent to applying equation 1 directly to the geometric to various levels of dysfunction, including the state of total
dysfunction, namely the death.(Jhe transition from optimum
mean of the two subcomponents.
health to ill-health is often gradual, and where one state
Step 2. Aggregating the subindices to produce the Human endsand the other begins is a matter of judgnient.
Development Index
The spectral concept of health emphasizes that the health
The HDI is the geometric mean of the three dimension of an individual is not static; it is a dynamic phenomenon
indices: and a process of continuous change, subject to frequent
1/3*I, 1/3
Income ' ) (2) subtle variations.^A/hat is considered maximum health today

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' Life Education
h
may be minimum tomorrow. That is, a person may function
The construction of HDI methodology can be illustrated at maximum levels of health today, and diminished levels of
with the example of India for the year 2019. health tomorrow. It implies that health is a state not to be
attained once and for all, but ever to be renewed. There are
Indicator Value degrees.or “levels of health” as there are degrees or~severity
Life expectancy at birth (years) 69.7 ot illness. As long as we are alive there is some degree of
Mean years of schooling (years) 6.5 health in us.
Expected years of schooling (years) 12.2
GNI per capita (PPP $) 6,681 Positive health
Better health
Freedom from sickness
69.7 - 20 49.7
Life expectancy index = = 0.764
85-20 ”65"
Unrecognized sickness
6.5-0 Mild sickness
Mean years of schooling index = —15-0 = 0.433 Severe sickness
Death

Expected years of schooling index = = 0.677

lo.U — 0
FIG. 2
The health sickness spectrum
0.433 + 0.677
Education index = = 0.555
2
DETERMINANTS OF HEALTH
In (6,681) - In (100)
Inrnmp inrlpv — = 0.634 Health is multifactorial. The factors which influence
In (75,000) - In (100) health lie both within the individual and externally in the
society in which he or she lives. It is a truism to say that what
man is and to what diseases he may fall victim depends on a
Human development index = 0.764 x 0.555 x 0.634
combination of two sets of factors - his genetic factors and
the environmental factors to which he is exposed. These
= 0.645 factors interact and these interactions may be health­
promoting or deleterious. Thus, conceptually, the health of
The countries are divided into low HDI (less than 0.550). individuals and whole communities may be considered to be
medium HDI (between 0.550 to 0.699), high UDI (between the result of many interactions. Only a brief indication of
0.700 to 0.799), and very high HDI for more than 0.800 the more important determinants or variables are shown in
values 729J. Fig. 3.

by R△J
 DETERMINANTS OF HEALTH 19
social values, attitudes and activities (31). It is composed of
cultural and behavioural patterns and lifelong personal
habits (e.g., smoking, alcoholism) that have developed
through processes of socialization. Lifestyles are learnt
through social interaction with parents, peer groups, friends
and siblings and through school and mass media.
Health requires the promotion of healthy lifestyle. A
considerable body of evidence has accumulated which
indicates that there is an association between health and
lifestyle of individuals (32). Many current-day health
problems especially in the developed countries (e.g.,
coronary heart disease, obesity, lung cancer, drug addiction)
are associated with lifestyle changes. In developing countries
such as India where traditional lifestyles still persist, risks of
illness and death are connected with lack of sanitation, poor
nutrition, personal hygiene, elementary human habits,
customs and cultural patterns.^
It may be noted that not all lifestyle factors are harmful.
There are many that can actually promote health. Examples
include adequate nutrition, enough sleep, sufficient physical
activity,_etc. In short, the achievement of optimum health
demands adoption of healthy lifestyles. Health is both a
consequence of an individual’s lifestyle and a factor in
determining it (31).
3. Environment
Source : (30) It was Hippocrates who first related disease to

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environment, e.g., climate, water, air, etc. Centuries later,
FIG. 3 Pettenkofer in Germany revived the concept of disease­
Determinants of health environment association.
1. Biological determinants Environment is classified as “internal” and ^external”.
G_h e internal environment of man pertains to “each and
The physical and mental traits of every human being are every component part, every tissue, organ and organ­
to some extent determined by the nature of his genes at the system and their harmonious functioning within the system”.
moment of conception. The genetic make-up is unique in Internal environment is the domain of internal medicine;
that it cannot be altered after conception. A number of The external or macro-environment consists of those things
diseases are now known to be of genetic origin, e.g., to which man is exposed after conception. It is defined as
chromosomal anomalies, errors of metabolism, mental “all that which is external to the individual human host”
retardation, some types of diabetes, etc. The state of health, (33). It can be divided into p hysicaf,—biological __ and
therefore depends partly on the genetic constitution of man. psychosocial components, any or all of which can affect the
Nowadays, medical genetics offers hope for prevention and health of man and his susceptibility to illness. Some
treatment of a wide spectrum of diseases, thus the prospect epidemiologists have used the term “micro-environment”
of better medicine and longer, healthier life. A vast field of (or domestic environment) to personal environment which
knowledge has yet to be exploited. It plays a particularly includes the individual’s way of Jiving and lifestyle, e.g.,
important role in genetic screening and gene therapy. eating habits, other personal habits (e.g., smoking or
(Thus, from the genetic stand-point, health may be drinking), use of drugs, etc. It is also customary to speak
defined as that “state of the individual which is based upon about occupational environment, socio-economic
the absence from the genetic constitution of such genes as environment and moral environment. <
correspond to characters that take the form of serious defect UL is an established fact that environment has a direct
and derangement and to the absence of any aberration in impact on the physical, mental and social well-being of
respect of the total amount of chromosome material in the those living in it. The environmental factors range from
karyotype or stated in positive terms, from the presence in housing, water supply, psychosocial stress and family
the genetic constitution of the genes that correspond to the structure through social'and economic support systems, to
normal characterization and to the presence of a normal the organization of health and social welfare services in the
karyotype” (8). community.
The “positive health” advocated by WHO implies that a The environmental components (physical, biological and
person should be able to express as completely as possible psychological) are not water-tight compartments. They are
the potentialities of his genetic heritage. This is possible only so inextricably linked with one another that it is realistic and
when the person is allowed to live in healthy relationship fruitful to view the human environment in toto when_.we
with his environment - an environment that transforms consider the influence of environment on the health status of
genetic potentialities into phenotypic realities (18). the population. If"the environment is favourable to the
individual, he can make full use of his physical and mental
2. Behavioural and socio-cultural conditions capabilities. Protection and promotion of family and
The term “lifestyle” is rather a diffuse concept often used environmental health is one of the major issues in the world
to denote “the way people live”, reflecting a whole range of today.
by R△J
 CONCEPT OF HEALTH AND DISEASE
20__
4. Socio-economic conditions children can influence the incidence/prevalence of particular
Socio-economic conditions have long been known to diseases. Provision of safe water can prevent mortality and
influence human health. For the majority of the world’s morbidity from water-borne diseases. The care of pregnant
people, health status is determined primarily by their level of women and children would contribute to the reduction of
socio-economic development, e.g., per capita GNP maternal and child morbidity and mortality. To be effective,
education, nutrition, employment, housing, the political the health services must reach the social periphery,
system of the country, etc. Those of major importance are : equitably distributed, accessible at a cost the country and
community can afford, and socially acceptable (6). All these
(i) Economic status ■ The per capita GNP^isJhe most are ingredients of what is now termed “primary health care”,
widely accepted measure of general economic performance. which is seen as the way to better health.
There can be no doubt that in many developing countries, it
is the economic progress that has been the major factor in Health services can also be seen as essential for social and
reducing morbidity, increasing life expectancy and economic development. It is well to remind ourselves that
improving the quality of life (Table 7 ).Frh^_economic. status “health care does not produce good health” (37). Whereas,
determines the purchasingjjower, standard of living, quality there is a strong correlation between GNP and expectation of
of life, family size and the pattern of disease and deviant life at birth, there is no significant correlation between medical
behaviour in the community. It is also an important factor in density and expectation of life at birth (38). The most we can
seeking health care. Ironically, affluence may also be a expect from an effective health service is good care (37). The
contributory cause of illness as exemplified by the high rates epidemiological perspective emphasizes that health services,
of coronary heart disease, diabetes and obesity in the upper no matter how technically elegant or cost-effective, are
socio-economic groups. ultimately pertinent only if they improve health (39).
6. Ageing of the population
LBy the year 2020, the world is estimated to have more
than 1.4 billion people aged 60 and over, and more than
two-thirds of them living in developing countries. Although
the elderly in many countries enjoy better health than
hitherto, a major concern of rapid population ageing is the
increased prevalence of chronic diseases and disabilities,

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both being conditions that tend to accompany the ageing
process and deserve special attention.
7. Gender
The 1990s have witnessed an increased concentration on
women’s issues. In 1993, the Global Commission on Women’s
Health was established. The commission drew up an agenda
for action on women’s health covering nutrition, reproductive
health, the health consequences of violence, ageing, lifestyle
related conditions and the occupational environment. It has
brought about an increased awareness among policy-makers
of women’s health issues and encourages their inclusion in all
development plans as a priority. |
8. Other factors
We are witnessing the transition from post industrial age
to an information age and experiencing the early days of
two interconnected revolutions, in information and in
(ii) (pducationj: A second major factor influencing health communication. The development of these technologies
statu^i ucation (especially female education). The world offers tremendous opportunities in providing an easy and
map of illiteracy closely coincides with the maps of poverty, instant access to medical information once difficult to
malnutrition, illhealth, high infant and child mortality rates. retrieve. It contributes to dissemination of information
Studies indicate that education, to some extent, worldwide, serving the needs of many physicians, health
compensates the effects of poverty on health, irrespective of professionals, biomedical scientists and researchers, the
the availability of health facilities. The small state of Kerala mass media and the public.
in India is a striking example, ^erala has an estimated infant Other contributions to the health of population derive
mortality rate of 6 compared to 28 for all-India in, 2020. A from systems outside the formal health care system, i.e.,
major factor in the low infant mortality of Kerala is its high health related systems (e.g., food and agriculture, education,
female literacy rate of 98.3 per cent as compared to 71.5^per industry, social welfare, rural development), as well as
cent for all-India for the year 2019-20 (34). adoption of policies in the economic and social fields that
(ih^^ccupatior^ The very state of being employed in would assist in raising the standard of living. This would
productive~wofk“promotes health, because the unemployed include employment opportunities, increased wages,
usually show a higher incidence of illhealth and death. For prepaid medical programmes and family support systems.
many, loss of work may mean loss of income and status. It In short, medicine is not the sole contributor to the health
can cause psychological and social damage. and well-being of population. The potential of intersectoral
(iv)\£Po/itica/ system) : Health is also related to the contributions \to the health of communities is increasingly
countryTTTotitTcat~s9sfem. Often the main obstacles to the recognized.
implementation of health technologies are not technical, but
rather political. Decisions concerning resource allocation,by R△J
 ECOLOGY OF HEALTH

ECOLOGY OF HEALTH to adapt himself to ecological changes is not unlimited. Man

can adapt himself only in so far as the mechanisms of
Ecology is a key word in present-day health philosophy. adaptations are potentially present in his genetic code (18).
It comes from the Greek “Oikos” meaning a house. Ecology
is defined as the science of mutual relationship between RIGHT TO HEALTH
living organisms and their environments. Human ecology is
a subset of more general science of ecology. It is defined as With the establishment of WHO, for the first time the right
the study of human groups as influenced by environmental to health was recognized internationally. The WHO
factors, including social and behavioural factors. A constitution affirms that “the enjoyment of the highest
macro-level, holistic approach to the study of human attainable standard of health is one of the fundamental right
organization (40). of every human being, without distinction of race, religion,
political belief, economic or social condition”. Over the time
A full understanding of health requires that humanity be this recognition was reiterated in a wide array of formulation
seen as part of an _ ecosystem. The human ecosystem in several international and regional human rights (43).
includes in addition to the natural environment, all the
dimensions of the man-made environment - physical, The International Covenant on Economic, Social and
chemical, biological, psychological: in short, our culture and Cultural Rights, widely considered as the central instrument
all its products (41). Disease is embedded in the ecosystem of protection for the right to health recognizes “the right to
of man. Ujealth, according to ecological concepts, is health of everyone to the enjoyment of the highest
visualized as a state of dynamic equilibrium between man attainable standard of physical and mental health”. It is
and his environment. important to note that the covenant gives both physical
health and mental health equal consideration (44). The
By constantly altering his environment or_ecosystem by steps to be taken to achieve the full realization of the right to
such activities as urbanization, industrialization, health include those necessary for (45) :
deforestation, land reclamation, construction of irrigation
canals and dams, man has created for himself new health (a) The provision for the reduction of stillbirth rate and
problems. For example, the greatest threat to human health in infant mortality, and for the healthy development of the
India today is the ever-increasing, unplanned urbanization, child;
growth of slums and deterioration of environment's a result, (bklhe. improvement of all aspects of emdronmentaLand

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diseases at one time thought to be primarily “rural” have industrial hygienej
acquired serious urban dimensions. The agents of a number of (c) <The prevention, treatment and control of epidemic,
diseases, for example, dengue and chikungunya fever, which endemic, occupational and other diseases; and
were effectively controlled have shown a recrudescence. The (d) The creation of conditions which would assure to all
reasons for this must be sought in changes in the human medical service and medical attention in the event of
ecology. Man’s intrusion into ecological cycles of disease has sickness A
resulted in zoonotic diseases such as kyasanur forest disease, To operationalize the above provisions, the UN
rabies, yellow fever, monkeypox, lassa fever, etc. The Bhopal Committee on Economic, Social and Cultural Rights adopted
gas tragedy in 1984 highlights the danger of locating a General Comment on “Right to Health” in the year 2000,
industries in urban areas. The nuclear disaster in Soviet Russia and set out that the right to health extends not only to timely
in April 1986 is another grim reminder of environmental and appropriate health care but also to the underlying
pollution. Construction of irrigation systems and artificial determinants of health, such as access to safe and potable
lakes has created ecological niches favouring the breeding of water, adequate sanitation, an adequate supply of safe food,
mosquitoes and snails. In fact, ecological factors are at the nutrition and housing, healthy occupational and
root of the geographic distribution of disease. Therefore it has environmental conditions and access to health-related
been said that good public health is basically good ecology. education^Zand information, including on sexual and
Some have equated ecology with epidemiology. The reproductive health (45). According to General Comment,
main distinction between epidemiology and ecology is that the right to health also has a “core content” referring to the
while epidemiology is the study of the relationship between minimum essential level of the right with above mentioned
variations in man's environment and his state of health (or key elements in addition to the supply of essential drugs.!
disease), ecology embraces the i nterrelaHonsKip of all living (The human right to health care means that hospitals,
things. In this regard, epidemiology constitutes a special clinics, medicines and doctor’s services must be accessible,
application of human ecology or that part of ecology relating available, acceptable (non-discrimination, physical
to the state of human health (42). accessibility, affordability and information accessibility), and
It is now being increasingly recognized that environmental of good quality for everyone, on an equitable basis, where
factors and ecological considerations must be built into the and when needed. The key principles are : (a)^Jniversaliiy;
total planning process to prevent degradation of ecosystems. (b) Equity: (c) Accountability; (d) Transparency; and
Prevention of disease through ecological or environmental (e) Participation.
manipulations or interventions is much safer, cheaper and a At the international level, the Universal Declaration of
more effective rational approach than all the other means of Human Rights (Art. 25) established in 1948 acknowledges
control. It is through environmental manipulations that the relationship between health and well-being, and its link
diseases such as cholera and other diarrhoeal diseases, with other rights. The other international human rights
typhoid, malaria and other vector borne diseases, and treaties recognizing the right to health are as follows:
hookworm disease could be brought under control or
eliminated. The greatest improvement in human health thus 1. The 1965 International Convention on the Elimination
may be expected from an understanding and modification of of all forms of Racial Discrimination (Art. 5);
the factors that favour disease occurrence in the human 2. The 1966 International Covenant on Economic, Social
ecosystem. Professor Rene Dubos believes that man’s capacity and Cultural Rights (Art. 12);
by R△J
22 CONCEPT OF HEALTH AND DISEASE

3. The 1979 Convention on the Elimination of all forms of The shift in disease patterns from acute to chronic disease
Discrimination against Women (Art. 11, 12 and 14); makes self care both a logical necessity and an appropriate
4. The 1989 Convention on the Rights of the Child (Art. 24); strategy. For example, by teaching patients self care (e.g.,
recording one’s own blood pressure and blood sugar level,
5. The 1990 International Convention on the Protection of
the burden on the official health services would be
the Rights of All Migrant Workers and Members of their
considerably reduced. In other words, health must begin
Families (Art. 28, 43 and 45);
with the individual.
6. The 2006 Convention on the Rights of Persons with
Disabilities (Art. 25). 2. Community responsibility
Numerous conferences and declarations, such as Health can never be adequately protected by health
declaration of Alma-Ata on Primary Health Care and WHO services without the active understanding and involvement
designed plan “Health for all by the year 2000”, which of communities whose health is at stake. Until quite recently,
consists of a series of goals and programmes, to_jachieve throughout the world, people were neglected as a health
minimum level of health for all. Later on, “Promoting resource; they were merely looked upon as sources of
Health”, one of the fundamental aspect of primary health pathology or victims of pathology and consequently as a
care, has been addressed independently by four successive “target” for preventive and therapeutic services. This
conferences - Ottawa, Canada in 1986; Jakarta, Indonesia negative view of people’s role in health has changed
in 1997; ’Cairo in 1994 and Conference on Women in because of the realization that there are many things which
Beijing, 1995. The United Nation’s Millennium Development the individual cannot do for himself except through united
Goals, Declaration of Commitment on HIV/AIDs and more community effort. The individual and community
recently Sustainable Development Goals, 2015 : the 2030 responsibility are complementary, not antithetical. The
Agenda for Sustainable Development has health centrally current trend is to “demedicalize” health and involve the
positioned. The right to health or the right to health care is communities in a meaningful way. This implies a more active
recognized in at least 115 countries constitution. involvement of families and communities in health matters,
viz. planning, implementation, utilization, operation and
RESPONSIBILITY FOR HEALTH evaluation of health services. In other words, the emphasis
has shifted from health care for the people to health

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Health is on one hand a highly personal responsibility care by the people. The concept of primary health care
and on the other hand a major public concern. It thus centres round people’s participation in their own activities.
involves the joint efforts of the whole social fabric, viz. the The Village Health Guides’ scheme in India, launched in
individual, the community and the state to protect and 1977 and ASHA under National Health Mission are
promote health. examples of community participation.
1. Individual responsibility There are three ways in which a community can
participate (47): (i) the community can provide in the shape
Although health is now recognized a fundamental human
of facilities, manpowerjogistic support, and possibly funds
right, it is essentially an individual responsibility. It is not a
(ii) it also means the community can be actively involved in
commodity that one individual can bestow on another. No
planning, management, and evaluation, and (iii) an equally
community or state programme of health services can give
important contribution that people can make is by joining in
health. In large measure, it has to be earned and maintained
and using the health services. This is particularly true of
by the individual himself, who must accept a broad spectrum
of responsibilities, now known as “self care”. preventive and protective measures. Further, no standard
pattern of community participation can be recommended
Self care in health since there is a wide range of economic and social problems,
as well as political and cultural traits among and within the
Presently the trend in health care is self care. It is defined as
communities. What is essential is flexibility of approach.]
“health activities, including promotion, maintenance,
treatment care and health related decision making, carried out ^However, community involvement is not easy to obtain
by individuals and families” (24). It refers to those activities as extensive experience has indicated (48). The traditional
individuals undertake in promoting their own health, Indian society is cut across on rigid religion and caste lines,
preventing their own disease, limiting their own illness, and and appropriate role for each caste group has been a serious
restoring their own health. These activities are undertaken obstacle in securing complete community participation (49).
without professional assistance, although individuals are And in the health sector, the greatest resistance to health
informed by technical knowledge and skills. The generic guide’s involvement in primary health care came from the
attribute of self care is its non-professional, non-bureaucratic, medical profession than- the lay public (50). Community
non-industrial character; its naturaFplace in social life (46j. participation has become an aphorism that is still awaiting
Self care activities comprise observance of simple rules of genuine realization in many countries of the world.
behaviour relating to diet, sleep, exercise, weight, alcohol, Long ago, Henry Sigerist, the medical historian stated
smoking and drugs. Others include attention to personal that “The.people’s health ought to be, the concern of the
hygiene, cultivation of healthful habits and lifestyle, people themselves. They must struggle for it and plan for it.
submitting oneself to selective medical examinations and The war against disease and for health cannot be fought by
screening; accepting immunization and carrying out other physicians alone. It is a people’s war in which the entire
specific disease-prevention measures, reporting early when population must be mobilized permanently!” (51).
sick and accepting treatment, undertaking measures for the
prevention of a relapse or of the spread of the disease to 3. State responsibility
others. To these must be added family planning which is The responsibility for health does not end with the
essentially an individual responsibility. individual and community effort. In all civilized societies, the
by R△J
 HEALTH AND DEVELOPMENT 23
State assumes responsibility for the health and welfare of its made through introduction of modern public health
citizens. The Constitution of India provides that health is a measures alone. According to this way of thinking, the role
State responsibility. The relevant portions are to be found in of human beings in the developing process was grossly
the Directive Principles of State Policy, which are as below : underestimated.
The State shall, in particular, direct the policy towards The period 1973-1977 witnessed considerable rethinking
securing- on this subject (49,). There was profound modification of the
....that the health and strength of workers, men and women economic theory. It became increasingly clear that economic
and the tender age of children are not abused and that development alone cannot solve the major problems of
citizens are not forced by economic necessity to enter poverty, hunger, malnutrition and disease. In its place, “non­
avocations unsuited to their age or strength. economic” issues (e.g., education, productive employment,
....that childhood and youth are protected against housing, equity, freedom and dignity, human welfare) have
exploitation and against moral and material abandonment. emerged as major objectives in development strategies.
The State shall, within the limits of its economic capacity and The experiences of a few developing countries (e.g., Sri
development, make effective provision for securing the right Lanka, Costa Rica, and the state of Kerala in India) illustrate
to work, to education and to public assistance in cases of dramatically the way in which health forms part of
unemployment, old age, sickness and disablement, and in development. This was because the efforts in the health field
other cases of undeserved want. were simultaneously reinforced by developments in other
The State shall make provision for securing just and humane sectors__ such as education, social welfare and land
conditions of work and maternity relief. reforms (52). The link between health and development has
The State shall regard the raising of the level of nutrition and been clearly established, the one being the starting point for
standard of living of its people and the improvement of public the other and vice versa.
health as among its primary duties. Since health is an integral part ofdevelopment, all sectors
- The Constitution of India; Part IV of society have an effect on health. In other words, health
India is a signatory to the Alma-Ata Declaration of 1978 services are no longer considered merely as a complex of
and the Millennium Development Goals of -2Q00. The solely medical measures but a “subsystem” of an overall
National Health Policy, approved by Parliament in 1983 and socio-economic system. In the finaTanalysTs, human health
and well-being are the ultimate goal of development.

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later on in 2002 have resulted in a greater degree of state
involvement in the management of health services, and the
establishment of nation-wide systems of health services with Lessons from Kerala State
emphasis on primary health care approach. (Kemla is the southern-most state of India. With a
population of 3.56 crore, and an estimated population
4. International responsibility density of 926 per sqjsm, the state of Kerala is extremely
The health of mankind _requires the cooperation of crowded^ Its annual per capita income of Rs. 2,36,093
governments, the people, national and international (2021-22) was more than the national average of
organizations both within and outside the United Nations Rs. 1,28,829. Kerala has^surpassed all thejndian states in
system in achieving our health goals. This cooperation certain important measures of ,Jiealth_jmd social
covers such subjects as exchange of experts, provisiormof development, as shown in Table 1.
drugs and supojies. border meetings with regard to control
of communicable diseases. The ITCD.C (Technical TABLE 1
Cooperation in Developing Countries), ASEAN (Association Comparison of Kerala and all-India Health Statistics
of South-East Asian Nations) and ^SXARC) (South Asia
Association for Regional Cooperation) are important
regional mechanisms for such cooperation.
The eradication of smallpox and polio, the pursuit of
“Health for All”, Millennium Development Goals,
Sustainable Development Goals, and The Global Strategy
for Women’s, Children’s and Adolescent’s Health (2016-
2030); and the campaign against smoking and AIDS are a
few recent examples of international responsibility for the
control of disease and promotion of health. Today, more
than ever before, there is a wider international
understanding on matters relating to health and {‘social
injustices’' in the distribution of health services. TheJAQTOjs
a major 'actor in fostering international cooperation in
health- In keeping with its constitutional mandate, WHO acts
as a directing and coordinating authority on international
health work^
Kerala has demonstrated that, in a democratic system
HEALTH AND DEVELOPMENT with a strong political commitment to equitable socio­
economic development, high levels of health can be
“Health is essential to socio-economic development” has
achieved even on modest levels of income. Kerala can
gained increasing recognition. It was commonly thought in
therefore be considered a yardstick for judging health
the 1960s that socio-economic progress was not essential for
improving the health status of people in developing status in the country.
countries, and that substantial and rapid progress could be Studies have shown that the efforts in the health field
by R△J
24 CONCEPT OF HEALTH AND DISEASE

were simultaneously reinforced by developments in other Characteristics of indicators

sectors. Literacy (especially female literacy) has played a key Indicators have been given scientific respectability; for
role in improving the health situation. This was probably example ideal indicators
responsible for the high rate of utilization of health facilities.
Long-standing programmes directed at social welfare raised a. should be valid, i.e., they should actually measure
not only educational levels of the population but also what they are supposed to measure;
developed a social infrastructure, including a transport b. should be reliable and objective, i.e., the answers
network which provided easy access to services. An effective should be the same if measured by different people in
programme of land reform had given poor people access to similar circumstances; j
land resources for food production at the household level.
Kerala has demonstrated that good health at low cost is c. (should be sensitive, i.e., they should be sensitive to
attainable by poor countries, but requires major political and changes in the situation concerned,
social commitment. | d. should be specific, i.e., they should reflect changes
only in the situation concerned,
HEALTH DEVELOPMENT e. should be feasible, i.e., they should have the ability
r> to obtain data needed, and;
Health development is defined as “the_ process of
continuous progressive improvement of the health status of f. (should be relevant, i.e., they should contribute to the
a populatiorf (53). Its product is rising level of human well- understanding of the phenomenon of interest.
being, marked not only by reduction in the burden of
But in real life there are few indicators that comply with
disease, but also by the attainment of positive physical and
all these criteria. Measurement of health is far from simple.
mental health related to satisfactory economic functioning
No existing definition (including the WHO definition)
and social integration (54).
contains criteria for measuring health. This is because
The concept of health development as distinct from the health, like happiness, cannot be defined in exact
provision of medical care is a product of recent policy measurable terms. Its presence or absence is so largely a
thinking. It is based on the fundamental principle that matter of subjective judgement. Since we have problems in
governments have a responsibility for the health of their defining health, we also have problems in measuring health

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people and at the same time people should have the right as and the question is largely unresolved. Therefore,
well as the duty, individually and collectively to participate measurements of health have been framed in terms of illness
in the development of their own health. (or lack of health), the consequences of ill-health (e.g.,
Health development contributes to and results from social morbidity, disability) and economic, occupational and
and economic development. Therefore, health development domestic factors that promote ill-health - all the antitheses
has been given increasing emphasis in the policies and of health.
programmes of the United Nations system. One example is Further, health is multidimensional, and each dimension
thaFof World Bank which is providing funds for the health is influenced by numerous factors, some known and many
component of economic development programmes. The unknown. This means we must measure health
UNDP has also shown a growing interest in health
multidimensionally. Thus the subject of health measurement
development, as has the World Bank.
is a complicated one even for professionals. Our
understanding of health, therefore, cannot be in terms of a
INDICATORS OF HEALTH single indicator; it must be conceived in terms of a profile,
A question that is often raised is: How healthy is a given employing many indicators, which may be classified as:
community ? Indicators are required not only to measure the 1. Mortality indicators
health status of a community, but also to compare the_health
status of one country with that of another; for assessment of 2. Morbidity indicators
health care needs; for allocation of scarce resources; and for 3. Disability rates
monitoring and evaluation of health services, activities, and
4. Nutritional status indicators
programmes. Indicators help to measure the extent to which
the objectives and targets of a programme are being 5. Health care delivery indicators
attained. A 6. Utilization rates
As the name suggests, indicators are only an indication of a 7. Indicators of social and mental health
given situation or a reflection of that situation. In WHO’s
guidelines for health programme evaluation (55) they are 8. Environmental indicators
defined as variables which help to measure changes. Often 9. Socio-economic indicators
they are used particularly when these changes cannot be 10. Health policy indicators
measured directly, as for example health or nutritional status
(54). If measured sequentially over time, they can indicate 11. Indicators of quality of life, and
direction and speed of change and serve to compare different 12. Other indicators.
areas or groups of people at the.same moment in time (55).
There has been some confusion over terminology: 1. Mortality indicators
health indicator as compared to health index (plural: (a/.Crude death rate: This is considered a fair indicator of
indices or indexes). It has been suggested that in relation to the comparative health of the people. It is defined as the
health trends, the term indicator is to be preferred to number of deaths per 1000 population per year in a given
index, whereas health index is generally considered to be community. It indicates therate_at which people are dying.
an amalgamation of health indicators (56) Strictly speaking, health should not be measured by the
by R△J
 INDICATORS OF HEALTH 25
number of deaths that occur in a community But in many European countries, the proportion is less than 2 per
countries, the crude death rate is the only available indicator 1000 live births. High rate reflects high birth rates, high child
of health. When used for international comparison, the mortality rates and shorter life expectancy (28).
usefulness of the crude death rate is restricted because it is (g) Adult mortality rate : The adult mortality rate is
influenced by the age^sex.composition of the population. defined as the probability of dying between the age of
Although not a perfect measure of health status, a decrease 15 and 60 years per 1000 population. The adult mortality
in death rate provides a good tool for assessing the overall rate offers a way to analyze health gaps between countries in
health improvement in a population. Reducing the number the main working groups. The probability of dying in
of deaths in the population is an obvious goal of jnedicine adulthood is greater for men than for women in almost all
and health care, and success or failure to do so is a measure countries, but the variations between countries is very large.
of a nation’s commitment to better health? In Japan, less than 1 in 10 men (and 1 in 20 women) die in
(b) Expectation of life : Life expectancy at birth is “the these productive age group, compared to almost 2-3 in
average number of years that will be lived by those born 10 men (and 1-2 women) in Angola (58).
alive into a population if the current age-specific mortality (h) .Maternal (puerperal) mortality rate : Maternal
rates persist”. Life expectancy at birth is highly influenced by (puerperal mortalit accounts for the greatest proportion of
the infant mortality rate where that is high. Life expectancy deaths among women of reproductive age in most of the
at the age of 1 excludes the influence of infant mortality, and developing world. There are enormous variations___________ in
life expectancy at the age of 5 excludes the influence of child maternal mortality rate according to country’s level of socio­
mortality. Life expectancy at birth is used most frequently economic status ‘
(57). It is estimated for both sexes separately. An increase in
the expectation of life is regarded, inferentially, as an (i) Disease-specific mortality rate : Mortality rates can be
improvement in health status. computed for specific diseases. As countries begin to
extricate themselves from the burden of communicable
Life expectancy is a good indicator of socio-economic
diseases, a number of other indicators such as deaths from
development in general. As an indicator of long-term
cancer, cardiovascular diseases, accidents, diabetes, etc
survival, it can be considered as a positive health indicator.
have emerged as measures of specific disease problems.
It has been adopted as a global health indicator]
(j) Proportional mortality rate : The simplest measure of

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(c) CAge^speci/ic death rates : Death rates can be
expressed for specific age groups in a population which are estimating the burden of a disease in the community is
defined by age. An age-specific death rate is defined as total proportional mortality rate, i.e., the proportion of all deaths
number of deaths occurring in a specific age group of the currently attributed to it. For example, coronary heart
population (e.g. 20-24 years) in a defined area during a disease is the cause of 25 to 30 per cent of all deaths in most
specific period per 1000 estimated total population of the western countries. The proportional mortality rate from
same age group of the population in the same area during communicable diseases has been suggested as a useful
the same period. health status indicator; it indicates the magnitude of
preventable mortality.
(d) Infant mortality rate : Infant mortality rate is the ratio
of deaths under 1 year of age in a given year to the total (k) Case fatality rate : Case fatality rate measures the risk
number of live births in the same year; usually expressed as of persons dying from a certain disease within a given time
a rate per 1000Jive births. It is one of the most universally period. Case fatality rate is calculated as number of deaths
accepted indicators of health status not only of infants, but from a specific disease during a specific time period divided
also of whole population and of the socio-economic by number of cases of the disease during the same time
conditions under which they live. In addition, the infant period, usually expressed as per 100. The case fatality rate is
mortality rate is a sensitive indicator of the availability, used to link mortality to morbidity. One function of the case
utilization and effectiveness ol health care, particularly fatality rate is to measure various aspects or properties of a
perinatal care. \ disease such as its pathogenicity, severity or virulence (59).
It can also be used in poisonings, chemical exposures or
(e) ^Child death rate : Another indicator related to the
other short-term non-disease cause of death.
overall health status is the early childhood (1-4 years)
mortality rate. It is defined as the number of deaths at ages (l) Q^ars of potential life lost (YPLL) : Years of potential
1-4 years in a given year, per 1000 children in that age life lost is based on the years of life lost through premature
group at the mid-point of the year concerned. It thus death. It is defined as one that occurs before the age to
excludes infant mortality. which a dying person could have expected to survive (before
Apart from its correlation with inadequate MCH services, an arbitrary determined age, usually taken age 75 years). A
it is also related to insufficient nutrition, low coverage by 30 year old who dies in a road accident could theoretically
immunization and adverse environmental ex osure and have lived to an average life expectancy of 75 years of age;
other exoganaus^ agents. Whereas the IMR may be more thus 45 years of life are lost.
than 10 times higher in the least developed countries than in Mortality indicators represent the traditional measures of
the developed countries, the child mortality rate may be as health status. Even today they are probably the most often
much as 25 times higher. This indicatesThe magnitude of the used indirect indicators of health. As infectious diseases
gap and the room for improvement J have been brought under control, mortality rates have
(f) Under-5 proportionate mortality rate : It is the declined to very low levels in many countries. Consequently
proportion of total deaths occurring in the under-5 age mortality indicators are losing their sensitivity as health
group. This rate can be used to reflect both infant and child indicators in developed countries. However, mortality
mortality rates. In communities with poor hygiene, the indicators continue to be used as the starting point in health
proportion may exceed 60 per 1000 live births. In some status evaluation.

by R△J
26 CONCEPT OF HEALTH AND DISEASE

2. Morbidity indicators Each year in perfect health is assigned a value of 1.0 down
to a value of 0.0 for death, i.e. 1 QALY (1 year of life x 1
To describe health in terms of mortality rates only is utility value = 1 QALY) is a year of life lived in perfect
misleading. This is because, mortality indicators do not health. Half a year lived in perfect health is equivalent to 0.5
reveal the burden of ill-health in a community, as for QALY (1 year x 0.5 utility value).
example mental illness and rheumatoid arthritis. Therefore,
morbidity indicators are used to supplement mortality data Disability-free life expectancy (Syn : active life
to describe the health status of a population. Morbidity expectancy) : Disability-free life expectancy (DFLE) is the
statistics have also their own drawback; they tend to average number of years an individual is expected to live
overlook a large number of conditions which are subclinical free of disability if current pattern of mortality and disability
or inapparent, that is, the hidden part of the iceberg of continue to apply (62).
disease__ Disability-adjusted life years (DALY) : DALY is a
The following morbidity rates are used for assessing measure of overall disease burden, expressed as a number of
ill-health in the community (60). years lost due to ill-health, disability or early death.
Originally developed by Harvard University for the World
a. incidence and prevalence
Bank in 1990,_the WHO subsequently adopted the method
b. notification rates in the year 2000. The DALY is becoming increasingly
c. ^attendance rates at out-patient departments, common in the field of public health and health impact
health centres, etc. assessment. The Global Burden of Disease project combines
the impact of premature mortality with that of disability. It
d. admission, readmission and discharge rates
captures the population impact of important fatal and non-
e. duration of stay in hospital, and fatal disabling conditions through a single measure. The
f. spells of sickness or absence from work or school. major measure used is disability-adjusted life years (DALYs)
which combines (58) :
3. Disability rates
- years of lost life (YLL) - calculated from the number
Since death rates have not changed markedly in recent of deaths at each age multiplied by the expected
years, despite massive health expenditures, disability rates remaining years of life according to a global

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related to illness and injury have come into use to standard-life expectancy
supplement mortality and morbidity indicators. The
disability rates are based on the premise or notion that - years lost to disability (YLD) where Jthe number of
health implies a full_range_of_daily activities. The commonly incident cases due to injury and illness is multiplied
used disability rates fall into two groups: (a) lEyent-type by the average duration of the disease and a
indicators and (b) person-type indicators (10, 61) weighting factor reflecting the severity of the
disease on a scale from 0 (perfect health) to
(a) Event-type indicators 1 (dead).
i) Number of days of restricted activity It is calculated by formula : DALY = YLL + YLD
ii) Bed disability days <The DALY relies on an acceptance that the most
appropriate measure of the effects of the_chronic illness is
iii) Work-loss days (or school-loss days) within a
specified period time. One DALY, therefore, is equal to one year of healthy
life lost. Japanese life expectancy statistics are used as a
(b) Person-type indicators standard for measuring premature death, as Japanese have
the longest life expectancy.
i) ( Limitation of mobility: For example, confined to
bed, confined to the house, special aid in getting DALY can reveal surprising things about a population’s
around either inside or outside the house. health. For example, the 1990 WHO report indicated that
5 out of 10 leading causes of disability were psychiatric
ii) Limitation of activity: For example, limitation to conditions. Psychiatric and neurological conditions account
perform the basic activities of daily living (ADL)- for about 28 per cent of years lived with disability, but
e.g., eating, washing, dressing, going_to toilet, accounts for only 1.4 per cent of all deaths and 1.1 per cent
moving about, etc; limitation in major activity, e.g., of years of life lost. Thus they have a huge impact on
ability to work at a job, ability to housework, etc. population. A crucial distinction among DALY studies is the
HALE (Health-Adjusted Life Expectancy) : The use of “social weighting”, in which the value of each year of
name of the indicator used to measure healthy life life depends on age. Commonly, years lived as a young
expectancy has been changed from disability-adjustedjife aduIFare valued more highly than years spent as a young
expectancy^(DALE) to health-adjusted life expectancy child or older adults. This weighting system reflects societie’s
(HALE). HALE is based on life expectancy at birth but interest in productivity and receiving a return on its
includes an adjustment for time_spent in poor health. It is investment in upbringing of the children. The effects of the
most easily understood as the equivalent number of years in interplay between life expectancy and years lost,
full health that a newborn can expect to live based on discounting, and social weighting are complex, depending
current rates of ill-health and mortality. on the severity and duration of illness*
^Quality-adjusted life years (QALY) : QALY is a
measure of disease burden including both the quality and 4. Nutritional status indicators
quantity of life lived. It is used in assessing the value for Cblutritional status is a positive health indicator. Three
money of a medical intervention. The QALY is based on the nutritional status indicators are considered important as
number of years of life that would be added by intervention. indicators of health status. They are (57) :
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 INDICATORS OF HEALTH 27
a. anthropometric measurements of preschool baby and battered-wife syndromes and neglected and
children, e.g., weight and height, mid-arm abandoned youth in the neighbourhood. These social
circumference; indicators provide a guide to social action for improving the
b. heights (and sometimes weights) of children at health of the people.
school entry; and 8. Environmental indicators
c. (prevalence of low birth weight (less than 2.5 kg).
Environmental indicators reflect the quality of physical
5. Health care delivery indicators and biological environment in which diseases occur and in
which the people live. They include indicators relating to
The frequently used indicators of health care delivery are: pollution of air and water, radiation, solid wastes, noise,
a. Doctor-population ratio exposure to toxic substances in food or drink. Among these,
b. Doctor-nurse ratio the most useful indicators are those measuring the
proportion of population having access to safe water and
c. Population-bed ratio sanitation facilities, as for example, percentage of
d. Population per health/subcentre, and households with safe water in the home or within 15
e. Population per_trajned birth attendant. minutes’ walking distance from a water standpoint or
protected well; adequate sanitary facilities in the home or
These indicators reflect the equity of distribution of health immediate vicinity (57).
resources in different parts of the country, and of the
provision of health care. 9. Socio-economic indicators
6. Utilization rates These indicators do not directly measure health.
Nevertheless, they are of great importance in the
"Tn order to obtain additional information on health interpretation of the indicators of health care. These
status, the extent of use of health services is often include :
investigated. Utilization of services - or actual coverage - is
expressed as the proportion of people in need of a service a. rate of population increase
who actually receive it in a given period, usually a year (57). b. per capita GNP
It is argued that utilization rates give some indication of the

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c. level of unemployment
care needed by a population, and therefore, the health
status of the population. In other words, a relationship exists d. dependency ratio
between utilization of health care services and health needs e. literacy rates, especially female literacy rates
and status. Health care utilization is also affected by factors f. family size
such as availability and accessibility of health services and
g. housing: the number of persons per room, and
the attitude of an individual towards his health and the
health_care_,system. A few examples of utilization rates are h. per capita “calorie” availability.
cited below:
10. Health policy indicators
a. proportion of infants who are “fully immunized”
against the 9 EPI diseases. ' The single most important indicator of political
commitment is “allocation of adequate resources”. The
b. (proportion of pregnant women who receive antenatal
relevant indicators are: (i) proportion of GNP spent on
care,_or ±ave their deliveries supervised by a trained
health__services (ii) proportion of GNP spent on health-
birth attendant. related activities (including water supply and sanitation,
c. percentage of the population using the various housing and nutrition, community development), and
methods of family planning. (iii) proportion of total health resources devoted to primary
d. bed ^occupancy rate (i.e., average daily in-patient health care.
census/average number of beds).
11. Indicators of quality of life
e. Caverage length of stay (i.e., days of care rendered/
discharges), and Increasingly, mortality and morbidity data have been
questioned as to whether they fully reflect the health status
f. bed turnover ratio (i.e., discharges/average beds). of a population. The_previous emphasis on using increased
The above list is neither exhaustive nor all-inclusive. The life expectancy as an indicator of health is no longer
list can be expanded depending upon the services provided. considered adequate, especially in developed countries, and
These indicators direct attention away from the biological attention has shifted more_towards concern about the
aspects of disease in a population towards the discharge of Quality of life enjoyed by individuals and communities.
social responsibility for the organization in delivery of health Quality of life is difficult to define and even more difficult to
care services. measure (see page 16). Various attempts have been made to
reach one composite index from a number of health
7. Indicators of social and mental health indicators. The physical quality of life index is one such
As long as valid positive indicators of social and mental index (see page 17). It consolidates three indicators, viz.
health are scarce, it is necessary to use indirect measures, infant mortality, life expectancy at age one, and literacy.
viz. indicators of social and mental pathology. These include Obviously more work is needed to develop indicators of
suicide, homicide, other acts of violence and other crime; quality of life.
road traffic accidents, juvenile delinquency; alcohol and
drug abuse; smoking; consumption of tranquillizers; obesity, 12. Social indicators
etc (57). To these may be added family violence, battered- Social indicators, as defined by the United Nations

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28 CONCEPT OF HEALTH AND DISEASE

Statistical Office, have been divided into 12 categories:- 2. Millennium Development Goals - Indicators
population; family formation, families and households; The Millennium Development Goals adopted by the
learning and educational services; earning activities; United Nations in the year 2000 provide an opportunity for
distribution of income, consumption, and accumulation; concerted action to improve global health. The health
social security and welfare services; health services and related goals and their indicators of progress are listed in
nutrition; housing and its environment; public order and Table 3.
safety; time use; leisure and culture; social stratification and
mobility (63). TABLE 3
Health-related Millennium Development Goals, and Indicators
13. Basic needs indicators
Goal. 1 Eradicate extreme poverty and hunger
Basic needs indicators are used by ILO. Those mentioned
in “Basic needs performance” (64) include calorie Indicator; 4. Prevalence of underweight children under five
years of age
consumption; access to water; life expectancy; deaths due to
disease; illiteracy, doctors and nurses per population; rooms 5. Proportion of population below minimum
per person; GNP per capita. level of dietary energy consumption
Goal. 4 Reduce child mortality
SPECIAL INDICATORS SERIES Indicator ; 13. Under-five mortality rate
14. Infant mortality rate
1. “Health for All” indicators 15. Proportion of 1-year-old children immunized
For monitoring progress towards the goal of Health for All against measles
by 2000 AD, the WHO has listed the following four Goal: 5. Improve maternal health
categories of indicators (Table 2).
Indicator : 16. Maternal mortality ratio
TABLE 2 17 Proportion of births attended by skilled health
Indicators selected for monitoring progress personnel
towards “Health for All” Goal: 6. Combat HIV/AIDS, malaria and other diseases

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Indicator : 18. HIV prevalence among young people aged 15
(1) Health policy indicators to 24 years
- political commitment to “Health for All”
19. Condom use rate of the contraceptive
- resource allocation prevalence rate
- the degree of equity of distribution of health services 20. Number of children orphaned by HIV/AIDS
- community involvement 21. Prevalence and death rates associated with
- organizational framework and managerial process malaria
(2) Social and economic indicators related to health: 22. Proportion of population in malaria-risk areas
using effective malaria prevention and
- rate of population increase treatment measures
- GNP or GDP 23. Prevalence and death rates associated with
- income distribution tuberculosis
- work conditions 24. Proportion of tuberculosis cases detected and
cured under Directly Observed Treatment,
- adult literacy rate
Short-course (DOTS)
housing
- food availability Goal. 7 Ensure environmental sustainability
Indicator : 29. Proportion of population using solid fuel
(3) Indicators for the provision of health care'
Indicator : 30. Proportion of population with sustainable
- availability access to an improved water source, urban and
- accessibility rural
- utilization Indicator . 31. Proportion of urban population with access to
- quality of care improved sanitation

(4) Health status indicators. Goal: 8. Develop a global partnership for development
- low birth weight (percentage) Indicator • 46 Proportion of population with access to
affordable essential drugs on a sustainable
- nutritional status and psychosocial development of basis
children
- infant mortality rate Source : (65)
- child mortality rate
- life expectancy at birth 3. Sustainable Development Goals
- maternal mortality rate On 25th September 2015, the United Nations General
- disease specific mortality ^Assembly adopted the new development agenda
^Transforming, our world : the 2030 agenda for sustainable
- morbidity - incidence and prevalence development” A The post-2015 framework goes beyond the
- disability prevalence MDGs. It’Tias 17 goals and 169 targets, including one
specific (3rd goal) for health with 13 targets as shown in
Source : (57) Table 4.

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 INDICATORS OF HEALTH 25
TABLE 4 indicators of Sustainable Development Goals (SDG),
Health Targets in Sustainable Development Goal 3 including universal health coverage, non-communicable
diseases and other key health-related environmental, social,
Goal TarSet economic and behavioural risk factors (67).
3 1 fey 2030, reduce the global matern^moHaljt^ ratio to less The list includes a selection of priority indicators relating
than 70 per 100,000 live births. ' to 4 domains that include health status, risk factors, service
coverage and health systems. They are as follows (67)\
? 2 fey 2030, end preventable deaths of newborns and children
under five years of age, with all countries aiming to reduce 1. Health status indicators
neonatal mortality to at least as low as 12 per 1000 live
births, and under-five mortality to at least as low as 25 per Mortality by age and sex
1000 live births.
- Life expectancy at birth
..3 By 2030, end the epidemics of AIDS, tuberculosis, malaria - Adolescent mortality rate
and neglected tropical diseases and combat hepatitis,
water-borne diseases and other communicable diseases. - Adult mortality rate between 15 and 60 years of age
- Under-five mortality rate (SDG 3.2.1)
3.4 By 2030, reduce by one-third premature mortality from - Infant mortality rate
non-communicable diseases through prevention and - Neonatal mortality rate (SDG 3.2.2)
treatment, and promote mental health and well-being.
- Stillbirth rate
3.5 Strengthen the prevention and treatment of substance abuse,
including narcotic drug abuse and harmful use of alcohol'. Mortality by cause
3.6 By 2020, halve the number of global deaths and injuries from - Maternal mortality ratio (SDG 3.1.1)
roacTtraffic accidents. - TB mortality rate
3.7 By 2030, ensure universal access to sexual and reproductive - AIDS-related mortality rate
health-care services, including for family planning, - Malaria mortality rate
information^ and education, and the integration_of - Premature non-communicable disease (NCD)
reproductive health into national strategies and mortality (SDG 3.4.1)
programmes. - Mortality from household and ambient air pollution
3.8 Achieve universal health coverage, including financial risk (SDG 3.9.1)

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protection, access to quality essential health-care services - Mortality from unsafe water, unsafe sanitation and
and’access to safe, effective, quality and affordable essential lack of hygiene (SDG 3.9.2)
medicines and vaccines for all. - Mortality from unintentional poisoning (SDG 3.9.3)
3.9 By_2030, substantially reduce the number of. deaths and - Suicide rate (SDG 3.4.2)
illnesses from hazardous chemicals and air, water and soil - Death rate due to road traffic injuries (SDG 3.6.1)
pollution and contamination^ | - Number of deaths, missing persons and persons
3.a Strengthen the implementation of the World Health affected by disaster per 100,000 people (SDG 1.5.1,
Organization Framework Convention on Tobacco Control in 11.5.1, 13.1.1)
all countries, as appropriate. - Mortality rate due to homicide (SDG 16.1.1)
3.b Support the research and development of vaccines and Fertility
medicines for the communicable and non-communicable
diseases that primarily affect developing countries, provide - Adolescent birth rate (SDG 3.7.2)
access to affordable essential medicines and vaccines, in - . Total fertility rate
accordance with the Doha Declaration^on the TRIPS
Agreement and Public Health, which affirms the right of Morbidity
developing countries to use to the full the provisions in the - New cases of vaccine-preventable diseases
Agreement on Trade-Related Aspects of Intellectual Property - New cases of IHR-notifiable diseases and other
Rights regarding flexibilities to protect public health, and, in
particular, provide access to medicines for all. notifiable diseases
- HIV prevalence rate
3.c (^Substantially increase health financing and the recruitment, - HIV incidence rate (SDG 3.3.1)
development, training and retention of the health work-force
in developing countries, especially in least-developed
- Hepatitis B surface antigen prevalence
countries and small island developing states ) - Hepatitis B incidence (SDG 3.3.4)
- Sexually transmitted infections (STIs) incidence rate
3 d Strengthen the capacity of all countries, in particular - Congenital syphilis rate
developing countries, for early warning, risk reduction and
management of national and global health risks. - TB incidence rate (SDG 3.3.2)
- TB notification rate
Source : (66) - Malaria parasite prevalence among children aged
6-59 months
4. Global Reference list of Core Health - Malaria incidence rate (SDG 3.3.3)
Indicators (2018) - Cancer incidence, by type of cancer
“The Global Reference List”, is a standard set of lflQcore 2. Risk factor indicators
indicators prioritized by the global community to provide
concise information on the health situation and trends, Nutrition
including responses at national and global levels.
- Exclusive breast-feeding rate 0-5 months of age
The 2018 revision of the Global Reference List builds on - Early initiation of breast-feeding
the previous 2015 version. The 2018 list of indicators - Incidence of low birth weight among newborns
contains modifications and additions that were made in - Children under 5 years who are stunted (SDG 2.2.1)
2017 to reflect the recommended health and health related - Children under 5 years who are wasted (SDG 2.2.2)
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30 CONCEPT OF HEALTH AND DISEASE

- Children under 5 years who are overweight (SDG 2.2.2) - HIV-positive new and relapse TB patients on ART
- Anaemia prevalence in children during TB treatment
- Anaemia prevalence in women of reproductive age
(also: severe anaemia) Tuberculosis
- Drug susceptibility testing coverage for TB patients
Infections - TB treatment coverage
- Prevention of HIV in key populations - Treatment coverage for drug-resistant TB
Environmental risk factors Malaria
- Population using safely managed drinking-water - Intermittent preventive therapy for malaria during
services (SDG 6.1.1) pregnancy (IPTp)
- Population using safely managed sanitation services - Use of insecticide treated nets (ITNs)
(SDG 6.2.1a/6.2.1b) (also: population with - Treatment of confirmed malaria cases
handwashing facility with soap and water) - Indoor residual spraying (IRS) coverage
- Population with primary reliance on clean fuels and
Neglected tropical diseases
technologies (SDG 7.1.2)
- Air pollution level in cities (SDG 11.6.2) - Number of people requiring interventions against
neglected tropical diseases (SDG 3.3.5)
Non-communicable diseases - Coverage of preventive chemotherapy for selected
- Total alcohol per capita (age 15+ years) consumption neglected tropical diseases
(SDG 3.5.2) Screening and preventive care
- Tobacco use among persons aged 15+ years (SDG
3.a.l) (also adolescents) - Cervical cancer screening
- Raised blood pressure among adults Mental Health
- Overweight and obesity in adults (also: School-age
children and adolescents) - Coverage of services for severe mental health disorders
- Raised blood glucose/diabetes among adults Substance abuse
- Salt intake
- Treatment coverage for alcohol and drug dependence

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- Insufficient physical activity in adults (also: adolescents)
(SDG 3.5.1)
Injuries/harmful traditional practices Essential health services
- Intimate partner violence prevalence (SDG 5.2.1) - Coverage of essential health services (SDG 3.8.1)
- Non-partner sexual violence prevalence (SDG 5.2.2)
- Prevalence of female genital mutilation/cutting 4. Health system indicators
(SDG 5.3.2)
- Sexual violence against children (SDG 16.2.3) Quality and safety of care
- Early marriage (SDG 5.3.1) - Perioperative mortality rate
- Frequency rates of occupational injuries (SDG 8.8.1) - Obstetric and gynaecological admissions owing to
abortion
3. Service coverage indicators - Institutional maternal mortality ratio
Reproductive, maternal, newborn, child and adolescent - Maternal death reviews
- ART retention rate
- Demand for family planning satisfied with modern - TB treatment success rate
methods (SDG 3.7.1) - Service-specific availability and readiness
- Contraceptive prevalence rate
- Antenatal care coverage Access
- Births attended by skilled health personnel (SDG - Out-patient service utilization (also: in-patient
3.1.2) (also: institutional delivery - overall and in admissions and surgical volume)
“baby-friendly” institutions) - Health facility density and distribution (also: access to
- Postpartum care coverage - women emergency surgery)
- Postnatal care coverage - newborn - Hospital bed density
- Care-seeking for symptoms of pneumonia - Access to a core set of relevant essential medicines
- Coverage of diarrhoea treatment (SDG 3.b.3)
- Vitamin A supplementation coverage
Health work-force
Immunization - Health worker density and distribution (SDG 3.C.1)
- Immunization coverage rate by vaccine for each - Output training institutions
vaccine in the national schedule (SDG 3.b.l)
Health information
HIV - Birth registration (SDG 16.9.1)
- People living with HIV who know their status - Death registration (SDG 17.19.2)
- Prevention of mother-to-child transmission - Completeness of reporting by facilities (also:
- Antiretroviral therapy (ART) coverage completeness and timeliness for notifiable diseases)
- HIV viral load suppression
Health financing
HIV/TB - Total current expenditure on health as % of gross
- Coverage of treatment for latent TB infection (LTBI) domestic product (also: total capital expenditure on
- HIV test results for TB patients health as % of current + capital expenditure on health)
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 100 CORE HEALTH INDICATORS
11
- Public domestic sources of current spending on health Health security
as % of current health expenditure (also: private) - International Health Regulations (IHR) core capacity
- External source of current spending on health (% of index (SDG 3.d.l)
current expenditure on health)
- Proportion of the population with impoverishing Governance
health expenditure - Existence of national health sector policy/strategy/
- Proportion of the population with large household
plan
expenditure on health as a share of total household
consumption or income (SDG 3.8.2) The list also presents the indicators according to level of
- Total net official development assistance to medical the results of chain framework (input, output, outcome and
research and basic health sectors (SDG 3.b.2) impact).

100 CORE HEALTH INDICATORS (PLUS HEALTH-RELATED SDGs) BY RESULTS CHAIN

Inputs and_____ Output •■> Outcome Impact

processes

Health financing Service access Coverage of interventions Health status

Total current and availability Demand for family planning satisfied with modern methods Life expectancy at birth
expenditure on - Out-patient (SDG 3.7 1) - Adolescent mortality rate
health as % of service Contraceptive prevalence rate - Adult mortality rate between
gross domestic utilization (Also - Antenatal care coverage 15 and 60 years of age
product (Also: in-patient - Births attended by skilled health personnel (SDG 3 1.2) (Also: - Under-five mortality rate
total capital admissions and institutional delivery - overall and in “baby-friendly” institutions) (SDG 3.2 1)
expenditure on surgical volume) - Postpartum care coverage - women - Infant mortality rate
health as % of - Service-specific - Postnatal care coverage - newborn - Neonatal mortality rate
current + capital availability and - Care-seeking for symptoms of pneumonia (SDG 3.2 2)
expenditure on readiness - Coverage of diarrhoea treatment - Stillbirth rate
health) - Access to a core - Vitamin A supplementation coverage Maternal mortality ratio
set of relevant - Immunization coverage rate by vaccine for each vaccine in the (SDG 3 1 1)
- Public domestic national schedule (SDG 3.b.l) - TB mortality rate
sources of current essential
medicines People living with HIV who know their status - AIDS-related mortality rate
spending on - Prevention of mother-to-child transmission Malaria mortality rate
health as % of (SDG 3.b.3)

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- Antiretroviral therapy (ART) coverage - Premature non-communicable
current health Service quality - HIV viral load suppression disease (NCD) mortality
expenditure and safety - Coverage of treatment for latent TB infection (LTBI) (SDG 3.4.1)
(Also private) - Perioperative - HIV-positive new and relapse TB patients on ART during TB treatment Mortality from household and
- External source of mortality rate - Drug susceptibility testing coverage for TB patients ambient air pollution
current spending - Obstetric and - TB treatment coverage (SDG 3.9.1)
on health gynaecological - Treatment coverage for drug-resistant TB - Mortality from unsafe water,
(% of current admissions - Intermittent preventive therapy for malaria during pregnancy (IPTp) unsafe sanitation and lack of
expenditure on owing to - Use of insecticide treated nets (ITNs) hygiene (SDG 3 9.2)
health) abortion - Treatment of confirmed malaria cases - Mortality from unintentional
- Total net official - Indoor residual spraying (IRS) coverage poisoning (SDG 3.9 3)
- Institutional - Number of people requiring interventions against neglected - Suicide rate (SDG 3 4.2)
development maternal
assistance to tropical diseases (SDG 3.3 5) - Death rate due to road traffic
mortality ratio - Coverage of preventive chemotherapy for selected neglected injuries (SDG 3 6.1)
medical research - Maternal death
and basic health tropical diseases - Number of deaths, missing
reviews - Cervical cancer screening persons and persons affected
sectors
(SDG 3.b.2) ART retention - Coverage of services for severe mental health disorders by disaster per 100.000 people
rate - Treatment coverage for alcohol and drug dependence (SDG 3.5 1) (SDG 1.5 1, 11.5.1, 13.1.1)
Health work-force - HIV test results - Coverage of essential health services (SDG 3.8.1) Mortality rate due to homicide
- Health worker for TB patients Risk factors and behaviours (SDG 16.1 1)
density and - TB notification - Adolescent birth rate
- Exclusive breast-feeding rate 0-5 months of age (SDG 3 7.2)
distribution rate - Early initiation of breast-feeding
(SDG3.c 1) Total fertility rate
TB treatment - Incidence of low birth weight among newborns - New cases of vaccine-
- Output training success rate - Children under 5 years who are stunted (SDG 2 2.1) preventable diseases
institutions - Children under 5 years who are wasted (SDG 2.2 2) - New cases of IHR-notifiable
Health security - Children aged under 5 years who are overweight (SDG 2.2 2)
Health International diseases and other notifiable
- Anaemia prevalence in children diseases
infrastructure Health Anaemia prevalence in women of reproductive age (Also severe
Regulations - HIV prevalence rate
- Health facility anaemia) HIV incidence rate (SDG 3 3.1)
density and (IHR) core - Prevention of HIV in key populations
capacity index Hepatitis B surface antigen
distribution Population using safely managed drinking-water services prevalence
(Also: access to (SDG3d.l) (SDG 6.1 1) Hepatitis B incidence
emergency - Population using safely managed sanitation services (SDG 3.3.4)
surgery) (SDG 6.2 la/6.2 lb (forthcoming)) (Also population with - Sexually transmitted infections
- Hospital bed handwashing facility with soap and water) (STIs) incidence rate
density - Population with primary reliance on clean fuels and technologies - Congenital syphilis rate
(SDG 7 1.2) - TB incidence rate (SDG 3 3.2)
Health information Air pollution level in cities (SDG 11.6 2) Malaria parasite prevalence
- Birth registration - Total alcohol per capita (age 15+ years) consumption (SDG 3 5.2) among children aged 6-59
(SDG 16.9 1) Tobacco use among persons aged 15+ years (SDG 3.a 1) months
- Death registration (Also adolescents) - Malaria incidence rate
(SDG 17.19.2) - Raised blood pressure among adults (SDG 3.3 3)
- Completeness of - Overweight and obesity in adults (Also: School-age children and - Cancer incidence, by type of
reporting by adolescents) cancer
facilities - Raised blood glucose/diabetes among adults
(Also - Salt intake Financial risk protection
completeness and Insufficient physical activity in adults (Also: adolescents) - Proportion of the population
timeliness for - , Intimate partner violence prevalence (SDG 5.2.1) with impoverishing health
notifiable - Non-partner sexual violence prevalence (SDG 5.2.2) expenditure
diseases) - Prevalence of female genital mutilation/cutting (SDG 5.3.2) - Proportion of the population
Existence of - Sexual violence against children (SDG 16.2.3) with large household
national health Early marriage (SDG 5.3 1) expenditure on health as a
sector policy/ Frequency rates of occupational injuries (SDG 8.8 1) share of total household
strategy/plan consumption or income
(SDG 3.8 2)

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 CONCEPT OF HEALTH AND DISEASE
32
5. Health Index of India (Niti Aayog) (68) (The health index is a weighted composite index, which is
C~Niti Aayog of India recently ranked all states _andJUIs in basecTonindicators in three domains : (a) Health outcomes
an attempt to_measure the nations health performance. The (70 per cent); (b) Governance and information (12 per cent);
states and UTs are grouped in three categories to ensure and (c) Key inputs and processes (18 per cent). Each domain
comparisons among similar entities namely 21 larger states, is assigned a weight based on its importance Jfflithin a domain
8 smaller states and 7 Union Territories as shown in Table 5. or sub-domain, the weight has been equally distributed
among the indicators, a e 6 provides the detailed health
TABLE 5 index with indicators, their definitions, the data sources and
Categorization of states and UTs specifics of base year (BY) and reference year (RY) (68).

Number DEVELOPED AND DEVELOPING REGIONS

Category of States States and UTs
and UTs The world today is divided into developed and
developing regions on the basis of some common features
Larger 21 Andhra Pradesh, Assam, Bihar, shared by them. The former is represented by countries such
states Chhattisgarh, Gujarat, Haryana, Himachal as USA and UK, and the latter by countries such as India.HL
Pradesh, Jammu & Kashmir, Jharkhand,
Karnataka, Kerala, Madhya Pradesh, one_defined development as the organization of society to
Maharashtra, Odisha, Punjab, Rajasthan, provide-adequate housing, food, health services, education
Tamil Nadu, Telangana, Uttar Pradesh, and employrnent for the majority of people, then many
Uttarakhand, West Bengal developingcountries are wide of the mark. Social medicine
Smaller 8 Arunachal Pradesh, Goa, Manipur, is concerned with disparities that exist among countries. This
states Meghalaya, Mizoram, Nagaland, Sikkim, is because socio-economic factors and health problems are
Tripura interlinked. An account of these disparities is given below:
Union 7 Andaman & Nicobar, Chandigarh, Dadra
Territories & Nagar Haveli, Daman & Diu, Delhi, 1. Social and economic characteristics
Lakshadweep, Puducherry Most people in the developing countries live in rural areas

TABLE 6

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Health Index : Indicators, definitions, base and reference years
Base Year (BY)
S.No. Indicator Definition & Reference
Year (RY)
DOMAIN 1 - HEALTH OUTCOMES
Sub-domain 1.1 - Key outcomes (Weight. larger states - 500, smaller states & UTs-100)
1.1.1 Neonatal mortality Number of infant deaths of less than 29 days per thousand live births BY:2015
rate (NMR) during a specific year. RY 2016
1.1.2 Under-five mortality Number of child deaths of less than 5 years per thousand live births BY 2015
rate (U5MR) during a specific year RY •2016
1.1 3 Total fertility Average number of children that would be born to a woman if she experiences BY :2015
rate (TFR) the current fertility pattern throughout her reproductive span (15-49 years), RY :2016
during a specific year.
1.1.4 Proportion of low birth Proportion of low birth weight (< 2.5 kg) newborns out of the total number of BY :2015-16
weight (LBW) among newborns weighed during a specific year born in a public health facility. RY :2017-18
newborns
1.1.5 Sex ratio at birth (SRB) The number of girls born for every 1,000 boys born during a specific year. BY:2012-15
RY : 2014-16
Sub-domain 1.2 - Intermediate outcomes (Weight. larger & smaller states - 300, UTs-250)
1.2 1 Full immunization Proportion of infants 9-11 months old who have received BCG, 3 doses BY • 2015-18
coverage of DPT. 3 doses of OPV and one dose of measles against estimated number RY;2017-18
of infants during a specific year.
1.2.2 Proportion of Proportion of deliveries conducted in public and private health facilities BY .2015-16
institutional deliveries against the number of estimated deliveries during a specific year RY:2017-18
1.2.3 Total case notification Number of new and relapsed TB cases notified (public + private) By • 2016
rate of tuberculosis (TB) per 100,000 population during a specific year. RY :2017
1.2.4 Treatment success rate Proportion of new cured and their treatment completed against the total BY :2015
of new microbiologically number of new microbiologically confirmed TB cases registered RY :2016
confirmed TB cases during a specific year.
1.2.5 Proportion of people Proportion of PLHIVs receiving ART treatment against the number of BY :2015-16
living with HIV (PLHIV) estimated PLHIVs who needed ART treatment for the specific year. RY:2017-18
on antiretroviral
therapy (ART)

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 DEVELOPED AND DEVELOPING REGIONS

Base Year (BY)

S.No. Indicator Definition & Reference
Year (RY)

DOMAIN 2 - GOVERNANCE AND INFORMATION

Sub-domain 2.1 - health monitoring and data integrity (Weight: 70)

2.1.1 Data Integrity Measure : Percentage deviation of reported data from standard survey data to BY&RY
a. Institutional deliveries assess the quality/integrity of reported data for a specific period. 2015-16 (NFHS)
b. ANC registered within BY&RY: 2011-12
first trimester to 2015-2016
(HMIS)

Sub-domain 2.2 - Governance (Weight -60)

2.2 1 Average occupancy of an Average occupancy of an officer (in months), combined for following posts in BY . April 1, 2013-
officer (in months), last three years . March 31, 2016
combined for following 1. Principal Secretary
three posts at state level 2 Mission Director (NHM)
for last three years 3. Director (Health Services) RY . April 1, 2015-
1. Principal Secretary March31,2018
2. Mission Director (NHM)
3. Director (Health Services)

2.2.2 Average occupancy of a Average occupancy of a CMO (in months) for all the districts BY: April 1,2013-
full-time officer (in months) in last three years March31,2016
for all the districts in last
three years - District Chief RY: April 1,2015-
Medical Officers (CMOs) March31,2018
or equivalent post
(heading District Health

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Services)

DOMAIN 3 - KEY INPUTS/PROCESSES

Sub-domain 3.1 - health systems/service delivery (Weight - 200)

3.1.1 Proportion of vacant Vacant health-care provider positions in public health facilities against total BY: As on
health-care provider sanctioned health-care provider positions for following cadres (separately March 31, 2016
positions (regular 4- for each cadre) during a specific year :
contractual) in public a. Auxiliary nurse mid-wife (ANM) at sub-centers (SCs) RY • As on
health facilities b. Staff nurse (SN) at Primary Health Centers (PHCs) and Community March 31, 2018
Health Centers (CHCs)
c. Medical officers (MOs) at PHCs
d Specialists at District Hospitals (Medicine, Surgery, Obstetrics and
Gynaecology, Paediatrics, Anaesthesia, Ophthalmology, Radiology,
Pathology, Ear-Nose-Throat (ENT), Dental, Psychiatry)

3.1.2 Proportion of total staff Availability of a functional IT-enabled HRMIS measured by the proportion BY : As on
(regular + contractual) of staff (regular + contractual) for whom an e-payslip can be generated March 31, 2016
for whom an e-payslip in the IT- enabled HRMIS against total number of staff
can be generated in the (regular + contractual) during a specific year RY : As on
IT-enabled Human March 31, 2018
Resources Management
System (HRMIS).

3.1.3 a Proportion of specified Proportion of public sector facilities conducting specified number BY •2015-16
type of facilities of C-sections* per year (FRUs) against the norm of one FRU
functioning as First per 500,000 population during a specific year. RY 2017-18
Referral Units (FRUs)

b. Proportion of Proportion of PHCs providing all stipulated health-care services** round BY :2015-16
functional 24x7 PHCs the clock against the norm of one 24x7 PHC per 100,000 population
during a specific year. RY :2017-18

3 1.4 Proportion of districts Proportion of districts with functional CCUs [with desired equipment BY As on
with functional Cardiac (ventilator, monitor, defibrillator, CCU beds, portable ECG machine, March 31, 2016
Care Units (CCUs) pulse oxymeter etc.), drugs, diagnostics and desired staff as per RY . As on
programme guidelines] against total number of districts. March 31, 2018

3.1.5 Proportion of ANC Proportion of pregnant women registered for ANC within 12 weeks of BY ■2015-16
registered within first pregnancy during a specific year.
trimester against total RY :2017-18
registrations

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 CONCEPT OF HEALTH AND DISEASE

Base Year (BY)

S.No. Indicator Definition & Reference
Year (RY)

3.1.6 Level of registration Proportion of births registered under Civil Registration System (CRS) BY :2014
of births against the estimated number of births during a specific year RY :2016
3.1.7 Completeness of I DSP Proportion of Reporting Units (RUs) reporting in stipulated time period BY;2015
reporting of P and L forms against total RUs, for P and L forms during a specific year. RY: 2017
3.1.8 Proportion of CHCs with Proportion of CHCs that are graded above 3 points against total number of BY ; 2015-16
grading above 3 points CHCs during a specific year. RY.2017-18
3 1.9 Proportion of public health Proportion of specified type of public health facilities with accreditation BY ; As on
facilities with accreditation certificates by a standard quality assurance program against the total March 31, 2016
certificates by a standard number following specified type of facilities during a specific year
quality assurance program 1. District hospital (DH)/Sub-district hospital (SDH) RY; As on
(NQAS/NABH/ISO/AHPI) 2. CHC/Biock PHC March 31, 2018
3.1 10 Average number of days Average time taken (in number of days) by the State Treasury to transfer BY : 2015-16
for transfer of Central funds to implementation agencies during a specific year.
NHM fund from State RY: 2017-18
Treasury to implementation
agency (Department/Society)
based on all tranches of
the last financial year
* Criteria for fully operational FRUs: SDHs/CHCs - conducting minimum 60 C-sections per year (36 C-sections per year for Hilly and North-
Eastern States except for Assam); DHs - conducting minimum 120 C-sections per year (72 C-sections per year for Hilly and North-Eastern
States except Assam).
** Criteria for functional 24x7 PHCs: 10 deliveries per month (5 deliveries per month for Hilly and North-Eastern States except Assam)
# Centre NHM Finance data includes the RCH flexi-pool and NHM-Health System Strengthening flexi-pool data (representing a substantial
portion of the NHM funds) for calculating delay in transfer of funds.

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and urban slums. There is a rigid hierarchy and class population growth is slowing down almost everywhere
structure moulded by tradition and long-standing customs. except Africa. The fertility rate is now at or below
The family, often a joint family, is a strong binding force. replacement level in 44 per cent of countries in the world.
People depend mainly on agriculture and there is a lack of High fertility has multiple consequences for health and
alternative employment opportunities. The GNP per capita health related issues. Continued rapid population growth in
ranges from US $ 2000 to 6000 in most developing low and lower-middle-income countries, along with higher
countries. The production and consumption per capita are fertility rates in poorest segments of the population makes it
low. They have an economic potential which is not fully harder to eradicate poverty, combat hunger and
realized; this refers to unemployed labour, natural resources malnutrition, invest in health and education, improve access
and fertility of the soil. Science and technology are not fully to basic services, plan and develop cities, protect local
applied. The level of literacy is low - it averages only 63 per ecosystems and promote peaceful societies (66).
cent in the least developed countries. The quality of life is In mid-2017, the World Population reached 7.4 billion,
poor because of the scarcity of essential goods, facilities and of which 60 per cent live in Asia. The population in
money. There is isolation caused by distance, poor developing countries is a “young” population; the
communication and transport facilities. The environment is proportion of persons under 15 years of age in the year
unfavourable predisposing to communicable diseases and 2016 was about 41 per cent in the least developed countries
malnutrition. The vast majority of people are not able to pay and 24 in other developing countries, as compared to about
for medical services. There is a long tradition of free medical 16 per cent in the developed countries. The proportion of
services provided by the State. people over 65 years of age in developing countries is about
In the developed countries, most people (8 out of 10) are 5 per cent, compared to 18 per cent in the developed
urban residents. Urban life differs from that in the villages by countries (69). The social and economic backlashes of this
being more impersonal. Women are economically employed. age distribution are being felt in both the developing and
Agriculture is second to industry. Great use is made of scientific developed countries - the former having to bear the heavy
disciplines. The standard of living and quality of life are high. burden of providing for a population which is mainly young;
The GNP per capita ranges from US $ 5000 to 40,600 in most and the latter having to deal with the problems of ageing.
developed countries. The adult literacy is almost universal.
3. Contrasts in health (Health gap)
2. Demographic characteristics (While accurate statistical data are difficult to obtain, even
Demographic trends fundamentally influence country’s perfunctory glance at available data (Table 7) are sufficient
economic, social and health conditions. Population growth, to illustrate the wide health a between population in the
changes in fertility rates and population structure, all have a developed and developing countries. )
profound influence, as do migration (which is increasingly a Table 7 shows that the present gap in life expectancy at
cross-border issue) and growing urbanization which may birth between—-developed and developing countries is
spur economic growth but also put strain on food and water 15-20 years. Developed countries are characterized by
resources. longer life expectancy and lower infant and child mortality
Fertility rates are falling globally and as a consequence, rates, and the opposite is true of developing countries.

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 THE URBAN RURAL DIVIDE IN HEALTH AND DEVELOPMENT .35
TABLE 7 Asia, the majority of the population is still rural. The average
Selected health and socio-economic indicators annual rate of change of percentage to urban is 1.1 per cent
Developing High HD1
in Africa and 1.5 per cent in Asia. Despite the rise of an
Least developed
Indicator countries countries countries unprecedented number of large cities, most urban residents
in developing countries live in places with a populatin of less
1 Life expectancy at 65.3 71.1 79.5 than half a million.
birth (2019) There is no universal definition of “Urban”. Countries
2. IMR (per 1000 live 45 33.0 3
births) (2019) differ in their definitions of urban, although it is fairly
3. Under 5 mortality 63 40 4 common for the urban population to consist of those living
per 1000 live in towns and cities of a few thousand or more. How
births (2019) countries define urban can affect our ability to compare
4. Maternal mortality 412 224 14 “urban” across countries. For example, in India the term
per 100,000 live “urban” refers to towns (places with a municipal
births (2017) corporation, municipal area committee, town committee,
5 Doctor-population 2.5 11.5 30.4 notified area committee, or cantonment board); or, all places
ratio per 10,000 having 5,000 or more inhabitants, a density of not less than
(2010-18) 1,000 persons per square mile or 400 per square kilometer,
6 Nurse-population 9 33 114
pronounced urban characteristics, and at least three fourths
ratio per 10,000
(2007-13) of the adult male population employed in pursuits other
7. GNI, per capita than agriculture. In contrast, Peru defines “urban” simply as
(US $ PPP) (2019) populated centers with 100 or more dwellings (70).
Male 3,846 14,136 55,720 During the year 2020, the total urban population in the
Female 2.083 6.923 33.668 world was 56 per cent. In more developed countries, 81 per
8. Public health 4.9 5.8 12.5 cent population was urban, compared to 68 per cent in less
expenditure
(as % of GDP) developed countries and 43 per cent in least develped
US $ (2019) countries.
9. Projected expected Across indicators, those living in urban areas usually fare

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years of schooling better than their rural counter-parts. Young people are more
(2020) likely to stay in school longer; women marry later and have
Male 10.4 12.3 16.0
Female 9.4 12.2 16.6 small families; fewer infants die in their first year of life. Rate
10 Access to safe 61 92 95 of modern contraceptive use in urban and rural areas are
water % steadly increasing in most developing countries, although
population (2017) urban areas have consistently shown high use. Nevertheless,
11 Access to adequate 34 69 98 progress can vary significantly by country, even in the same
sanitation % region. Country level data, however, can mask further
population (2017) disparities within urban areas, where the gaps between poor
12.Universal service 46 61 79 and rich can be striking. The urban poor frequently remain
coverage (2019) marginalized and may fare no better than rural dwellers. In
many developing countries where urbanization is occurring
Source : (29) rapidly, infrastructure and services including health care;
water and sanitation cannot keep pace leaving the urban
CFhe_burden of disease pattern of developed, developing poor unable to find or afford services. Often, the poorest
high mortality, and developing low mortality countries in the urban children are at least twice as likely to die before they
world differ substantially. This phenomenon reflects what is reach their fifth birthday.
known as the “epidemiological transition”. <As life
expectancy increases, the major causes of death and In Delhi, India, only 19 per cent of the poorest women
disability in general shift from communicable, maternal and have a skilled attendant at birth compared to 99 per cent
amont wealthiest women, yet data at the national level in
perinatal causes to chronic, non-communicableojies-_>
India show skilled attendance at delivery in urban and rural
To sum up, the world health situation leaves much to be areas at 74 per cent and 43 per cent respectively (70).
desired. Millions of people in the developing countries have
incomes too low to ensure basic nutrition and have little The indicators used in urban-rural divide are as follows : The
year of the Indian data is given in bracket with each indicator.
access to essential health__servic.es. In a number of
industrialized countries, rapid increases in health cost have Demography
called into question the relationship between health care Population % Urban (2021) 35.39
and health indicators. A search for alternative approaches
Urban Rural
has led to the view that primary health care is the most
important means, whereby, the health sector, with Total Fertility Rate (2019-21) 1.6 2.1
intersectoral coordination, can close the health gap and Women Ages 15-19 who have begun 3.8 7.9
improve the health status of the population. childbearing (%) (2019-21)
Socio-economic
THE URBAN-RURAL DIVIDE Population below National Poverty 13.7 25.7
IN HEALTH AND DEVELOPMENT Line (%) (2011-12)
Employment in agriculture 47
A majority of world’s population live in urban areas, a (% of total employment) 2004/2013
milestone that was reached only within the last decade. The Women who are literate 83 69.3
world continues to become more urban, yet in Africa and (%) (2019-21)

by R△J
 CONCEPT OF HEALTH AND DISEASE

Urban Rural Health system

Maternal and Child Health The “health system” is intended to deliver health
Antenatal Care (at least 4 visits) (%) (2019-21) 68.1 54.2 services. It can be defined as “the human and material
Skilled attendance at delivery (%) (2019-21) 94 81.8 resources that a nation or community deploys to preserve,
Infant Mortality Rate (2020) 19 31 protect, and restore health and to minimize suffering caused
by disease and injury, and the corresponding administrative
Children under age 5 who are 27.3 33.8
underweight (%) (2019-21) and organizational arrangements” (40).
Children who are stunted (2019-21) 30.1 37.3 The components of the health system include: concepts
Children who are overweight (2019-21) 4.2 3.2 (e.g., health and disease); ideas (e.g., equity, coverage,
effectiveness, efficiency, impact); objects (e.g., hospitals,
Family Planning health centres, health programmes) and persons (e.g.,
Married women ages 15-49 using 58.6 55.5 providers and consumers). Together, these form a whole in
modern contraception (%) (2019-21) which all the components interact to support or control one
Unmet need for family planning (%) (2019-21) 8.4 9.9 another (72). The aim of a health system is health
Drinking water and sanitation development - a process of continuous and progressive
Population with access to improved 98.7 94.6 improvement of the health status of a population.
drinking water source (%) (2019—21)
Population with access to improved 81.5 64.9
Levels of health care
sanitation facility (%) (2019-21) Health services are usually organized at three levels, each
level supported by a higher level to which the patient is
Source : (34)
referred. These levels are:
HEALTH SERVICE PHILOSOPHIES (a) Primary health care : This is the first level of
contact between the individual and the health system where
Health care “essential” health care (primary health care) is provided)/ A
Health care is an expression of concern for fellow human majority of prevailing health complaints and problems carr-
beings. It is defined as a “multitude of services rendered to Be~satisfactorily dealt wrfff at this level. This level of care is
closest to the people. IrFThenndian context, this care is

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individuals, families or communities by the agents of the
health services or professions, for the purpose of promoting, provided by the primary health centres and their subcentres,
maintaining, monitoring or restoring health” (33). Such with community participation.
services might be staffed, organized, administered and (b) Secondary health care : At this level, more
financed in every imaginable way, but they all have one complex problems are dealt with. This care comprises
thing in common: people are being “served”, that is, essentially curative services and is provided by the district
diagnosed, helped, cured, educated and rehabilitated by hospitals and community health centres. This level serves as
health personnel (21). In many countries, health care is the first referral level in the health system.
completely or largely a government function. (c) Tertiary health care : This level offers super­
Health care includes “medical care”. Many people specialist care. This care is provided by the regional/central
mistakenly believe that both are synonymous. Medical care level institutions. These institutions provide not only highly
is a subset of a health care system. The term “medical care specialized care, but also planning and managerial skills and
(which ranges from domiciliary care to resident hospital teaching for specialized staff. In addition, the tertiary level
care) refers chiefly to those personal services that are supports and complements the actions carried out at the
provided directly by physicians or rendered as a result of the primary level.
physician’s instructions” (71).
Health team concept
Cfclealth care has many characteristics; they include:
It is recognized that the physician of today is overworked
i. appropriateness (relevance), i.e., whether the professionally. It is also recognized that many of the
service is needed at all in relation to essential human functions of the physician can be performed by auxiliaries,
needs, priorities and policies; given suitable training. An auxiliary worker has been
ii. comprehensiveness i.e., whether there is an defined as one “who has less than full professional
'optimum mix of preventive, curative and promotional qualifications in a particular field and is supervised by a
services; professional worker”. The WHO no longer uses the term
iii. -Adequacy, i.e., if the service is proportionate to “paramedical” for the various health professions allied with
requirement; medicine (53).
iv. ^vailability, i.e., ratio between the population of an The practice of modern medicine has become a joint
administrative unit and the health facility (e.g., effort of many groups of workers, both medical and non­
population per centre; doctor-population ratio); medical, viz. physicians, nurses, social workers, health
assistants, ASHA and a host of others. The composition of
v. / accessibility, i.e., this may be geographic
the team varies. The hospital team is different from the team
accessibility, economic accessibility or cultural
that works in the community. Whether it is a hospital team
accessibility;
or community health work team, it is important for each
viy affordability, i.e., the cost of health care should be team member to have a specific and recognized function in
within the means of the individual and the state; and the team and to have freedom to exercise his or her
viiyfeasibility, i.e., operational efficiency of certain particular skills. In this context, a\health team has been
procedures, logistic support, manpower and material defined as “a group of persons who share a common health
resources. goal and common objectives, determined by community

by R△J
 HEALTH FOR ALL 37
needs and towards the achievement of which each member - prevention and control of endemic diseases;
of the team contributes in accordance with her/his - (appropriate treatment of common diseases and
competence and skills, and respecting the functions of the injuries; and
other”) (73). The auxiliary is an essential member of the - provision of essential drugs. 1
team. The team must have a leader. The leader should be
able to evaluate the team adequately and should" know, the The concept of primary health care involves a concerted
motivations of each member in order to stimulate and effort to provide the rural population of developing
enhance their.potentialities. The health-team concept has countries with at least the bare minimum of health services.
takerTa firm root in the delivery of health services both in The list can be modified to fit local circumstances. For
the developed and developing countries. The health team example, some countries have specifically included mental
approach aims to produce the right “mix” of health health, physical handicaps, and the health and social care of
personnel for providing full health coverage of the entire the elderly. The primary health care approach integrates at
population. The mere presence of a variety of health the community level all the factors required for improving
professionals is not sufficient to establish teamwork; it is the the health status of the population. As a signatory to the
proper division and combination of their operations from Alma-Ata Declaration, the Government of India, has
which the benefits of divided labour will be derived (74). pledged itself to provide primary health care. Obstacles to
the implementation of primary health care in India include
Health for All shortage of health manpower, entrenchment f curative
After three decades of trial and error and dissatisfaction culture within the existing health system, and a high
in meeting people’s basic health needs, the World Health concentration of health services and health persormeTTn
Assembly, in May 1977, decided that the main social goal of urban areas (49).
governments and WHO in the coming years should be the
“attainment by all the people of the world by the year Health promotion (75)
2000 A.D. of a level of health that will permit them to lead a The first international conference on health promotion
socially and economical! 1 roductive ;?e”. This goal has was held in Ottawa in November 1986, primarily in
come to be popularly known as “Health for All by the year response to growing expectation for a new public health
2000” (HFA). The background to this “new” philosophy was movement around the world. It was built on progress made

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the growing concern about the unacceptably low levels of through Declaration on Primary Health Care at Alma-Ata,
health status of the majority of the world’s population and the debate at the World Health Assembly on
especially the rural poor and the gross disparities in health intersectoral action for health. The conference resulted in
between the rich and poor, urban and rural population, both proclamation of the Ottawa Charter for Health
between and within countries, (the essential principle of Promotion, which has been a source of guidance and
“HFA” is the concept of “equity in health”, that is, all people inspiration for health promotion since that time.
should have an opportunity to enjoy good health.j
'^Health is a basic human right and is essential for social
Primary health care and economic development. Increasingly health promotion
The concept of primary health care came into lime-light is 'bing recognizecT as an essential element of health
in 1978 following an international conference in Alma-Ata, development. Health promotion, through investment and
USSR. It has been defined as: action, has a marked impact on the determinants of health
so as to create the greatest health gain for people, to
‘(Essential health care based on practical, scientifically sound contribute significantly to the reduction of inequities of
and socially acceptable methods and technology made health, and to further human rights. The_ultimate goal is to
universally^ accessible to individuals and 'ami 'ies irT the
community Ihrough their full participation and at a cost that increase health expectancy.
the~~community and the country can afford to maintain_at The Jakarta Declaration on Health Promotion (the
every stage of their development in the_spirit of self- fourth conference held in July 1997) offered a vision and
determination^^ focus for health promotion into the 21st century. The
The primary health care approach is based on principles determinants of health; new challenges in the 21st century;
of social_equity, nation-wide coverage, self-reliance, and the fundamental conditions and resources for health are
intersectoral coordination, and people’s involvement in the peace, shelter, education, social security, social relations,
planning and implementation of "health programmes in food, income, the empowerment of women, a stable
pursuit of common health goals. Thib approach has been ecosystem, sustainable resource use, social justice, respect
described as “Health bythe people” and “placing people’s for human rights, and equity. Above all, poverty is the
health in people’s hands”. Primary health care was accepted greatest threat to health.
by the member countries of WHO as the key to achieving
the goal of HFA by the year 2000 A.D. Demographic trends such as urbanization, an increase in
the number of older people and the high prevalence of
The Declaration of Alma-Ata (6) stated that primary chronic diseases pose new problems in all countries. Other
health care includes at least: social, behavioural and biological changes such as increased
~ (education about prevailing health problems and sedentary behaviour, resistance to antibiotics and other
methods of preventing and controlling lHem;\ commonly available drugs, increased drug abuse, and civil
- (promotion of food supply and proper nutrition; and domestic violence threaten the health and well-being of
hundreds of millions of people. New and re-emerging
an adequate supply of safe water and basic sanitation; infectious diseases, and the greater recognition of mental
- cmaternal and child health care, including family health problems, require an urgent response. It is vital that
planning^—) approaches to health promotion evolve to meet changes in
- immunization against infectious diseases; the determinants of health. To address emerging threats to
by R△J
 CONCEPT OF HEALTH AND DISEASE
38.
health, new forms of action are needed. The challenges for the problem of unattended diseases affecting
the coming years will be to unlock the potential for health developing countries. We are committed to the
promotion inherent in many sectors of society, among local prevention and treatment of non-communicable
communities, and within families. diseases, including behavioural, developmental and
The Ottawa charter incorporates five key action areas in neurological disorders, which constitute a major
health promotion. They are : challenge for sustainable development.
a/^uild healthy public policy, Out of the 17 goals, 3rd goal is devoted specifically to
health, and is framed in deliberately broad terms that are
b^Xreate supportive environment for health, relevant to all countries and all populations. “Ensure healthy
c^/Sfrenghthen community action for health, lives and promote well-being for all at all ages”. The health
d^leVelop personal skills, and goal is associated with 13 targets, including four means of
implementation targets labelled 3.a to 3.d. Overall, the
e.^je^orient health services SDGs have 169 targets. (See chapter 9 for details).
A Logo was created for Ottawa conference. Since then,
WHO kept this symbol as the Health Promotion Logo, as Health policy
it stands for the approaches to health promotion as outlined Policies are general statements based on human
in Ottawa Charter. The Logo represents a circle with aspirations, set of values, commitments, assessment of
3 wings. It incorporates five key action areas in health current situation and an image of a desired future situation
promotion and three basic health promotion strategies. (53) national health policy is an expression of goals for
Health promotion strategies and programmes should be improving the health situation, the priorities among these
adapted to the local needs and possibilities of individual goals^and the main directions for attaining them (76).
countries and regions to take into account differing social, Health policy is often defined at the nationalTeveLJ
cultural and economic systems. Each country will have to develop a health policy of its
own aimed at defined goals, for improving the people’s
Millennium Development Goals (MDGs) health, in the light of its own problems, particular
In the Millennium Declaration of September 2000, circumstances, social and economic structures, and political

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Member States of the United Nations made a most and administrative mechanisms. Am ong the_crucial fa ctors
passionate committment to address the crippling poverty affecting realization of these goals are: a political
and multiplying misery that grip many areas of the world. commitment; financial implications: administrative reforms;
Governments had set a date of 2015 by which they would community^articipation and basic legislation. (77J.
meet the Millennium Development Goals: eradicate extreme A landmark in the development of health policy was the
poverty and hunger, achieve universal primary education, worldwide adoption of the goal of HFA by 2000 A.D.
promote gender equality and empower women, reduce child A further landmark was the Alma-Ata Declaration (1978)
mortality, improve maternal health, combat HIV/AIDS, calling on all governments to develop and implement
malaria and other diseases, ensure environmental primary health care strategies to attain the target of “HFA”
sustainability and develop a global partnership for by 2000 A.D. and more recently, Millennium Development
development. Goals, and Sustainable Development Goals.

Sustainable Development Goals (66) Health services research

The 2030 Sustainable Development Agenda is of Health research has several ramifications. It may include
unprecedented scope and ambition, applicable to all (a)^Siomedical research, to elucidate outstanding health
countries, and goes well beyond the MDGs. While poverty problems and develop new or better ways of dealing with
eradication, health, education, and food security and them; (t^Itftersectoral research, for which relationships
nutrition remain priorities, the Sustainable Development would have to be established with the institutions concerned
Goals (SDGs) comprise a broad range of economic, social with the other sectors, and (c^Ftealth services research
and environmental objectives, and offer the prospect of or health practice research (now called “health systems
more peaceful and inclusive societies. research”).
Paragraph 26 of the 2030 agenda for sustainable The concept of health services research (HSR) was
development addresses health as follows: developed during 1981-1982. It has been defined as “the
To promote physical and mental health and well-being, systematic study of the means by which biomedical and other
and to extend life expectancy for all, we must achieve relevant knowledge is brought to bear on the health
universal health coverage and access to quality health of individuals and communities under a given set of
care. No one must be left behind. We commit to conditions” (78). HSR is wide in scope. It deals with all aspects
accelerating the progress made to date in reducing of management of health services, viz. prioritization of health
newborn, child and maternal mortality by ending all problems, planning, management, logistics and delivery of
such preventable deaths before 2030. We are health care services. It deals with such topics, as manpower,
committed to ensuring universal access to sexual and organization, the utilization of facilities, the quality of health
reproductive health-care services, including for family care, cost-benefit and cost-effectiveness (79).
planning, information and education. We will equally Thousands of people suffer morbidity, mortality and
accelerate the pace of progress made in fighting disability not because of deficiencies in biomedical
malaria, HIV/AIDS, tuberculosis, hepatitis, Ebola and knowledge but as a result of the failure to apply this
other communicable diseases and epidemics, including knowledge effectively. Health services research aims to
by addressing growing anti-microbial resistance and correct this failure (80).
by R△J
 CONCEPT OF DISEASE
39
The concept of HSR is holistic and multidisciplinary. The is possible to be victim of disease without feeling ill, and to
prime purpose of HSR is to improve the health of the people be ill without signs of physical impairment. In short, an
through improvement not only of conventional health adequate definition of disease is yet to be found - a
services but also of other services that have a bearing on definition that is satisfactory or acceptable to the
health. HSR is essential for the continuous evolution and epidemiologist, clinician, sociologist and the statistician.
refinement of health services (78).
CONCEPT OF CAUSATION
CONCEPT OF DISEASE
Upto the time of Louis Pasteur (1822-1895), various
There have been many attempts to define disease. concepts of disease causation were in vogue, e.g., the
Webster defines disease as “a condition injvhich body supernatural theory of disease, the theory of humors, the
health is impaired, a departure Irom a state of health, an concept of contagion, miasmatic theory of disease, the theory
aTferationTof the human body interruptin^the-performance of spontaneous generation, etc. Discoveries in microbiology
of vital functions”. The Oxford English Dictionary defines marked a turning point in our aetiological concepts .
disease as “a condition of the body or some part or organ of
the body in which its functions are disrupted or deranged”. Germ theory of disease
From an ecological point of view, disease is defined as “a Mention has already been made about the germ theory of
maladjustment of the human organism to the environment” disease in chapter 1. This concept gained momentum during
(81) . From a sociological point of view, disease is the 19th and the early part of 20th century. The emphasis
considered a social phenomenon, occurring in all societies had shifted from empirical causes (e.g., bad air) to microbes
(82) and defined and fought" in terms of the particular as the sole cause of disease. The concept of cause embodied
cultural forces prevalent in the society. The simplest in the germ theory of disease is generally referred to as a
definition is, of course, that disease isjust the opposite of one-to-one relationship between causal agent and disease.
healths i.e., any deviation from normal functioning or state The disease model accordingly is :
of complete physical or_menta! well-being - since health and
disease are mutually exclusive. JThese definitions are Disease agent —> Man —> Disease
considered inadequate because they do not give a criterion The germ theory of disease, though it was a revolutionary
by which to decide when a disease state begins, nor do they

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concept, led many epidemiologists to take one-sided view
lend themselves to measurement of disease. of disease causation. That is, they could not think beyond
The WHO has defined health but not disease. This is the germ theory of disease. It is now recognized that a
because disease has many shades (“spectrum of disease”) disease is rarely caused by a single agent alone, but rather
ranging from inapparent (subclinical) cases to severe depends upon a number of factors which contribute to its
manifest illness. Some diseases commence acutely (e.g., occurrence. Therefore, modern medicine has moved away
food poisoning), and some insidiously (e.g., mental illness, from the strict adherence to the germ theory of disease.
rheumatoid arthritis). In some diseases, a “carrier” state
occurs in which the individual remains outwardly healthy, Epidemiological triad
and is able to infect others (e.g., typhoid fever). In some The germ theory of disease has many limitations. For
instances, the same organism may cause more than one example, it is well-known, that not everyone exposed to
clinical manifestation (e.g., streptococcus). In some cases, tuberculosis develops tuberculosis. The same exposure,
the same disease may be caused by more than one organism however, in an undernourished or otherwise susceptible
(e.g., diarrhoea). Some diseases have a short course, and person may result in clinical disease. Similarly, not everyone
some a prolonged course. It is easy to determine illness exposed to beta-haemolytic streptococci develops acute
when the signs and symptoms are manifest, but in many rheumatic fever. There are other factors relating to the host
diseases the border line between normal and abnormal is and environment which are equally important to determine
indistinct as in the case of diabetes, hypertension and whether or not disease will occur in the exposed host. This
mental illness. The end-point or final outcome of disease is demanded a broader concept of disease causation
variable - recovery, disability or death of the host. that synthesized the basic factors of agent, host and
Distinction is also made between the words disease, environment (Fig. 4).
illness and sickness which are not wholly synonymous. The
term “disease” literally means “without ease” (uneasiness) -
disease, the opposite of ease - when something is wrong
with bodily function. “Illness” refers not only to the presence
of a specific disease, but also to the individual’s perceptions
and behaviour in response to the disease, as well as the
impact of that disease on the psychosocial environment
(83) . “Sickness” refers to a state of social dysfunction.
Susser (84) has suggested the following usage:
Disease is a physiological/psychological dysfunction;
Illness is a subjective state of the person who feels FIG. 4
aware of not being well; Epidemiological triad
Sickness is a state of social dysfunction, i.e., a role The above model - agent, host and environment - has
that the individual assumes when ill (“sickness role”). been in use for many years. It helped epidemiologists to
The clinician sees people who are ill rather than the focus on different classes of factors, especially with regard to
diseases which he must diagnose and treat (85). However, it infectious diseases (86).
by R△J
4Q CONCEPT OF HEALTH AND DISEASE

The triangle of epidemiology (59) proponent of this concept. But the “germ theory of disease”
The traditional triangle of epidemiology is shown in or “single cause idea” in the late 19th century over­
Figure 5. This triangle is based on the communicable disease shadowed the multiple cause theory.
model and is useful in showing the interaction and As a result of advances in public health, chemotherapy,
interdependence of agent, host, environment, and time as antibiotics and vector control communicable diseases began
used in the investigation of diseases and epidemics. The to decline - only to be replaced by new types of diseases, the
agent is the cause of disease; the host is an organism, so-called “modern” diseases of civilization, e.g., lung cancer,
usually a human or an animal, that harbours the disease, the coronary heart disease, chronic bronchitis, mental illness,
environment is those surroundings and conditions external etc. These diseases could not be explained on the basis of the
to the human or animal that cause or allow disease germ theory of disease nor could they be prevented by the
transmission; and time accounts for incubation periods, life traditional methods of isolation, immunization or
expectancy of the host or the pathogen, and duration of the improvements in sanitation. The realization began to dawn
course of illness or condition. that the “single cause idea” was an oversimplification and
Agents of infectious diseases include bacteria, viruses, that there are other factors in the aetiology of diseases -
parasites, fungi, and molds. With regard to non-infectious social, economic, cultural, genetic and psychological which
disease, disability, injury, or death, agents can include are equally important. As already mentioned, tuberculosis is
chemicals from dietary foods, tobacco smoke, solvents, not merely due to tubercle bacilli; factors such as poverty,
radiation or heat, nutritional deficiencies, or other overcrowding and malnutrition contribute to its occurrence.
substances, such as poison. One or several agents may The doctrine of one-to-one relationship between cause and
contribute to an illness. disease has been shown to be untenable, even for microbial
diseases, e.g., tuberculosis, leprosy.
A host offers subsistence and lodging for a pathogen and
may or may not develop the disease. The level of immunity, It is now known that diseases such as coronary heart
genetic makeup, level of exposure, state of health, and disease and cancer are due to multiple factors. For example,
overall fitness of the host can determine the effect a disease excess of fat intake, smoking, lack of physical exercise and
organism will have on it. The makeup of the host and the obesity are all involved in the pathogenesis of coronary heart
ability of the pathogen to accept the new environment can disease. Most of these factors are linked to lifestyle and
also be a determining factor because some pathogens thrive human behaviour. Epidemiology has contributed

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only under limited ideal conditions. For example, many significantly to our present day understanding of
infectious disease agents can exist only in a limited multifactorial causation of disease. Medical men are looking
temperature range. “beyond the “germ theory” of disease into the total life
situation of the patient and the community in search of
Environmental factors can include the biological aspects multiple (or risk) factors of disease. Fig. 6 presents an
as well as social, cultural, and physical aspects of the adapted and advanced model of the triangle of
environment. The surroundings in which a pathogen lives epidemiology. This new model includes all facets of the
and the effect the surroundings have on it are a part of the communicable disease model, and to make it more relevant
environment. Environment can be within a host or external and useful with regard to today's diseases, conditions,
to it in the community. Finally, time includes severity of disorders, defects, injuries, and deaths; it also reflects the
illness in relation to how long a person is infected or until the causes of current illnesses and conditions. Behaviour,
condition causes death or passes the threshold of danger lifestyle factors, environmental causes, ecologic elements,
towards recovery. Delays in time from infection to when physical factors, and chronic diseases must also be taken into
symptoms develop, duration of illness, and threshold of an account. The term agent is replaced by causative factors,
epidemic in a population are time elements with which the which implies the need to identify multiple causes or a
epidemiologist is concerned. aetiologic factors of disease, disability, injury and death (59).
Environment Causative factors

Groups or Environment
FIG. 5 populations behaviour, culture,
The triangle of epidemiology and their Physiological factors,
Source : (59) c haracteristi cs Ecological elements
The primary mission of epidemiology is to provide FIG. 6
information that results in breaking one of the legs of the Advanced model of the triangle of epidemiology
triangle, thereby disrupting the connection among Source : (59)
environment, host, and agent, and stopping the outbreak. The purpose of knowing the multiple factors of disease is
to quantify and arrange them in priority sequence
Multifactorial causation (prioritization) for modification or amelioration to prevent or
The concept that disease is due to multiple factors is not a control disease. The multifactorial concept offers multiple
new one. Pettenkofer of Munich (1819-1901) was an early approaches for the prevention/control of disease.
by R△J
 NATURAL HISTORY OF DISEASE 41
Web of causation an agent (or cause of disease) and the environment. The
This model of disease causation was suggested by term natural history of disease is a key concept in
MacMahon and Pugh in their book: “Epidemiologic epidemiology. It signifies the way in which a disease evolves
Principles and Methods” (87). This model is ideally suited in over time from the earliest stage of its prepathogenesis
the study of chronic disease, where the disease agent is often phase to its termination as recovery, disability or death, in
not known, but is the outcome of interaction of multiple the absence of treatment or prevention. Each disease has its
factors. own unique natural history, which is not necessarily the
same in all individuals, so much so, any general formulation
The “web of causation” considers all the predisposing of the natural history of disease is necessarily arbitrary.
factors of any type and their complex interrelationship with
each other. Fig. 7 illustrates the complexities of a causal web The natural history of disease is best established by
of myocardial infarction (which is by no means complete). cohort studies (see page 83). As these studies are costly and
The basic tenet of epidemiology is to study the clusters of laborious, our understanding of the natural history of
causes and combinations of effects and how they relate to disease is largely based on other epidemiological studies,
each other (88). It can be visualized that the causal web such as cross-sectional and retrospective studies, undertaken
(Fig. 7) provides a model which shows a variety of possible in different population settings, both national and
interventions that could be taken which might reduce the international. What the physician sees in the hospital is just
occurrence of myocardial infarction. an “episode” in the natural history of disease. The
The web of causation does not imply that the disease epidemiologist, by studying the natural history of disease in
cannot be controlled unless all the multiple causes or chains the community setting, is in a unique position to fill the gaps
of causation or at least a number of them are appropriately in our knowledge about the natural history of disease.
controlled or removed. This is not the case. Sometimes A schematic diagram of the natural history of disease is
removal or elimination of just only one link or chain may be shown in Fig. 8. It is a necessary framework to understand
sufficient to control disease, provided that link is sufficiently the pathogenetic chain of events for a particular disease,
important in the pathogenetic process. In a multifactorial and for the application of preventive measures. It is
event, therefore, individual factors are by no means all of customary to describe the natural history of disease as
equal weight. The relative importance of these factors may consisting of two phases: prepathogenesis (i.e., the process
be expressed in terms of “relative risk” (see page 81). in the environment) and pathogenesis (i.e., the process in

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NATURAL HISTORY OF DISEASE man). Let us consider the events that take place in the
natural history of disease, using infectious disease as a
Disease results from a complex interaction between man, principal model (89).

1
Myocardial ischaemia

Myocardial infarction
FIG. 7
Web of casuation for myocardial infarction

by R△J
 CONCEPT OF HEALTH AND DISEASE
42

PERIOD OF PRE-PATHOGENESIS PERIOD OF PATHOGENESIS

--------------------
-------------------------------► -►-----------------■-------------------------- k
DISEASE PROCESS —> Before man is involved —> —> The course of the disease in man —>
----------------- ►
Agent Host DEATH
----------------- ►
Chronic state
Defect
Disability
Illness
Clinical horizon Signs & symptoms
Environmental Factors
(known and unknown) Immunity
Bring agent and Tissue and and
host together or physiologic changes resistance
produce a disease Stimulus or agent becomes »
provoking stimulus established and increases RECOVERY
by multiplication ---------------------►

human Interaction of host —> Host reaction —>

host and stimulus
Early Discernible Advanced Convale-
pathogenesis —> early lesions —> disease —> scence
> -------------------- » - k- — ■— »■

LEVELS OF PRIMARY PREVENTION SECONDARY TERTIARY PREVENTION

PREVENTION PREVENTION
—>-----------------------
MODES OF HEALTH SPECIFIC EARLY DIAGNOSIS DISABILITY
INTERVENTION PROMOTION PROTECTION AND TREATMENT REHABILITATION
LIMITATION

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FIG. 8
Natural history of disease
(From Preventive Medicine for the Doctor in His Community, by Leavell & Clark with permission of McGraw-Hill Book Co.)

1. Prepathogenesis phase The causative factors of disease may be classified as

This refers to the period preliminary to the onset of AGENT, HOST and ENVIRONMENT. These three factors are
referred to as epidemiological triad. The mere presence
disease in man. The disease agent has not yet entered man,
of agent, host and favourable environmental factors in the
but the factors which favour its interaction with the human
prepathogenesis period is not sufficient to start the disease
host are already existing in the environment. This situation is
in man. What is required is an interaction of these three
frequently referred to as “man in the midst of disease” or
factors to initiate the disease process in man. The agent,
“man exposed to the risk of disease”. Potentially we are all host and environment operating in combination determine
in the prepathogenesis phase of many diseases, both not only the onset of disease which may range from a single
communicable and non-communicable. case to epidemics (as depicted in Fig. 9’s black area) but
also the distribution of disease in the community.
2. Pathogenesis phase
The pathogenesis phase begins with the entry of the
disease “agent” in the susceptible human host. The further
events in the pathogenesis phase are clear-cut in infectious
diseases, i.e., the disease agent multiplies and induces tissue
and physiological changes, the disease progresses through a
period of incubation and later through early and late
pathogenesis. The final outcome of the disease may be
recovery, disability or death. The pathogenesis phase may
be modified by intervention measures such as immunization
and chemotherapy.
It is useful to remember at this stage that the host’s
reaction to infection with a disease agent is not predictable.
That is, the infection may be clinical or subclinical; typical or
atypical or the host may become a carrier with or without
having developed clinical disease as in the case of
diphtheria and hepatitis B.
FIG. 9 In chronic diseases (e.g., coronary heart disease,
Epidemiologic concept of interactions of hypertension, cancer), the early pathogenesis phase is less
Agent, Host and Environment dramatic. This phase in chronic diseases is referred to as
(Adapted from Health Services Reports, Vol. 87, page 672) presymptomatic phase. During the presymptomatic stage,

by R△J
 NATURAL HISTORY OF DISEASE
43
there is no manifest disease. The pathological changes are mongolism, turner’s syndrome, and (vi) Immunological
essentially below the level of the “clinical horizon”. The factors, e.g., agammaglobulinemia.
clinical stage begins when recognizable signs or symptoms
appear. By the time signs and symptoms appear, the disease 7. Social agents
phase is already well advanced into the late pathogenesis It is also necessary to consider social agents of disease.
phase. In many chronic diseases, the agent-host- These are poverty, smoking, abuse of drugs and alcohol,
environmental interactions are not yet well understood. unhealthy lifestyles, social isolation, maternal deprivation,
etc.
Agent factors Thus the modern concept of disease “agent” is a very
The first link in the chain of disease transmission is a broad one; it includes both living and non-living agents.
disease agent. The disease “agent” is defined as a
substance, living or non-living, or a force, tangible or Host factors (intrinsic)
intangible, the excessive presence or relative lack of which In epidemiological terminology, the human host is
may initiate or perpetuate a disease process. A disease may referred to as “soil” and the disease agent as “seed”. In
have a single agent, a number of independent alternative some situations, host factors play a major role in
agents or a complex of two or more factors whose combined determining the outcome of an individual’s exposure to
presence is essential for the development of the disease (33). infection (e.g., tuberculosis).
Disease agents may be classified broadly into the The host factors may be classified as (i) Demographic
following groups : characteristics such as age, sex, ethnicity; (ii) Biological
1. Biological agents characteristics such as genetic factors; biochemical levels of
the blood (e.g., cholesterol); blood groups and enzymes;
These are living agents of disease, viz, viruses, rickettsiae, cellular constituents of the blood; immunological factors;
fungi, bacteria, protozoa and metazoa. These agents exhibit and physiological function of different organ systems of the
certain “host-related” biological properties such as: body (e.g,, blood pressure, forced expiratory ventilation),
(i) infectivity: this is the ability of an infectious agent to etc. (iii) Social and economic characteristics such as socio­
invade and multiply (produce infection) in a host; economic status, education, occupation, stress, marital
(ii) pathogenicity: this is the ability to induce clinically status, housing, etc. and (iv) Lifestyle factors such as

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apparent illness, and (iii) virulence: this is defined as the personality traits, living habits, nutrition, physical exercise,
proportion of clinical cases resulting in severe clinical use of alcohol, drugs and smoking, behavioural patterns,
manifestations (including sequelae). Thecase fatality rat^Ts^ etc. The association of a particular disease with a specific set
one way of measuring virulence (86). of host factors frequently provides an insight into the cause
of disease. The host factors of importance are further
2. Nutrient agents
discussed in chapter 3.
These are proteins, fats, carbohydrates, vitamins,
minerals and water. Any excess or deficiency of the intake of Environmental factors (extrinsic)
nutritive elements may result in nutritional disorders. Protein The study of disease is really the study of man and his
energy malnutrition (PEM), anaemia, goitre, obesity and environment. Hundreds of millions of people are affected by
vitamin deficiencies are some of the current nutritional preventable diseases originating in the environment in which
problems in many countries. they live. For human beings the environment is not limited,
3. Physical agents as it normally is for plants and animals, to a set of climatic
factors. For example, for man, social and economic
Exposure to excessive heat, cold, humidity, pressure, conditions are more important than the mean annual
radiation, electricity, sound, etc may result in illness. temperature. Thus the concept of environment is complex
and all-embracing. The external or macro-environment is
4. Chemical agents
defined as “all that which is external to the individual human
(i) Endogenous: Some of the chemicals may be produced host, living and non-living, and with which he is in constant
in the body as a result of derangement of function, e.g., urea interaction”. This includes all of man’s external surroundings
(uraemia), serum bilirubin (jaundice), ketones (ketosis), uric such as air, water, food, housing, etc.
acid (gout), calcium carbonate (kidney stones), etc. For descriptive purposes, the environment of man has
(ii) Exogenous: Agents arising outside of human host, been divided into three components - physical, biological
e.g., allergens, metals, fumes, dust, gases, insecticides, etc. and psychosocial. It should be emphasized that this
These may be acquired by inhalation, ingestion or separation is artificial. They are closely related to each other
inoculation. and with host factors.
5. Mechanical agents a. Physical environment
Exposure to chronic friction and other mechanical forces The term “physical environment” is applied to non-living
may result in crushing, tearing, sprains, dislocations and things and physical factors (e.g., air, water, soil, housing,
even death. climate, geography, heat, light, noise, debris, radiation, etc)
with which man is in constant interaction. Man’s victory over
6. Absence or insufficiency or excess of a factor his physical environment has been responsible for most of
necessary to health the improvement in health during the past century. In most
These may be (i) Chemical factors: e.g., hormones (insulin, developing countries, defective environment (e.g., lack of
oestrogens, enzymes) (ii) Nutrient factors: given under no. 2 sanitation) continues to be the main health problem. Man
above (iii) Lack of structure: e.g., thymus (iv) Lack of part of has altered practically everything in his physical
structure, e.g., cardiac defects (v) Chromosomal factors, e.g., environment to his advantage. In doing so, he has created

by R△J
 CONCEPT OF HEALTH AND DISEASE
44
for himself a host of new health problems such as air Psychosocial factors can also affect negatively man’s
pollution, water pollution, noise pollution, urbanization, health and well-being. For example, poverty, urbanization,
radiation hazards, etc. The increasing use of electrical and migration and exposure to stressful situations such as
electronic devices, including the rapid growth of bereavement, desertion, loss of employment, birth of a
telecommunication system (e.g., satellite systems), radio­ handicapped child may produce feelings of anxiety,
broadcasting, television transmitters and radar installations depression, anger, frustration, and so forth; and these
have increased the possibility of human exposure to feelings may be accompanied by physical symptoms such as
electromagnetic energy. headache, palpitation and sweating. But these emotional
Man is living today in a highly complicated environment states also produce changes in the endocrine, autonomic
which is getting more complicated as man is becoming more and motor systems, which, if prolonged and in interaction
ingenious. If these trends continue, it is feared that the very with genetic and personality factors, may lead to structural
“quality of life” we cherish may soon be in danger. changes in various bodily organs. The resulting
psychosomatic disorders include conditions such as
b. Biological environment duodenal ulcer, bronchial asthma, hypertension, coronary
heart disease, mental disorders and socially deviant
The biological environment is the universe of living things behaviour (e.g., suicide, crime, violence, drug abuse). Of
which surrounds man, including man himself. The living primary concern is coronary heart disease which may be
things are the viruses and other microbial agents, insects, related to lifestyle and psychosocial stress. In many
rodents, animals and plants. These are constantly working countries, road accidents are now the principal cause of
for their survival, and in this process, some of them act as death in young people. It is related to psychosocial states
disease-producing agents, reservoirs of infection, such as boredom, anxiety, frustration and other
intermediate hosts and vectors of disease. Between the pre-occupations that can impair attention.
members of the ecological system (which includes man)
there is constant adjustment and readjustment. For the most Man today is viewed as an “agent” of his own diseases;
part, the parties manage to effect a harmonious inter­ his state of health is determined more by what he does to
relationship, to achieve a state of peaceful co-existence, himself than what some outside germ or infectious agent
even though this may not be always enduring. When for any does to him. For example, the medical cause of lung cancer
reason, this harmonious relationship is disturbed, ill-health may be a chemical substance in cigarettes, but the

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results. In the area of biological environment also, psychosocial cause is behaviour - smoking. From a
preventive medicine has been highly successful in protecting psychosocial point of view, disease may be viewed as a
the health of the individual and of the community. maladjustment of the human organism to his psychosocial
environment resulting from misperception, misinterpretation
c. Psychosocial environment and misbehaviour (90). The epidemiologists today are as
It is difficult to define “psychosocial environment” against much concerned with psychosocial environment, as with
the background of the highly varied social, economic and physical or biological environment, in search for aetiological
cultural contexts of different countries and their social causes of disease.
standards and value systems. It includes a complex of Because of the fact that man exists concurrently in so
psychosocial factors which are defined as “those factors many environmental contexts, it has become customary to
affecting personal health, health care and community well­ speak of man in his “total environment”. The social
being that stem from the psychosocial make-up of environment is so inextricably linked with the physical and
individuals and the structure and functions of social groups” biological environments that it is realistic and necessary to
(60). They include cultural values, customs, habits, beliefs, view the human environment in toto to promote health. A
attitudes, morals, religion, education, lifestyles, community stable and harmonious equilibrium between man and his
life, health services, social and political organization. environment is needed to reduce man’s vulnerability to
In addition to this broad aspect of psychosocial disease and to permit him to lead a more productive and
environment, man is in constant interaction with that part of satisfying life.
the social environment known as “people”. He is a member
of a social group, the member of a family, of a caste, of a Risk factors
community and of a nation. Between the individual and For many diseases, the disease “agent” is still
other members of the group, there can be harmony or unidentified, e.g. coronary heart disease, cancer, peptic
disharmony, interests and points of view that are shared or ulcer, mental illness, etc. Where the disease agent is not
that are in conflict. The behaviour of one individual can firmly established, the aetiology is generally discussed in
affect others more or less directly; conflict and tension terms of “risk factors”.
between the individual and the group as a whole or between The term “risk factor” is used by different authors with at
the individual and other members of the group can yield least two meanings (33):
great distress. The law of the land, customs, attitudes,
beliefs, traditions, all regulate the interactions among groups a. an attribute or exposure that is significantly associated
of individuals and families. with the development of a disease (91);
b. a determinant that can be modified by intervention,
The impact of social environment has both positive and
thereby reducing the possibility of occurrence of
negative aspects on the health of individuals and disease or other specified outcomes (33);
communities. A favourable social environment can improve
health, provide opportunities for man to achieve a sense of Risk factors are often suggestive, but absolute proof of
fulfilment, and add to the quality of life. Therefore, customs cause and effect between a risk factor and disease is usually
and traditions favouring health must be preserved. Beneficial lacking. That is, the presence of a risk factor does not imply
social behaviour (e.g., community participation) should be that the disease will occur, and in its absence, the disease
restored where it has disappeared due to social changes. will not occur. The important thing about risk factors is that

by R△J
 RISK FACTORS
__ 45
they are observable or identifiable prior to the event they The detection of risk factors should be considered a prelude
predict. It is also recognized that combination of risk factors to prevention or intervention. For each risk factor ascertained,
in the same individual may be purely additive or synergistic the question has to be asked whether it can be reduced in a
(multiplicative). For example, smoking and occupational cost-effective way and whether its reduction will prevent or
exposure (shoe, leather, rubber, dye and chemical delay the unwanted outcome (95). Since the detection
industries) were found to have an additive effect as risk procedure usually involves whole population, it bears some
factors for bladder cancer (87). On the other hand, smoking similarity to presymptomatic screening for disease (93).
was found to be synergistic with other risk factors such as
hypertension and high blood cholesterol (92). That is, the Risk groups
effects are more than additive. Another approach developed and promoted by WHO is to
Risk factors may be truly causative (e.g., smoking for lung identify precisely the “risk groups” or “target groups” (e.g., at-
cancer); they may be merely contributory to the undesired risk mothers, at-risk infants, at-risk families, chronically ill,
outcome (e.g., lack of physical exercise is a risk factor for handicapped, elderly) in the population by certain defined
coronary heart disease), or they may be predictive only in a criteria and direct appropriate action to them first. This is
statistical sense (e.g., illiteracy for perinatal mortality). known as the “risk approach”. It has been summed up as
Some risk factors can be modified; others cannot be “something for all, but more for those in need - in proportion
modified. The modifiable factors include smoking, to the need” (53). In essence, the risk approach is a
hypertension, elevated serum cholesterol, physical activity, managerial device for increasing the efficiency of health care
obesity, etc. They are amenable to intervention and are services within the limits of existing resources (96). WHO has
useful in the care of the individual. The unmodifiable or been using the risk approach in MCH services since a long time
immutable risk factors such as age, sex, race, family history (Table 9).
and genetic factors are not subject to change. They act more TABLE 9
as signals in alerting health professionals and other Guidelines for defining “at-risk” groups
personnel to the possible outcome (93).
Risk factors may characterize the individual, the family, a. Biological situation:
the group, the community or the environment. For example, - age group, e.g., infants (low birth weight), toddlers, elderly
some of the individual risk factors include age, sex, smoking, sex, e.g., females in the reproductive age period

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hypertension, etc. But there are also collective community physiological state, e.g., pregnancy, cholesterol level, high
blood pressure
risks - for example, from the presence of malaria, from air - genetic factors, e.g. family history of genetic disorders
pollution, from substandard housing, or a poor water supply - other health conditions (disease, physical functioning,
or poor health care services. The degree of risk in these unhealthy behaviour)
cases is indirectly an expression of need. Therefore, it is
stated that a risk factor is a proxy for need - indicating the b. Physical situation:
need for promotive and preventive health services. - rural, urban slums
- living conditions, overcrowding
Epidemiological methods (e.g., case control and cohort - environment: water supply, proximity to industries
studies) are needed to identify risk factors and estimate the
c. Sociocultural and cultural situation:
degree of risk. These studies are carried out in population
social class
groups among whom certain diseases occur much more
- ethnic and cultural group
frequently than other groups. By such comparative studies, - family disruption, education, housing
epidemiologists have been able to identify smoking as a risk customs, habits and behaviour (e.g., smoking, lack of
for lung cancer; high serum cholesterol and high blood exercise, over-eating, drug addicts)
pressure as risk factors for coronary heart disease. The - access to health services
contribution of epidemiology in the identification of risk lifestyles and attitudes
factors has been highly significant. Risk factors associated
with some major disease groups are as shown in Table 8. Source : (97)
Modern epidemiology is concerned with the identification
TABLE 8 of risk factors and high-risk groups in the population. Since
Prominent risk factors resources are scarce, identification of those at risk is
Disease
imperative. It helps to define priorities and points to those
Risk factors
most in need of attention. The knowledge of risk factors and
Heart disease Smoking, high blood pressure, elevated risk groups can be used to prevent disease in so far as we are
serum cholesterol, diabetes, obesity, able to remove or minimize the risk.
lack of exercise, type A personality
Cancer Smoking, alcohol, solar radiation, Spectrum of disease
ionizing radiation, work-site hazards, The term “spectrum of disease” is a graphic
environmental pollution, medications, representation of variations in the manifestations of disease.
infectious agents, dietary factors It is akin to the spectrum of light where the colours vary from
Stroke High blood pressure, elevated one end to the other, but difficult to determine where one
cholesterol, smoking colour ends and the other begins. At one end of the disease
Motor vehicle accidents Alcohol, non-use of seat belts, speed, spectrum are subclinical infections which are not ordinarily
automobile design, roadway design identified, and at the other end are fatal illnesses. In the
Diabetes Obesity, diet middle of the spectrum lie illnesses ranging in severity from
cirrhosis of liver Alcohol mild to severe. These different manifestations are simply
reflections of individuals’ different states of immunity and
Source : (94)
receptivity. Leprosy is an excellent example of the spectral
by R△J
46 CONCEPT OF HEALTH AND DISEASE

concept of disease. For almost every disease there exists a Control activities may focus on primary prevention or
spectrum of severity, with few exceptions such as rabies. In secondary prevention, most control programmes combine
infectious diseases, the spectrum of disease is also referred the two. The concept of tertiary prevention is comparatively
to as the “gradient of infection”. less relevant to control efforts.
The sequence of events in the spectrum of disease can be In disease control, the disease “agent” is permitted to
interrupted by early diagnosis and treatment or by persist in the community at a level where it ceases to be a
preventive measures which if introduced at a particular public health problem according to the tolerance of the local
point will prevent or retard the further development of the population. A state of equilibrium becomes established
disease. The concept of spectrum of disease provides for between the disease agent, host and environment
inclusion of all cases, both subclinical and clinical, in the components of the disease process. An excellent
study of disease. embodiment of this concept is malaria control, which is
distinct from malaria eradication.
Iceberg of disease
Disease elimination
A concept closely related to the spectrum of disease is the
concept of the iceberg phenomenon of disease. According to (between control and eradication, an intermediate goal
this concept, disease in a community may be compared with has-been described, called “regional elimination” (99). The
an iceberg (Fig. 10). The floating tip of the iceberg term “elimination” is used to describe interruption of
represents what the physician sees in the community, i.e., transmission of disease, as for example, elimination of
clinical cases. The vast submerged portion of the iceberg meastesr-polio and diphtheria from large geographic regions
represents the hidden mass of disease, i.e., latent, or areasj>('33). Regional elimination is now seen as an
inapparent, presymptomatic and undiagnosed cases and important precursor of eradication (99).
carriers in the community. The “waterline” represents the Disease eradication
demarcation between apparent and inapparent disease.
Eradication literally means to “tear out by roots”.
In some diseases (e.g., hypertension, diabetes, anaemia, Eradication of disease implies termination of all transmission
malnutrition, mental illness) the unknown morbidity (i.e., of infection by extermination of the infectious agent (33). As
the submerged portion of the iceberg) far exceeds the known the name implies, eradication is an absolute process, and
morbidity. The hidden part of the iceberg thus constitutes an not a relative goal. It is “all or none phenomenon”. The

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important, undiagnosed reservoir of infection or disease in word eradication is reserved to cessation of infection and
the community, and its detection and control is a challenge disease from the whole world (99).
to modern techniques in preventive medicine. One of the
major deterrents in the study of chronic diseases of Today, smallpox is the only disease that has been
unknown aetiology is the absence of methods to detect the eradicated globally. Every disease like every, human being is
subclinical state - the bottom of the iceberg (98). unique with its own epidemiological characteristics and
specific strategies for control.
During recent years, three diseases have been seriously
advanced as candidates for global eradication within the
foreseeable future: polio, measles and dracunculiasis. The
feasibility of eradicating polio appears to be greater than
that of others and the goal is in sight as Afghanistan and
Pakistan are the only two countries endemic for
poliomyelitis at present.
Experience gained from eradication programmes (e.g.,
malaria, yaws) has shown that once the morbidity of a
disease reaches a very low level, a “residual” infection
usually persists in the population leading to a state of
equilibrium between the agent, host and environmental
components of the disease process. In this situation, there
are always hidden foci of infection, unrecognized methods
of transmission, resistance of the vector or organism, all of
which may again flare up when the agent-host-environment
equilibrium is disturbed (100). Failure to understand this led
to disappointment in the eradication programmes mounted
CONCEPTS OF CONTROL against malaria, yaws, plague, kala-azar and yellow fever.

Disease control Monitoring and surveillance

According to standard dictionaries, the words monitoring
The term “disease control” describes (ongoing)
and surveillance are almost synonymous. But in public
operations aimed at reducing:
health practice they have taken on rather specific and
i. the incidence of disease somewhat different meanings (101):
ii. the duration of disease, and consequently the risk of
transmission i) Monitoring
iii. the effects of infection, including both the physical ^Monitoring is “the performance and analysis of routine
and psychosocial complications; and measurements aimed at detecting changes in the
environment or health status of population” (33). Thus we
iv. the financial burden to the community. have monitoring of air pollution, water quality, growth and
by R△J
 CONCEPT OF CONTROL 47
nutritional status, etc. It also refers to on-going measurement estimate the disease prevalence in theTotaLuopulation. The
of performance of a health service or a health professional, advantages of such a system are that the reporting biases are
or of the extent to which patients comply with or adhere to minimized, and feed-back of information to the providers is
advice from health professionals. simplified.
In management, monitoring refers to “the episodic Sentinel surveillance agencies could be interested and
oversight of the implementation of an activity, seeking to competent physicians (or institutions) in selected areas to
ensure that input deliveries, work schedules, targeted report the cases of disease in their areas. This system would
outputs, and other required actions are proceeding provide more valuable and detailed information than could
according to plan” (102). It keeps track of achievements, be obtained from the traditional notification system (103).
staff movements and utilization, supplies and equipment, Finally, these sentinel sites could be developed into a
and the money spent in relation to the resources available so notification system for providing more detailedJnformation,
that if anything goes wrong, immediate corrective measures which, in some settings, may be less costly than developing
can be taken. and maintaining an ongoing notification system.
ii) Surveillance Evaluation of control
Surveillance is defined in many ways (40) : (^Evaluation is the process by which results are compared
1. Continuous analysis, interpretation, and feedback of witFTthe intended objectives, or more simply the assessment
systematically collected data, generally using methods of how well a programme is performing). Evaluation should
distinguished by their practicality, uniformity, and always be considered during the planning and
rapidity rather than by accuracy or completeness. By implementation stages of a programme or activity.
observing trends in time, place, and persons, changes Evaluation may be crucial in identifying the health benefits
can be observed or anticipated and appropriate action, derived (impact on morbidity, mortality, sequelae, patient
including investigative or control measures, can be satisfaction). Evaluation can be useful in identifying
taken. Sources of data may relate directly to disease or to performance difficulties. Evaluation studies may also be
factors influencing disease. Thus they may include carried out to generate information for other purposes, e.g.,
mortality and morbidity reports based on death to attract attention to a problem, extension of control
certificates, hospital records, general practice sentinels, activities, training and patient management, etc. The
or notifications; laboratory diagnosis; outbreak reports; principles of evaluation are discussed in chapter 23.

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vaccine uptake and side effects; sickness absence
records; changes in disease agents, vectors, or reservoirs; CONCEPTS OF PREVENTION
serological surveillance through serum banks. The latter
can also be seen as an example of biological monitoring. The goals of medicine are to promote health, to preserve
2. Systematic and continuous collection, analysis, and health, to restore health when it is impaired, and to minimize
interpretation of data, closely integrated with the timely suffering and distress. These goals are embodied in the word
and coherent dissemination of the results and assessment “prevention” (33). Successful prevention depends upon a
to those who have the right to know so that action can knowledge of causation, dynamics of transmission,
be taken. It is an essential feature of epidemiological and identification of risk factors and risk groups, availability of
public health practice. The final phase in the surveillance prophylactic or early detection and treatment measures, an
chain is the application of information to health organization for applying these measures to appropriate
promotion and to disease prevention and control. A persons or groups, and continuous evaluation of and
surveillance system includes a functional capacity for development of procedures applied (104).
data collection, analysis, and dissemination linked to It is not necessary (although desirable) to know
public health programmes. It is often distinguished from everything about the natural history of a disease to initiate
monitoring by the notion that surveillance is continuous preventive measures. Often times, removal or elimination of
and ongoing, whereas monitoring tends to be more a single known essential cause may be sufficient to prevent a
intermittent or episodic. disease. The objective of preventive medicine is to intercept
Surveillance programmes can assume any character and or oppose the “cause” and thereby the disease process. This
dimension - thus we have epidemiological surveillance, epidemiological concept permits the inclusion of treatment
demographic surveillance, nutritional surveillance, etc. as one of the modes of intervention (89).
According to the above definitions, monitoring becomes Levels of prevention
one specific and essential part of the broader concept In modern day, the concept of prevention has become
embraced by surveillance. Monitoring requires careful broad-based. It has become customary to define prevention
planning and the use of standardized procedures and in terms of four level:
methods of data collection, and can then be carried out over
extended periods of time by technicians and automated 1. primordial prevention
instrumentation. Surveillance, in contrast, requires 2. primary prevention
professional analysis and sophisticated judgement of data 3. secondary prevention
leading to recommendations for control activities.
4. tertiary prevention
Sentinel surveillance These levels of prevention are shown in Fig. 10 in relation
^Scuroutine notification system can identify all cases of to the natural history of disease. Authorities on preventive
infection or disease. A method for identifying the missing medicine do not-agree on the precise boundaries between
cases and thereby supplementing the notified cases is these levels, but that does not minimize their importance. For
required^This is known as asenfinel surveillan r.p ” The example, the supply of food supplements to a family could be
sentinel data is extrapolated to the entire population to primary prevention for some members, and secondary

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 48 CONCEPT OF HEALTH AND DISEASE

prevention (curative) for others. These differences of opinion eliminating a number of communicable diseases like
are more semantic than substantive (33). A general discussion cholera, typhoid and dysentery and controlling several
of these concepts is given below: others like plague, leprosy and tuberculosis, not by medical
interventions but mainly by raising the standard of living
1. Primordial prevention (primary prevention). And much of this success came even
Primordial prevention, a new concept, is receiving special before immunization became universal routine. The
attention in the prevention of chronic diseases. This is application of primary prevention to the prevention of
primary prevention in its purest sense, that is, prevention of chronic disease is a recent development. To have an impact
the emergence or development of risk factors in countries or on the population, all the above three approaches
population groups in which they have not yet appeared. For (primordial prevention, population strategy and high-risk
example, many adult health problems (e.g., obesity, strategy) should be implemented as they are usually
hypertension) have their early origins in childhood, because complementary.
this is the time when lifestyles are formed (for example, In summary, primary prevention is a “holistic” approach.
smoking, eating patterns, physical exercise). In primordial It relies on measures designed to promote health or to
prevention, efforts are directed towards discouraging protect against specific disease “agents” and hazards in the
children from adopting harmful lifestyles. The main environment. It utilizes knowledge of the prepathogenesis
intervention in primordial prevention is through individual phase of disease, embracing the agent, host and
and mass education. environment. Fundamental public health measures and
2. Primary prevention activities such as sanitation; infection control; immunization;
protection of food, milk, and water supplies; environmental
Primary prevention can be defined as “action taken prior protection; and protection against occupational hazards and
to the onset of disease, which removes the possibility that a accidents are all basic to primary prevention. Basic personal
disease will ever occur”. It signifies intervention in the hygiene and public health measures, have had a major
pre-pathogenesis phase of a disease or health problem (e.g., impact on halting communicable disease epidemics.
low birth weight) or other departure from health. Primary Immunization, infection control (eg, hand washing),
prevention may be accomplished by measures designed to refrigeration of foods, garbage collection, solid and liquid
promote general health and well-being, and quality of life of waste management, water supply protection and treatment,
people or by specific protective measures. These are and general sanitation have reduced infectious disease

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discussed in detail elsewhere under “Mode of Intervention”. threats to populations. The safety and low cost of primary
Primary prevention is far more than averting the prevention justifies its wider application. Primary prevention
occurrence of a disease and prolonging life. It includes the has become increasingly identified with “health education”
concept of “positive health”, a concept that encourages and the concept of individual and community responsibility
achievement and maintenance of “an acceptable level of for health (107).
health that will enable every individual to lead a socially and
economically productive life”. It concerns an individual’s 3. Secondary prevention
attitude towards life and health and the initiative he takes Secondary prevention can be defined as “action which
about positive and responsible measures for himself, his halts the progress of a disease at its incipient stage and
family and his community. prevents complications”. The specific interventions are early
The concept of primary prevention is now being applied diagnosis (e.g., screening tests, case finding programmes)
to the prevention of chronic diseases such as coronary heart and adequate treatment. By early diagnosis and adequate
disease, hypertension and cancer based on elimination or treatment, secondary prevention attempts to arrest the
modification of “risk-factors” of disease. The WHO has disease process; restore health by seeking out unrecognized
recommended the following approaches for the primary disease and treating it before irreversible pathological
prevention of chronic diseases where the risk factors are changes have taken place; and reverse communicability of
established (105) : infectious diseases. It may also protect others in the
community from acquiring the infection and thus provide, at
a. population (mass) strategy
once, secondary prevention for the infected individuals and
b. high-risk strategy primary prevention for their potential contacts (86).
(^Population (mass) strategy Secondary prevention is largely the domain of clinical
Another preventive approach is “population strategy” medicine. The health programmes initiated by governments
which is directed at the whole population irrespective of are usually at the level of secondary prevention. The
individual risk levels. For example, studies have shown that drawback of secondary prevention is that the patient has
even a small reduction in the average blood pressure or already been subject to mental anguish, physical pain; and
serum cholesterol of a population would produce a large the community to loss of productivity. These situations are
reduction in the incidence of cardiovascular disease (106). not encountered in primary prevention.
The population approach is directed towards socio­ Secondary prevention is an imperfect tool in the control
economic, behavioural and lifestyle changes (106). of transmission of disease. It is often more expensive and less
effective than primary prevention. In the long run, human
b. High-risk strategy health, happiness and useful longevity will be achieved at far
The high-risk strategy aims to bring preventive care to less expense with less suffering through primary prevention
individuals at special risk. This requires detection of than through secondary prevention (108).
individuals at high risk by the optimum use of clinical
methods. 4. Tertiary prevention
Primary prevention is a desirable goal. It is worthwhile to When the disease process has advanced beyond its early
recall the fact that the industrialized countries succeeded in stages, it is still possible to accomplish prevention by what
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 MODES OF INTERVENTION 49
might be called “tertiary prevention” (89). It signifies i< health education
intervention in the late pathogenesis phase. Tertiary ii. * environmental modifications
prevention can be defined as “all measures available to iii. -nutritional interventions
reduce or limit impairments and disabilities, minimize iv. lifestyle and behavioural changes
suffering caused by existing departures from good health
and to promote the patient’s adjustment to irremediable (i) Health education: This is one of the most cost-
coriclitions” (33). For example, treatment, even if effective interventions. A large number of diseases could be
undertaken late in the natural history of disease may prevent prevented with little or no medical intervention if people
sequelae and limit disability. When defect and disability are were adequately informed about them and if they were
more or less stabilized, rehabilitation may play a preventable encouraged to take necessary precautions in time.
role. Modern rehabilitation includes psychosocial, Recognizing this truth, the WHO’s constitution states that
vocational, and medical components based on team work “the extension to all people of the benefits of medical,
from a variety of professions. Tertiary prevention extends psychological and related knowledge is essential to the fullest
the concept of prevention into fields of rehabilitation. attainment of health”. The targets for educational efforts
may include the general public, patients, priority groups,
Table 10 summarizes the levels of prevention. health providers, community leaders and decision-makers.
MODES OF INTERVENTION (ii) Environmental modifications: A comprehensive
approach to health promotion requires environmental
“Intervention” can be defined as any attempt to intervene modifications, such as provision of safe water; installation of
or interrupt the usual sequence in the development of sanitary latrines; control of insects and rodents; improvement
disease in jnamJThis may be by the provision of treatment, of housing, etc. The history of medicine has shown that many
education, help or social support. Five modes of infectious diseases have been successfully controlled in
intervention have been described which form a continuum western countries through environmental modifications,
corresponding to the natural history of any disease. These even prior to the development of specific vaccines or
levels are related to agent, host and environment and are chemotherapeutic drugs. Environmental interventions are
shown in Fig. 9. They are: non-clinical and do not involve the physician.
1. Health promotion (iii) Nutritional interventions: These comprise food

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distribution and nutrition improvement of vulnerable
2. Specific protection
groups; child feeding programmes; food fortification;
3. Early diagnosis and treatment nutrition education, etc.
4. Disability limitation (iv) Lifestyle and behavioural changes: The
5. Rehabilitation conventional public health measures or interventions have
not been successful in making inroads into lifestyle reforms.
1. Health promotion The action of prevention in this case, is one of individual
Health promotion is “the process of enabling people to and community responsibility for health (see page 22), the
increase control over, and to improve health ” (109). It is not physician and in fact each health worker acting as an
directed against any particular disease, but is intended to educator than a therapist. Health education is a basic
strengthen the host through a variety of approaches element of all health activity. It is of paramount importance
(interventions). The well-known interventions in this area are: in changing the views, behaviour and habits of people.

TABLE 10
Levels of prevention
Level Phase of disease Aim Actions Target
Primordial Underlying economic, social, Establish and maintain Measures that inhibit the Total population or
and environmental conditions that emergence of environmental, selected groups; achieved
conditions leading to minimize hazards to economic, social and through public health policy
causation health behavioural conditions. and health promotion.
Primary Specific causal factors Reduce the incidence Protection of health by Total population, selected
of disease personal and community groups and individuals at
efforts, such as enhancing high-risk; achieved through
nutritional status, providing public health programmes
immunizations, and eliminating
environmental risks.
Secondary Early stage of disease Reduce the prevalence Measures available to individuals Individuals with established
of disease by and communities for early disease; achieved through
shortening its duration detection and prompt intervention early diagnosis and
to control disease and treatment.
minimize disability (e.g. through
screening programmes)
Tertiary Late stage of disease Reduce the number Measures aimed at softening the Patients; achieved through
(treatment, rehabilitation) and/or impact of impact of long-term disease and rehabilitation.
complications disability; minimizing suffering;
maximizing potential years
of useful life.
Source : (58)

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 CONCEPT OF HEALTH AND DISEASE

Since health promotion comprises a broad spectrum of are the only effective mode of intervention. Early effective
activities, a well-conceived health promotion programme therapy has made it possible to shorten considerably the
would first attempt to identify the “target groups” or at-risk period of communicability and reduce the mortality from
individuals in a population and then direct more acute communicable diseases.
appropriate message to them (110). Goals must be defined. Mass treatment: A mass treatment approach is used in the
Means and alternative means of accomplishing them must control of certain diseases, viz. yaws, pinta, bejel, trachoma
be explored. It involves “organizational, political, social and and filaria, The rationale for a mass treatment programme is
economic interventions designed to facilitate environmental the existence of at least 4-5 cases of latent infection for each
and behavioural adaptations that will improve or protect clinical case of active disease in the community. Patients with
health” (111). a latent (incubating) infection may develop disease at any
2. Specific protection time. In such cases, mass treatment is a critical factor in the
interruption of disease transmission. There are many variants
To avoid disease altogether is the ideal but this is possible of mass treatment - total mass treatment, juvenile mass
only in a limited number of cases. The following are some treatment, selective mass treatment, depending upon the
of the currently available interventions aimed at specific nature and prevalence of disease in the community (103).
protection: (a) immunization (b) use of specific nutrients
(c) chemoprophylaxis (d) protection against occupational 4. Disability limitation
hazards (e) protection against accidents (f) protection from When a patient reports late in the pathogenesis phase, the
carcinogens (g) avoidance of allergens (h) the control of mode of intervention is disability limitation. The objective of
specific hazards in the general environment, e.g., air this intervention is to prevent or halt the transition of the
pollution, noise control (i) control of consumer product disease process from impairment to handicap.
quality and safety of foods, drugs, cosmetics, etc.
Concept of disability
Health protection
The sequence of events leading to disability and
The term “health protection” which is quite often used, is handicap have been stated as follows (114):
not synonymous with specific protection. Health protection
is defined as “The provision of conditions for normal mental -^Disease —» impairment —> disability —> handicap
and physical functioning of the human being individually The WHO (115) has defined these terms as follows:

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and in the group. It includes the promotion of health, the
prevention of sickness and curative and restorative medicine (i) Impairment : An impairment is defined as “any loss
in all its aspects” (58). In fact, health protection is conceived or abnormality of psychological, physiological or anatomical
as an integral part of an overall community development structure or function”, e.g., loss of foot, defective vision or
programme, associated with activities such as literacy mental retardation. An impairment may be visible or
campaigns, education and food production (112). Thus invisible, temporary or permanent, progressive or regressive.
health protection covers a much wider field of health Further, one impairment may lead to the development of
activities than specific protection. “secondary” impairments as in the case of leprosy where
damage to nerves (primary impairment) may lead to plantar
3. Early diagnosis and treatment ulcers (secondary impairment).
A WHO Expert Committee (113) defined early detection of (ii) Disability : Because of an impairment, the affected
health impairment as “the detection of disturbances of person may be unable to carry out certain activities
homoeostatic and compensatory mechanism while considered normal for his age, sex, etc. This inability to
biochemical, morphological, and functional changes are still carry out certain activities is termed “disability”. A disability
reversible.” Thus, in order to prevent overt disease or has been defined as “any restriction or lack of ability to
disablement, the criteria of diagnosis should, if possible, be perform an activity in the manner or within the range
based on early biochemical, morphological and functional considered normal for a human being”.
changes that precede the occurrence of manifest signs and (iii) Handicap : As a result of disability, the person
symptoms. This is of particular importance in chronic diseases. experiences certain disadvantages in life and is not able to
Early detection and treatment are the main interventions discharge the obligations required of him and play the role
of disease control. The earlier a disease is diagnosed and expected of him in the society. This is termed “handicap”,
treated the better it is from the point of view of prognosis and and is defined as “a disadvantage for a given individual,
preventing the occurrence of further cases (secondary cases) resulting from an impairment or a disability, that limits or
or any long-term disability. It is like stamping out the “spark” prevents the fulfilment of a role that is normal (depending on
rather than calling the fire brigade to put out the fire. age, sex, and social and cultural factors) for that individual”.
Strictly speaking, early diagnosis and treatment cannot be Taking accidents as an example, the above terms can be
called prevention because the disease has already explained further as follows (95):
commenced in the host. However, since early diagnosis and
treatment intercepts the disease process, it has been Accident Disease (or disorder)
included in the schema of prevention, in as much as the goal Loss of foot Impairment (extrinsic or intrinsic)
of prevention is “to oppose or intercept a cause to prevent Cannot walk Disability (objectified)
or dissipate its effect.” (89). Unemployed ......... Handicap (socialized)
Early diagnosis and treatment though not as effective and
FIG. 11
economical as “primary prevention” may be critically Concept of disability
important in reducing the high morbidity and mortality in
certain diseases such as essential hypertension, cancer The intervention in disability will often be social or
cervix and breast cancer. For many others such as environmental as well as medical. While impairment which
tuberculosis, leprosy and STD, early diagnosis and treatment is the earliest stage has a large medical component,

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 CHANGING PATTERN OF DISEASE 51
disability and handicap which are later stages have large tuberculosis, cardiac patients and others. The purpose of
social and environmental components in terms of rehabilitation is to make productive people out of non­
dependence and social cost (95). productive people.
It is now recognized that rehabilitation is a difficult and
Disability prevention
demanding task that seldom gives totally satisfactory results;
Another concept is “disability prevention”. It relates to all but needs enthusiastic cooperation from different segments
the levels of prevention: (a) reducing the occurrence of of society as well as expertise, equipment and funds not
impairment, viz. immunization against polio (primary readily available for this purpose even in affluent societies. It
prevention); (b) disability limitation by appropriate treatment is further recognized that interventions at earlier stages are
(secondary prevention); and, (c) preventing the transition of more feasible, will yield results, and are less demanding of
disability into handicap (tertiary prevention) (115). scarce resources.
The major causes of disabling impairments in the developing
countries are communicable diseases, malnutrition, low quality CHANGING PATTERN OF DISEASE
of perinatal care and accidents. These are responsible for about Although diseases have not changed significantly through
70 per cent of cases of disability in developing countries. human history, their patterns have. It is said that every decade
Primary prevention is the most effective way of dealing with the produces its own pattern of disease. The truth of this will be
disability problem in developing countries (115). obvious when one compares the leading causes of death
globally for the year 2000 and 2019, as shown in Fig. 11 (118).
5. Rehabilitation
Rehabilitation has been defined as “the combined and 1. Ischaemic heart disease 6.8
coordinated use of medical, social, educational and • 8.9
vocational measures for training and retraining the
2. Stroke 5.5
individual to the highest possible level of functional ability”
-O- 6.2
(116). It includes all measures aimed at reducing the impact
of disabling and handicapping conditions and at enabling 3. Chronic obstructive pulmonary disease
the disabled and handicapped to achieve social integration __________^°OS3.2
(115). Social integration has been defined as the active
4. Lower respiratory infections

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participation of disabled and handicapped people in the
mainstream of community life (117). -----26 O ) 3.1
It involves Rehabilitation medicine or Physical medicine or 5. Neonatal conditions
Physiatry has emerged in recent years as a medical speciality. 2J__ 32
It aims to enhance and restore functional ability and quality of 6. Trachea, bronchus, lung cancers
life to those with physical impairments or disabilities. A
physiatrist specializes in restoring optional function to people —^OX 1.8
with injuries to the muscles, bones, ligaments or nervous 7. Alzheimer’s disease and other dementias
system. Six formal sub-specialization are recognized are: 0.6
neuromuscular medicine, pain medicine, paediatric
rehabilitation medicine, spinal cord injury medicine, sports 8. Diarrhoeal diseases
medicine and brain medicine. Paramedical and non-medical ----- — 2.6
persons are involved in the discipline. They are physical
medicine or physiotherapy, occupational therapy, speech 9. Diabetes mellitus
therapy, audiology, psychology, education, social work, - -• 1.5
vocational guidance and placement services. The following 10. Kidney diseases
areas of concern in rehabilitation have been identified: 0.813
—O-< 1.3
{a) Medical rehabilitation - restoration of function.
Xb) Vocational rehabilitation - restoration of the capacity 0 2 4 6 8 10
to earn a livelihood. Number of deaths (in millions)
(jp Social rehabilitation - restoration of family and social O 2000 • 2019
relationships.
(^Psychological rehabilitation - restoration of personal FIG. 11
dignity and confidence. Leading causes of death globally
Source : (118)
Rehabilitation is no longer looked upon as an extra­
curricular activity of the physician. The current view is that In the year 2019, the top 10 causes of death accounted
the responsibility of the doctor does not end when the for 55 per cent of the 55.4 million deaths worldwide. The
“temperature touches normal and stitches are removed”. top global causes of death, in order of total number of lives
The patient must be restored and retrained “to live and work lost, are associated with three broad topics : cardiovascular
within the limits of his disability but to the hilt of his (ischaemic heart disease, stroke), respiratory (chronic
capacity ’. As such medical rehabilitation should start very obstructive pulmonary disease, lower respiratory infections)
early in the process of medical treatment. and neonatal conditions, which include birth asphyxia and
Examples of rehabilitation are: establishing schools for birth trauma, neonatal sepsis and infections, and preterm
the blind, provision of aids for the crippled, reconstructive birth complications. In the year 2019, globally, 7 of the 10
surgery in leprosy, muscle re-education and graded exercises leading causes of deaths were noncommunicable diseases.
in neurological disorders, change of profession for a more These seven causes accounted for 80 per cent of the top 10
suitable one and modification of life in general in the case of deaths.
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52 CONCEPT OF HEALTH AND DISEASE

The world’s biggest killer is ischaemic heart disease, 2. Ischaemic heart disease
responsible for 16.59 per cent of the total deaths. Since year 3. Stroke
2000, the largest increase in deaths has been for this 4. Lower respiratory infections
disease. Stroke and chronic obstructive pulmonary disease 5. Diarrhoeal diseases
are the 2nd and 3rd leading causes of death responsible for
6. Road injury
approximately 10.16 and 5.34 per cent of total deaths
respectively. Lower respiratory infection ranked as the 4th 7. Chronic obstructive pulmonary disease
leading cause of death. However, the number of deaths has 8. Diabetes mellitus
gone down substantially : in 2020 it claimed 2.55 million 9. Tuberculosis
lives, 460,000 fewer than in year 2000 (118). 10. Congenital anomalies
Neonatal conditions are ranked 5th in the list. However, However, these data do not include COVID-19 as death
deaths from neonatal conditions are one of the categories statistics available actually releate to 2019. However, the
for which the global decrease in deaths in absolute numbers WHO estimated COVID-19 to have caused more than 1.5
over the past two decades has been the greatest : these million deaths worldwide in 2020. This would have tied it
conditions killed 2 million newborns and young children in with diarrhoeal diseases and diabetes, which were 8th on
2019, 1.2 million fewer than in 2000 (118). the list of top causes of deaths worldwide, assuming these
Deaths from trachea, bronchus and lung cancers have figures stay more or less the same (121).
risen from 1.2 million to 1.8 million and are now ranked 6th
among the leading cause of death. In 2019, Alzheimer’s INDIA
disease and other forms of dementia ranked as 7th leading
TABLE 11
cause. Women are disproportionately affected. Globally,
65 per cent of deaths from Alzheimer’s disease and Top 10 causes of death in rural & urban areas: 2015-2017
dementia are in women (118).
Percentage
One of the largest decline in the number of deaths is from Rank Cause of Death Proportion of death
diarrhoeal diseases with global deaths falling from Male Female Person
2.6 million in year 2000 to 1.5 million in year 2019.
Rural Area
Diabetes has entered the top 10 causes list following a

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significant increase of 70 per cent since 2000. Diabetes is 1. Cardiovascular diseases 27.0 24.0 25.8
also responsible for the largest rise in male deaths among the 2 Respiratory diseases 7.2 8.0 7.5
top 10 diseases. Other diseases which were among the top 3 Malignant and other neoplasms 5.6 7.0 6.2
10 causes of death in 2000 are no longer on the list, 4. Fever of unknown origin 4.4 6.4 5.2
HIV/AIDS is one of them. Deaths from HIV/AIDS have fallen 5. Digestive diseases 5.8 3.8 4.9
by 51 per cent during the last 20 years, moving from the
6 Perinatal conditions 6.0 2.6 4.6
world’s 8th leading cause of death in 2000 to the 19th
position in the year 2019. Kidney diseases have risen from 7 Unintentional injuries . other 4.5 4.4 45
the world’s 13th position to the 10th position in the list, than motor vehicle accidents
mortality has increased from 813,000 in year 2000 to 8 Unintentional injuries : motor 5.4 16 39
1.3 million in year 2019 (118). Tuberculosis is no longer in vehicle accidents
the global top 10, falling from 7th place in 2000 to 13th in 9. Diarrhoeal diseases 2.8 4.1 3.3
2019, with a 30 per cent reduction in global deaths. Yet, it 10. Ill-defined/All other symptoms, 11 8 18.7 14.7
remains among the top 10 causes of deaths in the African signs and abnormal clinical and
and South-East Asian regions, where it is the 8th and 5th laboratory findings
leading cause respectively. The new estimates show that All other remaining causes 19 4 19.3 19 4
6 of the top 10 causes of death in the low-income countries Urban Area
are still due to communicable diseases. This includes malaria
(6th), tuberculosis (8th) and HIV/AIDS (9th position). 1. Cardiovascular diseases 33 7 28.3 31.5
2. Malignant and other neoplasms 6.0 8.1 6.8
In 2019, people are living longer (73 years) than in 2000
(67 years). Likewise, disability is also on the rise. To a large 3. Respiratory diseases 57 6.6 6.1
extent, the diseases and health conditions that are causing the 4. Digestive diseases 6.7 4.1 5.6
most deaths are those that are responsible for the greatest 5. Fever of unknown origin 3.8 5.5 4.5
number of healthy life-years lost. Heart disease, diabetes, 6 Unintentional injuries : motor 5.9 1.9 4.3
stroke, lung cancer and chronic obstructive pulmonary vehicle accidents
disease were collectively responsible for nearly 100 million 7 Diabetes mellitus 3.7 4.1 3.8
additional healthy life-years lost in 2019 compared to 2000.
8. Perinatal conditions 4.6 1.9 3.5
Injuries are also major cause of disability and death. There
has been significant rise in road traffic injuries in the African 9. Unintentional injuries: other 3.4 3.6 3.5
than motor vehicle accidents
region since 2000, with an almost 50 per cent increase in both
death and DALYs. Globally, 75 per cent deaths from road 10. Ill-defined/All other symptoms, 10.5 17.9 13.5
traffic injuries are male. The region of Americas is the only signs and abnormal clinical and
laboratory findings
one for which drug use disorder is in top 10 contributors to
life-years lost due to premature deaths and disability (119). All other remaining causes 16.2 18.2 17 0
Top 10 global causes of disability-adjusted life years Note : Symptoms, signs and abnormal clinical and laboratory findings
not elsewhere classified (NEC) (R00-R99) was not properly
(DALYs) in 2019 are as follows (120) : diagnosed, so it may not be considered as second leading cause group.
1. Neonatal conditions Source : (122)

by R△J
 POPULATION MEDICINE 53
Table 11 shows the top causes of death in rural and urban health at Yale University, gave the oft-quoted definition of
area for period of year 2015-2017. The top 10 causes of public health. The WHO Expert Committee on Public
deaths in the rural and urban areas are common except for Health Administration, adapting Winslow’s earlier definition,
deaths due to diarrhoeal diseases in rural area and diabetes has defined it as (124):
mellitus in urban area. However, their relative order varies. “the science and art of preventing disease, prolonging life,
Cardiovascular diseases which is leading cause of death and promoting health and efficiency through organized
both the areas accounts for 31.5 per cent of deaths in urban community efforts for the sanitation of the environment,
vis-a-vis 25.8 per cent in rural area. The difference in the control of communicable infections, the education of
proportion of male deaths due to perinatal condition is the individual in personal hygiene, the organization of
higher than female deaths both in rural and urban areas. medical and nursing services for early diagnosis and
Higher proportion of deaths of female due to respiratory preventive treatment of disease, and the development of
diseases and malignant & other neoplasm is noted (122). social machinery to ensure for every individual a standard
of living adequate for the maintenance of health, so
The factors which play a role in the changing patterns of organizing these benefits as to enable every citizen to
disease are multiple. They include changing lifestyles and realize his birthright of health and longevity”.
living standards, demographic factors, urbanization and
industrialization, medical interventions, maintenance of Whereas in developing countries, public health has not
people with transmissible genetic defects, and the made much headway in terms of sanitary reforms and
widespread effects of technology on ecology. control of communicable diseases, it has made tremendous
strides in the industrialized western countries resulting in
The changing pattern of disease in both developed and longer expectation of life and significant decline in death
developing countries and the emergence of new problems rates. As a result of improvements in public health during
emphasize the need for forward-looking approaches in the past 50 or 60 years, public health in the developed
health planning and management. countries has moved from sanitation and control of
communicable diseases (which have been largely controlled)
POPULATION MEDICINE to preventive, therapeutic and rehabilitative aspects of
chronic diseases and behavioural disorders.
Knowledge about human health and disease is sum of the
contributions of a large number of disciplines, classified as A EURO symposium in 1966 (56) suggested that the
definition of public health should be expanded to include

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(a) basic sciences (b) clinical sciences, and (c) population
medicine. The basic sciences (e.g., biochemistry, physiology, the organization of medical care services. This was endorsed
microbiology) are primarily sited in laboratories; clinical by another Expert Committee of WHO in 1973 (125). Thus
activities are carried out in hospitals, and population modern public health also includes organization of medical
medicine in the community. Tuberculosis provides a good care, as a means of protecting and improving the health of
illustration of the three different approaches to the same people (126). Since the organization of public health tends
disease. The basic sciences are concerned with tubercle to be determined by cultural, political and administrative
bacilli; the clinical sciences with the treatment of tuberculosis patterns of the countries, there is a wide mosaic of
in the individual, and population medicine with prevention organizational arrangements.
and control of tuberculosis in the community (86). All these Public health, in its present form, is a combination of
approaches are highly interrelated. scientific disciplines (e.g., epidemiology, biostatistics,
In different settings, population medicine is referred to laboratory sciences, social sciences, demography) and skills
as hygiene, public health, preventive medicine, social and strategies (e.g., epidemiological investigations, planning
medicine or community medicine. All these share common and management, interventions, surveillance, evaluation)
ground in their concern for promotion of health and that are directed to the maintenance and improvement of
prevention of disease. Each has originated at a different the health of the people (126).
time, and each has introduced a new direction or emphasis. With the adoption of the goal of “Health for All”, a new
So there should be little expectation that definitions can be public health was evident worldwide, which may be defined
other than arbitrary and imprecise (123). It has been truly as:
said that every definition is dangerous. . “the organized application of local, state, national and
international resources to achieve “Health for All”, i.e.,
Hygiene attainment by all people of the world by the year 2000 of a
The world “hygiene” is derived from Hygeia, the level of health that will permit them to lead a socially and
goddess of health in Greek mythology. She is represented as economically productive life”.
a beautiful woman holding in her hand a bowl from which a Although the term “public health” has lost its original
serpent is drinking. In Greek mythology, the serpent testifies meaning, the term is still widely used. Terms like preventive
the art of healing which symbol is retained even today. medicine, social medicine and community medicine are
Hygiene is defined as “the science of health and embraces used as synonyms for public health. Public health is not only
all factors which contribute to healthful living”. a discipline but has become a “social institution” (33)
created and maintained by society to do something about
Public health the death rate and sanitary conditions and many other
The term “public healffi” came into general use around matters relating to life and death (127). In this sense public
1840. It arose from the need to protect “the public” from the health is both a body of knowledge and also a means to
spread of communicable diseases. Later, it appeared in 1848 apply that knowledge.
in the name of a law, the Public Health Act in England to
crystallize the efforts organized by society to protect, Preventive medicine
promote, and restore the people’s health. Preventive medicine developed as a branch of medicine
In 1920, C.E.A. Winslow, a former professor of public distinct from public health, based on aetiology. It is, by
by R△J
54 CONCEPT OF HEALTH AND DISEASE

definition, applied to “healthy” people. It scored several Social medicine

successes in the prevention of communicable diseases based The term “social medicine” was first introduced by Jules
on immunization, so much so, in its early years, preventive
Guerin, a French physician in 1848. In 1911, the concept of
medicine was equated with the control of infectious social medicine was revived by Alfred Grotjahn of Berlin
diseases. A brief account of the advances made in
who stressed the importance of social factors as
preventive medicine is given in chapter 1.
determinants of health and disease. These ideas of social
As concepts of the aetiology of disease changed through medicine spread throughout Europe and England after the
time, so too have the techniques and activities of preventive First World War (see page 8).
medicine. Preventive medicine is no longer concerned, as it
used to be, with immunization, important though it may be. By derivation, social medicine is “the study of man as a
The concept of preventive medicine has broadened to social being in his total environment”. It is concerned with all
include health promotion, treatment, and prevention of the factors affecting the distribution of health and illhealth in
disability as well as specific protection (90). Preventive population, including the use of health services (129). Social
medicine has thus come to include both specific medical medicine is not a new branch of medicine, but rather an
measures (e.g., immunization), as well as general health extension of the public health idea reflecting the strong
promotional measures (e.g., health education). Within this relationship between medicine and social sciences.
change in the definition and scope of preventive medicine, it Professor Crew of Edinburgh defined social medicine as
has become clear that promoting health and preventing follows: “Social medicine stands upon two pillars, medicine
illness involve responsibilities and decisions at many levels - and sociology. Social medicine, by derivation is concerned
individual, public and private; and that these efforts are with the health of groups of individuals and individuals
applied to whole population or to segments. In this, within these groups with a view to create, promote,
preventive medicine has become akin to public health. preserve, and maintain optimum health. The laboratory to
Preventive medicine has become a growing point in practice social medicine is the whole community; the tools
medicine (128). It has branched into newer areas such as for diagnosing community ills are epidemiology and
screening for disease, population control, environmental biostatistics; and social therapy does not consist in
control, genetic counselling and prevention of chronic diseases. administration of drugs, but social and political action for
Community prevention and primordial prevention (see page the betterment of conditions of life of man. Social medicine

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47) are relatively new concepts which are being applied in the is one more link in the chain of social organizations of a
community control of coronary heart disease, hypertension civilized community”. Terms such as social anatomy, social
and cancer with palpable success (106). The emergence of physiology, social pathology and social therapy came into
preventive paediatrics, preventive geriatrics and preventive vogue to describe the various aspects of social medicine.
cardiology are relatively new dimensions of prevention.
Although the term “social medicine” was introduced
Since preventive medicine has increasingly tended to be more than 150 years ago, the characteristic aspect was its
applied to the organized health activities of the community repeated advent and disappearance. It never came to be
(56), the term “preventive medicine” is regarded as generally accepted. There was no unanimity in its objectives
synonymous with public health. Both terms often appear in or subject matter. This is reflected in more than
combination (e.g., Maxcy-Rosenau Textbook of “Public 50 definitions given to social medicine.
Health and Preventive Medicine”).
Social medicine had achieved academic respectability in
Associated with the concept of public health, preventive England when John Ryle was appointed as professor of
medicine has been defined as meaning “not only the social medicine at Oxford, and Crew at Edinburgh. The
organized activities of the community to prevent occurrence post-war period (1945-1967) saw considerable expansion
as well as progression of disease and disability, mental and of social medicine as an academic discipline (129).
physical, but also the timely application of all means to
promote the health of individuals, and of the community as With the development of epidemiology as a new discipline
a whole, including prophylaxis, health education and similar and a practical tool in the planning, provision and evaluation
work done by a good doctor in looking after individuals and of health services, interest in social medicine began to wane. In
families” (56). In this the goals of preventive medicine and 1968, the Report of the Royal Commission on Medical
public health have become identical, i.e., Health for All. In Education (Todd Report) for the first time referred to
line with this extension of the scope of preventive medicine, “community medicine” instead of social medicine, and defined
it is now customary to speak of primary, secondary and it in terms which embraced social medicine, but went beyond
tertiary levels of prevention (56). The cornerstone of it, by giving greater emphasis to the organizational and
preventive medicine is, however, “primary prevention”. administrative aspects than had academic social medicine in
Community health the past (129). This gave a blow to the further development of
social medicine which had tended in many countries to be
The term “community health” has replaced in some displaced by the newer term “community medicine” (56).
countries, the terms public health, preventive medicine and
social medicine. A EURO symposium in 1966 (56) defined Community medicine
community health as including “all the personal health and
environmental services in any human community, The term “community medicine” is a newcomer. It is the
irrespective of whether such services were public or private successor of what has been previously known as public
ones”. In some instances, community health is used as a health, preventive medicine, social medicine and
synonym for “environmental health”. It is also used to refer community health. Since community medicine is a recent
to “community health care”. Therefore, a WHO Expert introduction, it has borrowed heavily from the concepts,
Committee in 1973 (125) observed that without further approaches and methods of public health, preventive
qualification, the term “community health” is ambiguous, medicine and social medicine.
and suggested caution in the use of the term. The history of community medicine in England is
by R△J
 HOSPITAL AND COMMUNITY 55
interesting. It was instituted by Ordinance and by Act of HOSPITALS AND COMMUNITY
Parliament (130). The Todd Commission (1968) forcibly
recommended that every medical school in England should The hospital is a unique institution of man. A WHO
have a department of community medicine. The Royal Expert Committee in 1963 (134) proposed the following
College of Physicians of Edinburgh and London and the working definition of a hospital: “A hospital is a residential
Royal College of Physicians and Surgeons of Glasgow establishment which provides short-term and long-term
established the Faculty of community medicine, which came medical care consisting of observational, diagnostic,
into being in March 1972 as the central body with a therapeutic and rehabilitative services for persons suffering
responsibility of setting standards and overseeing the quality or suspected to be suffering from a disease or injury and for
of postgraduate education and training in the field (131). On parturients. It may or may not also provide services for
the night of 31st March 1974, the traditional medical officer ambulatory patients on an out-patient basis”.
of health passed into the pages of the history book, and was The criticism levelled against the hospital is that it exists
thereafter designated as the “community physician”. in splendid isolation in the community, acquiring the
The term community medicine means different things in euphemism “an ivory tower of disease”; it absorbs vast
different countries (56). For example, in most European proportion (50 to 80 per cent) of health budget; it is not
countries various aspects of community medicine are taught people-oriented; its procedures and styles are inflexible; it
at medical universities, though under different names, such overlooks the cultural aspects of illness (treating the disease
as general practice, family medicine, community medicine without treating the patient); the treatment is expensive; it is
or social medicine (132). Even in the same country and intrinsically resistant to change, and so on. The relative
region, the variation in the amount and range of teaching isolation of hospitals from the broader health problems of
remains remarkable (131). These variations are reflected in the community which has its roots in the historical
the definitions quoted below (56). development of health services has contributed to the
dominance of hospital model of health care.
(a) The field concerned with the study of health and
disease in the population of a defined community or In 1957, an Expert Committee of WHO (135)
group. Its goal is to identify the health problems and emphasized that the general hospital cannot work in
needs of defined population (community diagnosis) isolation; it must be a part of a social and medical system
and to plan, implement and evaluate the extent to that provides complete health care for the population.

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which health measures effectively meet these needs. Subsequent years witnessed the efforts of WHO, UNICEF
and non-governmental agencies to involve hospitals in
(b) The practice of medicine concerned with groups or providing basic and referral services. The establishment of
population rather than with individual patients. This primary health centres was a step forward to integrate
includes the elements listed in definition (a), together preventive and curative services.
with the organization and provision of health care at a
community or group level. The community hospital should be a flexible institution,
capable of adapting its resources to the total health care
(c) The term is also used to describe the practice of needs of the community. This adaptation requires hospital
medicine in the community, e.g., by a family administration that is both a science and art. Dr. Rene Sand
physician. Some writers equate the terms “family has said that the right patient should receive the right care at
medicine” and “community medicine”; others confine the right time in the right place at the right cost (136). This
its use to public health practice. ideal, seemingly simple, is perhaps never achieved, like all
(d) Community oriented primary health care is an other ideals because of a complex set of interacting and
integration of community medicine with the primary often conflicting social forces operating both within and
health care of individuals in the community. In this outside the hospital system.
form of practice, the community practitioner or With the acceptance of the goal of “Health for All”, there
community health team has responsibility for health is involvement of hospitals in primary health care activities.
care at a community or at an individual level. Member countries of WHO have enunciated in their national
It will be seen that a common thread runs through all the policies to reorient and restructure their health care systems
above definitions. Diagnosis of the state of health of a on the basis of primary health care. Primary health care
community is an important foundation of community cannot work unless there is effective hospital support to deal
medicine. As used in the present context, community with referred patients, and to refer patients who do not
medicine is a practice which focuses on the health needs of require hospital attention to one of the other primary health
the community as a whole. The combination of community care services. Without hospital support primary health care
medicine with “primary health care” extends the functioning could not achieve its full potential. The trend is now set to
of both elements to a health care system which aims to redefine the role of the hospital as a community health
change the state of health of the community by intervention oriented institution, which means that it is not only disease
both at the individual and group level. The foundations of oriented but has responsibilities in the field of preventive
community medicine are in no way different from those of medicine and health promotion (137).
modern public health and social medicine, viz.
epidemiology, biostatistics, social sciences and organization Functions of a physician
of health care which includes planning, implementation and The object of medical education is to prepare a doctor
evaluation (133). (physician) for the tasks he is likely to be given. In view of
It is anomalous that in England and United States where the fact that there is no internationally accepted definition of
the term community medicine is freely used, their standard the word “physician”, the WHO has adopted the following
textbooks on the subject are still titled Public Health (e.g., definition (138).
Oxford “Textbook of Public Health;” Maxcy-Rosenau: ‘A physician is a person who, having been regularly
“Public Health and Preventive Medicine”). admitted to a medical school, duly recognized in the
by R△J
56 CONCEPT OF HEALTH AND DISEASE

country in which it is located, has successfully completed him in making a community diagnosis. The focus is on the
the prescribed courses of studies in medicine and has identification of the basic health needs and health problems
acquired the requisite qualification to be legally licensed to of the community. The needs as felt by the community
practise medicine (comprising prevention, diagnosis, (some of which may have no connection at all with health)
treatment and rehabilitation) using independent should be next investigated and listed according to priority
judgement to promote community and individual health”. for community treatment.
In India, at present, a doctor soon after graduation, has
often to take charge of a health centre (population 30,000) Community treatment
which is usually in a rural area. He is called upon to provide Community treatment or community health action is the
promotive, preventive, curative, rehabilitative and emergency sum of steps decided upon to meet the health needs of the
care services appropriate to meet the main health problems in community taking into account the resources available and
the community, with special attention to vulnerable groups. the wishes of the people, as revealed by community
The functions of the health centre are discussed elsewhere. diagnosis. Improvement of water supplies, immunization,
The functions of a doctor (physician) may be summarized as health education, control of specific diseases, health
follows: legislation are examples of community health action or
(a) The care of the individual: A physician must be able to interventions. Action may be taken at three levels: at the
assess the state of health of the individual. This would level of the individual, at the level of the family and at the
include a clinical diagnosis, a simple laboratory diagnosis as level of the community (139).
well as an assessment of the individual’s state of nutrition, A programme of community action must have the
level of development, social and emotional state and the following characteristics: (a) it must effectively utilize all the
health needs. He must then be able to take any further available resources, (b) it must coordinate the efforts of all
measures necessary for treatment, prevention and referral to other agencies in the community, now termed as
higher levels of health care. He must be particularly expert “intersectoral coordination”, and (c) it must encourage the
in common conditions, in first-aid and in the management of full participation of the community in the programme. These
acute emergencies. Because of the large numbers involved, are the principles on which primary health care, as defined in
he must know how to delegate work to his auxiliaries. the Alma-Ata Declaration, is based. This approach is a
(b) The care of community: The care of the community significant departure from the earlier basic services approach.

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centres round the eight essential elements of primary health
care as stated in the Alma-Ata Declaration (see page 37). DISEASE CLASSIFICATION
The physician is the leader of the “health team”. He There is a wide variation among countries in the criteria
provides primary health care through the health team at the and standards adopted for diagnosis of diseases and their
grass-root level. He should be familiar with community notification, making it difficult to compare national statistics.
diagnosis, prioritization of health problems and community A system of classification was needed whereby diseases could
treatment. be grouped according to certain common characteristics, that
(c) The physician as a teacher: The term “doctor” by would facilitate the statistical study of disease phenomena.
derivation means to teach. Therefore the physician has a Over the years, many approaches were tried to classify
major responsibility as a teacher and educator. In his diseases. John Graunt in the 17th century in his study of Bills
practice, in his professional associations and in his of Mortality, arranged diseases in an alphabetical order.
community activities, the physician has wide educational Later, a more scientific approach was adopted in classifying
opportunities. But unfortunately, the physician’s role as a diseases according to certain characteristics of the disease or
teacher is a neglected one. Many physicians are reluctant to injuries such as (a) the part of the body affected (b) the
capitalize on their role as educators. As a teacher, the aetiologic agent (c) the kind of morbid change produced by
physician can play an effective role in community health the disease, and (d) the kind of disturbance of function
education so that individuals, families and communities produced by the disease or injury. Thus there are many axes
assume greater responsibility for their own health and of classification, and the particular axis selected will depend
welfare, including self-care. He can also generate and on the interest of the investigator (140).
mobilize community participation in health programmes
through effective propagation of relevant information. International classification of diseases
All the above criteria formed the basis of the International
Community diagnosis classification of diseases (ICD) produced by WHO and
The diagnosis of disease in an individual patient is a accepted in the year 1940 for national and international use.
fundamental idea in medicine. It is based on signs and Since its inception, ICD has been revised about once every
symptoms and the making of inferences from them. When 10 years; the 10th revision, came into effect on January 1,
this is applied to a community, it is known as community 1993. Earlier, the scope of ICD was expanded in the sixth
diagnosis. The community diagnosis may be defined as the revision in 1948 to cover morbidity from illness and injury.
pattern of disease in a community described in terms of the The ICD also provides a basis that can be adapted for use in
important factors which influence this#pattern (139). other fields.
The community diagnosis is based on collection and ICD is the foundation for the identification of health
interpretation of the relevant data such as (a) the age and trends and statistics globally and is the international
sex distribution of a population; the distribution of standard for reporting diseases and health conditions. It is a
population by social groups; (b) vital statistical rates such as diagnostic classification standard for all clinical and research
the birth rate, and the death rate; (c) the incidence and purposes. ICD defines the universe of diseases, disorders,
prevalence of the important diseases of the area. In injuries and other related health conditions, listed in a
addition, a doctor must be able to find information on a comprehensive, hierarchical fashion that allows for : easy
wide variety of social and economic factors that may assist storage, retrieval and analysis of health information for
by R△J
 DISEASE CLASSIFICATION 57
evidence-based decision-making; sharing and comparing 7. Sleep-wake disorders.
health information between hospitals, regions, settings and 8. Disease of the visual system.
countries; and data comparison in the same location across
9. Diseases of the nervous system.
different time period.
10. Diseases of the ear and mastoid process.
ICD-11 (141) 11. Diseases of the circulatory system.
The ICD-11 has been updated for the 21st century to 12. Diseases of the respiratory system.
reflect the significant progress in science and medicine over 13. Diseases of the digestive system.
the past 30 years and has been designed for the use with
14. Diseases of the skin.
digital health applications and application systems. The
digital platform for ICD-11 can be accessed online or 15. Diseases of the musculoskeletal system and connective
downloaded remotely free of charge and in multiple tissue.
languages via the online browser. It comprises over 55,000 16. Diseases of the genitourinary system.
entities. 17. Conditions related to sexual health.
Besides diseases, ICD includes disorders, injuries, 18. Pregnancy, childbirth and the puerperium.
external causes, signs and symptoms, substances, 19. Certain conditions originating in the perinatal and
medicaments, anatomy, devices, histopathology, severity neonatal period.
and much more and 120,000 clinical terms (and can code
millions of terms), with thousands of new categories and 20. Developmental anomalies.
updated classification schemes, and is intended to supersede 21. Symptoms, signs or clinical findings, not elsewhere
the 10th Revision, which was more than 28 years old and classified.
clinically outdated. 22. Injury, poisoning or certain other consequences of
New to ICD-11 is a chapter on sexual health, which external causes.
brings together several conditions that were previously 23. External causes of morbidity and mortality.
classified differently. Gender incongruence is included in this 24. Factors influencing health status or contact with health
new chapter, reflecting an understanding that it is not a services.

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mental health condition. Re-classification should help to 25. Codes for special purposes.
reduce the stigma attached to gender-defined states.
Another new chapter focuses on traditional medicine, 26. Supplementary chapter, Traditional Medicine
commonly used across many countries. In a landmark Conditions - Module I.
decision, stroke is now listed as a neurological disorder and V. Supplementary section for functioning assessment.
not as a disorder of the circulatory system. This important X. Extension codes.
change was long overdue and it brings stroke out of the
shadow of heart disease. Linkages with other classifications and
The new classification of HIV recognizes advances in HIV terminologies (139)
therapy, which should be seen as a chronic condition. The ICD-11 incorporates on links with the following
Allergy is coded under diseases of the immune system. classifications and terminologies through the ICD-11
Attention deficit hyperactivity disorder’s updated description foundation :
states that the symptoms no longer have to occur within
a. International Classification of Disease for Oncology -
fixed age range to lead to diagnosis. The updates also
ICD-0
enable better reporting of antimicrobial resistance, with
codes that are more in line with the Global Antimicrobial b. International Classification of External Causes of Injury -
Resistance Surveillance System. ICECI
In this iteration of the ICD, special attention has been c. International Classification of Functioning, Disability and
dedicated to mental health. Simpler diagnostic descriptions Health - ICF
will make mental health diagnosis more accessible to d. International Classification of Primary Care - ICPC
health-care professionals globally. For instance, the ICD-11 e. Other terminologies such as OrphaNet and
list of post-traumatic stress disorder criteria have been SNOMED-CT
reduced to facilitate easier diagnosis and improve access to
treatment. Addictive conditions, such as gaming and The International Classification of Functioning,
hoarding disorders, have been added. Compulsive sexual Disability and Health (ICF) (142)
behaviour was included as an impulse control disorder.
The ICF is a framework for organizing and documenting
The International Classification of Diseases 11th Revision information on functioning and disability (WHO 2001). It
has been adopted by the World Health Assembly in 2019 conceptualizes functioning as a “dynamic interaction
and it will come into effect from 1st January 2022. between a person’s health condition, environmental factors
The ICD-11 contains following chapters : and personal factors”.
1. Certain infectious and parasitic diseases. ICF provides a standard language and conceptual basis
2. Neoplasms. for the definition and measurement of disability, and it
3. Diseases of blood and blood forming organs. provides classification and codes. It integrates the major
models of disability - the medical model and the social
4. Disorders of the immune system. model - as a bio-psycho-social synthesis. It recognizes the
5. Endocrine, nutritional and metabolic diseases. role of environmental factors in the creation of disability, as
6. Mental, behavioural or neurodevelopmental disorders. well as the health conditions.
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58 CONCEPT OF HEALTH AND DISEASE

Functioning and disability are understood as umbrella 27. India Study Channel (2011), Difference between old and new
terms denoting the positive and negative aspects of calculation methods of HDI.
functioning from a biological, individual and social 28. UNDP (2011), Human Development Report 2011, Oxford University
Press.
perspective. ICF, therefore provides definitions and
29. UNDP (2020), Human Development Report 2020.
categories in neutral language, wherever possible. ICF is
30. WHO (1998), International Digest of Health Legislation, Vol. 49, No.
aetiology - neutral, i.e., disability is not differentiated by 1,1998.
aetiology. The ICF covers the entire life span. ICF organizes 31. WHO (1986). Techn.Rep.Ser.,No.731.
information in two parts. Part 1 deals with functioning and 32. Wingard, D.L. (1982). Am.J.Epid, 116 (5) 765.
disability while part 2 covers contextual factors. Each part 33. Last, J.M. (1983). A Dictionary of Epidemiology, Oxford University
has two components : Press.
a. Functioning and disability : 34. Govt, of India (2021), National Family Health Survey (NFHS-5),
2019-20, Ministry of Health and Family Welfare, New Delhi.
- Body function and body structures. 35. Banerji, (1985). Health & Family Planning Services in India, Lok
- Activities and participation. Paksh,N. D.
b. Contextual factors : 36. UNICEF (2018), The State of World's Children 2018.
37. WHO (1986). WHO Chr., 32 (7) 295.
- Environment factors 38. WHO (1978). WHO Chr., 32 (9) 356.
- Personal factors 39. Noble, John, (1976). Primary Care & Practice of Med., Little Brown,
Boston.
ICF can be used to structure a holistic approach to
40. Miquel Porta, A Dictionary of Epidemiology, Sixth Edition, Oxford
management of any patient with any health condition, University Press.
ensuring person - centred care. As ICF does not belong to any 41. Editorial (1982). Canad. J. Pub. Hlth, 73 (3) 153.
single discipline, it is ideal tool to link and integrate information 42. Susser, M.W. (1973). Causal thinking in the health sciences, Ox.U.P
to different health professionals. This can result in better 43. Circle of Rights, Economic, Social and Cultural Rights Activisms : A
patient experience; a bio-psycho-social-spiritual approach to Training Resource, Module 14, The Right to Health.
patient care; improved health outcomes; the strengthening of 44. WHO, Fact Sheet No. 31, The Right to Health.
health systems; improved inter-professional education, 45. WHO (2007), Joint - Fact Sheet WHO/OHCHR/323.
collaboration and practice, task sharing and task shifting. 46. Levin, L.S. and E.L. Idler (1983). Ann.Rev.Pub.Health, 4: 181-201
47. Djukanovic, V. and Mach, E.P. (1975). Alternative approaches to

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References meeting basic health needs in developing countries, A Joint UNICEF/
1. WHO (1979). Health for All, Sr.No.2. WHO Study.
2. WHO (1980). WHO Chr., 34 (2) 80. 48. WHO (1987). Techn.Rep.Ser., No.744.
3. Ahmed, and Coelho, (1979). Toward a Hew Definition of .Health, 49. WHO (1986). Seventh Report World Health Situation, Vol.4
Pleum, N. Y. Evaluation of the strategy for health for all, WHO, SEARO.
4. Dubos, R. (1965). Man Adapting, New Haven, Yale Uni.Press. 50. WHO (1984). Strengthening Ministries of Health for Primary Health
Care, WHO Offset Publ.No.82.
5. WHO (1986). Concepts of Health Behaviour Research, Reg. Health
Paper No. 13, SEARO, New Delhi. 51. Sigerist, H.E. (1941). Medicine and Human Welfare, New Haven,
6. WHO (1978). Health for All, Sr.No.l. Yale University Press.
7. WHO (1957). Techn.Rep.Ser.,No.137. 52. WHO (1984). Intersectoral Linkages and Health Development, WHO
Offset Publ.No.83.
8. Crew, F.A.E. (1965). Health its Nature and Conservation, Pergamon
Press, London. 53. WHO (1984). Health for All, Ser.No.9.
9. Sartorius, N. (1983). Bull WHO, 61 (1) 5. 54. WHO (1984). Health Planning and Management Glossary.
Reg.Health Paper 2, SEARO, New Delhi.
10. Fillenbaum, G.G. (1984) The Wellbeing of the Elderly, WHO Offset
Publ.No.84. 55. WHO (1981). Health for All, Sr.No.6.
11. Cmich, D.E. (1984) Jr.School Health, 54 (1) 30-32. 56. Hogarth, J. (1978). Glossary for Health Care Terminology, Public
12. Donald, C.A. et al (1978). Social Health. In : Conceptualization and Health in Europe-4.
measurement of health for adults in the health insurance study, Santa 57. WHO (1981). Health for All, Sr.No.4.
Monica, CA, Rand Corporation, Vol 4. 58. WHO (2006). Basic Epidemiology, Second Ed., R. Bonita,
13. Eberst, R.M. (1984). Jr.School Health, 54 (3) 99-104. R. Beaglehole, T. Kjellstrom.
14. WHO (1985). Techn.Rep.Ser.,No.714. 59. Ray M. Merrill, Thomas C. Timmreck, Introduction to Epidemiology,
15. Indian Council of Social Science Research and ICMR (1981). Health 4th Ed., Jones and Bartlett Publishers.
for All, an alternative strategy, Voluntary Health Asso. of India, New 60. WHO (1976). Techn. Rep.Ser., No.587.
Delhi. 61. Wilson, R.W. and T.F. Drury (1984). Ann Rev. Pub.Health. 5:83-106.
16. Twaddle, A.C. and Hassler, R.M. (1977). A Sociology of Health, St. 62. Last, John M., A Dictionary of Epidemiology, Fourth Ed. (2001),
Louis, Mosby. Ox.U.P
17. Charles, Sir John (1970). WHO Chr., 24 (9) 391. 63. UN Dept, of Economic and Social Affairs (1978). Social Indicators,
18. Dubos, R. (1969). WHO Chro., 23:499. Statistical Paper Series M.No.63.
19. Carlos, M. (1978). BullPAHO, 12:7. 64. Sheehan, and Hopkins, (1979). Basic needs performance, ILO,
20. Nagpal, R. and Sell, H. (1985). Subjective Wellbeing, Reg. Health Geneva.
Papers No. 7, SEARO, WHO New Delhi. 65. WHO (2003), World Health Report 2003, Shaping the future.
21. WHO (1975). Promoting Health in the Human Environment, 66. WHO (2015), Health in 2015, from MDGs (Millennium Development
Geneva. Goals) to SDGs (Sustainable Development Goals).
22. United Nations (1961). International Definition and Measurement of 67. WHO (2018), Global Reference List of 100 Core Health Indicators,
Levels of Living-an interim guide, UN Publ. 61, IV F. 2018.
23. WHO (1976). WHO Chr, 30 (8) 312. 68. Govt, of India (2019), Healthy States, Progressive India, Report of
24. WHO (2004), A Glossary of Terms for Community Health Care and the Niti Aayog on the Ranks of States and Union Territories.
Services for Older Persons, Vol. 5. Ageing and Health Technical 69. UNFPA (2017), State of World’s Population 2017, Worlds Apart,
Report. Reproductive health and rights in an age of inequality.
25. Morris, D.M. and Michelle, B.M. (1982). Measuring the condition of 70. Population Reference Bureau (2015), The Urban-Rural Divide in
India’spoor-PQLI, Promilia & Co., New Delhi-1. Health and Development.
26. UNDE Human Development Report 2015, Oxford University Press. 71. Lee PR. and P.E. Franks (1977). Preventive Medicine, 6, 209: 226.
by R△J
 REFERENCES 59
72. WHO (1980). Information systems for health services, Public Health 108. Suchman, L.M. (1970). Public Health Reports, 85:1.
in Europe-13, Regional Office for Europe. 109. WHO (1987). World Health, May 1987.
73. WHO (1987). Techn.Rep.Ser.,No.746. 110. Lauzon, R.R. J. (1977). Canad. J.Pub.Health, 68:311.
74. Kohn,R. (1983). The health centre concept in primary health care, 111. WHO (1984). Techn.Rep.Ser.,No.713.
Public health in Europe-22, Regional Office for Europe. 112. WHO (1976). WHO Chr.,30 (1) 16.
75. WHO (1986). Health promotion, Ottawa Charter, First International 113. WHO (1973). Tech.Rep.Ser., No.535.
Conference, 21st Nov. 1986. 114. WHO (1980). International classification of impairments, disabilities,
76. WHO (1981). Health for All, Sr.No.5. handicaps. WHO, Geneva.
77. WHO (1980). Sixth Report, World Health Situation. 115. WHO (1981). Techn.Rep.Ser., No.668.
78. WHO (1983). The concept of Health Services Research, SEARO 116. WHO (1969). Techn.Rep.Ser., No.419.
Techn.Publ.l, New Delhi. 117. WHO (1984). World Health, May 1984.
79. Grundy, F.and W.A. Reinke (1973). Health Practice Research and 118. WHO (2020). The top 10 causes of death, 9th Dec. 2020.
Formalized Management Methods, WHO, Geneva. 119. WHO (2020). WHO reveals leading causes of death and disability
80. WHO (1979). WHO Chr., 33(2)49. world-wide 2000-2019, 9th Dec. 2020.
81. Gregg Alan (1956). Amer. J. Public Health, 46: 1384. 120. WHO (2020). Global Health Observatory, Global health estimates
82. Suchman, E.A. (1963). Sociology and the field of Public Health, life expectancy and leading causes of death and disability, 2020.
Russel Sage Foundation, New York. 121. WHO (2020). World’s leading causes of death statistics, 11th Dec.
83. Ouslander, J.G. and J.C. Beck (1982). Ann.Rev.Public Health, 3:58. 2020.
84. Susser, M.W. and Waston, W. (1971). Sociology in Medicine, 2nd ed. 122. Govt, of India (2022), Causes of death statistics 2015-17, Office of
London, Oxford University Press. the Registrar General and Census Commissioner, India, New Delhi,
85. Le Riche, W.H. and Jean Milner (1971). Epidemiology as Medical Ministry of Home Affairs, March 2022.
Ecology, Churchill Livingstone, Edinburgh. 123. Clark, Duncan and B. MacMohan (1981). Preventive and
86. Mausner, J.S. and Kramer, S. (1985). Mausner and Bahn: Community Medicine, 2nd ed., Boston: Little, Brown & Co.
Epidemiology-An Introductory Text, Saunders. 124. WHO (1952). Techn.Rep.Ser., No.55.
87. MacMahon, B.and Pugh, T.F. (1970). Epidemiology: Principles and 125. WHO (1973). Techn.Rep.Ser., No.533.
Methods, Boston: Little, Brown. 126. Roger Detels and Lester Breslow (1984). In: Oxford Textbook of
88. Stallones, R.A. (1971). Environmental Ecology and Epidemiology, Public Health. Vol 1. W.W. Holland, et al (eds) Oxford University
PAHO Scientific Publ. No. 231. Press.
89. Leavell, H.R. and Clark, E.G. (1965). Preventive Medicine for the 127. Brockington, F. (1958). World Health, A pelican book.
Doctor in his Community, McGraw Hill, New York. 128. Norton, Alan (1969). The New Dimensions of Medicine, 20th century
90. Suchman, E.A. (1970). Arch.Env. Health, 20:105.

telegram-@Cherry_2412
studies, Hodder and Stoughton, London.
91. WHO (1980). WHO Chr., 34 (5) 189. 129. Chave, S.P.W. (1984). In: Oxford Textbook of Public Health, Vol 1,
92. WHO (1979). Techn.Rep.Ser.,No.636. Oxford University Press.
93. Backett, E.M. et al (1984). The risk approach to health care, Public 130. Stewart, G.T. (1974). Int.J.Epid, 3 (3) 275.
health papers No.76. 131. Warren, M.D. and Roy M.Acheson (1973). Int.J.Epi., 2 (4) 371-378.
94. Fielding, J.E. (1984). Ann.Rev.Public Health, 5:239. 132. WHO (1985). Primary prevention coronary heart disease, EURO
95. WHO (1984). Techn.Rep.Ser., No.706. Reports and Studies 98.
96. WHO (1977). WHO Chr., 31:150. 133. Kark, S.L. etal (1973). Int J. Epid, 2 (4) 419.
97. WHO (1976). Tech.Rep.Ser.No.593. 134. WHO (1963) Techn.Rep.Ser.,No. 261.
98. Lilienfeld, A.M. and Lilienfeld, D. (1979). Foundations of 135. WHO (1957). Techn.Rep.Ser., No. 122.
Epidemiology, New York, Oxford University Press. 136. Rene Sand (1952). The Advance to Social Medicine, Lon. Staples
99. Stuart-Harris, Charles (1981). World Health Forum, 2 (2) 305. Press.
100. Soper, F.L. (1962). Am. J.Public Health, 52:724-745. 137. WHO (1987). Techn.Rep.Ser., No.744.
101. WHO (1972). Health Hazards of the Human Environment, WHO 138. WHO (1972). WHO Chr., 26 (4) 181.
Geneva. 139. King Maurice ed (1982). Medical Care in Developing Countries,
102. John M. Last (2001), A Dictionary of Epidemiology, 4th Ed. Ox.U.P
103. WHO (1986). Techn.Rep.Ser.,No.736. 140. Kupka, K. (1978). WHO Chr., 32:219-225.
104. WHO (1979). WHO Chr.,33 (2) 50. 141. WHO (2019), ICD 11, Implementation or Transition Guide, 2019,
105. WHO (1982). Techn.Rep.Ser.,No.678. Revision.
106. WHO (1986). Techn. Rep.Ser., No.732. 142. WHO (2013), How to use the ICF, A practical manual for using the
107. Dept, of Health and Social Security (1976). Prevention and Health International Classification of Functioning, Disability and Health, Oct.
Everybody’s Business, London, HMSO. 2013.

by R△J
 3 Principles of Epidemiology
1

and Epidemiologic Methods

“I keep six honest serving men; they taught me all I know.
Their names are what, why, when, how, where and who. ”

Epidemiology is the basic science of preventive and There appears to be almost as many definitions of
social medicine. Although of ancient lineage, it made only epidemiology as there are authors who have written on the
slow progress upto the start of 20th century. Epidemiology subject, ranging from Hippocrates to those of the present
has evolved rapidly during the past few decades. Its day. A short list is given below (2, 3) :
ramifications cover not only study of disease distribution 1. That branch of medical science which treats epidemics
and causation (and thereby prevention), but also health and (Parkin, 1873).
health-related events occurring in human population. 2. The science of the mass phenomena of infectious
Modern epidemiology has entered the most exciting phase diseases (Frost, 1927).
of its evolution. By identifying risk factors of chronic disease,
3. The study of disease, any disease, as a mass
evaluating treatment modalities and health services, it has
phenomenon (Greenwood, 1934), and

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provided new opportunities for prevention, treatment,
4. The study of the distribution and determinants of
planning and improving the effectiveness and efficiency of
health services. The current interest of medical sciences in disease frequency in man (MacMahon, 1960).
epidemiology has given rise to newer off-shoots such as
infectious disease epidemiology, chronic disease
Definition
epidemiology, clinical epidemiology, serological Epidemiology has been defined as (4)
epidemiology, cancer epidemiology, malaria epidemiology, study of the occurrence and distribution of health-
neuro epidemiology, genetic epidemiology, occupational related events, states, and processes in specified
epidemiology, psychosocial epidemiology, and so on. This populations, including the study of the determinants
trend is bound to increase in view of the increasing influencing such processes, and the application of this
importance given to the pursuit of epidemiological studies. knowledge to control relevant health problems, j
That these studies have added substantially to .the Study includes surveillance, observation, screening,
advancement of medical knowledge is indisputable. This hypothesis testing, analytic research, experiments, and
Chapter studies the basic concepts and principles of prediction. Distribution refers to analysis by time, place (or
epidemiology as an introduction to the subject. space), and population (i.e. classes or subgroups of persons
affected in an organization, population or society, or at
History regional and global scales). Determinants are the geophysical,
Epidemiology began with Adam and Eve, both trying to biological, behavioural, social, cultural, economic, and
investigate the qualities of the “forbidden fruit”. political factors that influence health. Health-related events,
Epidemiology is derived from the word epidemic states and processes include outbreaks, diseases, disorders,
(epi = among; demos = people; logos = study), which is a very causes of death, behaviours, environmental and socio­
old word dating back to the 3rd century B.C. The economic processes, effects of preventive programmes, and
foundation of epidemiology was laid in the 19th century, use of health and social services. Specified populations are
when a few classic studies made a major contribution to the those with common contexts and identifiable characteristics.
saving of life. Mention is made of an Epidemiological Application to control ... makes explicit the aim of
Society in London in 1850s under the presidency of the Earl epidemiology - to promote, protect, and restore health, and
of Shaftesbury (1). The Society’s main concern was the to advance scientific knowledge (4).
investigation of infectious diseases. The sudden growth of The wide variety of meanings attached to epidemiology is
bacteriology had smothered the development of the expression of the wide ranging subject-matter. The
epidemiology in the Universities. diseases included in the subject-matter have increased from
In the United States, Winslow and Sedgwick both lectured those which occur in epidemics to include those infectious
in epidemiology in the early 1920s, although the subject was diseases which are endemic in nature, and more recently
not given departmental status. In 1927, W.H. Frost became chronic diseases, accidents and mental health. Modern
the first professor of epidemiology in US. Later Major epidemiology has also taken within its scope the study of
Greenwood became the first professor of epidemiology and health-related states, events and “facts of life” occurring in
medical statistics in the University of London (1). human population. This includes study of the health services
Epidemiology has grown rapidly during the past few decades. used by the population, and to measure their impact.
It has now become firmly established in medical education. Epidemiology, like public health itself, is often more

by R△J
 AIMS OF EPIDEMIOLOGY

concerned with the well-being of society as a whole, than a. to describe the distribution and magnitude of health
with the well-being of individuals. and disease problems in human populations
Although there is no single definition to which all b. to identify aetiological factors (risk factors) in the
epidemiologists subscribe, three components are common to pathogenesis of disease; and
most of them. First, studies of disease frequency; second, studies c. to provide the data essential to the planning,
of the distribution; and third, studies of the determinants. Each implementation and evaluation of services for the
of these components confers an important message. prevention, control and treatment of disease and to
the setting up of priorities among those services.
1. Disease frequency In order to fulfil these aims, three rather different classes of
Inherent in the definition of epidemiology is epidemiological studies may be mentioned: descriptive
measurement of frequency of disease, disability or death, studies, analytical studies, and experimental or intervention
and summarizing this information in the form of rates and studies (7). These studies are described in the following pages.
ratios (e.g., prevalence rate, incidence rate, death rate, etc).
The ultimate aim of epidemiology is to lead to effective
Thus the basic measure of disease frequency is a rate or
action :
ratio. These rates are essential for comparing disease
frequency in different populations or subgroups of the same a. to eliminate or reduce the health problem or its
population in relation to suspected causal factors. Such consequences; and
comparisons may yield important clues to disease aetiology. b. to promote the health and well-being of society as a
This is a vital step in the development of strategies for whole.
prevention or control of health problems.
Equally, epidemiology is also concerned with the
Epidemiology and clinical medicine
measurement of health-related events and states in the The basic difference between epidemiology and clinical
community (e.g., health needs, demands, activities, tasks, medicine is that in epidemiology, the unit of study is a “defined
health care utilization) and variables such as blood pressure, population” or “population at-risk”; in clinical medicine, the
serum cholesterol, height, weight, etc. In this respect, unit of study is a “case” or “cases”. In clinical medicine, the
epidemiology has the features of a quantitative science. physician is concerned with disease in the individual patient,
Much of the subject matter of measurement of disease and whereas the epidemiologist is concerned with disease patterns
health-related events falls in the domain of biostatistics, in the entire population. Epidemiology is thus concerned with

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which is a basic tool of epidemiology. both the sick and healthy. It has been stated that clinicians are
interested in cases with the disease, the statistician with the
2. Distribution of disease population from which the cases are derived, and the
It is well-known that disease, or for that matter health, is not epidemiologist is interested in the relationship between cases
uniformly distributed in human populations. The basic tenet of and the population in the form of a rate (8).
epidemiology is that the distribution of disease occurs in In clinical medicine, the physician seeks a diagnosis from
patterns in a community (3) and that the patterns may lead to which he derives a prognosis and prescribes specific
the generation of hypotheses about causative (or risk) factors. treatment. In epidemiology, an analogous situation exists.
An important function of epidemiology is to study these The epidemiologist is confronted with relevant data derived
distribution patterns in the various subgroups of the from a particular epidemiological study. He seeks to identify
population by time, place and person. That is, the a particular source of infection, a mode of spread or an
epidemiologist examines whether there has been an increase aetiological factor in order to determine a future trend and
or decrease of disease over time span; whether there is a higher recommend specific control measures (9). The
concentration of disease in one geographic area than in others; epidemiologist also evaluates the outcome of preventive and
whether the disease occurs more often in men or in a particular therapeutic measures instituted which provides the necessary
age-group, and whether most characteristics or behaviour of guidance and feed-back to the health care administrator for
those affected are different from those not affected (5). effective management of public health programmes.
Epidemiology addresses itself to a study of these variations or
patterns, which may suggest or lead to measures to control or In clinical medicine, the patient comes to the doctor; in
prevent the disease. An important outcome of this study is epidemiology, the investigator goes out into the community
formulation of aetiological hypothesis. This aspect of to find persons who have the disease or experience of the
epidemiology is known as “descriptive epidemiology”. suspected causal factor in question. Clinical medicine is
based on biomedical concepts with an ever-increasing
3. Determinants of disease concern for refining the technique of diagnosis and
treatment at the individual level. The subject matter of
A unique feature of epidemiology is to test aetiological clinical medicine is easily “perceived” by such techniques as
hypotheses and identify the underlying causes (or risk factors)
clinical and laboratory examinations including postmortem
of disease. This requires the use of epidemiological principles
reports. In contrast, the subject matter of epidemiology is
and methods. This is the real substance of epidemiology. This
“conceptual” and can only be symbolized in the form of
aspect of epidemiology is known as “analytical
tables and graphs (10).
epidemiology”. Analytical strategies help in developing
scientifically sound health programmes, interventions and Finally, it may be stated that clinical medicine and
policies. In recent years, analytical studies have contributed epidemiology are not antagonistic. Both are closely related,
vastly to our understanding of the determinants of chronic co-existent and mutually helpful. Most epidemiological
diseases, e.g., lung cancer and cardiovascular diseases. enquiries could never be established without appropriate
clinical consideration as to how the disease in question can
Aims of epidemiology be identified among individuals comprising the group under
According to the International Epidemiological scrutiny. Likewise, a knowledge of prevalence, aetiology and
Association (IEA), epidemiology has three main aims (6) \ prognosis derived from epidemiological research is

by R△J
■ PRINCIPLES OFEPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

important to the clinician for the diagnosis and management

of individual patients and their families (10).
following pages. It may be mentioned that international
comparisons may be difficult because of differences in
terminology. It requires standardization of definitions,
Epidemiological approach classifications, criteria and nomenclature.
The epidemiological approach to problems of health and
disease is based on two major foundations: BASIC MEASUREMENTS IN EPIDEMIOLOGY
a. Asking questions Epidemiology focuses, among other things, on
b. Making comparisons. measurement of mortality and morbidity in human
populations. The first requirement is therefore definition of
a. Asking questions what is to be measured and establishment of criteria or
Epidemiology has been defined as “a means of learning standards by which it can be measured. This is not only a
or asking questions....and getting answers that lead to prerequisite of epidemiological studies, but also one of its
fuither questions” (11). For example, the following goals (13). The clinician may not require a precise definition
questions could be asked (12) : of disease (e.g., migraine) for immediate patient care, but the
epidemiologist needs a definition (a) that is acceptable and
RELATED TO HEALTH EVENTS applicable to its use in large populations; and (b) that is
a. What is the event ? (the problem) precise and valid, to enable him to identify those who have
b. What is its magnitude? the disease from those who do not (10). Clear definitions
c. Where did it happen? help to minimize errors in classification of data. Standardized
d. When did it happen? methods of observation and recording are therefore essential
e. Who are affected? before commencing any epidemiological study.
f. Why did it happen?
Measurements in Epidemiology
RELATED TO HEALTH ACTION The scope of measurements in epidemiology is very
a. What can be done to reduce this problem and its broad and unlimited and includes the following : (14)
consequences ? a. Measurement of mortality
b. How can it be prevented in the future ? b. Measurement of morbidity
c. What action should be taken by the community ?

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c. Measurement of disability
By the health services? By other sectors ? Where d. Measurement of natality
and for whom these activities be carried out ? e. Measurement of the presence, absence or
d. What resources are required ? How are the activities distribution of the characteristic or attributes of the
to be organized ? disease
e. What difficulties may arise, and how might they be f. Measurement of medical needs, health care
overcome ? facilities, utilization of health services and other
Answer to the above questions may provide clues to health-related events
disease aetiology, and help the epidemiologist to guide g. Measurement of the presence, absence or
planning and evaluation. distribution of the environmental and other factors
suspected of causing the disease, and
b. Making comparisons h. Measurement of demographic variables.
The basic approach in epidemiology is to make Inspite of a wide range of presently available
comparisons and draw inferences. This may be comparison measurements, there are many areas which are not fully
of two (or more groups) - one group having the disease (or covered. As for example, measurement of the psycho-social
exposed to risk factor) and the other group(s) not having the aspects of health and disease. The components of well-being
disease (or not exposed to risk factor), or comparison need to be better identified.
between individuals. By making comparisons, the
epidemiologist tries to find out the crucial differences in the The basic requirements of measurements are validity,
host and environmental factors between those affected and reliability, accuracy, sensitivity and specificity. These are
not affected. In short the epidemiologist weighs, balances and discussed in the next chapter. Finally, measurement errors are
contrasts. Clues to aetiology come from such comparisons. unavoidable, no matter where and by whom measurements
are taken. The purpose of quality control in measurement is,
One of the first considerations before making therefore, not to eliminate errors, but to reduce them as much
comparisons is to ensure what is known as “comparability” as possible or at least to an acceptable level.
between the study and control groups. In other words, both
the groups should be similar so that “like can be compared In the above connection, the following terminology needs
with like”. For facts to be comparable, they must be explanation: (a) Variate: Any piece of information referring
accurate, and they must be gathered in a uniform way. For to the patient or his disease is called a variate. A variate can
example, the study and control groups should be similar be discrete, that is it can be present or absent, e.g., cancer
with regard to their age and sex composition, and similar lung, broken leg, or rash in measles or it can be continuously
other pertinent variables. The best method of ensuring distributed, e.g., blood pressure, serum cholesterol, height,
comparability, in such cases, is by randomization or random etc. (b) Circumstance: Any factor in the environment that
allocation (see page 90). Where random allocation is not might be suspected of causing a disease, e.g., air pollution,
possible (as in case control and cohort studies) what is polluted water, etc (10).
known as “matching” is done for selected characteristics that The frequency of a discrete variable or circumstance can be
might confound the interpretation of results. Another expressed as a rate in relation to population. The frequency of
alternative is standardization which usually has a limited continuously distributed variables or circumstances is
application to a few characteristics such as age, sex and expressed in the form of a frequency distribution using the
parity. These biostatistical concepts are elaborated in the summarizing indices of mean, centiles, standard deviations, etc.

by R△J
 BASIC MEASUREMENT IN EPIDEMIOLOGY
63
Tools of measurement Example 2:
The epidemiologist usually expresses disease magnitude The number of children with scabies at a certain time
as a rate, ratio or proportion. A clear understanding of the The number of children with malnutrition at a certain time
term is required for proper interpretation of epidemiological Other examples include: sex-ratio, doctor-population
data. The basic tools of measurement in epidemiology are : ratio, child-woman ratio, etc.
1. Rates
2. Ratios, and 3. PROPORTION
3. Proportions A proportion is a ratio which indicates the relation in
magnitude of a part of the whole. The numerator is always
1 RATE included in the denominator. A proportion is usually
When we say there were 500 deaths from motor vehicle expressed as a percentage.
accidents in City A during 2010, it is just nothing more than The number of childern with scabies at a certain time
counting deaths in that city during that particular year. Such Example :------------------------------------------------------------ X 100
a statement might be sufficient for the municipal The total number of children in the village at the
administrator to provide necessary health services. But it same time
conveys no meaning to an epidemiologist who is interested CONCEPT OF NUMERATOR AND DENOMINATOR
in comparing the frequency of accidents in City A with that
in City B. To allow such comparisons, the frequency must be 1. Numerator
expressed as a rate. Numerator refers to the number of times an event (e.g.,
A rate measures the occurrence of some particular event sickness, birth, death, episodes of sickness) has occurred in
(development of disease or the occurrence of death) in a a population, during a specified time-period. The
defined population during a given time period. It is a numerator is a component of the denominator in calculating
statement of the risk of developing a condition. It indicates a rate, but not in a ratio.
the change in some event that takes place in a population
over a period of time. An example of a typical rate is the 2. Denominator
death rate. It is written as below: The lower portion of a ratio. Numerator has little meaning

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Number of deaths in one year unless it is related to the denominator, The epidemiologist
Death rate = --------------------------------------- X 1000 has to choose an appropriate denominator while calculating
Mid-year population
a rate. It may be (a) related to the population, or (b) related
A rate comprises the following elements - numerator, to the total events.
denominator, time specification and multiplier. The time
dimension is usually a calendar year. The rate is expressed a. Related to the population
per 1000 or some other round figure (10,000; 100,000) The denominators related to the population comprise the
selected according to the convenience or convention to following: (i) MID-YEAR POPULATION: Because the
avoid fractions. population size changes daily due to births, deaths and
migration, the mid-year population is commonly chosen as a
The various categories of rates are :
denominator. The mid-point refers to the population
(1) Crude rates: These are the actual observed rates such estimated as on the first of July of an year, (ii) POPULATION
as the birth and death rates. Crude rates are also AT-RISK: This is an important concept in epidemiology
known as unstandardized rates. because it focuses on groups at risk of disease rather than on
(2) Specific rates: These are the actual observed rates due individuals. The term is applied to all those to whom an
to specific causes (e.g., tuberculosis); or occurring in event could have happened whether it did or not. For
specific groups (e.g., age-sex groups) or during example, if we are determining the rate of accidents for a
specific time periods (e.g., annual, monthly or weekly town, the population at risk is all the people in the town. But
rates). sometimes, it may be necessary to exclude people because
they are not at risk, as for example, in food poisoning, only
(3) Standardized rates: These are obtained by direct or those who ate the food are at risk of becoming ill. Similarly in
indirect method of standardization or adjustment, e.g., calculating “general fertility rate”, the denominator is
age and sex standardized rates (see page 66, 67). restricted to women of child-bearing age (i.e., 15-49 years);
older women and little girls are excluded because they are
2. RATIO not “at risk” of becoming pregnant. In short, “population at
Another measure of disease frequency is a ratio. It risk” is restricted solely to those who are capable of having or
expresses a relation in size between two random quantities. acquiring the disease or condition in question,
The numerator is not a component of the denominator. The (iii) PERSON-TIME: In some epidemiological studies (e.g.,
numerator and denominator may involve an interval of time cohort studies), persons may enter the study at different
or may be instantaneous in time. Broadly, ratio is the result times. Consequently, they are under observation for varying
of dividing one quantity by another. It is expressed in the time periods. In such cases, the denominator is a
form of: combination of persons and time. The most frequently used
person-time is person-years. Sometimes, this may be
x : y or 2L person-months, person-weeks or man-hours. For example,
V if 10 persons remain in the study for 10 years, there are said
Example 1: to be 100 person-years of observation. The same figure
The ratio of white blood cells relative to red cells is would be derived if 100 persons were under observation for
1:600 or 1/600, meaning that for each white cell, there one year. These denominators have the advantage of
are 600 red cells. summarizing the experience of persons with different

by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

durations of observation or exposure, (iv) PERSON- It will be seen from Fig. 1 that the international certificate
DISTANCE: A variant of person-time is person-distance, as of cause of death is in two parts. Part I deals with the
for example passenger-miles. (v) SUB-GROUPS OF THE immediate cause of death and the underlying cause.
POPULATION: The denominator may be subgroups of a ‘‘Causes of death : The causes of death to be entered on
population, e.g., age, sex, occupation, social class, etc. the medical certificate of cause of death are all those
b. Related to total events diseases, morbid conditions, or injuries that either resulted
in or contributed to death and circumstances of the accident
In some instances, the denominator may be related to total or violence which produced any such injuries.
events instead of the total population, as in the case of infant
mortality rate and case fatality rate. In the case of accidents, Underlying cause of death : The underlying cause of
the number of accidents “per 1000 vehicles” or “per million death is (1) the disease or injury that initiated the train of
vehicle-miles” will be a more useful denominator than the events leading to death or (2) the circumstances of the
total population, many of them may not be using vehicles. accident or violence that produced the fatal injury.”
In Part II is recorded any significant associated disease
MEASUREMENT OF MORTALITY that contributed to the death but did not directly lead to it.
Traditionally and universally, most epidemiological Death Certificate used in India
studies begin with mortality data. Mortality data are
relatively easy to obtain, and, in many countries, reasonably In order to improve the quality of maternal mortality and
accurate. Many countries have routine systems for collecting infant mortality data and to provide alternative method of
mortality data. Each year, information on deaths is analyzed collecting data on deaths during pregnancy and infancy, a
and the resulting tabulations are made available by each set of questions are added to the basic structure of
government. Mortality data provide the starting point for international death certificate for use in India.
many epidemiological studies. In fact, they are the major
resource for the epidemiologist. Limitations of mortality data^
Mortality data are not without limitations. Problems are
Death Certificate (Certificate of cause of death) posed by (afjncomplete reporting of deaths. This is not a
The basis of mortality data is the Death Certificate. For problem in developed countries, but in”“India and other
developing countries, this may be considerable, (b) Lack of

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ensuring national and international comparability, it is very
necessary to have a uniform and standardized system of accuracy: That is inaccuracies in the recording of age and
recording and classifying deaths. The death certificate cause of death. The practice of medical certification of death
recommended by WHO for international use is given in is not widespread. If it does exist, the cause of death is often
Fig. 1 (4). inaccurate or incomplete due to such difficulties as lack of
In India, Death Certificate is a vital record signed by a diagnostic evidence, inexperience on the part of the certifying
licensed physician or another designated health worker, that doctor and absence of postmortem which may be important
includes cause of death, decedant’s name, sex, birth date, in deciding the cause of death, (c) Lack of uniformity: There is
adhar number, place of residence and of death, and whether no uniform and standardized method of collection of data.
the deceased had been medically attended before death. This hampers national and international comparability
Occupation, birth place, and other information may be (d) Choosing a single cause ofdeath: Most countries tabulate
included. mortality data only according to the underlying cause of

CAUSE OF DEATH Approximate

interval between
onset and death
I
Disease or condition directly (a)
leading to death* due to (or as a consequence of)

Antecedent causes (b)..................................................

Morbid conditions, if any, due to (or as a consequence of)
giving rise to the above cause,
stating the underlying
condition last due to (or as a consequence of)
(d)..................................................

II
Other significant conditions
contributing to the death, but
not related to the disease or
condition causing it

*This does not mean the mode of dying, e.g.,

heart failure, respiratory failure. It means the
disease, injury, or complication that caused
death

FIG. 1
Death Certificate. The International Standard Form (ICD-10)
Source : .(4)

by R△J
 MORTALITY RATES AND RATIOS 65
death. Other diseases (or risk factors) and conditions which as shown in Table 1. It can be seen that population B has
contribute to the patient’s death are not tabulated, and higher age-specific rates in all age groups. This seeming
valuable information is thereby lost, (e) Changing: Changing contradiction is due to differences in the age-composition of
coding systems and changing fashions in diagnosis may affect the population. The higher crude death rate in population A
the validity. We also need uniform definitions and is due to its older population compared with population B
nomenclature. (i)(Diseases with low fatality: Lastly, mortality which has a relatively younger population. Currently, this is
statistics are virtual y use ess, r " ’ disease is associated with the prevailing situation in most developing countries with low
low fatality (e.g., mental diseases, arthritis). crude death rates, but high age-specific death rates.
Uses of mortality data TABLE 1
Statistics on causes of death are important and widely Crude and age-specific death rates
used for a number of purposes. They may be employed in
explaining trends and differentials in overall mortality, Popula Crude Age-specific death rates per 1000 population
indicating priorities for health action and the allocation of -tion death
rate 0-1 1-4 5-7 8-44 45-64 65 +
resources, in designing intervention programmes, and in the
assessment and monitoring of public health problems and A 15 2 13.5 0.6 0.4 1.5 10.7 59.7
programmes - moreover, they give important clues for
epidemiological research. B 9.9 22 6 10 0.5 3.6 18.8 61.1

In summary, the crude death rates have a major

MORTALITY RATES AND RATIOS disadvantage, that is, they lack comparability for
The commonly used measures are described below : communities with populations that differ by age, sex, race,
etc. However, they should always be examined first, and
1. Crude death rate later the age-specific death rates which are the most useful
The simplest measure of mortality is the "crude death rate’. single measures of mortality. By moving away from the
It is defined as “the number of deaths (from all causes) per crude death rate to the more detailed age-specific rates, an
1000 estimated mid-year population in one year, in a given attractive feature of the crude death rate, that is, its ability to
place”. It measures the rate at which deaths are occurring portray an impression in a single figure is lost.

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from various causes in a given population, during a specified
period. The crude death rate is calculated from the formula: 2. Specific death rates
When analysis is planned to throw light on aetiology, it is
Number of deaths during the year
----------------------------------------- X 1000 essential to use specific death rates. The specific death rates
Mid-year population may be - (a) cause or disease specific - e.g., tuberculosis,
It is important to recognize that the crude death rate cancer, accident; (b) related to specific groups - e.g., age­
summarizes the effect of two factors: specific, sex-specific, age and sex specific, etc. Rates can
also be made specific for many other variables such as
a. population composition income, religion, race, housing, etc. Specific death rates can
b. age-specific death rates (which reflect the probability help us to identify particular groups or groups “at-risk”, for
of dying) preventive action. They permit comparisons between
Table 1 shows the crude death rates of two populations, different causes within the same population. Specific death
A and B. The crude death rate for population A is 15.2 per rates are obtained mainly in countries in which a satisfactory
1000. The crude death rate for population B is 9.9 per 1000. civil registration system operates and in which a high
Apparently, population B appears healthier, than population A. proportion of deaths is certified medically.
The limitation of the crude death rate is exposed, when we Table 2 illustrates how some specific death rates in
compare the age-specific rates between the two populations common use are computed :
TABLE 2
Specific death rates

Number of deaths from tuberculosis during a calendar year

1. Specific death rate due to tuberculosis ------ ---------------- x 1,000
Mid-year population

Number of deaths among males during a calendar year

2. Specific death rate for males X 1,000
Mid-year population of males

Number of deaths of persons aged 15-20 during a calendar year

3. Specific death rate in age group 15-20 years ------------------------------------------------------------------------------------- X 1,000
Mid-year population of persons aged 15-20

Deaths in January X 12
4. Death rate for January -------------------------------- X 1,000
(Note: The deaths are multiplied by 12 in order Mid-year population
to make the monthly death rate comparable
with the annual death rate)
Deaths in the week X 52
5. Weekly death rate X 1,000
Mid-year population

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 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

3. Case fatality rate (Ratio) particular age-sex groups for the reduction of preventable
mortality (15). Proportional mortality rate does not indicate
Total number of deaths due the risk of members of the population contracting or dying
to a particular disease from the disease.
= -------------------------------------- x 100
Total number of cases due 5. Survival rate
to the same disease
It is the proportion of survivors in a group, (e.g., of
Case fatality rate represents the killing power of a disease. patients) studied and followed over a period (e.g., a 5-year
It is simply the ratio of deaths to cases. The time interval is period). It is a method of describing prognosis in certain
not specified. Case fatality rate is typically used in acute disease conditions. Survival experience can be used as a
infectious diseases (e.g., food poisoning, cholera, measles). yardstick for the assessment of standards of therapy. The
Its usefulness for chronic diseases is limited, because the survival period is usually reckoned from the date of
period from onset to death is long and variable. The case diagnosis or start of the treatment. Survival rates have
fatality rate for the same disease may vary in different received special attention in cancer studies.
epidemics because of changes in the agent, host and
environmental factors. Case fatality is closely related to Total number of patients alive
virulence. after 5 years
Survival rate = ------------------------------------------------- X 100
4. Proportional mortality rate (Ratio) Total number of patients diagnosed
or treated
It is sometimes useful to know what proportion of total
deaths are due to a particular cause (e.g., cancer) or what 6. Adjusted or standardized rates
proportion of deaths are occurring in a particular age group
(e.g., above the age of 50 years). Proportional mortality rate If we want to compare the death rates of two populations
expresses the “number of deaths due to a particular cause with different age-composition, the crude death rate is not
(or in a specific age group) per 100 (or 1000) total deaths”. the right yardstick. This is because, rates are only
Thus we have: comparable if the populations upon which they are based
are comparable. And it is cumbersome to use a series of age
specific death rates. The answer is “age adjustment” or “age

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(a) Proportional mortality from a specific disease
standardization”, which removes the confounding effect of
Number of deaths from the specific disease different age structures and yields a single standardized or
in a year adjusted rate, by which the mortality experience can be
= ------------------------------------------------------- X100 compared directly. The adjustment can be made not only for
Total deaths from all causes in that year age but also sex, race, parity, etc. Thus one can generate
age-sex, and race-adjusted rates.
(b) Under-5 proportionate mortality rate
Standardization is carried out by one of two methods -
Number of deaths under 5 years direct or indirect standardization. Both the methods begin by
of age in the given year choosing a “standard population”, not the age-structures of
= ----------------------------------------------------------------X 100 the populations.
Total number of deaths during the same period

(c) Proportional mortality rate for aged 50 years DIRECT STANDARDIZATION

and above
Two examples of direct standardization are given. In the
Number of deaths of persons aged first, a “standard population” is selected. A standard
50 years and above population is defined as one for which the numbers in each
= --------------------------------------------------------- X 100 age and sex group are known. A frequently used standard
Total deaths of all age groups in that year
age-composition (15) is shown in Table 3. The standard
population may also be “created” by combining 2
Proportional mortality rate is computed usually for a
populations; this is shown in the second example.
broad disease group (such as communicable diseases as a
whole) and for a specific disease of major public health The next step is to apply to the standard population, the
importance, such as cancer or coronary heart disease in age-specific rates of the population whose crude death rate
industrialized countries (15). is to be adjusted or standardized. As a result, for each age
group, an “expected” number of deaths (or events) in the
Proportional rates are used when population data are not
available. Since proportional mortality rate depends upon standard population is obtained; these are added together
two variables, both of which may differ, it is of limited value for all the age groups, to give the total expected deaths. The
in making comparison between population groups or final operation is to divide the “expected” total number of
different time periods. However, proportional rates are deaths by the total of the standard population, which yields
useful indicators within any population group of the relative the standardized or age-adjusted rate.
importance of the specific disease or disease group, as a
cause of death. Mortality from communicable diseases is Example 1
especially important as it relates mostly to preventable Example 1 shows: (a) the computation of age-specific
conditions. Since the prevailing causes of death vary death rates per 1000 population for city X (Table 3); and
according to age and sex, it is desirable to compute (b) application of these rates to a standard population to
proportionate mortality separately for each age and sex obtain the “expected deaths” and the standardized or age-
group in order to determine measures directed to adjusted death rate (Table 4).

by R△J
 DIRECT STANDARDIZATION 67
TABLE 3 TABLE 5
Calculation of age-specific death rates for City “X” Proportion of heavy smokers in cases and controls
(lung cancer)
Mid-year Deaths in Age-specific CASES CONTROLS
Age
population the year death rates Age Total No Heavy % No. Heavy %
subjects smokers smokers
0 4,000 60 15.0
1-4 4,500 20 4.4 40-49 500 400 200 50 100 50 50
5-14 4,000 12 3.0 50-59 500 100 10 10 400 40 10
15-19 5,000 15 3.0 Total 1,000 500 210 42 500 90 18
20-24 4,000 16 4.0
Source :(6)
25-34 8,000 25 3.1
35-44 9,000 48 5.3 Age adjustments were carried out (a) first, by combining
45-54 8,000 100 12.5 the number of subjects in both the age groups
55-64 7,000 150 21.4 (500+500=1,000) to create a standard population, and
(b) applying the observed age-specific proportions of heavy
53,500 446 smokers (i.e., 50% and 10% in both cases and controls) to
Crude death rate per 1000 = 8.3 the same standard population. The results (or “expected”
values) are shown in Table 6, which shows that the age
TABLE 4 adjusted proportions of heavy smokers are identical (30%)
for cases and controls. The previously observed difference is
Calculation of the standardized death rate for City “X” explained entirely by the difference in age composition.

Standard Age-specific Expected TABLE 6

Age population death rates deaths Age-adjusted proportions
per 1000
Expected number of heavy smokers

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0 2,400 15.0 36 Age Subjects
1-4 9,600 44 42 24 CASES CONTROLS
5-14 19,000 3.0 57 500 X 50 500 X 50
40-49 500 - 250 - 250
15-19 9,000 3.0 27 100 100
20-24 8,000 4.0 32 500 X 10 500 X 10
50-59 500 = 50 = 50
25-34 14,000 3.1 43.4 100 100
35-44 12,000 5.3 63.6 Total 1000 300 300
45-54 11,000 12.5 137.5 300 300
55-64 8,000 21.4 171 2 Standardized ------ X100 = 30 X100 = 30
rates 1000 1000
93,000 609 94
609 94 The direct method of standardization is feasible only if
Standardized death rate per 1000 =-------------- X 1000 6.56 the actual specific rates in subgroups of the observed
93,000
population are available, along with the number of
individuals in each subgroup.
It can be seen from Tables 3 and 4 that standardizing for
age distribution has reduced the crude death rate from 8.3 INDIRECT AGE STANDARDIZATION
to 6.56. The choice of the standard population is, to some
extent, arbitrary. Clearly, use of a different standard 1. Standardized mortality ratio (SMR)
population will give rise to a different value for the The simplest and most useful form of indirect
standardized death rate, but it must be remembered that standardization is the Standardized Mortality Ratio (SMR).
these standardized rates have been calculated so that they In England, it is the basis for the allocation of government
can be compared between themselves - they have no money to the health regions of the country. The concept is
intrinsic meaning other than for this purpose (16). that the regions with higher mortality also have the higher
It is usual to use the national population as standard morbidity, and should therefore receive proportionately
when inter-regional comparisons between cities within a higher funding to combat ill-health (16).
range are made. In order that comparisons can be made Standard mortality ratio is a ratio (usually expressed as a
over a period of years, a ‘standard population’ can be percentage) of the total number of deaths that occur in the
maintained for that period (16). The standard population study group to the number of deaths that would have been
used in Table 4 is given by WHO in its publication “Health expected to occur if that study group had experienced the
for All” Series No. 4, on page 77 (15). death rates of a standard population (or other reference
population). In other words. SMR compares the mortality in
Example 2 a study group (e.g., an occupational group) with the
Table 5 shows that in a study of lung cancer and smoking, mortality that the occupational group would have had if
42 per cent of cases and 18 per cent of controls were heavy they had experienced national mortality rates. In this
smokers. method, the more stable rates of the larger population are

by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

applied to the smaller study group. It gives a measure of the Three aspects of morbidity are commonly measured by
likely excess risk of mortality due to the occupation. morbidity rates or morbidity ratios, namely frequency,
Observed deaths
duration and severity. Disease frequency is measured by
*SMR = X 100 incidence and prevalence rates. The average duration per
Expected deaths
case or the disability rate, which is the average number of
If the ratio had value greater than 100, then the days of disability per person, may serve as a measure of the
occupation would appear to carry a greater mortality risk duration of illnesses. The case fatality rate may be used as
than that of the whole population. If the ratio had value less an index of severity (20). This section focuses on incidence
than 100, then the occupation risks of mortality would seem and prevalence rates, which are widely used to describe
to be proportionately less than that for the whole population. disease occurrence in a community.
Table 7 shows that the mortality experience of coal The value of morbidity data may be summarized as
workers was 129 per cent, which meant that their mortality follows:
was 29 per cent more than that experienced by the national
population. Values over 100 per cent represent an a. they describe the extent and nature of the disease load
unfavourable mortality experience and those below 100 per in the community, and thus assist in the establishment
cent relatively favourable mortality experience. Table 7 of priorities.
displays the calculations. b. they usually provide more comprehensive and more
accurate and clinically relevant information on patient
TABLE 7 characteristics, than can be obtained from mortality
Calculation of the SMR for coal workers data, and are therefore essential for basic research.
c. they serve as starting point for aetiological studies,
National Coal
population workers Observed Expected
and thus play a crucial role in disease prevention.
Age d. they are needed for monitoring and evaluation of
death rates population deaths deaths
per 1000 disease control activities.
25-34 3.0 300 09
♦
INCIDENCE
35-44 5.0 400 2.0
45-54 8.0 200 * 1.6 Incidence rate is defined as “the number of NEW cases

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55-64 25.0 100 ♦
25 occurring in a defined population during a specified period
of time”. It is given by the formula :
1,000 9 7.0
SMR = 9/7x100= 129 Number of new cases of specific
* It is not necessary to know these values; only the total for the disease during a given time period
whole age-range is required Incidence = ------------------------------------------------- X 1000
Population at-risk during that period
The SMR has the advantage over the direct method of
age adjustment in that it permits adjustment for age and For example, if there had been 500 new cases of an
other factors where age-specific rates are not available or illness in a population of 30,000 in a year, the incidence rate
are unstable because of small numbers. One needs to know would be:
only the number of persons in each age group in the study = 500/30,000 x 1000
population and the age-specific rates of the national = 16.7 per 1000 per year
population (or other reference population). It is possible to
use SMR if the event of interest is occurrence of disease Note: Incidence rate must include the unit of time used
rather than death. in the final expression. If you write 16.7 per 1000, this
would be inadequate. The correct expression is 16.7 per
2. Other standardization techniques 1,000 per year (21).
(a) A more complicated method of indirect adjustment It will be seen from the above definition that incidence
which yields absolute age adjusted rate, involves the rate refers
calculation of an index death rate and a standardizing factor a. only to new cases
for each population of interest. The reader is referred to A.B. b. during a given period (usually one year)
Hill’s “Principles of Medical Statistics”, (b) Life table is an c. in a specified population or “population at risk”,
age-adjusted summary of current all-causes mortality, unless other denominators are chosen.
(c) Regression, techniques: These are an efficient means of d. it can also refer to new spells or episodes of disease
standardization, (d) Multivariate analysis: A computer, using arising in a given period of time, per 1000 population.
regression or similar methods, can standardize for many For example, a person may suffer from common cold
variables simultaneously (17). more than once a year. If he had suffered twice, he
would contribute 2 spells of sickness in that year. The
MEASUREMENT OF MORBIDITY formula in this case would be:
Morbidity has been defined as “any departure, subjective Number of spells of sickness
or objective, from a state of physiological well-being” starting in a defined period
(18, 19). The term is used equivalent to such terms as Incidence rate = ----------------------------------------- X 1000
sickness, illness, disability etc. The WHO Expert Committee (spells) Mean number of persons
on Health Statistics noted in its 6th Report (18) that exposed to risk in that period
morbidity could be measured in terms of 3 units - Incidence measures the rate at which new cases are
(a) persons who were ill; (b) the illnesses (periods or spells of occurring in a population. It is not influenced by the
illness) that these persons experienced; and (c) the duration duration of the disease. The use of incidence is generally
(days, weeks, etc) of these illnesses. restricted to acute conditions.

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 PREVALENCE 69
Special incidence rates Point prevalence is given by the formula:
Examples include: Attack rate (case rate), Secondary Number of all current cases (old and new)
of a specified disease existing at
attack rate, Hospital admission rate, etc. a given point in time
= ---------------------------------------------------------X100
a. Attack rate Estimated population at the
An attack rate is an incidence rate (usually expressed as a same point in time
per cent), used only when the population is exposed to risk When the term “prevalence rate” is used, without
for a limited period of time such as during an epidemic. It any further qualification, it is taken to mean “point
relates the number of cases in the population at risk and prevalence” (18).
reflects the extent of the epidemic. Attack rate is given by the
Point prevalence can be made specific for age, sex and
formula:
other relevant factors or attributes.
Number of new cases of a specified (b) Period prevalence
disease during a specified time interval
Attack rate = -------------------------------------------------------- X 100
A less commonly used measure of prevalence is period
Total population at risk during the prevalence. It measures the frequency of all current cases (old
same interval and new) existing during a defined period of time (e.g.,
annual prevalence) expressed in relation to a defined
population. It includes cases arising before but extending into
b. Secondary attack rate or through to the year as well as those cases arising during the
It is defined as the number of exposed persons developing ’ year (Fig. 2). Period prevalence is given by the formula:
the disease within the range of the incubation period Number of existing cases (old and new)
following exposure to a primary case, (see page 103). of a specified disease during a given
period of time interval
USES OF INCIDENCE RATE = ------------------------------------------------------- X 100
The incidence rate, as a health status indicator, is useful Estimated mid-interval population at-risk
for taking action (a) to control disease, and (b) for research The terms incidence and prevalence are illustrated in

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into aetiology and pathogenesis, distribution of diseases,
and efficacy of preventive and therapeutic measures (15).
For instance, if the incidence rate is increasing, it might
indicate failure or ineffectiveness of the current control
programmes. Rising incidence rates might suggest the need
for a new disease control or preventive programme, or that
reporting practices had improved. A change or fluctuation in
the incidence of disease may also mean a change in the
aetiology of disease, e.g., change in the agent, host and
environmental characteristics. Analysis of differences in
incidence rates reported from various socio-economic
groups and geographical areas may provide useful insights
into the effectiveness of the health services provided (15)

PREVALENCE
----- Duration of illness
The term “disease prevalence” refers specifically to all
current cases (old and new) existing at a given point in time, Incidence would include cases - 3,4,5, and 8
or over a period of time in a given population. A broader Point prevalence (Jan 1) cases - 1,2, and 7
definition of prevalence is as follows: “the total number of all Point prevalence (Dec.31) cases - 1,3,5 and 8
Period prevalence (Jan-Dec) cases - 1,2,3,4,5,7, and 8
individuals who have an attribute or disease at a particular
time (or during a particular period) divided by the FIG. 2
population at risk of having the attribute or disease at this Number of cases of a disease beginning, developing and ending
point in time or midway through the period (2)”. Although during a period of time
referred to as a rate, prevalence rate is really a ratio.
Relationship between prevalence and incidence
Prevalence is of two types :
Prevalence depends upon 2 factors, the incidence and
(a) Point prevalence duration of illness. Given the assumption that the population
(b) Period prevalence is stable, and incidence and duration are unchanging, the
relationship between incidence and prevalence can be
(a) Point prevalence expressed as :________
CBoint prevalence of a disease is defined as the number of ) P= IxD
all current cases (old and new) of a disease at one point of = incidence x mean duration
time, in relation to a defined population. The “point” in Example (for a stable condition)
point prevalence, may for all practical purposes consist of a Incidence = 10 cases per 1000 population per year
day, several days, or even a few weeks, depending upon the Mean duration of disease = 5 years
time it takes to examine the population sample (21). Prevalence = 10 x 5 = 50 per 1000 population
by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Conversely, it is possible to derive incidence and duration which affect the course of the disease. In other words, the
as follows: element of duration reflects the prognostic factors, and
Incidence = P/D incidence reflects the causal factors. Therefore, incidence
rates should be optimally used in the formulation and testing
Duration = P/I of aetiological hypotheses. When incidence rates are not
The above equation (P = I x D) shows that the longer the available, prevalence rates (which are readily obtainable)
duration of the disease, the greater its prevalence. For may have to be used, but the contribution of duration
example, tuberculosis has a high prevalence rate relative to element always has to be assessed.
incidence. This is because new cases of tuberculosis keep
cropping up throughout the year, while the old ones may Uses of prevalence
persist for months or years. On the other hand, if the disease (ja) Prevalence helps to estimate the magnitude of health/
is acute and of short duration either because of rapid disease problems in the community, and identify potential
recovery or death, the prevalence rate will be relatively low high-risk_populations (b) Prevalence rates are especially
compared with the incidence rate. In some diseases (e.g., useful for administrative and planning purposes, e.g.,
food poisoning), the disease is so short-lived, there are no hospital beds, manpower needs, rehabilitation facilities, etc.
“old” cases. The same is true of conditions which are rapidly
fatal, such as homicides. Strictly speaking, these events have EPIDEMIOLOGIC METHODS
no prevalence. In other words, decrease in prevalence may
take place not only from a decrease in incidence, but also The primary concern of the epidemiologist is to study
from a decrease of the duration of illness through either disease occurrence in people, who during the course of their
more rapid recovery or more rapid death. lives are exposed to numerous factors and circumstances,
When we see a change in prevalence from one time some of which may have a role in disease aetiology. Unlike
period to another, this can result from changes in incidence, the clinician or the laboratory investigator, who is able to
changes in duration of disease or both. For example, study disease conditions more precisely, the epidemiologist
improvements in treatment may decrease the duration of employs carefully designed research strategies to explore
illness and thereby decrease prevalence of a disease. But if disease aetiology.
the treatment is such that by preventing death, and at the Epidemiological studies can be classified as observational
same time not producing recovery, may give rise to the

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studies and experimental studies with further subdivisions :
apparently paradoxical effect of an increase in prevalence.
Further, if duration is decreased sufficiently, a decrease in 1. Observational studies
prevalence could take place despite an increase in
incidence. a. Descriptive studies
b. Analytical studies
Prevalence has been compared with a photograph, an
instantaneous record; and incidence with a film, a (i) Ecological or Correlational, with populations
as unit of study
continuous record. Both the terms may perhaps be better
understood by taking into consideration a coffee house. (ii) Cross-sectional or Prevalence, with individuals
After the coffee house opens in the morning, people keep as unit of study
entering and leaving, each one remaining inside the coffee (iii) Case-control or Case-reference, with individuals
house for a short while. At any point of time, say 10 AM, we as unit of study
could go into the coffee house and count people over there. (iv) Cohort or Follow-up, with individuals
This corresponds to estimating the prevalence. The rate at as unit of study
which people enter the coffee house, say 10 people per
hour, is equivalent to the incidence. The relationship 2. Experimental studies Intervention studies
between incidence and prevalence is shown in Fig. 3 (22). a. Randomized or Clinical with patients as
controlled trials trials unit of study
b. Field trials with healthy
people as
unit of study
c. Community trials or Community with
intervention communities
studies as unit of study

These studies or methods cannot be regarded as

watertight compartments; they complement one another.
Observational studies allow nature to take its own course;
the investigator measures but does not intervene.
Descriptive study is limited to a description of the
occurrence of a disease in a population. An analytical study
goes further by analyzing relationship between health status
FIG. 3
Relationship between incidence and prevalence and other variables. Experimental or intervention studies
involve an active attempt to change a disease determinant
It is important to note the limitations of prevalence rate. It or the progress of a disease, and are similar in design to
is not the ideal measure for studying disease aetiology or experiments in other sciences. However, they are subject to
causation. We have seen that two factors determine extra constraints, since the health of the people in the study
prevalence, namely incidence and duration. Incidence is group may be at stake. The major experimental design is the
related to the occurrence of disease and duration to factors randomized controlled trial using patients as subjects. Field

by R△J
 DESCRIPTIVE EPIDEMIOLOGY

trials and community trials are other experimental studies in The defined population needs to be large enough so that
which the participants are healthy people and community age, sex and other specific rates are meaningful. The
respectively (23). community chosen should be stable, without migration into
In all epidemiological studies, it is essential to have a or out of the area. It should be clear who does and who does
clear definition of a case of the disease being investigated not belong to the population, as for example, visitors and
and of an exposed person. In absence of clear definitions of relations. Perhaps the most essential ingredient is
disease and exposure, great difficulties are likely to be community participation, which must be forthcoming.
experienced in interpreting the data. Furthermore, the population should not be overtly different
from other communities in the region. Finally, a health
DESCRIPTIVE EPIDEMIOLOGY facility should be close enough to provide relatively easy
access for patients requiring medical services. In the famous
The best study of mankind is man. This statement Framingham Heart Study in US, all the above criteria were
emphasizes the importance of making the best use of taken into consideration in choosing the study population.
observations on individuals or populations exposed to The concept of ‘defined population’ (or population at
suspected factors of disease. Meticulous observations made risk) is crucial in epidemiological studies. It provides the
in Africa by Burkitt led to the eventual incrimination of denominator for calculating rates which are essential to
Epstein-Barr virus (EBV) as the aetiological factor (possibly measure the frequency of disease and study its distribution
conditioned by other factors such as malarial infection) of and determinants. Epidemiologists therefore have been
the type of cancer known as Burkitt’s lymphoma. It was the labelled as men in search of a denominator (24).
epidemiological study in New Guinea of “Kuru”, a
hereditary neurological disorder, that led to the discovery of 2. Defining the disease under study
slow virus infections as the cause of chronic degenerative
neurological disorders in human beings. The list is endless. Once the population to be studied is defined or specified,
one must then define the disease or condition being
Descriptive studies are usually the first phase of an investigated. Here the needs of the clinician and
epidemiological investigation. These studies are concerned epidemiologist may diverge. The clinician may not need a
with observing the distribution of disease or health-related precise definition of disease (e.g., migraine) for immediate
characteristics in human populations and identifying the patient care. If the diagnosis is wrong, he can revise it
characteristics with which the disease in question seems to

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subsequently. But the epidemiologist, whose main concern
be associated. Such studies basically ask the questions. is to obtain an accurate estimate of disease in a population,
a. When is the disease occurring ? needs a definition that is both precise and valid to enable
- time distribution him (or observers working in field conditions) to identify
b. Where is it occurring ? those who have the disease from those who do not (10). The
- place distribution diagnostic methods for use in epidemiological studies must
be acceptable to the population to be studied, and
c. Who is getting the disease?
applicable to their use in large populations.
- person distribution
In other words, the epidemiologist looks out for an
The various procedures involved in descriptive studies “operational definition”, i.e., a definition by which the
may be outlined as below (Table 8) disease or condition can be identified and measured in the
defined population with a degree of accuracy. For example,
TABLE 8
tonsillitis might be defined clinically as an inflammation of
Procedures in descriptive studies the tonsils caused by infection, usually with streptococcus
pyogenes. This definition, like many other clinical definitions
1 Defining the population to be studied (and the WHO definition of ‘health’) serves to convey
2 Defining the disease under study particular information, but cannot be used to measure
3. Describing the disease by disease in the community. On the other hand, an
a. time “operational definition” spells out clearly the criteria by
b. place which the disease can be measured. Such criteria in the case
c. person of tonsillitis would include the presence of enlarged, red
4. Measurement of disease tonsils with white exudate, which on throat swab culture
5. Comparing with known indices grow predominantly S. pyogenes. If the definition is not
6. Formulation of an aetiological hypothesis valid, it would be a powerful source of error in the
presentation and comparability of measurements from
1. Defining the population different sources. With regard to certain diseases (e.g.,
Descriptive studies are investigations of populations, not neurological diseases) which often do not have
individuals. The first step is, therefore, to define the pathognomonic signs and symptoms, disease definition is a
“population base” not only in terms of the total number, but crucial concern for the epidemiologist. In such cases, the
also its composition in terms of age, sex, occupation, cultural epidemiologist frames his own definition keeping the
characters and similar information needed for the study. objectives of his study in view and aiming at the same time a
degree of accuracy sufficient for his purpose. Once
The “defined population” can be the whole population in
established, the case definition must be adhered to
a geographic area, or more often a representative sample
throughout the study.
taken from it. The defined population can also be a specially
selected group such as age and sex groups, occupational
groups, hospital patients, school children, small
3. Describing the disease
communities as well as wider groupings - in fact, wherever a The primary objective of descriptive epidemiology is to
group of people can be fairly accurately counted. describe the occurrence and distribution of disease (or

by R△J
72 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS
health-related events or characteristics within populations) may suggest : (1) a time relationship with exposure to a
by time, place and person, and identifying those suspectecLsource, (2) a cyclical or seasonal pattern
characteristics associated with presence or absence of suggestive of a particular infection, and common source or
disease in individuals. This involves systematic collection propagated spread of the disease. J
and analysis of data. Some of the characteristics most A. Common-source epidemics
frequently examined by epidemiologists in descriptive
studies are given in Table 9. It is only an initial separation or (a) Common-source, single exposure epidemics
grouping of variables according to time, place and person These are also known as “point-source” epidemics. The
and NOT a classification of causal factors. exposure to the disease agent is brief and essentially
simultaneous, the resultant cases all develop within one
TABLE 9
incubation period of the disease (e.g., an epidemic of food
Characteristics frequently examined poisoning). Fig. 4 illustrates a common-source, single
in descriptive studies exposure epidemic. The curve has usually one peak. One
point of interest is the “mediamincubation period”, it is.the.
Time Place Person
Year, season Climatic zones Age Birth order
Month, week Country, region Sex Family size
Day, hour of Urban/rural Marital Height
onset, Local community state Weight
Duration Towns Occupation Blood pressure
Cities Social status Blood cholesterol
Institutions Education Personal habits

TIME DISTRIBUTION
The pattern of disease may be described by the time of its

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occurrence, i.e., by week, month, year, the day of the week, FIG. 4
hour of onset, etc. It raises questions whether the disease is Source : (3) Epidemic curve
seasonal in occurrence; whether it shows periodic increase (The main features of a “point-source^ epidemic are :
or decrease; or whether it follows a consistent time trend. (i) the epidemic curve rises and falls rapidly, with—no
Such studies may yield important clues about the source or secondary waves (ii) the epidemic tends to be explosive,
aetiology of the disease, thereby suggesting potential there is~clustering of cases within a narrow interval of time,
preventive measures. Epidemiologists have identified three and (iii) more importantly, all the cases develop within one
kinds of time trends or fluctuations in disease occurrence. incubation period of disease.
I. Short-term fluctuations (Common-source epidemics are frequently, but not
II. Periodic fluctuations, and always, due to exposure to an infectious agent. They can
III. Long-term or secular trends result from Contamination of the environment (air, water,
food, soil) by industrial chemicals or pollutants, e.g., Bhopal
I. Short-term fluctuations gas tragedy in India and Minamata disease in “Japan
The best known short-term fluctuation in the occurrence resulting from consumption of fish containing high
of a disease is an epidemicl According to modern concepts concentration of methyl mercury.
an epidemic is defined as (The occurrence in a community or Clf the epidemic continues over more than one incubation
region of cases of an illness or other health-related events period, there is either a continuous or multiple exposure to a
clearly in excess of normal expectancy”, The community or common source, or a propagated spread, j
region, and the time period in which the cases occur, are
specified precisely. Epidemicity is thus relative to usual (b) Common-source, continuous or repeated exposure
frequency of the disease in the same area, among the (Sometimes the exposure from the same source may be
specified population, at the same season of the year (2). The prolonged - continuous, repeated or intermittent - not
data in Table 10 illustrates this point. necessarily at the same Time or j)lace. A prostitute may be a
common source in a gonorrhoea outbreak, but since she will
Types of epidemics infect her clients over a period of time there may be no
(Vhreejnajor types of epidemics may be distinguished. explosive rise inthenumber of cases. A well of
A. Common-source epidemics contaminated water, or a nationally distributed brand of
(a) Single exposure or “point-source” epidemics. vaccine (e.g. polio vaccine), or food, could result in similar
outbreaks. In these instances, the resulting epidemics tend to
(b) Continuous or multiple exposure epidemics
be more extended or irregular. _Jhe outbreak of respiratory
B. Propagated epidemics illness, the Legionnaire’s disease, in the summer of 1976 in
(a) Person-to-person Philadelphia (USAf was a common-source, continuous or
(b) Arthropod vector repeated exposure outbreak. This outbreak as in other
(c) Animal reservoir outbreaks of this type, continued beyond the range of one
C. Slow (modern) epidemics. incubation period. There was no evidence of secondary
cases among persons who had contact with ill persons (25).
A graph of the time distribution of epidemic cases is
called the “epidemic curve” (Fig. 4). The epidemic curve A variation to the above model is that an epidemic may

by R△J
 TIME DISTRIBUTION 23
be initiated from a common source and then continue as_ a ^Some epidemiologists would regard seasonal trend as a form
propagated epidemic. Water-borne cholera is a familiar of cyclicjrend. Table 10 shows a typical pattern of seasonal
xample, the epidemic reaches a sharp peak, but tails off trend, - the outbreaks of dengue/DF starting by month of
gradually over a longer period of time A July and peaking in September, October and November,
coinciding with late summer and rain.
B. Propagated epidemics
TABLE 10
A propagated epidemic is most often of infectious origin Seasonal trend of dengue/DHF in India 2005-2007
and results from person-to-person transmission of an
infectious agent (e.g., epidemics of hepatitis A and polio). Month 2005 2006 2007
I ' e epidemic usuall shows a radual rise and tails off over January 151 281 83
a much longer period of time. Transmission continues until February 80 193 64
the number of susceptibles is depleted or susceptible March 59 178 46
individuals are no longer exposed to infected persons or April 68 166 50
intermediary vectors. The speed of spread depends upon May 172 181 127
herd immunity, opportunities for contact and secondary June 130 269 175
attack rate. Propagated epidemics are more likely to occur July 742 478 487
whereTarge number of susceptibles are aggregated, or where 487
August 946 577
there is a regular supply of new susceptible individuals (e.g.,
September 4,852 1,275 974
birth, immigrants) lowering herd immunity. Fig. 5 illustrates
October 2,482 5,880 1,507
the course of a typical propagated epidemic in which the
agent is transmitted by contact between individuals. November 1,507 1,934 802
December 801 905 221
11. Periodic fluctuations Total 11,990 12,317 5,023
(i) Seasonal trend : Seasonal variation is a well-known
Source : (26)
characteristic of many communicable diseases, e.g., measles,
varicella, cerebrospinal meningitis, upper respiratory Gii) Cyclic trend : Some diseases occur in cycles spread
infechons, malaria etc. For example, measles is usually at its oyeT^short periods of time which may be days, weeks.
height in early spring and so is varicella. Upper respiratory months or years. For example, measles in the pre-

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infections frequently show a seasonal rise during winter vaccinatioig era appeared in cycles with major peaks every
months. Bacterial gastrointestinal infections are prominent in 2-3 years and rubella every 6-9 -ears. This was due to
summer months because of warm weather and rapid naturally occurring variations in herd immunity. A build-up
multiplication of flies. The seasonal variations of disease of susceptibles is again required in the “herd” before there
occurrence mayT)e related to environmental conditions (e.g., can be another attack. Influenza pandemics are known to
temperature, humidity, rainfall, overcrowding, li e cycle of occur at intervals of 7-10 years, due to antigenic variations.
vectors, etc.) which directly or indirectly favour disease Non-infectious conditions may also show periodic
transmission. However, in many infectious diseases (e.g., fluctuations, e.g., automobile accidents in US are more
polio),The basis for seasonal variation is unknown. Non- frequent on week-ends, especially Saturdays. A knowledge
infectious diseases and conditions may sometimes exhibit of cyclicity of disease is useful in that it may enable
seasonal variation, e.g., sunstroke, hay fever, snakebite. communities to defend themselves.

FIG. 5
Source : (5) Course of typical propagated epidemic

by R△J
74 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

III. Long-term or secular trends c. Rural-urban variations

The term “secular trend” implies changes in the d. Local distributions
occurrence of disease (i.e., a progressive increase or International variations
decrease) oyer a long period of time, generally several years
or decades. Although it may have short-term fluctuations Descriptive studies by place have shown that the pattern
imposed on it, a secular trend implies a consistent tendency of disease is not the same everywhere. For example, we
to change in a particular direction or a definite movement in know that cancer exists all over the world. There is,
one direction. Examples include coronary heart disease, however, a marked difference between the incidence of each
lung cancer and diabetes which have shown a consistent cancer in different parts of the world. Thus cancer of the
upward trend in the developed countries during Jhe past stomach is very common in Japan, but unusual in US?
50 years or so, followed by a decline of such diseases as Cancers of the oral cavity and uterine cervix are exceedingly
tuberculosis, typhoid fever, diphtheria and polio. common in India as compared to industrialized counfries.
(An international study of breast cancer showed that rates
Interpretation of time-trends i' er widely from country to country with the lowest
(By surveillance or monitoring of time-trends, the prevalence in Japan and the highest in the western
epidemiologist seeks which diseases are increasing, whish countries. Similarly, there are marked international
decreasing, and which are the emerging health problems and differences in the occurrence of cardiovascular diseases.
ofjthe effectiveness of measures to control old ones (17). He These variations have stimulated epidemiologists to search
tries to formulate aetiological_______ hypotheses, and seeks for cause-effect relationships between the environmental
explanations whether these changes were due to changes in factors and disease: The aim is to identify factors which are
the aetiological agent or variations in diagnosis, reporting, crucial in the cause and prevention of disease.
case fatality or changes in age distribution, or some other
determinants, specific and non-specific (e.g., changes"in
National variations
quality of life, socio-economic status and personal habits). It is obvious that variations in disease occurrence must
For example the “time-clustering” of cases of also exist within countries or national boundaries. For
adenocarcinoma of vagina in young women led to the example the distribution of endemic goitre, lathyrism,
incrimination of its cause, viz. in utero exposure to fluorosis, leprosy, malaria, nutritional deficiency diseases
diethylstilbestrol (27).(Even changes taking place over several have all shown variations in their distribution in India, with

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years or decades can be productive, of hypotheses, as in the some parts of the country more affected and others less
cases of lung cancer. By studying time trends, the affected or not affected at all. Such situations exist in every
epidemiologist seeks to provide guidelines to the health country. One of the functions of descriptive epidemiology is
administrator in matters of prevention or control of disease.^ to provide data regarding the type of disease problems and
their magnitude in terms of incidence, prevalence and
PLACE DISTRIBUTION mortality rates. Such information is needed to demarcate
the affected areas and for providing appropriate health care
(Geographical comparisons)
services.
(^Studies of the geography of disease (or geographical
pathology) is one of the important dimensions of descriptive Rural-urban variations
epidemiology. By studying the distribution of disease in Rural/urban variations in disease distribution are well
different populations we gain perspective on the fascinating known. Chronic bronchitis, accidents, lung cancer, cardio­
differences (or variations) in disease patterns not only vascular diseases, mental illness and drug dependance are
between countries, but also within countries.(The relative usually more frequent in urban than in rural areas. On the
importance of genes versus environment; cnaiiges with other hand, skin and zoonotic diseases and soil-transmitted
migration; andThe possible roles of diet and other aetiological helminths may be more frequent in rural areas than in urban
factors. In short geographical studies have profoundly areas. Death rates, especially infant and maternal mortality
influenced our understanding of disease, its nature, its rates, are higher for rural than urban areas. These variations
detriments and its relation to subsequent pathology. The may be due to differences in population density, social class,
geographic variation in disease occurrence has been one of deficiencies in medical care, levels of sanitation, education
the stimulants to national and mternational studies. . and environmental factors. The epidemiologist seeks to
(/The world is not a uniform unit. Cultures, standard of define groups which are at higher risk for particular diseases,
living and external environments vary greatly. The use of and provides guidelines to the health administrator for their
migrant studies is one way of distinguishing genetic and prevention and control.
environmental factors. The study of the geography of
diseases has developed its own special techniques, which
Local distributions
sometimes involve complex statistical analysis. The SMR is CJnner and outer city variations in disease frequency are
one of them. well known. These variations are best studied with the aid of
(^Geographic patterns provide an important source of clues ‘spot maps’ or ‘shaded maps’. These maps show at a glance
about the causes of the disease. The range of geographic areas of high or low frequency, Jhe boundaries and patterns
studies include those concerned with local variationsi^At a ot disease distribution. For example if the map shows
broader level, international comparisons may examine “clustering” of cases, it may suggest a common source of
infection or a common risk factor shared b all the cases. It
mortality and morbidity in relation to socio-economic
factors^dietary differences and the differences in culture and was by such a stu y spot map of fatal cases), John Snow of
behaviour. These variations may be classified as : England in his classic Investigation of cholera epidemic in
1854 in the Golden Square district of London was able to
a. International variations focus attention on the common water pump in Broad street
b. National variations as the source of infection (Fig. 6). Based on Tris descriptive

by R△J
 PLACE DISTRIBUTION 75

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FIG. 6
Spot map of Asiatic cholera in London

findings, Snow was able to hypothesize that cholera was a hypotheses. The clinician is also benefited fromjmowledge
water-borne disease, long before the birth of bacteriology. It that a patient comes to him from a certain geograp Ficarea
was by a spot map by “place of employment” Maxey which is endemic for certain infrequent diseases such as
hypothesized a rodent reservoir for typhus fever in 1920s yaws or leishmaniasis, as it helps him to focus attention on
which led to the discovery that typhus fever was not a single these diseases to which the patient may have been exposed.
disease entity, as it was earlier thought. Also, the evidence of (The geographic distribution of disease may change, if
case clustering based on sexual contact or blood product use changes occur in the agent, host and environmental factors.
provided the clue that AIDS (Acquired Immune Deficiency The empires of malaria, plague and many other diseases
Syndrome) was an infectious disease, have shrunk due to changes in the epidemiological triad. On
In short the geographic differences in disease occurrence the other hand, since 1961 cholera has shown an increasing
is an important dimension of a descriptive study. These geographic distribution due to changes in the disease agent.
differences are determined by the ..agent host and Since the mode of living and environmental factors vary
environmental factors. The classic example of place-related from country to country, one would expect to find differences
diseases include yellow fever, schistosomiasis, sleeping in the geographic distribution and frequency of disease/
sickness and endemic goitre. There have also been studies
on asthma, cancer, cardiovascular diseases, blood groups Migration studies
and abnormal haemoglobins by geographic location. In Charge scale migration of human populations from one
short, all diseases whether acute or chronic, communicable country to another provides a unique opportunity to
or non-communicable, show definite patterns of geographic evaluate the role of the possible genetic and environmental
distribution. factors—in the occurrence of disease in a population.
The epidemiologist is interested in geographic variations Supposing there are marked geographic differences in the
in disease occurrence .(Geographic distribution may provide occurrence of a disease in two areas, area “A” and area “B”.
evidence of the source of disease and its mode of Spread. By Let us assume that the environments in these two places are
relating these variations to_ agent, host and environmental very different. The question arises whether the
factors, he tries to derive clues to the source of disease and environmental differences in the two areas account for the
its mode of spread to formulate and test aetioloqical variations in the occurrence of the disease in question.

by R△J
76_ PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Ideally, samples of population in area “A” should be sent age groups, it implies that all age groups are equal
to area “B”, and vice versa to study change in incidence of susceptible, and there was no previous immunity. Mar
disease. In human populations this is hardly possible, so we chronic and degenerative diseases (e.g., cancer) show
restrict our study to observation of changes in disease progressive increase in prevalence with advancing age. Th
frequency among migrants. may reflect a persistent and cumulative exposure to a caus
Migrant studies can be carried out in two ways : agent or risk factor (13).
(a) comparison of disease and death rates for migrants Bimodality : Sometimes there may be two separate peal
with those of their kin who have stayed at home. This instead of one in the age incidence curve of a disease as i
permits study, of genetically similar groups butdivingjinder theTase of Hodgkin’s disease, leukaemia, and female brea
different environmental conditions or exposures. If the cancer. This phenomenon is known as bimodality. Fig.
disease and death rates in migrants are similar to country of shows the age incidence curve for Hodgkin’s disease i
adoption over a period of time, the likely explanation would USA (30). The curve is bimodal with an initial peak betwee
be change in the environment. A special case is the use of the ages 15 and 35 years, and a later peak starting at ag
twins who have been exposed to different environments of 50. IJimodality is of special interest to epidemiologists,
migration. indicates that the study material is not homogeneous, an
that two distinct sets of causal factors might be operativ*
(b) comparison of migrants with local population of the even though the clinical and pathological manifestations (
host country provides information on genetically different the disease are the same at all ages.
groups livingTn_a_similar environment. If the migration rates
of disease and death are similar to the country of origin, the
likely explanation would be the genetic factors, t
Migrant studies have shown that men of Japanese
ancestry living in USA experience a higher rate of coronary
heart disease than do the Japanese in^Japan (28). Taking
another example, Japan has a higher rate for stomach
cancer and a lower rate Tor colon cancer_than the United
States Has. However, third-generation descendants of
Japanese immigrants to USA have rates of stomach and

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colon cancer like those of the total US population. These
studies suggest that as the Japanese were probably -adopting
the American way of life, their susceptibility to coronary
heart disease, gastric and colonic cancer was moving in the
direction of that found in the Americans, further, migrant AGE
studies may also indicate the duration of residence FIG. 7
necessary to acquire susceptibility to the disease in question Bimodality in Hodgkin’s disease
by comparing groups that left home at different ages. However, there are two points relating to bimodalitv
Studies of this kind provide a basis for further studies _of which make their interpretation difficult : (a) small number:
specific environmental factors to which the migrants may of observations are a frequent source of bimodality; (b) th<
have been exposed or of changes in their habits of life that absence~of bimodality does not signify that data have come
may be of aetiological importance^ from a homogeneous source. ]
(Migrant studies suffer from the usual defects of (b) Sex_j Sex is another host characteristic which is ofter
observational _ studies, deriving from lack of random studied in relation to disease, using such indices as sex-ratio
assignment to the groups under observation. Migrants may sex-specific morbidity and mortality rates. It has been founc
be self-selected in that fit, vigorous and perhaps the that certain chronic diseases such as diabetes,
temperamentally unstable are more likely to migrate (29). hyperthyroidism and obesity are strikingly more common in
The environmental factors may only act at a certain critical women than in men, and diseases such as lung_cancer and
point or at a certain specific age. If the incubation period of coronary heart disease are less frequent in women.
the disease is very long, migrants may not show any Variations in disease frequency between sexes have been
increased incidence or mortality from the disease for many ascribed to (a) basic biological differences between the sexes,
years. including sex-linked genetic inheritance, and (b) cultural
PERSON DISTRIBUTION and behavioural differences between the sexes (e.g.,
smoking, automobile use, alcoholism) due to different roles
In descriptive studies, the disease is further-characterized in social setting. In fact, it is the 4:1 male to female ratio in
by defining the persons who develop the disease by age, lung cancer that has helped to identify cigarette smoking as a
sex, occupation, martial status, habits, social class and other causal factor. Even larger differences exist in, for example,
host factors. These factors do not necessarily represent duodenal ulcer and coronary heart disease, that are~as yet
aetiological factors, but they contribute a good deal to our unexplained (31).
understanding of the natural history of disease. Some of the (c) Ethnicity : Differences in disease occurrence have been
host factors basic to epidemiological studies (Table 9) are noted between population subgroups of different racial and
discussed below. ethnic origin. These include tuberculosis, essential
(a) : Age is strongly related to disease than any other hypertension, coronary heart disease, cancer, and sickle cell
single host factor. Certain diseases are more frequent in anaemia. (These, differences, whether they are related to
certain age groups than in others, e.g., measles in childhood­ genetic or environmental factors, have been a stimulus to
cancer in middle age and atherosclerosis in old age. If the further studies. ]
attack rate of a communicable clisease^is"unTform in all the (d) Maritalstatus : In countries where studies on mortality

by R△J
 PERSON DISTRIBUTION

in relation to marital status have been .conducted, it was areas these diseases have created a serious problem in
found that mortality rates were always lower for married urban areas also.
males and females than for the unmarried, of the same age Human movement may be classified (i) asj>hort-term?
and sex. According to demographers and sociologists, the long-term, and permanent (ii) according to age, sex?
reason for this phenomenon may be found in the fact that education, occupation, (iii) internal or external (iv) urban
marriages are selective with respect to the health status of versus rural, etc. Migration has presented challenge to
persons, for those who are healthy are more likely to get confrol/prevention of disease, j
married, with the result that the risk of dying is also less.
Besides, married persons are generally more secure and To sum up, a study of the host factors in relation to
protected and they usually lead a more sober life than those disease occurrence Is an important dimension of descriptive
who are unmarried. All these factors are thought to epidemiology. Variations in the distribution of disease in
contribute to lower mortality rates among married persons. age, sex, occupation and other subgroups..of the population
can be the starting point for an epidemiological enquiry
Marital status can be a risk factor for some diseases and leading to formulation of an aetiological hypothesis for
conditions. The observation that cancer cervix is rare in nuns further study. Knowledge of the frequency of disease in
led to the hypothesis regarding marital status and cancer subgroups of the population has also generated the concept
cervix. Further studies led to the suggestion that cancer of “high risk groups”.
cervix may be associated with multiple sexual contacts and
promiscuity. This in turn raised the possibility of a possible 4. Measurement of disease
infectious agent transmitted venereally. Although the viral
aetiology of cancer cervix is not yet proved, this chain of It is mandatory to have a clear picture of the amount of
thinking serves to illustrate how an observation can be a disease (“disease load”) in the population. This information
starting point of an epidemiological enquiry. should be available in terms of mortality, morbidity, disability^
and so on, and should preferably be available for different
(e) (Occupation : It is now well recognized that man’s subgroups of the population.' Measurement of mortality is
occupation from which he earns his livelihood has an straightforward. Morbidity has two aspects - incidence and
important bearing on his health status. Occupation may alter prevalence (see page 68, 69). Incidence can be obtained from
the habit pattern of employees e.g., sleep, alcohol, smoking, ongitudinal” studies, and prevalence from “cross-sectional”
drug addiction, night shifts etc. It is obvious that persons studies, descriptive e; idemiology may use a cross-sectional

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working in particular occupations are exposed to particular or longitudinal design to obtain estimates of magnitude of
types of risks. For instance, while workers in coal mines are hea’t'. and disease problems in human populations, i
more likely to suffer from silicosis, those in sedentary
occupations face the risk of heart disease. Cross-sectional studies
(f) Social class : Epidemiological studies have shown that {fSross-sectional study is the simplest form of an
healthand diseases are not equally distributed in social observational study. It is based on a single examination of a
classes. Individuals in the upper social classes have a longer cross-section of population at one point in time - the results
life expectancy and better health and nutritional status than of which can be projected on the whole population provided
those in the lower social classes. Certain diseases (e.g., the sampling has been done correctly.<gross-sectional study
coronary heart disease, hypertension, diabetes) have shown is also known as “prevalence study”.\
a higher prevalence in upper classes than in the lower r Cross-sectional studies are more useful for chronic than
classes. Social class differences have also been observed in
mental illness and utilization of medical and health care short-lived diseases. For example, in a study of hypertension,
services. we can also collect data during the survey about age, sex,
physical exercise, body weight, salt intake and other
However, there is one snag. Social classification varies variables of interest Then we can determine how prevention
from country to country. It has different meanings for of hypertension is related to certain variables simultaneously
different persons. Therefore associations of disease with measured. Such a study tells us about the distribution of a
social class vary according to one’s concept of social class. disease in population rather than its aetiology.
Consequently, it is difficult to compare the results of studies
in which social class has been used differently by different The most common reason that epidemiologist examines
investigators (31). the inter-relationships between a disease, or one of its
precursors, and other variables is to attempt to establish a
(q)LBehauiour : Human behaviour is increasingly looked causal chain and so give lead to possible ways of preventing
upon as a risk factor in modern-day diseases such as that disease. A point which must be stressed is that the time
coronary heart disease, cancer, obesity and accidents. The sequence which is essential to the concept of causativity
behavioural factors which have attracted the greatest cannot be deduced from cross-sectional data. However,
attention are cigarette smoking, sedentary life, over-eating frequently there is evidence that permits ranking of events to
and drug abuse. To this must be added the mass movement form such a sequence. That is, the distribution patterns may
of people, such as occurs in pilgrimages, which lends suggest causal hypothesis which can be tested by analytical
themselves to the transmission of infectious diseases such as
studies. Although a cross-sectional study provides
cholera and diarrhoeal diseases, insect-borne and sexually information about disease prevalence, it provides very little
transmitted diseases^
information about the natural history of diseaseor about the
(h) (stress : Stress has been shown to affect a variety of rate of occurrence of new cases (incidence).
variables related to patients response, e.g., susceptibility to
disease, exacerbation of symptoms, compliance—with Longitudinal studies
medicabregimen, etc. There is an increasing emphasis on the value of
(i) Migration : In India diseases like leprosy, filaria and longitudinal studies in which observations are repeated in
malaria are considered to be rural problems. However, the same population over a prolonged period of time by
because of the movement of people from rural to urban means of follow-up examinations. Cross-sectional studies
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78 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

have been likened to a photograph, and longitudinal studies existence of a possible causal association between a facte
to a cine film. Longitudinal studies are useful (i) to studyT-he and a disease is usually recognized in descriptive studie
natural- history of disease- and its future outcome (ii) for Thus, if the disease is observed to be more frequent in
identifying risk factors of disease, and (iii) for finding_out particular group than in others, hypotheses are formulated t
incidence-rate or rate of occurrence of new cases of disease explain the increased frequency (c) provide background dat
in the community. Longitudinal studies provide^ valuable for planning, organizing and evaluating preventive^, an
information which the cross-sectional studies maynot curative services, and (d) they contribute to research b
provide, but longitudinal studies are difficult to organize and describing variations in disease” occurrence by time, plac
more time-consuming than cross-sectional^studjesS and person.»
Measurement can also be extended to health states and
events. For example, the study of blood pressure levels in a ANALYTICAL EPIDEMIOLOGY
population will reveal the normal values, rather than
abnormal ones related to disease. Analytical studies are the second.major___________ type c
epidemiological studies. In contrast to descriptive studie
5. Comparing with known indices that look at entire populations, in analytical studies, th
subject of interest is the individual within the populatior
ie essence of epidemiology is to make comparisons and

S questions. (By making comparisons between different

populations, and subgroups of tfie^same populationTTFis
possible to arrive at clues to disease aetiology. We can also
The object is not to formulate, but to test hypotheses
Nevertheless, although individuals are evaluated i
analytical studies, the inference is not to individuals, but t
the population from which they are selected.
identify or define groups which are at increased risk for
certain diseases^ Analytical studies comprise two distinct types c
observational studies :
6. Formulation of a hypothesis
a. case control study
(Sv studying the distribution of disease, and utilizing the
techniques of descriptive epidemiology, it is often possible to b. cohort study.
formulate hypotheses relating to disease aetiology^ A From each of these study designs, one can determine :
hypothesis is a supposition, arrived at from observation or
reflection. It can be accepted or rejected, using the a.(whether or not a statistical association exist

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techniques of analytical epidemiology. An epidemiological between a disease and a suspected factor; and
hypothesis should specify the following (13) : b/jt one exists, the strength of the Association.
a. (the population - the characteristics of the persons to A schematic design of case control and cohort studies i
whonFfhe hypothesis applies shown in Fig. 8.
b. (Jhe_specific cause being considered Design of a Case Control Study
c. the expected outcome - the disease
TIME
d. ((the_dose-response relationship - the amount of the --------------------------------------------- ►
cause needed to lead to a stated incidence of the Direction of inquiry
effect
Start with:
e. (the time-response relationship - the time period that
will elapse between exposure to the cause and
observation of the effect.
In other words, a hypothesis should be formulated in a
manner that it can be tested taking into consideration the
above elements. In practice, the components of a hypothesis
are often less well-defined.
For example :
“Cigarette smoking causes lung cancer” - is an
incomplete hypothesis. Design of a Cohort Study
An improved formulation TIME
->
“The smoking of 30-40 cigarettes per day causes lung Direction of inquiry
cancer in 10 per cent of smokers after 20 years of
exposure”
The improved formulation suggests data needed to test
the hypothesis, i.e., the number of cigarettes smoking per
day, years of exposure, and so on. The success or failure of a
research project frequently depends upon the soundness of
the hypothesis (13).
Uses of descriptive epidemiology
Descriptive studies : (a)_ provide data regarding the
magnitude of the disease load and types of disease problems
in the community in terms of morbidity and mortality rates
Schematic diagram of the design of case control and cohort studies
and ratios (b) provide clues to disease aetiology, and help in
the formula'hon of an aetiological hypothesis. That is, the Source : (32)

by R△J
 CASE CONTROL STUDY

CASE CONTROL STUDY and contro

Case control studies, often called “retrospective studies” The first step is to identify a suitable group of cases and a
are a common first approach to test causal hypothesis. In group of controls. While identification of cases is relatively
recent years, the case control approach has emerged as a easy, selection of suitable controls may present difficulties.
permanent method of epidemiological investigation. The In this connection, definite guidelines have been laid down
case control method has three (distinct features^ such as the following (5, 10, 13).
a. (both exposure and outcome (disease) have occurred (1) SELECTION OF CASES
before the start of the study I
(^[Definition of a case : The prior definition of what
b. (the study proceeds backwards from effect to cause;
constitutes a “case” is crucial to the case control study. It
and
involves two specifications : (i) (DIAGNOSTIC CRITERIA :
c. it uses a control or,comparison group to support or £fhe diagnostic criteria of the disease and the stage of
refute an inference. disease, if any (e.g., breast cancer Stage I) to be included in
By definition, a case control study involves two the study must be specified before the study is undertaken.
populations - cases and controls.Cln case control studies, the Supposing we are investigating cases of cancer, we should
unit is the individual rather than the group. The focus is on a be quite clear that we have, for our cases, a group
disease or some other health problem that has already histologically the same.kQnce the diagnostic criteria are
developed. established, they should not be altered or changed till the
Case control studies are basically comparison studies. study is over, (ii) (ELIGIBILITY CRITERIA : The second
Ceases and controls must be comparable with respect to criterion is that ol eligibility. (A criterion customarily
known confounding factors” such as age, sex, occupation, employed is the requirement that only newly diagnosed
social status, etc. The questions asked relate to personal (incident) cases within a specified period of time are
characteristics and antecedent exposures which may be eligible than old cases or cases in advanced stages of the
responsible for the condition studied. For example, one can disease (prevalent cases).
use as “cases” the immunized children and use as “controls” (b) (Sources of cases : The cases may be drawn from
un-immunized children, and look for factors of interest in (i) hospitals, or (ii) general population, (i) HOSPITALS : It is
their past histories.CCase control studies have been used often convenient to select cases from hospitals. The cases

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effectively for studies of many cancers, and other serious may be drawn from a single hospital or a network of
conditions such as cirrhosis of the liver, lupus erythematosis, hospitals, admitted during a specified period of time. The
and congestive heart failure. entire case series or a random sample of it is selected for
The basic design of a case control study is shown in study, (ii) GENERAL POPULATION : In a population-based
Table 11. It is a 2x2 table which provides a very useful case control stiidy, all cases of the study disease occurring
framework to discuss the various elements which make up a within a defined geographic area during a specified period
case control study. To illustrate, if it is our intention to test of time are ascertained, often through a survey, a disease
the hypothesis that “cigarette smoking causes lung cancer”, registry or hospital network. The entire case series or a
using the case control method, the investigation begins by random sample of it is selected for study. The cases should
assembling a group of lung cancer cases (a+c), and a group be fairly representative of all cases in the community.
of suitably matched controls (b+d). One then explores the
past history of these two groups for the presence or absence (2) SELECTION OF CONTROLS
of ^smoking, which is suspected to be related to the Th e controls must be free from the disease under study.
occurrence of cancer lung. If the frequency of smoking, a/ They must be as similar to the cases as possible, except for_the
(a + cl is higher in cases than in controls b/(b + d), an absence of the disease under study. As a rule, a comparison
association is said to exist between smoking and lung cancer. group is identified before a study is done, comprising of
CCase control studies have their major use in the chronic persons who have not been exposed Jo the disease or some
disease problem when the causal pathway may span many other factor whose influence is being studied.difficulties may
decades! arise in the selection of controls if the disease under
TABLE 11 investigation occurs in subclinical forms whose diagnosis is
difficult. Selection of an appropriate control group is
Framework of a case control study
therefore an important prerequisite, for it is against this, we
(The 2x2 contingency table)
— make comparisons, draw inferences and make judgements
about the outcome of the investigation (10).
Suspected or Cases, Control
risk factors (Disease present) (Disease absent) C Sources _of controls : The possible sources from which
controls may be selected include hospitals, relatives.
Present a b
neighbours and general population, (i) HOSPITAL
Absent c d CONTROLS: The controls may be selected from thejsame
a+c b+d hospital as the cases, but with different illneses other than
the study disease. For example, if we are going to study
Basic steps cancer cervix patients, the control group may comprise
There are four basic steps in conducting a case control patients with cancer breast, cancer of the digestive tract, or
study : patients with non-cancerous lesions and other patients.
Usually it is unwise to choose a control group from a group
1. Selection of cases and controls of patients with one disease. Uhis is because, hospital
2. Matching \X controls are often a source of “selection bias”. Many hospital
3. Measurement of exposure, and patients may have diseases which are also influenced by_the
4. Analysis and interpretation.^/ factor under study. For example, if one was studying the
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80 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

relationship of smoking and myocardial infarction and (b)(Age could be a confounding variable. Supposing, we
chooses bladder cancer cases as controls, the relationship are investigating the relationship between steroid
between smoking and myocardial infarction may not have contraceptive andbreast cancer. If the women taking these’
been demonstrated. Therefore, great care must be taken contraceptives were younger than those in the comparison
when using other patients as comparison subjects, for they group, they would necessarily be at lower risk of breast
differ in many ways from a normal healthy population. cancer since this disease becomes increasingly common with
Ideally the controls should have undergone the same increasing age.Clhis “confounding” effect of age can be
diagnostic workjjp as cases, but have been found to be neutralized by matching so that both the groups have arT
negative. But this may rioTbe acceptable to most controls equal proportion of each age group. In~otFer~words,
(ii) RELATIVES : The controls may also be taken up from (matching protects against an unexpected strong association
relatives (spouses and siblings). Sibling controls are between the matching factor (e.g., age) and the disease
unsuitable where genetic conditions are under study. (e.g., breast cancer). In a similar fashion other confounding
(iii) NEIGHBOURHOOD CONTROLS : The controls may be variables will have to be matched.
drawn from persons living in the same locality as cases,
While matching it should be borne in mind that the
persons working in the same factory or children attending
suspected aetiological factor or the variable we wish to
the same school, (iv) GENERAL POPULATION : Population
measure should not~T5~e matched, because by matching, its
controls can be obtained from defined geographic areas, by
aetiological role is eliminated in that study. The cases and
taking a random sample of individuals free of the study
controls will then become automatically alike with respect to
disgase. We must use great care in the selection of controls
that factor. In the above example, it would be useless to
to be certain that they accurately reflect the population that
match cases and controls on steroid contraceptive use; by
is free of the disease of interest.
doing so, the aetiological role of steroid contraceptive
OdoW—many controls are needed ? If many cases are cannot be investigated.
available, and large study is contemplated, and if the cost to
coHecTcase and control is about equal, then one tends to There are several kinds of matching procedures. One is
use one control for each-case. If the study groupjs small (say C group matching. This may be done by assigning cases to
under 50) as many as 2,3, or even 4 controls can be selected sub-categories (strata) based on their characteristics (e.g.,
for each study subject.__] age, occupation, social______ class) and then_____ establishing
appropriate controls. The frequency distribution of the

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To sum up, selection of proper cases and controls is matched variable must be similar in study and comparison
crucial to the interpretation of the results of case control groups. Matching is also done by pairs. For example, for
studies.(gome investigators select cases from one source and each case, a control is chosen which can be matched quite
controls from more than one source to avoid the influence of closely. Thus, if we have a 50 year old mason with Ti
“selection bias’. Such studies are recommended by particular disease, we will search for.50 year old mason
epidemiologists. It is also desired to conduct more than one without the disease as a control. Thus one can obtain pairs
case control study, preferably in different geographic areas. of patients and controls of the same sex, age, duration and
If the findings are consistent, it serves to increase the validity severity of illness, etc. But there may be great difficulties in
(i.e., accuracy) of the inferences, failure to select obtaining cases and controls matched on all characteristics,
comparable controls can introduce “bias” into results oi case" and it may be necessary to wait a considerable period of
control studies and decrease the confidence one can place in time before obtaining a sufficient number of matched pairs.
the findings. ( Therefore, some leeway is necessary in matching for
variables (34, 35). llLshould be noted that if matching is
2. Matching overdone, it may be difficult to find controls Further with
Cjhe controls may differ from the cases in a number of excess zeal in matching, there may be a tendency to reduce
factors such as age, sex, occupation, social status, etc. An the odds ratio?
important consideration is to ensure comparability between
cases and controls. This involves what is known as 3. Measurement of exposure
“matching” .(^latching is defined as the process by which we Definitions and criteria about exposure (or variables
select controls in such a way that they are similar to cases which may be of aetiological importance) are just as
with regard to certain pertinent selected variables (e.g., age) important as those used to define cases and controls.
which are known to influence the outcome ol disease and (^Information about exposure should be obtained in precisely
which, if not adequately matched for comparability, could the same manner both for cases and controls. This may be
distort or confound the results^ A “confounding factor” is obtained by interviews, by questionnaires or by studying
defined as one which is associated both with exposure and past records of cases such as hospital records, employment
disease, and is distributed unequally in study and control — records, etc. It is important to recognize that when case
gioupd More specifically a “confounding factor” is one that, control studies are being used to test associations, the mn^t
although associated with “exposure” under investigation, is important factor to be considered, even more important
itself, independently of any such association, a “risk factor” than the P. values obtained, is the question of “bias” or
for the disease. Two examples are cited to explain systematic error which must be ruled out (see page 81).
confounding.
(a)Gn the study of the role of alcohol in the aetiology of 4. Analysis
oesophageal cancer, smoking is a confounding factor The final step is analysis, to find out
because (i) it is associated with the consumption of alcohol
and (ii) it is an independent risk factor for oesophageal (a) (Exposure rates among cases and controls to
cancer. In these conditions, the effects of alcohol suspected factor
consumption can be determined' only if the influence of (b) LEstimation of disease risk associated with exposure
smokipglFneutralized by matching (33). (Odds ratio)
by R△J
 CASE CONTROL STUDY

(a) EXPOSURE RATES a c

f^A^case control study provides a direct estimation of the (a + b) * (c + d)
px£M?sure rates (frequency of exposure) to a suspected factor A typical case control study does not provide incidence
TjTdisease and non-disease groups. Table 12 shows how rates from which relative risk can be calculated directly,
exposure rates may be calculated from a case control study. because there is no appropriate denominator or population
at risk, to calculate these rates. In general, the relative risk
TABLE 12
can be exactly determined only from a cohort study.
A case control study of smoking and lung cancer
Cases Controls Total Odds Ratio (Cross-product ratio)
(with lung cancer) (without lung From a case control study, we can derive what is known as
cancer)
Odds Ratio (OR) which is a measure of the strength of the
Smokers 33 55 88 association between risk factor and outcome. Odds ratio is
(less than 5 (a) (b) (a+b) closely related to relative risk.Tf he derivation of odds ratio is
cigarettes a day) based on three assumptions : (a) the disease being investigated
Non-smokers 2 27 29 must be relatively rare: (b) the cases must be representative of
(c) (d) (c+d) those with the disease, and (c) the controls must be
Total 35 82 n = a+b representative of those without thedisease. The odds ratio is the
(a+c) (b+d) +c+d cross product of the entries in Table 11 which is reproduced
Source : (36) below:
Diseases
Exposure rates
Yes No
a. Cases = a/(a+c) = 33/35 = 94.2 per cent
Exposed a b
b. Controls = b/(b+d) = 55/82 = 67.0 per cent Not exposed c d
P < 0.001’”
Odds ratio = ad/bc
Table 12 shows that the frequency, rate of lung cancer was
definitely higher among smokers than among non-smokers. Using the data in Table 12, the odds ratio would be

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The next step will be to ascertain whether there is a statistical estimated as follows : • —----- -
association between exposure status and occurrence of lung ad
cancer. This question can be resolved by calculating the Odds ratio = (---------- )/(------- ) = --------
P value, which in this case is less than 0.001. b d . be
The particular test of significance will depend upon the 33x27
= ------------------- = 8.1 8.1
variables under investigation. If we are dealing with discrete 55x2
variables, as in the present case (smoking and lung cancer;
exposure and disease) the results are usually presented as In the above example, smokers of less than 5 cigarettes
rates or proportions of those present or absent in the study per day showed a risk of having lung cancer 8.1 times that of
and in the control group. The test of significance usually non-smokers. Odds ratio is~a~key parameter in the analysis
adopted is the standard error of difference between two of case control studies.
proportions or the Chi-square. testjQn the other hand, if we
are dealing with continuous variables (e.g., age, blood, Bias in case control studies
pressure), the data will have to be grouped and the test_of (jBias is any systematic error in the determination of the
significance used is likely to be the standard error of association -between the exposure and disease. The relative
difference between two means, or test. risk estimate may increase or decrease as a result ofthe bias;
(According to convention, if P is less than coequal to it reflects some type of non-comparability between the study
0.05, it is regarded as “statistically significant” <The smaller and control groups. The possibility of bjas must be
the P value, the greater the statistical significance or considered when evaluating a possible cause, and effect
probability that the association is not due to chance alone. relationship. \
However, statistical association (P. value) does not imply Many varieties of bias may arise in epidemiological
causation. Statement of P value is thus an inadequate, studies. Some of these are : (a) Bias due to confounding :
although common end-point of case control studies. Mention has already been made about confounding as an
important source of bias. This bias can be removed..-by
(b) ESTIMATION OF RISK matching in case control studies, (b) Memory or recall bias :
The second analytical step is estimation of disease risk When cases and controls are asked questions about their
associated with exposure. It should be noted (Table 12) that past history, it may be more likely for the cases to recall the
if the exposure rate was 94.2 per cent in the study group, it existence of certain events or factors, than the controls who
does not mean that 94.2 per cent of those smoked would are healthy persons. For example, those who have had a
develop lung cancer. The estimation of disease risk myocardial infarction might be more likely to remember and
associated with exposure is obtained by an index known as recall certain habits or events than those who have not.
“Relative Risk” (RR) or “risk ratio”, which is defined as the Thus cases may have a different recall of past events t an
(latio between the incidence of disease among exposed controls, (c) Selection bias.: The cases and .controls niav not
persons and incidence among non-exposed. It is given by"' be representative of cases and controls in the gengnd
the formula: population. There may be systematic—differences in
Incidence among exposed characteristics between cases and controls. The selection
Relative risk = bias can be best controlled by its prevention (d) Berkesonian
T Incidence among non-exposed bias : A special example of bias is Berkesonian Eias, termed

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I PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS
82.
after Dr. Joseph Berkeson who recognized this problem. The 7 young women (15 to 22 years) born in one Boston
bias arises because of the different rates of admission to hospital between 1966 and 1969. The apparent “tjme
hospitals for people with different diseases (i.e., hospital clustering” of cases - 7 occurring within 4L_y^ars-at a single
cases and controls), (e) Interuiewer’s bias : Bias may also KospitaT - led to this enquiry. An eighth case occurred in
occur when the interviewer knows the hypothesis and also 1969 in a 20 year old patient who was treated at another
knows who the cases are. This prior information may lead Boston hospital in USA.
him to question the cases more thoroughly Than controls The cause of this tumor was investigated by a case control
regarding a positive history of the suspected causal factor. A study in 1971 to find out the factors that might be associated
useful check on this kind of bias can be made by noting the with this tumor(As this was a rare disease, for each case, four
length of time taken to interview the average case and the matched controls were put up. The controls were identified
average control. This type of bias can be eliminated by from the birth records of the hospital in which each case was
double-blinding (see page 91). born. Female births occurring closest in time to each patient
were selected as controls. Information was collected by
Advantages and disadvantages personal interviews regarding (a) maternal age (b) maternal
Table 13 summarizes the advantages and disadvantages smoking (c) antenatal radiology, and (d) diethyl-stilbestrol
of case control studies. (DES! exposure in i'oetal life. The results of the study are
TABLE 13 shown in Table 14 which shows that cases differed
Advantages and disadvantages of case control studies significantly from the controls in their past history. Seven of
the eight cases had been exposed to DES in foetal life. This
ADVANTAGES drug had been given to their mothers during the first
1. Relatively easy to carry out. trimester of pregnancy to prevent possible miscarriage. But
2. Rapid and inexpensive (compared with cohort studies) none of the mothers in the control group had received DES.
3. Require comparatively few subjects^ __________ Since this study, more cases have been reported and the
4. Particularly suitable to investigate rare diseases or diseases association with DES has been confirmed. The case control
about which little is known But adiseaseAvhich is rare in the method played a critical role in revealing exposure to DES
general population (e.g., leukaemia in adolescents) may not
be rare in special exposure group (e g. prenatal X-rays) in utero as the cause of vaginal adenocarcinoma in the
5. No risk to subjects. exposed child 10-20 years later.

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6. Allows the study of several different aetioloqical factors (eg., TABLE 14
smokingrphysical activity and personality characteristics in
myocardial infarction). Association between maternal DES therapy and
7. <Risk factors can be identified Rational prevention and adenocarcinoma of vagina amongst female offspring
control programmes can be established.
Information Cases Controls Significance
8. No attrition problems, because case control studies do not acquired (32) level
require follow-up of individuals into the future. (8)
retrospectively
9 Ethical problems minimal,
DISADVANTAGES Maternal age 26.1 29.3 ns.
1 (Problems of bias relies on memory or past records, the Maternal smoking 7 21 n.s
accuracy of which may be uncertain; validation of Antenatal radiology 1 4 n.s.
information obtained is difficult or sometimes impossible. Oestrogen exposure 7 - P<0.00001
2. Selection of an appropriate control group may be difficult
Source : (27)
3 tWe_cannot measure incidence, and can only estimate the
relative risk. Example 2: Oral contraceptives and thromboembolic
4 (Do not distinguish between causes and associated factors disease (48, 49).
5 Not suited to the evaluation of therapy or prophylaxis of
disease. By August 1965, the British Committee on Safety of
6 Another major concern is the representativeness of cases and Drugs had received 249 reports of adverse reactions and 16
controls. reports of death in women taking oral contraceptives. It
became apparent that epidemiological studies were needed
Source : (37, 38)
to determine whether women who took oral contraceptives
Examples of case control studies were at greater risk of developing thromboembolic disease.
Case control studies have provided much of the current In 1968 and 1969, Vassey and Doll reported the findings
base of knowledge in epidemiology. Some of the early case of their case control studies in which they interviewed
control studies centred round (cigarette smoking and lung women who had been admitted to hospitals with venous
cancer (36, 39, 40). Other studies include: (maternal thrombosis or pulmonary embolism without medical cause
smokino^and congenital malformations (41),(radiation and and compared the history with that obtained from other
leukaemia (42),(oral contraceptive use and hepatocellular women who had been admitted to the same hospital with
adenoma (43),(herpes simplex and Bell palsvft (44)(induced other diseases and who were matched for age, marital status
abortion" and spontaneous abortion i (45), (physical activity and parity.
and coronary deathjffd), Artificial sweeteners and bladder It was found that out of 84, 42 (50%) of those with
cancey (47), etc. venous thrombosis and pulmonary embolism had been
A few studies are cited in detail : using oral contraceptives, compared with 14% of controls
(Table 15). The studies confirmed that taking the pill and
having pulmonary embolism co-existed more frequently
An excellent example of a case control study is than would be expected by chance. The relative risk of users
adenocarcinoma of the vagina in young women. It is not to non-users was 6.3:1. That is, the investigators found that
only a rare disease, but also the usual victim is over 50 years users of oral contraceptives were about 6 times as likely as
of age. There was an unusual occurrence of this tumor in non-users to develop thromboembolic disease.
by R△J
 COHORT STUDY 83
TABLE 15 as derived from clinical observations and supported by
Case control studies on the safety of oral contraceptives descriptive and case control studies (b) when exposure is
rare, but the incidence of disease high among exposed, e.g.,
Per cent who
used oral
special exposure groups like those in industries, exposure to
No
contraceptives X-rays, etc (c) when attrition of study population can be
minimized, e.g., follow-up is easy, cohort is stable, co­
Cases (venous 84 50 operative and easily accessible, and (d) when amplejunds
thrombosis and are available.
pulmonary embolism)
Controls 168 14 Framework of a cohort study
Source : (48, 49) In contrast to case control studies which proceed from
“effect to cause”, the basic approach in cohort studies is to
Example 3 : Thalidomide tragedy (50). work from “cause to effect” k(Fig. 8). That is, in a case
control study, exposure and disease have already occurred
Thalidomide was first marketed as a safe, non-barbiturate
when the study is initiated. In a cohort study, the exposure
hypnotic in Britain in 1958. In 1961, at a congress of
has occurred, but the disease has not.
Gynaecologists, attention was drawn to the birth of a large
number of babies with congenital abnormalities, which was The basic design of a simple cohort study is shown in
previously rare. In the same year, it was suggested that Table 16. We begin with a group or cohort (a+b) exposed to
thalidomide might be responsible for it. a particular factor thought to be related to disease
occurrence, and a group (c+d) not exposed to that
A retrospective study of 46 mothers delivered of
particular factor. The former is known as “study cohort”,
deformed babies showed that 41 were found to have
thalidomide during their early pregnancy. This was and the latter “control cohort!.
compared with a control of 300 mothers who had delivered .TABLE 16
normal babies; none of these had taken thalidomide. Framework of a cohort study
Laboratory experiments confirmed that thalidomide was
Disease
teratogenic in experimental studies (50).
Cohort yes no Total

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COHORT STUDY Exposed to a b a+b
putative aetiologic
Cohort study is another type of analytical (observational) factor
study which is usually undertaken to obtain additional
Not exposed to c d c+d
evidence to refute or support the existence of an association putative aetiologic
between suspected cause and disease. Cohort study is factor
known by a variety of names : prospective study, longitudinal
study, incidence study, and forward-looking study. The most In assembling cohorts, the following general
widely used term, however, is “cohort study” (5). considerations are taken into account :
The distinguishing features of cohort studies are : a. (The .cohorts must be free from the disease under
study. Thus, if the disease under study is coronary
a. Ithe cohorts are identified prior to the appearance of heart disease, the cohort members are first examined
the disease under investigation and those who already have evidence of the disease
b. T thg study groups, so defined, are observed over a under investigation are excluded. J
period of time to determine the frequency of b. Insofar as the knowledge of the disease permits, both
disease among them) the groups (i.e., study and control cohorts) should be
c. (thejiudy proceeds forward from cause to effect.] equally susceptible to the disease under study, or
Concept of cohort efficiently reflect any difference in disease occurrence
(for example, males over 35 years would be
In epidemiology, the term “cohort” is defined as a group of appropriate for studies on lung cancer).
people who share a common characteristic or experience c. Both the groups should be comparable in respect of all
within a defined time period (e.g., age, occupation, exposure the possible variables, which may influence the
to a drug or vaccine, pregnancy, insured persons, etc) (Thus a frequency of the disease; and
group of people born on the same day or in the same period d. The diagnostic and eligibility criteria otythe disease
of time (usually a year) form a “tyrth cohort”. All those born must be defined beforehand; this will depend upon
in 2010 form the birth cohort of 2010 .(Persons exposed to a the availability of reliable methods for recognizing the
common drug, vaccine or infection within a defined period
disease when it develops.)
constitute an “exposure cohort”. A group of males or females
married on the same day or in the same period of time form a The groups are then followed, under the same identical
“marriage cohort”. A cohort might be all those who survived conditions, over a period of time to determine the outcome
a myocardial infarction in one particular year. of exposure (e.g., onset of disease, disability or death) in
both the groups. In chronic diseases such as cancer the time
C^The comparison group may be the general population
required for the follow-up may be very long.
from which the cohort is drawn, or it may be another cohort
of persons thought to have had little or no exposure to the Table 16 shows (a+b) persons were exposed to the factor
substance in question, but otherwise similar. under study, ‘a’ of which developed the disease during the
follow-up period; (c + d) persons were not exposed, ‘c’ of
Indications for cohort studies which became cases (it is assumed for simplicity of
Cohort studies are indicated : (a) when there is good presentation that there were no intermittent deaths or losses
evidence of an association between exposure_and_disease, during the follow-up period). After the end of the follow-up,
by R△J
84 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

the incidence rate of the disease in both the groups is cancer in uranium miners, study of the mortality experience
determinedTlf it is found thanhOicidence of the disease in of groups of physicians in relation to their probable
the exposed group, a/(a+b) is significantly higherthan in the exposure to radiation (55,56,57). More recently,
non-exposed group, c/(c+d), it would suggest that the angiosarcoma of the liver, a very rare disease, has been
disease and suspected cause are associated. Since the reported in excess frequency in relation to poly-vinyl
approach is prospective, that is, studies are planned to chloride (58). This association was picked up only because
observe events that have not yet occurred, cohort studies of the retrospective cohort design. Retrospective cohort
ar^jrequently referred to as “prospective” studies. studies are generally more economical and produce results
A well-designed cohort study is considered the most more quickly than prospective rnhnrtstiidips
reliable means of showing an association between a suspected 3. Combination of retrospective and prospective
risk factor and subsequent disease because it eliminates many
of the problems of the case control study and approximates cohort studies ( AnJb'tTpetUj? j
the experimental model of the physical sciences. J In this type of study, both the7 retrospective and
prospective elements are combined. The cohort is identified
Types of cohort studies from past records, and is assessed of date for the outcome.
Three types of cohort studies have been distinguished The same cohort is followed up prospectively into future for
on the basis of the time of occurrence of disease in relation further assessment of outcome.
to the time at which the investigation is initiated and Court-Brown and Doll (1957) applied this approach to
continued : study the effects of radiation. They assembled a cohort in
1. Prospective cohort studies •■'■■"1955 consisting of 13,352 patients who had received large
doses of radiation therapy for ankylosing spondylitis between
2. Retrospective cohort studies, and
1934 and 1954. The outcome evaluated was death from
3. A combination of retrospective and prospective cohort leukaemia or aplastic anaemia between 1935 and 1954.
studies. They found that the death rate from leukaemia or aplastic
1. Prospective cohort studies anaemia was substantially higher in their cohort than that of
the general population. A prospective component was added
A prospective cohort study (or “current” cohort study) is to the study and the cohort was followed, as established in
one in which the outcome (e.g., disease) has not yet

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1955, to identify deaths occurring in subsequent years (59).
occurred at the time the investigation begins. Most
prospective studies begin in the present and continue into ELEMENTS OF A COHORT STUDY
future. For example, the long-term effects of exposure to
uranium was evaluated by identifying a group of uranium The elements of a cohort study are :
miners and a comparison group of individuals not exposed 4/ Selection of study subjects
to uranium mining and by assessing subsequent ^2^ Obtaining data on exposure
development of lung cancer in both the groups. The principal
finding was that the uranium miners had an excess frequency ^3^ Selection of comparison groups
of lung cancer compared to non-miners. Since the disease 4^ Follow-up, and
had not yet occurred when the study was undertaken, this 5/ Analysis.
was a prospective cohort design. The US Public Health
Service’s Framingham Heart Study (51), Doll and Hills (52) 1. Selection of study subjects
prospective study on smoking and lung cancer, and study of The subjects of a cohort study are usually assembled in
oral contraceptives and health by the Royal College of one of two ways - either from general population or select
General Practitioners (53) are examples of this type of study. groups of the population that can be readily studied (e.g.,
persons with different degrees of exposure to the suspected
2. Retrospective cohort studies causal factor).
A retrospective cohort study (or “historical” cohort study) (a) (Genera/ population}. When the exposure or cause of
is one in which the outcomes have all occurred before the death is fairly frequent in the population, cohorts may be
start of the investigation. The investigator goes back in time, assembled from the general population, residing in well-
sometimes 10 to 30 years, to select his study groups from defined geographical, political and administrative areas
existing records of past employment, medical or other (e.g., Framingham Heart Study). If the population is very
records and traces them forward through time, from a past large, an appropriate sample is taken, so that the results can
date fixed on the records, usually up to the present. This be generalized to the population sampled. The exposed and
type of study is known by a variety of names : retrospective unexposed segments of the population to be studied should
cohort study, “historical” cohort study, prospective study in be representative of the corresponding segments of the
retrospect and non-concurrent prospective study. general population.
The successful application of this approach is illustrated (b) (Specia/ groups : These may be special groups or
in one study undertaken in 1978 - a cohort of 17,080 exposure groups that can readily be studied : (i) Select
babies born between January 1, 1969 and December 31, groupis : These may be professional groups (e.g., doctors,
1975 at a Boston hospital were investigated of the effects of nurses, lawyers, teachers, civil servants), insured persons,
electronic foetal monitoring during labour. The outcome obstetric population, college alumni, government
measured was neonatal death. The study showed that the employees, volunteers, etc. These groups are usually a
neonatal death rate was 1.7 times higher in unmonitored homogeneous population. Doll’s prospective study on
infants (54). The most notable retrospective cohort studies smoking and lung cancer was carried out on British doctors
to date are those of occupational exposures, because the listed in the Medical Register of the UK in 1951 (60). The
recorded information is easily available, e.g., study of the study by Dorn on smoking and mortality in 293,658
role of arsenic in human carcinogenesis, study of lung veterans (i.e., former military service) in United States
by R△J
 ELEMENTS OF COHORT STUDY

having life insurance policies is another example of a study TABLE 17

based on special groups (61). These groups are not only Age standardized death rates per 100,000 men per year
homogeneous, but they also offer advantages of accessibility by amount of current smoking
and easy follow-up for a protracted period (ii) Exposure
Classification of
groups : Qf_the exposure is_ rare, a more economical exposure (cigarettes) No. of deaths Death rate
procedure is to select a cohort of persons known to have
experi^ncedJhe^exposure. In other words, cohorts may be 1/2 pack 24 95.2
selected because of special exposure to physical, chemical 1/2-1 pack 84 107.8
and other disease agents. A readily accessible source of 1-2 packs 90 2292
these groups is workers in industries and those employed in 2 packs + 97 264.2
high-risk situations (e.g., radiologists exposed to X-rays).
Source : (6)
When cohorts have been selected because of special
exposure, it facilitates classification of cohort members (b) External comparisons
according to the degree or duration of exposure to the L^When information on degree of exposure is not available,
suspected factor for subsequent analytical study. it is necessary to put up an external control, to evaluate the
2. Obtaining data on exposure experience of the exposed group, e.g., smokers and non-
smokers, a cohort of radiologists compared with a cohort of
Information about exposure may be obtained directly from ophthalmologists, etc. The study and control cohorts should
the (a) Cohort members : through personal interviews or be similar in demographic and possibly important variables
mailed questionnaires. Since cohort studies involve large other than those under study.
numbers of population, mailed questionnaires offer a simple
and economic way of obtaining information. For example, (c) Comparison with general population rates
Doll and Hill (62) used mailed questionnaires to collect If none is available, the mortality experience of the exposed
smoking histories from British doctors, (b) Review of group is compared with the mortality experience of the general
records: Certain kinds of information (e.g., dose of radiation, population in the same geographic area as the exposed
Tin ds of surgery, or details of medical treatment) can be people, e.g., comparison of frequency of lung cancer among
obtained only from medical records, (c) Medical examination uranium mine workers with lung cancer mortality in the
or special tests : Some types of information can be obtained general population where the miners resided (56); comparison

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only by medical examination or special tests, e.g., blood of frequency of cancer among asbestos workers with the rate in
pressure, serum cholesterol, ECG. (d) Environmental general population in the same geographic area (63).
surveys : This is the best source for obtaining information on Rates for disease occurrence in sub-groups of the control
exposure levels of the suspected factor in the environment cohort by age, sex, and other variables considered
where the cohort lived or worked. In fact, information may be important may be applied to the corresponding sub-groups
needed from more than one or all of the above sources. of the study cohort (exposed cohort) to determine the
Information about exposure (or any other factor related “expected” values in the absence of exposure. The ratio of
to the development of the disease being investigated) should “observed!’ and “expected” values provides a measure of the
be collected in a manner that will allow classification of effect of the factor under study.
cohort members : The limiting factors in using general population rates for
(a) according to whether or not they have been exposed comparison are : (i) non-availability of population rates for
to the suspected factor, and the outcome required; and (ii) the difficulties of selecting the
(b) according to the level or degree of exposure, at least in study and comparison groups which are representative of
broad classes, in the case of special exposure groups the exposed and non-exposed segments of the general
(Table 17). population.
In addition to the above, basic information about
demographic variables which might affect the frequency of 4. Follow-up
disease under investigation, should also be collected. Such One of the problems in cohort studies is the regular follow­
information will be required for subsequent analysis. up of all the participants. Therefore, at the start of the study,
methods should be devised depending upon the outcome to
3. Selection of comparison groups be determined (morbidity or death), to obtain data for
There are many ways of assembling comparison groups : assessing the outcome. The procedures required comprise :
(a) Cperiodic medical examination of each member of the
(a) Internal comparisons cohort
In some cohort studies, no outside comparison group is (b) reviewing physician and hospital records
required. The comparison groups are in-built. That is, single (c) routine surveillance of death records,^and
cohort enters the study, and its members may, on the basis (d) (mailed questionnaires, telephone calls, periodic home
of information obtained, be classified into several visits - preferably all three on an annual basis.
comparison groups according to the degrees or levels of
exposure to risk (e.g., smoking, blood pressure, serum Of the above, periodic examination of each member of the
cholesterol) before the development of the disease in cohort, yields greater amount of information on the individuals
question. The groups, so defined, are compared in terms of examined, than would the use of any other procedure.
their subsequent morbidity and mortality rates. Table 17 However, inspite of best efforts, a certain percentage of
illustrates this point. It shows that mortality from lung cancer losses to follow-up are inevitable due to death, change of
increases with increasing number of cigarettes smoked residence, migration_or withdrawal of occupation. These
reinforcing the conclusion that there is valid association losses may bias the results. It is, therefore, necessary to build
between smoking and lung cancer. into the study design a system for obtaining basic

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86 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

information on outcome for those who cannot be followed In our hypothetical example (Table 18), the relative risk is
up in detail for the full duration of the study (14). The safest 10. It implies that smokers are 10 times at greater risk of
course recommended is to achieve as close to a 95 per cent developing lung cancer than non-smokers. The larger the
follow-up as possible (13). RR, the greater the “strength” of the association between the
suspected factor and disease. It may be noted that risk does
5. Analysis not necessarily imply causal association.
The data are analyzed in terms of:
(a) Incidencgjrates of outcome among exposed and non­ ATTRIBUTABLE RISK
exposed,
( Attributable risk (AR) is the difference in incidence rates
(b) Estimation of risk. ordlsease (or death) between an exposed group and non­
(a) Incidence rates exposed group. Some authors use the term “risk difference”
to attributable risk.
In a cohort study, we can determine incidence rates
directly in those exposed and those not exposed. A Attributable risk is often expressed as a per cent. This is
hypothetical example is given in Table 18 showing how given by the formula :
incidence rates may be calculated : Incidence of disease rate among exposed
- incidence of disease rate among non-exposed
TABLE 18 = ------------------------------------------------------------------------X100
Contingency table applied to hypothetical Incidence rate among exposed
cigarette smoking and lung cancer example Attributable risk in our example (Table 18) would be :
Cigarette Developed Did not develop Total
1° 1
smoking lung cancer lung cancer 1~ x 100 - 90 per cent

Yes 70 6930 7000 Attributable risk indicates to what extent the disease
(a) (b) (a + b) under study can be attributed to the exposure. The figure in
our example indicates that the association between smoking
No 3 2997 3000
(c) (d) (c + d) and lung cancer is causal, 90 per cent of the lung cancer
among smokers was due to their smoking. This suggests the

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Incidence rates amount of disease that might be eliminated if the factor
(a) among smokers = 70/7000 = 10 per 1000 under study could be controlled or eliminated.
(b) among non-smokers = 3/3000 = 1 per 1000
POPULATION-ATTRIBUTABLE RISK
Statistical significance : P < 0.001
Another concept is “population-attributable risk”. It is the
(b) Estimation of risk incidence of the disease (or death) in the total population
Having calculated the incidence rates, the next step is to minus the incidence of disease (or death) among those who
estimate the risk of outcome (e.g., disease or death) in the were not exposed to the suspected causal factor (Table 19).
exposed and non-exposed cohorts. This is done in terms of
two well-known indices: (a) relative risk, (b) attributable risk. TABLE 19
Lung cancer death rates among smokers
RELATIVE RISK and non-smokers : LJK physicians

Relative risk (RR) is the ratio of the incidence of the Deaths per 100,000 person-years
disease (or death) among exposed and the incidence among Heavy smokers 224 Exposed to suspected
non-exposed. Some authors use the term “risk ratio” to refer factor (a)
to Relative risk. Non-smokers 10 Non-exposed to suspected
Incidence of disease (or death) among exposed causal factor (b)
RR_= ------------------------------------------------------------------------ Deaths in 74 (c)
Incidence of disease (or death) among non-exposed total populatioi
In our hypothetical example (Table 18) Individual RR a/b - =22.40
RR of lung cancer = -y- = 10 Population AR (c-b)/c = 86 per cent
Estimation of relative risk (RR) is important in aetiological Source : (60)
enquiries (It is a direct measure (or index) of the “strength”
of the association between suspected cause ancT ettec|. A The concept of population attributable risk is useful in
relative risk of one indicates no association; relative risk that it provides an estimate of the amount by which the
greater than one suggests “positive” association between disease could be reduced in that population if the suspected
exposure and the disease under study. A relative risk of 2 factor was eliminated or modified. In our example (Table 19)
indicates that the incidence rate of disease is 2 times higher one might expect that 86 per cent of deaths from lung
in the exposed group as compared with the unexposed. cancer could be avoided if the risk factor of cigarettes were
Equivalently, this represents a 100 per cent increase in risk. eliminated.
A relative risk of 0.25 indicates a 75% reduction in the
incidence rate in exposed individuals as compared with the Relative risk versus attributable risk
unexposed (37). It is often useful to consider the 95 per cent Relative risk is important in aetiological enquiries. Its size
confidence interval of a relative risk since it provides an is a better index than is attributable risk for assessing the
indication of the likely and maximum levels of risk. aetiological role of a factor in disease. The larger the relative

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 POPULATION-ATTRIBUTABLE RISK 87
risk, the stronger the association between cause and effect. changed their classification. Evenjn very common chronic
But relative risk does not reflect the potential public health diseases like coronary heart T- -.se, cohort studies are
importance as does the attributable risk. That is, attributable difficult to carry out. It is difficult to keep a large number of
risk gives a better idea than does relative risk of the impact individuals under medical surveillance indefinitely,
of successful preventive or public health programme might (c) Certain administrative problems such as loss of
have in reducing the problem. experienced staff, loss of funding and extensive record
Two examples are cited (Tables 20 and 21) to show the keeping are inevitable, (d) It is not unusual to lose a
practical importance of distinguishing relative and absolute substantial proportion of the original cohort - they may
risk. In the first example, (Table 20) the RR of a migrate, lose interest in the study or simply refuse to provide
cardiovascular complication in users of oral contraceptives is any required information, (e) Selection of comparison
independent of age, whereas the AR is more than 5 times groups which are representative of the exposed and
higher in the older age groups. This epidemiological unexposed segments of the population is a limiting factor.
observation has been the basis for not recommending oral Those who volunteer for the study may not be representative
contraceptive in those aged 35 years and over. of all individuals with the characteristic of interest, (f) There
may be changes in the standard methods or diagnostic
TABLE 20 criteria of the disease over prolonged follow-up. Once we
The relative and attributable risks of cardiovascular have established the study protocol, it is difficult to introduce
complications in women taking oral contraceptives new knowledge or new tests later, (g) Cohort studies are
expensive, (h) The study itself may alter people’s behaviour.
Cardiovascular risk Age If we are examining the role of smoking in lung cancer, an
100,000 patient years 30-39 40-44 increased concern in the study cohort may be created. This
Relative risk 2.8 2.8 may induce the study subjects to stop or decrease smoking,
(i) With any cohort study we are faced with ethical problems
Attributable risk 3.5 20.0
of varying importance. As evidence accumulates about the
Source : (64) implicating factor in the aetiology of disease, we are obliged
to intervene and if possible reduce or eliminate this factor,
The second example (Table 21) shows that smoking is
attributable to 92 per cent of lung cancer, and 13.3 per cent and (j) Finally, in a cohort study, practical considerations
dictate that we must concentrate on a limited number or
of CHD. In CHD, both RR and AR are not very high

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factors possibly related to disease outcome
suggesting not much of the disease could be prevented as
compared to lung cancer. The main differences between case control and cohort
studies are summarized in Table 22.
TABLE 21
Risk assessment, smokers us non-smokers TABLE 22
Death rate/1000 Main differences between case control and cohort studies
Cause of death RR AR (%)
Smokers Non-smokers
Case control study Cohort study
Lung cancer 0.90 0.07 12 86 92.2
CHD 4.87 4.22 1.15 13.3 1. ^Proceeds from “effect to Proceeds from “cause to
cause T. effect”.
Source (65) 2. Starts with the disease^ Starts with people exposed to
risk factor or suspected
Advantages and disadvantages of cohort studies cause.
Advantages 3 -Tests whether the suspected Tests whether disease occurs
* cause occurs more frequently more frequently in those
(a) Incidence can be calculated, (b) Several possible in those with the disease than exposed, than in those not
outcomes related to exposure can be studied simultaneously among those without the similarly exposed.
- that is, we can study the association of the suspected disease.
factor with many other diseases in addition to the one under 4. Usually the first approach to Reserved for testing of
study. For example, cohort studies designed to study the the testing of a hypothesis, precisely formulated
association between smoking and lung cancer also showed but also useful for exploratory hypothesis.
association of smoking with coronary heart disease, peptic studies.
ulcer, cancer oesophagus and several others, (c) (£ohort 5. involves fewer number of (involves larger number of
studies provide a direct estimate of relative risk, (d) Dose- subjects subjects^)
response ratios can also be calculated, and (e) Since 6. Yields relatively quick results. C^ong follow-up period often
comparison groups are formed before disease develops, needed, involving delayed
certain forms of bias can be minimized like mis-classification results. J
of individuals into exposed and unexposed groupsj) 7 Suitable for the study of rare Inappropriate when the
diseases. disease or exposure under
Disadvantages investigation is rare f
Cohort studies also present a number of problems : 8. Generally yields only estimate Yields incidence rates, RR as
(a) Cohort studies involve a large number^f_people. They of RR (odds ratio). well as AR.
are generally unsuitable for investigating uncommon
9. Cannot yield information about Can yield information about
diseases or diseases with low incidence in the population. diseases other than that more than one disease
(b) It takes a long time to complete the study and obtain selected for study.) outcome
results (20-30 years or more in cancer studies) by which time
lOXEelatively inexpensive. Expensive.
the investigators may have died or the participants may have

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88 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Examples of cohort studies contraceptives and health conducted by the Royal College
of General Practitioners in England (1974). It was initiated
Example 1 (^Smoking and lung cancer. in 1968, after 2 years of planning. 23,000 users of the pill
At least eight prospective studies on the relation of aged 15-49 years together with a similar number of controls
smoking to lung cancer had been done. Doll and,Hill (52, using other methods or no method of contraception were
62, 66), Hammond and Horn (67, 68) and Dorn (61) were brought under observation of 1400 general practitioners.
the first to report their findings. During follow-up doctors recorded the diagnoses of episodes
of illness, and information about pregnancies and deaths.
In October 1951, Doll and Hill sent a questionnaire to
59,600 British doctors listed in the Medical Register of the The study brought out the risks and benefits of oral
UK enquiring about their smoking habits. This enabled them contraceptive use. For example, the study showed that the
to form two cohorts (smokers and non-smokers) who were risk of hypertension increases, and the risk of benign breast
disease decreases with the dose of norethisterone acetate
similar in all other respects like age, education and social
(progestogen) in the combined pill which is an important
class. They received usable replies from 40,701 physicians -
finding. The study found an increased mortality from
34,494 men and 6,207 women. These were followed for
diseases of cardiovascular system in pill users confirming the
4 years and 5 months by obtaining notifications of
results of retrospective case control studies (69).
physicians’ deaths from the Registrar General, the General
Medical Council and the British Medical Association. For
every death certified as due to lung cancer, confirmation
EXPERIMENTAL EPIDEMIOLOGY
was obtained by writing to the physician certifying the death In the 1920s, “experimental epidemiology” meant the
and also, when necessary to the hospital or consultant to study of epidemics among colonies of experimental animals
whom the patient had been referred. The results of the study such as rats and mice. In modern usage, experimental
are shown in Table 19. epidemiology is often equated with RANDOMIZED
CONTROLLED TRIALS (2).
Example 2 : The Framingham heart study (51).
Experimental or intervention studies are similar in
The Framingham heart study was initiated in 1948 by the approach to cohort studies excepting that the conditions in
United States Public Health Service to study the relationship which study is carried out are under the direct control of the
of a number of (risk) factors (e.g., serum cholesterol, blood investigator. Thus experimental studies involve some action,

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pressure, weight, smoking) to the subsequent development intervention or manipulation such as deliberate application
of cardiovascular disease. The town of Framingham or withdrawal of the suspected cause or changing one
(Massachusetts) had a population of 28,000 in 1948. The variable in the causative chain in the experimental group
study was planned for 20 years in view of the slow while making no change in the control group, and observing
development of heart disease. and comparing the outcome of the experiment in both the
The lower and upper limits of the study population was groups. This contrasts sharply with observational studies
set at 30 and 59 years. Out of 10,000 people in this age (e.g., descriptive, case control and cohort studies), where
group a sample of 6,507 persons of both sexes were invited the epidemiologist takes no action but only observes the
to participate in the study, out of which 5,209 participated. natural course of events or outcome.
The initial examination revealed that 82 subjects had The aims of experimental studies may be stated as
clinically evident CHD. These were excluded from the follows : (a) to provide “scientific proof” of aetiological (or
sample leaving a total of 5,127. risk) factors which may permit the modification or control of
4,469 (69 per cent) of the 6,507 in the initial sample those diseases : and (b) tcFprovide a method of measuring
actually underwent the first examination. After the first the effectiveness and efficiency of health services for the
examination, the study population was examined every 2 prevention, control and treatment of disease and Improve
years for a 20 year period. Information was obtained with the health of the community.
regard to serum cholesterol, blood pressure, weight and Experimental studies have all the advantages and
cigarette smoking. Although biennial examinations were the disadvantages of the usual prospective cohort studies plus
main source of follow up information, other means were also three additional problems namely cost, ethics and feasibility.
adopted to detect CHD (e.g., Death certificate records). Experimental studies have become a major area of
Among other things, the study showed increasing risk of epidemiological studies. They may be conducted in animais
CHD with increasing serum cholesterol levels in the 45-54 or human beings.
age group. The study also showed that the association
between smoking and CHD varied with manifestations of the
Animal studies
disease. Thus, smoking was more strongly associated with Throughout history animals have played an important
sudden death from CHD than with less fatal forms of the role in men’s quest for knowledge about himself and his
disease. Risk factors have been found to include male sex, environment. Animal studies have contributed to our
advancing age, high serum lipid concentration, high blood knowledge of anatomy, physiology, pathology, microbiology,
pressure, cigarette smoking, diabetes mellitus, obesity, low immunology, genetics, chemotherapy and so many~others.
vital capacity and certain ECG abnormalities. The predictive At the .beginning of this century, Webster in United States
value of serum lipids, blood pressure and cigarette smoking and Topley, Wilson and Greenwood in England had carried
have been repeatedly demonstrated. The Framingham heart out classical animal experiments. Their studies centred
study became a prototype of similar studies in US and other round inducing epidemics in animals and in studies of herd
countries. immunity under laboratory conditions.
More important application of animal experiments have
Example 3 : Oral contraceptives and health (53). been in (a) experimental reproduction of human disease in
Another example is the cohort study of oral animals to confirm aetiological hypothesis and to study the

by R△J
 EXPERIMENTAL EPIDEMIOLOGY 89
pathogenetic phenomena or mechanisms (b) testing the experiment. Thus when an illness is fatal (e.g., excessive
efficacy of preventive and therapeutic measuresjsuch^as haemorrhage) and the benefit of treatment (e.g., blood
vaccines and drugs., and (c) completing the natural history of transfusion) is self-evident, it would be ethically unacceptable
diseaseTToi^example, naturaf[y_occurring leprosy has been to prove or disprove the therapeutic value of blood
fduhaTh armadillos* Data obtained from studying these transfusion. However, such instances represent only a small
animals mdlcafethat lepra bacilli might exist outside of part of the total research effort. On the other hand, in the
humans. present era of scientific medicine, many unscientific or
Animal experiments have their own advantages and scientifically unsound procedures are still being carried out.
limitations. The (Advantages are that the experimental For instance, in the study of prescription drugs, a panel of
animals can be bred"in laboratories and manipulated easily experts in USA found that only 23 per cent of some 16,000
accordingto the wishes of the investigator. A more drugs could be classified unequivocally as “effective” (38). It
important point isThat they multiply rapidly and enable the is now conceded that it is equally unethical if a drug or
investigators to carry out certain~experiments (e.g., genetic procedure is brought into general use without establishing its
experiments) which in human population would take several effectiveness by controlled trials. Thejhalidomide disaster and
years and involve many generations. The limitations of the occurrence of carcinoma of the vagina in the offspring of
aTrirrrai'experiments are that not all human diseases can be pregnant women treated with diefhylstilbestrol highlight the
reproduced in animals. Secondly^ alljthe conclusions derived unfortunate consequence of therapy on the basis of
fronrcrniffiaTexperirpents may not be strictly applicable to uncOTTtrotted~6bservations. The WHO in 1980 has laid down a
human beings. An excellent example to illustrate this point is strict code of practice in connection with human trials (70).
the WHO trial of typhoid vaccine in Yugoslavia in the mid- Experimental studies are of two types :
1950s. Laboratory tests in animals showed the alcohol-killed a. (Randomized controlled trials (i.e., those involving a
and preserved vaccine to be more effective _than t e process of random allocation); and
traditional heat-1 Tiled phenol-preserved vaccine. But
randomized controlled trials m human beings demonstrated b. (Non-randomized or “non-experimental” trials (i.e.,
that,.contrary to laboratory evidence, the alcohol-preserved those departing from strTcT randomization for practical
vaccine was found to be less than half as ^effective in purposes, but in such a manner that non­
preventing typhoid fever as the traditional phenol-preserved randomization does not seriously affect the theoretical
vaccine introduced by Almorth Wright. This highlights the basis of conclusions).

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difficulties encountered in extrapolating findings from
animal experiments in man. RANDOMIZED CONTROLLED TRIALS

Human experiments Too often physicians are guided in their daily work by
clinical impressions of their own or their teachers. These
(Human experiments will always be needed to investigate impressions, particularly when they are incorporated in
disease aetiology and to evaluate the preventive and textbooks and repeatedly quoted by reputed teachers and
therapeutic measures .^These studies are even more essential their student*acquire authority, just as if they were proved
in the investigation of diseases that cannot be reproduce in facts. Similarly many public health measures are introduced
animals. on the basis of assumed benefits without subjecting them to
Historically, in 1747, James Lind performed a human rigorous testing. The history of medicine amply illustrates
experiment (clinical trial) in which he added different this. For instance, it took centuries before therapeutic blood
substances to diet of 12 soldiers who were suffering from letting and drastic purging were abandoned by the medical
scurvy. He divided his patients into 6 pairs and profession.
supplemented the diets of each pair with cider, elixir vitriol, It is mainly in the last 35 to 40 years, determined efforts
vinegar, sea water; a mixture of nutmeg, garlic, mustard and have been made to use scientific techniques to evaluate
tamarind in barTey water; and two oranges and one lemon methods of treatment and prevention. tAn important
daily. All the subjects were studied for 6 days. At the end of advance in this field has been the development oL_an
6 days the LIMEYS recovered from scurvy and were found assessment method, known as Randomized Controlled Trial
fit for duty. Then came Edward Jenner’s experiment with (RCT). It is really an epidemiologic experiment. 'Since^ts
cowpox in 1796. Other classical experiments are Finlay and introduction, the RCT has questioned the validity of such
Reed’s experiments (1881-1900) to elucidate thefihosquito- widely used treatments as oral hypoglycaemic agents,
borne nature of yellow fever and Goldberger’s classical varicose vein stripping, tonsillectomy, hospitalization 6T~all
experiments in 1915 inducing pellagra by diets deficient in patients with myocardial infarction, multiphasic screening,
nicotinic acid, thereby proving pellagra to be a_nutritional and toxicity and applicability of many preventive and
deficiency disease, not an infectious disease as was then therapeutic procedures.
supposed. Since then, human "beingsTiave participated^
studies of malaria, syphilis, hepatitis, measles, polio and The design of a randomized controlled trial is given in
others. These experiments have played decisive roles in Fig. 9. For new programmes or new therapies, the RCT is
investigating disease aetiology and in testing preventive and the No.l method of evaluation. The basic steps in
therapeutic measures. conducting a RCT include the following :
(-Although the experimental method is unquestionably the aL Drawing up a protocol.
most incisive approach to scientific problem, ethical and 2. Selecting reference and experimental populations.
logistic considerations often prevent its "application to the Randomization.
study of disease in~Tiumans. Therefore, before launching Manipulation or intervention.
human experiments, be ’ ’enefits of the experiment have to I e
weighed against risks involved,._ The volunteers should be Follow-up.
made fully aware of all* possible consequences of the outcome.

by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

• Select suitable population workers, obstetric population and so on according to the

(Reference or target population) nature of the study.
(b)**Experimental or study population : The study
population is derived from the reference population. It is the
Select suitable sample actual population that participates in the .lexuerimental
(Experimental or study population)
study? Tdeally, it should be randomly chosen from the
reference population, so that it has the same_chara£teristics
as~the reference population. If the study population differs
Those not eligible from the reference population, it may not be possible to
generalize the findings of the study to the reference
population.
Make necessary exclusions
When an experimental population has been defined, its
members are invited to participate in the studyL.lt is
Those who do not important to choose a stable population whose cooperation
wish to give consent is assured to avoid losses to follow-up. The participants or
volunteers must fulfil the following three criteria :
RANDOMIZE
a. they must give “informed consent”, that is they must
agree to participate in' the trial after having been fully
1 informed about the purpose, procedures ~an~d possible
Experimental Control dangersjpf the trial;
group group b. fthey should be representative of the population to
whichjh£v belong (i.e., reference population); and
c. ^they should be qualified or eligible for the trial. That is,
Manipulation & follow-up
let us suppose, we are testing theeffectiveness^f a new drug
for the treatment of anaemia. If the volunteers are not
anaemic, we will then say, they are not eligible or qualified
ASSESSMENT for the trial. Similarly, let us suppose; we are going to test the

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effectiveness of a new vaccine against whooping cough. If
FIG.9
Design of a randomized controlled trial the volunteers are already immune to the disease in
question, we will then say, they are not qualified for the trial.
1. The protocol In other words, the participants must be fully susceptible to
the disease under study.
One of the essential features of a randomized controlled
trial is that the study is conducted under a strict protocol. It must be recognized that persons who agree to
The protocol specifies the aims and objectives of the study, participate in a study are likely to differ from those who do
questions to be answered, criteria for the selection of study not, in many ways that may affect the outcome under
and control groups, size of the sample, the procedures for investigation.
allocation of~subjects into study and control groups,
treatments to beapplied - when ancTwhere and how to what 3. Randomization
kind of patients, standardization of working procedures and (^Randomization is a statistical procedure by which the
schedules as well as responsibilities of“the parties involved in participants are allocated into groups usually called “study”
the trial, upto the stage of evaluation of outcome of the and “control” groups, to receive or not to receive jan
study. A protocol-is essential especially when a number of experimental preventive or therapeutic procedure,
centres are participating in the trial. Once a protocol has manoeuvre or intervention.(Randomization is an attempt to
been evolved, it should be strictly adhered to throughout the eliminate “bias” and allow for comparability. Theoretically it
study. The protocol (aims at ^preventing bias and to reduce is possjble to assure comparability by matching. But when
the sources of error in the study/) one matches, one can only match those factors which are
Preliminary test runs : Sometimes, before a protocol is known to beJmportant. There may be other factors which
completed, preliminary (pilot) studies have to be jnade to are important but whose effect js not recognized or cannot
find out the Teasibility_or operational efficiency of certain be determined. By a process of randomization, hopefully,
procedures, or unknown effects, or on the acceptability of these factors will be distributed equally between the two
certain policies. Sometimes it is useful to have a short test groups.
run of the protocol to see whether it contains any flaws. It is (^Randomization is the “heart” of a control trial. It will give
important that the final version of the protocol should be the greatest confidence that the groups are comparable so
agreed upon by all concerned before the trial begins. that “like can be compared with like”. It ensures that the
investigator has no control over allocation of "participants to
2. Selecting reference and experimental populations either study or control group, thus eliminating what is
(a) Reference or target^popxdation : It is the population to known as “selection bias”. In other words, by random
which the findings of the trial, if found successful, are allocation, every individual gets~an equal chance of being
expected to be applicable (e.g., a drug, vaccine or other allocated into either group or any of the trial groups.
•------------------------ - —■
procedure). A reference population may be as broad as It is crucial that both the groups should be alike with
mankind or it may be geographically limited or limited to regard to certain variables or characteristics that might affect
persons in specificage, sex2 occupational or social groups. the outcome of the experiment (e.g., age, sex), the entire
Thus the reference population may comprise the population study population can be stratified into_sui-gmups^<xording
of a wholejdty, or a population of school children, industrial to the variable, and individual^within each sub-group can

i by R△J
 RANDOMIZED CONTROLLED TRIALS

then_be_randomly allocated into study and control groups. It knew they were receiving a new form of treatment. This is
is always desirable to check that the groups formed initially known as “subject variation”. 'Secondly there may be
are basically similar in composition. Randomization is done observer bias, that is the investigator measuring the
only after the participant has entered tRe study, that is after outcome of a therapeutic trial may be influenced if he knows
having Been" qualified dor the trial and has given his beforehand, thp_.partir.nlar procedure or therapy to which the
informed consent to participate in the study. Randomization patient has been subjected. This is known as “observer
is best dond"by using a table of random^numbers {see bias." Thirdly, there may be bias in evaluation - thaTisTthe
chapter 20). investigator may subconsciously give a favourable report of
The essential difference between a randomized controlled the outcome of the trial. Randomization cannot guard
trial and an analytical study is that in the latter, there is no against "these sorts of bias, nor the size of the sample. In
randomization because a differentiation into diseased and order to reduce these problems, a technique known as
non-diseased (exposed or non-exposed) groups has already “blinding” is adopted, which will ensure that the outcome js
taken place. The only option left to ensure comparability in assessed objectively. \
analytical studies is by matching. Blinding : Blinding can be done in three ways -
(a) SINGLE BLIND TRIAL : The trial is so planned that the
4. Manipulation participant is not aware whether he belongs to the study
paving formed the study and control groups, the next group or control group. (B) DOUBLE BLIND TRIAL : The
step is to intervene or manipulate the study (experimental) trial is so planned that neither the doctor nor the participant
group by the deliberate application or withdrawal or is aware of the group allocation and the treatment received.
reduction of the suspected causal factor (e.g., this may be a (C) TRIPLE BLIND TRIAL : This goes one step further. The
drug, vaccine, dietary component, a habit, etc) as laid down participant, the investigator and the~person analyzing the
in the protocol. data are all “blind”. Ideally, of course, triple blinding should
be used; but the double blinding is the most frequently used
(Jhis manipulation creates an independent variable (e.g., method when a blind trial is conducted (5). When an
drug, vaccine, a new procedure) whose effect_isihen outcome such as death is being measured, blinding is not so
determined by measurement of jthe^final outcome, which essential.
constitutes the dependent variable (e.g., incidence of
disease, survival time, recoveryjoeriod). SOME STUDY DESIGNS

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5. Follow-up It is useful to consider here some of the study designs of
(This implies examination of the experimental and control controlled trials :
group subjects at defined intervals of time, in a standard
1. Concurrent parallel study designs
manner, with equal intensity, under the same given
circumstances, in the same time frame till finafassessment of In this situation (Fig. 10-a), comparisons are made
outcome. The duration of the trial is usually based on_the between two randomly assigned groups, one ftroup exposed
expectation that a significant difference (e.g., mortality) will to specific treatment, and the other group not exposed.
be demonstrable at a given point in time after the start of the Patients remain in the study group or the controTgrou'p for
trial. Thus the follow-up may be short or may require many the duration of the investigation.
years depending upon the study undertaken. \
2. Cross-over type of study designs
It may be mentioned that some losses to follow-up are
inevitable due to factors, such as death, migration and Loss This is illustrated in Fig. 10-b. With this type of study
of interest. This is known as attrition. If the attrition is design, each patient serves as his own control. As before, the
substantial, it may be difficult to generalise the results of the fhitients are randomly assigned to a study group and control
study to the reference population. Every effort, therefore, group. The study group receives the treatment under
should be made to minimize the losses to follow-up. consideration. The control group receives some alternate
form of active treatment or placebo. The twogmups__are
6. Assessment observed over time. Then the patients in each group are
taken off their-medication or placebo to allow for the
The final step is assessment of the outcome of the trial in elimination of the medication from fKe~body and for the
terms of : (a) Positive results : that is, benefits of the possibility of any “carry over” effects, as shown in Fig. 10-b
experimental measure such as reduced incidence or severity by the diag^naTTines. After this period of medication (the
of the disease, cost to the health service or other appropriate length of this interval is determined by the pharmacologic
outcome in the study and control groups, (b) (Negative properties of the drug being tested), the two groups are
results : that is, severity and frequency of side:ejfects and switched. Those who receivedjhe treatment under study are
complications, if any, including death. Adverse effects may be changed to the control group therapy or placebo, and vice
missed if they are not sought. versa.
ffihe incidence of positive/negative results is rigorously Cross-over studies offer a number of advantages. With
compared in both the groups, and the differences, if any, are such a design, all patients can be assqred that sometime
tested for statistical significance. Techniques are available during the course of investigation, they will receive the new
for the analysis of data as they are collected (sequential therapy. Such studies generally economize on the total
analysis), but it is more useful to analyze the results at the number of patients required at the expense"^of the time
end of the trial. necessary to complete the study. This method of study is not
Bias may arise from errors of assessment of the outcome suitable if the drug of interest cures the disease, jf the drug is
due to human element. These may be from three sources : effective only during a certain stage of the disease or^tflhe
First, there may be bias on the part of the participants, who disease changes radically during the periocTd’f time required
may subjectively feel better or report improvement iffhey for the study.

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92 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

------------------- >
Time

Observation
\ r~ COMPARE
\/ OUTCOME
x EXPOSED
AND
UNEXPOSED
TO R

►
Time

w FIG. 10
Schematic diagram of the design of concurrent parallel and cross-over controlled therapeutic trials (73).

TYPES OF RANDOMIZED CONTROLLED TRIALS children between 6-18 months who were entered into the
trial were randomly allocated in study and control groups.

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1. Clinical trials (The vaccine was given in three, monthly injections, and the
children were followed up at monthly intervals to detect the
For the most part, “clinical trials” have been concerned
occurrence of whooping cough. The study group comprised
with evaluating therapeutic agents, mainly drugs. The last
of SJSOXchildren who were vaccinated, and 149 developed
decades have seen clearly the utility of clinical trials. Some
whooping cough. The control group consisted of 3,757
of the recent examples include - evaluation of beta-blockers
unvaccinated children, and 687 of them developed the
in reducing cardiovascular mortality in patient surviving the
infection. This gave an attack rate of 1.45 per 1000 child
acute phase of myocardial infarction (71); trials of folate
months in the vaccinated group and 6.72 per 1000 child
treafment/supplementatibn before conception to prevent
months in the control group. The difference was significant.
recurrence of neural tube defects (72); trials of aspirin on
cardiovascular mortality and beta-carotene on cancer ('Analysis of a preventive trial must result in a clear
incidence; efficacy of tonsillectomy for recurrent throat statement about (a) the benefit the community will^derive
infection (73); randomized controlled trial of coronary from the measure (b) the risks involved, and (cTthegosts to
bypass surgery for the prevention of myocardial infarction the health"service in terms' of money, men and materTal
(74), etc. The list is endless. resources (22). Since preventive trials involve larger number
of subjects and sometimes a longer time span to obtain
Unfortunately, not all clinical trials are susceptible to being
results, there may be greater number of practical problems
blinded. For example, there is no way to perform a clinical
in their organisation and execution]
trial of tonsillectomy and adenoidectomy without its being
obvious who received surgery and who did not, a reason why 3. Risk factor trials
the value of these procedures continues to be uncertain.
Many ethical, administrative and technical problems are (2type of preventive trial is the trial of risk factors in which
involved in the conduct of clinical trials. Nevertheless, they the investigator intervenes to interrupt the usual sequence in
are a powerful tool and should be carried out before any new the development of disease for those individuals who have
therapy, procedure or service is introduced. “risk factor” for developing the disease^ often this involves
risk factor modification. The concepLof “risk factor” gave a
2. Preventive trials new dimension to epidemiological research.
In general usage, prevention is synonymous with primary For example, the major risk factors of coronary heart
prevention, and the term “preventive trials” implies trials of disease are elevated blood cholesterol, smoking,
primary preventive measures. These trials are purported to hypertension and sedentary habits. Accordingly, the four
prevent or eliminate disease on an experimental basis ./The main possibilities of intervention in coronary heart disease
most frequently occurring type of preventive trials arelfie are : reduction of blood cholesterol, the cessation of
trials of vaccines and chemoprophylactic drugs. The basic smoking, control of hypertension and promotion of regular
principles of experimental design are also applicable to these physical activity. Risk factor trials can be “single-factor” or
trials. It may be necessary to apply the trial to groups of “multi-factor” trials. Both the approaches are
subjects instead of to individual subjects. For example, in complementary, and both are needed.
1946, the Medical Research Council of UK conducted an The WHO (77) promoted a trial on primary prevention of
extensive trial (76) to test whooping cough vaccine from coronary heart disease using clofibrate to lower serum
three manufacturers in ten separate field trials. Those cholesterol, which was accepted as a significant risk factor

by R△J
 SOME STUDY DESIGNS 93
for CHD. This study is the largest preventive trial yet
conducted, comprising more than 15,000 men of whom
one-third received clofibrate and two-third received olive oil
as a control treatment. The study was conducted in 3 centres
in Europe (Edinburgh, Prague, and Budapest). The design
was double-blind and randomization was successfully
achieved. The mean observation was 9.6 years. The trial
showed a significant reduction in non-fatal cardiac
infarction, but unfortunately, there were 25 per cent more
deaths in the clofibrate-treated group than in the control
group possibly due to long-term toxic effect of the drug. The
trial illustrates the kind of contribution that an
epidemiological approach can make to protect the public
health against possible adverse effects of long-term
medication with potent drugs (77).
The other widely reported risk-factor intervention trials in
coronary heart disease are : (a) The Stanford Three
Community Study (b) The North Karelia Project in Finland
(c) The Oslo Study, and (d) The Multiple Risk Factor
Intervention Trial (MRF1T) in USA. FIG. 11
Incidence of retrolental fibroplasia in New York, 1938-1956
4. Cessation experiments
The dramatic rise and fall in frequency of RLF can be
Another type of preventive trial is the cessation seen in Fig. 11. It will be noted that RLF reached its peak
experiment. In this type of study, an attempt is made to during the years 1952-53. The sharp drop in the graph after
evaluate the termination of a habit (or removal of suspected 1953 highlights the results of the decreased use of oxygen.
agent) which is considered to be causally related to a RLF illustrates one of the problems often introduced by
disease. If such action is followed by a significant reduction technological or scientific advances.

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in the disease, the hypothesis of cause is greatly
strengthened. The familiar example is cigarette smoking and Since most diseases are fatal, disabling or unpleasant,
lung cancer. If in a randomized controlled trial, one group of human experiments to confirm an aetiological hypothesis
cigarette smokers continue to smoke and the other group are rarely possible.
has given up, the demonstration of a decrease in the 6. Evaluation of health services
incidence of lung cancer in the study group greatly
strengthens the hypothesis of a causal relationship. A large Randomized controlled trials have been extended to
randomized controlled trial has been mounted to study the assess the effectiveness and^efficiency of health _services.
role of smoking cessation in the primary prevention of Often, choices have to be made between alternative policies
coronary heart disease (78). of health care delivery. The necessity of choice arises from
the fact that resources are limited, and priorities must be set
5. Trial of aetiological agents for the implementation of a large number of activities which
could contribute to the welfare of the society. An excellent
One of the aims of experimental epidemiology is to example or such an evaluation is the controlled trials in the
confirm or refute an aetiological hypothesis. The best known chemotherapy of tuberculosis in India^which demonstrated
example of trial of an aetiological agent relates to retrolental that “domiciliary treatment” of pulmonary tuberculosis was
fibroplasia (RLF). Retrolental fibroplasia, as a cause of as effective as the more costlier “hospital or sanatorium”
blindness, was non-existent prior to 1938. It was originally treatment. The results of the study have gained international
observed and reported by T.L.Terry, a Boston acceptance and ushered in a new era - the era of
ophthalmologist in 1942 (79), and later in many other domiciliary treatment, in the treatment of tuberculosis.
countries outside the USA.
^4ore recently, multiphasic screening which has achieved
RLF was recognized as a leading cause of blindness by great popularity in some countries, was evaluated by a
descriptive studies which showed that beginning in about randomized controlled trial in South-East London. The study
1940-1941, the incidence of the disease increased at an led to the withholding of vast outlay of resources required to
alarming rate (Fig. 11), and that this previously unknown mount a national programme of multiphasic screening in UK
disease was occurring only in premature babies. Analytical (82, 83). Another example is that related to studies which
studies demonstrated its close association with have shown that many of the health care delivery tasks
administration of oxygen to premature babies. A large traditionally performed by physicians can be performed by
randomized controlled trial was mounted involving 18 nurses and other paramedical workers, thus saving physician
hospitals in United States by Kinsey and Hemphill (80, 81) time (84). These studies are also labelled as “health services
in which premature babies with birth weight of 1500 gram or research’Lstudies.
less were allocated into experimental and control groups. In
the experimental group, all the babies received 50 per cent NON-RANDOMIZED TRIALS
oxygen therapy for 28 days, while in the control group
(“curtailed oxygen group”) oxygen was used only for clinical Although the experimental method is almost always to be
emergency. It was later found that all of the babies in the preferred, it is not always possible for ethical, administrative
“curtailed oxygen group” who developed RLF had received and other reasons to resort to a randomized controlled trial
some oxygen. There were no cases among those who in human beings. For example, smoking and lung cancer
received none, confirming the aetiological hypothesis. and induction of cancer by viruses have not lent themselves
by R△J
91 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

to direct experimentation in human beings. Secondly, some source of water supply in their households. The results of the
preventive measures can be applied only to groups or on a experiment are given in Table 23.
community-wide basis (e.g., community trials of water
fluoridation). Thirdly, when disease frequency is low and the TABLE 23
natural history long (e.g., cancer cervix) randomized Deaths from cholera per 10,000 houses and sources of
controlled trials require follow-up of thousands of people for water supply of these houses, London 1853
a decade or more. The cost and logistics are often
prohibitive. These trials are rare. In such situations, we must Sources of Number of Deaths from Deaths in
depend upon other study designs - these are referred to as water supply houses cholera each 10,000
non-randomized (or non-experimental) trials. houses
Southwark & 40,046 1263 315
Where the approach is sophisticated in randomized Vauxhall Co.
controlled trials, it is rather crude in non-randomized trials.
As there is no randomization in non-experimental trials, the Lambeth Co. 26,107 98 37
degree of comparability will be low and the chances of a
spurious result higher than where randomization had taken It will be seen from Table 23 that deaths were fewer in
place. In other words, the validity of causal inference houses supplied by Lambeth company compared to houses
remains largely a matter of extra-statistical judgement. supplied by Southwark and Vauxhall company. The
Nevertheless, vital decisions affecting public health and inference was obvious - the Lambeth company water came
preventive medicine have been made by non-experimental from an intake on the River Thames well above London,
studies. A few examples of non-randomized trials are whereas the Southwark and Vauxhall company water was
discussed below : derived from the sewage polluted water basin. The great
difference in the occurrence of cholera among these two
1. Uncontrolled trials populations gave clear demonstration that cholera is a
water-borne disease. This was demonstrated long before the
There is room for uncontrolled trials (i.e., trials with no advent of the bacteriological era; it also led to the institution
comparison group). For example, there were no randomized of public health measures to control cholera.
controlled studies of the benefits of the Pap test (cervical
cancer) when it was introduced in 1920s. Today, there is 3. Before and after comparison studies

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indirect epidemiological evidence from well over a dozen
uncontrolled studies of cervical cancer screening that the Pap These are community trials which fall into two distinct
test is effective in reducing mortality from this disease. Initially groups:
uncontrolled trials may be useful in evaluating whether a A. Before and after comparison studies without control,
specific therapy appears to have any value in a particular and
disease, to determine an appropriate dose, to investigate B. Before and after comparison studies with control.
adverse reactions, etc. However, even in these uncontrolled
trials, one is using implied “historical controls”, i.e., the A. Before and after comparison studies without control
experience of earlier untreated patients affected by the same These studies centre round comparing the incidence of
disease. disease before and after introduction of a preventive
Since most therapeutic trials deal with drugs which do not measure. The events which took place prior to the use of the
produce such remarkably beneficial results, it is becoming new treatment or preventive procedure are used as a
increasingly common to employ the procedures of a double­ standard for comparison. In other words, the experiment
blind controlled clinical trial in which the effects of a new serves as its own control; this eliminates virtually all group
drug are compared to some concurrent experience (either differences. The classic examples of “before and after
placebo or a currently utilized therapy). comparison studies” were the prevention of scurvy among
sailors by James Lind in 1750 by providing fresh fruit;
2. Natural experiments studies on the transmission of cholera by John Snow in
Where experimental studies are not possible in human 1854; and later, prevention of polio by Salk and Sabin
populations, the epidemiologist seeks to identify “natural vaccines.
circumstances” that mimic an experiment. For example, in In order to establish evidence in before and after
respect of cigarette smoking, people have separated comparison studies, the following are needed; (a) data
themselves “naturally” into two groups, smokers and non- regarding the incidence of disease, before and after
smokers. Epidemiologists have taken advantage of this introduction of a preventive measure must be available
separation and tested hypothesis regarding lung cancer and (b) there should be introduction or manipulation of only one
cigarette smoking. Other populations involved in natural factor or change relevant to the situation, other factors
experiments comprise the following groups : (a) migrants remaining the same, as for example, addition of fluorine to
(b) religious or social groups (c) atomic bombing of Japan drinking water to prevent dental caries (c) diagnostic criteria
(d) famines (e) earthquakes, etc. A major earthquake in of the disease should remain the same (d) adoption of
Athens in 1981 provided a “natural experiment” to preventive measures should be over a wide area
epidemiologists who studied the effects of acute stress on (e) reduction in the incidence must be large following the
cardiovascular mortality. They showed an excess of deaths introduction of the preventive measure, because there is no
from cardiac and external causes on the days after the major control, and (f) several trials may be needed before the
earthquake, but no excess deaths from other causes (85). evaluation is considered conclusive.
John Snow’s discovery that cholera is a water-borne Table 24 gives an example of a “before and after
disease was the outcome of a natural experiment. Snow in comparison study” in Victoria (Australia) following
his “grand experiment” identified two randomly mixed introduction of seat-belt legislation for prevention of deaths
populations, alike in other important respects, except the and injuries caused by motor vehicle accidents.
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 NON-RANDOMIZED TRIALS 95
TABLE 24 ASSOCIATION AND CAUSATION
Effect of adoption of compulsory seat-belt legislation in ^Descriptive studies help in the identification of the
Victoria, Australia-1971 disease problem in the community; and by relating disease
1970 1971 % change to host, agent and environmental factors, it endeavours to
suggest an aetiological hypothesis. ^Analytical.___________ and
Deaths 564 464 -17 7 experimental studies test the hypotheses derived from
Injuries 14620 12454 14.8 descriptive studies and confirm or refute the_observed
association between suspected causes and disease. When
Table 24 shows a definite fall in the numbers of deaths the disease is multifactorial (e.g., coronary heart disease)
numerous factors or variables become implicated in the web
and injuries in occupants of cars, following the introduction
of causation, and the notion of “cause” becomes confused.
of compulsory seat-belts in one state of Australia.
The more associations, the more investigations to
disentangle the web of causation. The epidemiologist whose
B. Before and after comparison studies with control
primary interest is to establish a “cause and effect”
In the absence of a control group, comparison between relationship has to sift the husk from the grain. He proceeds
observations before and after the use of a new treatment or from demonstration of statistical association to
procedure may be misleading. In such situations, the demonstration that the association is causal.
epidemiologist tries to utilize a “natural” control group i.e., CEhederms “association” and “relationship” are often used
the one provided by nature or natural circumstances. If interchangeably. (Association may be defined_~as__ the
preventive programme is to be applied to an entire concurrence of two variables more often than would be
community, he would select another community as similar expected by chance. In other words, events are said to h.
as possible, particularly with respect to frequency and associated when they occur more frequently together than
characteristics of the disease to be prevented. One of them one would expect by chance (2). Association does not
is arbitrarily chosen to provide the study group and the necessarily imply a causal relationship.\
other a control group. In the example cited (e.g., seat-belt
It will b£ useful to consider here the concept of
legislation in Victoria, Australia), a natural “control” was
correlation .^Correlation indicates the decree of association
sought by comparing the results in Victoria with other states

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between two ch r .cteristics. The correlation coefficie ts
in Australia where similar legislation was not introduced.
range from -1.0 to +1.0_. A correlation coefficient of 1.0
The findings are given in Table 25. means that the two variables exhibit a perfect linear
relationship. However, correlation cannot be used to invoke
TABLE 25
causation, because the sequence of exposure preceding
Effect of adoption of compulsory seat-belt legislation in disease (temporal association) cannot be assumed to have
Victoria, 1971 compared with other states where similar occurred. Secondly, correlation does not measure risk. It
legislation was not introduced may be said that causation implies correlation, but
correlation does not imply causation.
Association can be broadly grouped under three headings :
a. Spurious association
b. Indirect association
c. Direct (causal) assHPiation
(i) one-to-one causal association
(ii) multifactorial causation.
In the example cited above, the existence of a control a. Spurious association
with which the results in Victoria could be compared
strengthens the conclusion that there was definite fall in the Sometimes an observed ^association between, a disease
number of deaths and injuries in occupants of cars after the and suspected factor may not be real. For example, a study
introduction of compulsory seat-belt legislation. in UK of 5174 births at home and 11,156 births in hospitals
showed perinatal mortality rates of 5.4 per 1000 in the
In the evaluation of preventive measures, three questions home births, and 27.8 per 1000 in the hospital births (86).
are generally considered : (a) How much will it benefit the Apparently, the perinatal mortality was higher in hospital
community ? This will depend upon the effectiveness of the births than in the home births. It might be concluded that
preventive measure and the acceptance of the measure by homes are a safer place for delivery of births thanHiospitals.
the community. The combined outcome of effectiveness and Such a conclusion is spurious or artifactual, because in
acceptability is measured by the difference in the incidence general, hospitals attract women at high risk for delivery
rate^mong the experimental and control groups, (b) What because of their special equipment and expertise, whereas
are the risks to the recipientsTThese include the immediate this is not the case with home deliveries. The high perinatal
and long-term risks, (c) Cost in money and man power? This mortality rate in hospitals might be due to this fact alone,
is done to find out whether the preventive measure is and not because the quality of care was inferior. There might
economical and practical in terms of money spent. It is now be other factors also such as differences in age, parity,
conceded that no health measure should be introduced on a prenatal care, home circumstances, general^ health and
large scale without proper evaluation. disease state between the study and control groups.^ This
Recent problems that have engaged the attention of type of bias where “like” Js_. not compared with “like”
epidemiologists are studies of medical care and health (selection bias) is very important in epidemiological studies.
services; planning and evaluation of health measures, It may lead to a spurious association or an association when
services and research. none actually- existed.-
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96 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

b. Indirect association c. Direct (causal) association

Many associations which at first appeared to be causal
have been found on further study to be due to indirect (i) One-to-one causal relationship
association, (the indirect association is a statistical Two variables are stated to be causally related (AB) if a
association between a characteristic (or variable) of interest change in A is followed by a change in B. If it does not, then
and a disease due to the presence of another factor, known their relationship cannot be causal. This is known as “one-
or unknown, that is common to both the characteristic and to-one” causal relationship. This model suggests that when
theclisease. This third factor (i.e., the common factor) is also the factor A is present, the disease B must result.
known as the ‘^confounding” variable. Since it is related Conversely, when the disease is present, the factor must also
both to the disease and to the variable, it might explain the be present. Measles may be one disease in which such a
statistical association between disease and a characteristic relation exists (3).
wholly or in part. Such confounding variables (e.g., age, sex,
social class) are potentially and probably present in all data Epidemiologists are interested in identifying the “cause”.
and represent a formidable obstacle to overcome in trying to The most satisfactory procedure to demonstrate this would
assess the causal nature of the relationship. Two examples of be by direct experiment. But this procedure is scarcely
an indirect association are given below. available to the epidemiologist. And, in some cases, the
“cause” is not amenable to manipulation.
The above concept of one-to-one causal relationship was
the essence of Koch’s postulates. The proponents of the
germ theory of disease insisted that the cause must be :
a. Qiecessary, and
b. sufficient for the occurrence of disease
before it can qualify as cause of disease. In other words,
whenever the disease occurs, the factor or cause must be
present.
Model of an indirect association

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Although Koch’s postulates are theoretically sound, the
(a) Altitude and endemic goitre “necessary and sufficient” concept does not fit well for many
Cfendemic goitre is generally found in hjgh_ altitudes, diseases. Taking for example tuberculosis, tubercle bacilli
showing thereby an association between altitude and cannot be found in all cases of the disease but this does not
endemic goitre (Fig. 12). We know, that endemic goitre is rule out the statement that tubercle bacilli are the cause of
not due to altitude but due to environmental deficiency of tuberculosis (5). That the cause must be “sufficient” is also
iodine. Fig. 12 illustrates how a common factor (i.e., iodine not always supported by evidence. In tuberculosis, it is well-
deficiency) can result in an apparent association between known that besides tubercle bacilli, there are additional
two variables, when no association exists/This amplifies the factors such as host susceptibility which are required to
earlier statement that statistical association does not produce the disease.
necessarily mean causation. The concept of one-to-one causal relationship is further
complicated by the fact that sometimes, a single cause or
(b) Sucrose and CHD
factor may lead to more than one outcome, as shown in
Yudkin and Roddy (87) found a higher intake of sugar by Fig. 13. In short, one-to-one causal relationship, although
patients with myocardial infarction. Their study was based ideal in disease aetiology, does not explain every situation.
on an enquiry by questionnaire method into dietary habits
of cases and controls. They put forward an attractive Streptococcal tonsillitis
hypothesis that people who consume lot of sugar are far Haemolytic Scarlet fever
more likely to have a heart attack than those who take little. streptococci
Further studies were undertaken to test whether sugar Erysipelas
intake was associated with other variables such as cigarette
smoking, which might be causally related to CHD. Bennet FIG. 13
and others (88) found that heavy cigarette smoking was Model in which one factor is shown to lead to more than one disease
positively associated with an increase in the number of cups
of hot drinks consumed daily and the amount of sugar (ii) Multifactorial causation
consumed. They concluded that it was cigarette smoking (The causal thinking is different when we consider a non-
and not sugar consumption which was implicated in the communicable disease or condition (e.g., CHD) where the
aetiology of CHD. In their study, they did not find any aetiology is multifactorial. Two models are presented in
evidence of increasing trend of CHD with increasing Figures 14 and 15 to explain the complex situation. In one
consumption of sugar. Finally, proof came from model (Fig. 14), there are alternative causal factors (Factors
experimental studies that high sucrose feeding did not 1, 2 and 3) each acting independently. This situation is
induce arteriosclerotic disease in animals. exemplified in lung cancer where more than one aetiological
Sometimes knowledge of indirect associations can be factor (e.g., smoking, air pollution, exposure to asbestos)
applied towards reducing disease risk. Before the discovery can produce the disease independently. It is possible as our
of the cholera vibrio, elimination of certain water supplies knowledge of cancer increases, we may discover a common
achieved a marked decrease in new cases of the disease. biochemical event at the cellular level that can be produced
Such indirect associations must be pursued, for it is likely by each of the factors. The cellular or molecular factor will
that they may provide aetiological clues. then be considered necessary as a causal factor (5)
by R△J
 ASSOCIATION BETWEEN CIGARETTE SMOKING AND LUNG CANCER 97
for establishing whether or not an observed association
plays a causal role in the aetiology of a disease. The data
fulfilling the criteria were covered adequately in Smoking
> Disease and Health, the initial report of the Advisory Committee to
the Surgeon General of the Public Health Service in 1964
(89). The later reports of US Public Health Service from
1964-1973, and similar other reports (e.g., Report of the
A model of multifactorial causation (4). Royal College of Physicians, London : Smoking or Health,
1977) summarized newer data supporting the validity of the
In the second model (Fig. 15) the causal factors act
hypothesis. Let us examine the cigarette smoking and lung
cumulatively to produce disease. This is probably the correct
cancer hypothesis in the light of the above criteria.
model for many diseases. It is possible that each of the several
factors act independently, but when an individual is exposed
to 2 or more factors, there may be a synergistic effect.
1. Temporal association
This criterion centres round the question: Does the
suspected cause precede the observed effect ? A causal
association requires that exposure to a putative cause must
precede temporarily the onset of a disease which if is
purported to produce to allow for any necessary period of
in uction and latency. This requirement is basic to the
causal concepts
In certain acute diseases such as water and food-borne
A model of multifactorial causation showing synergism (4) outbreaks, discovery of temporal sequence of two variables
(e.g., drinking contaminated water and diarrhoea) is not
From the above discussion, it is reasonable to conclude
often a serious problem. However, in many chronic diseases,
that “one-to-one” relationship in causation is an
because of insidious onset and ignorance of precise
oversimplification. In biological phenomena, the
requirement that “cause” is both “necessary” and induction periods, it becomes hard to establish a temporal
sequence as to which came first - the suspected agent_prThe

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“sufficient” condition is not easily reached, because of the
existence of multiple factors in disease aetiology. This has disease, because one is dealing with a continuous evolving
created a serious problem to the epidemiologist, who is in process.
search of causes of disease. Lung cancer occurs in smokers of long-standing; this
satisfies the temporaLrequirement. Further, the increase in
ADDITIONAL CRITERIA FOR JUDGING CAUSALITY consumption of cigarettes preceded by about 30 years~ffie
increase in death rates from lung cancer. These observations
In the absence of controlled experimental evidence to are compatible with the long latent period characteristic of
incriminate the “cause”, certain additional criteria have carcinogenesis.
been evolved for deciding when an association may be
considered a causal association. An elegant elucidation of 2. Strength of association
these criteria appears in “Smoking and Health” the Report
of the Advisory Committee to the Surgeon General of the The strength of association is based on answers to two
Public Health Service in US (89). Bradford Hill (90, 91) and questions:
others (92) have pointed out that the likelihood of a causal a. Relative risk - is it large ?
relationship is increased by the presence of the following b. Is there a dose^response, duration-response
criteria. relationship ?
1. (^Temporal association In general,Ghe larger the relative risk, the greater the
2. ^Strength of association likelihood of a causal associatipnj Furthermore, the
3. CSpecificity of the association likelihood of a causal relationship is strengthened if there is a
^(^Consistency of the associati biological gradient or dose-response relationship - i.e., with
increasing levels of exposure to the risk factor, an increasing
5.1 Biological plausibility rise in incidence of the disease is found.QLthere is no-dose-
6. Coherence of the association response or duration-response relationship, that would be
The Surgeon-General’s Report (1964) states that the an argument against the relationship being caysaLJ
causal significance of an association is a matter of In the absence of experimental data on humans, the
judgement which goes beyond any statement of statistical causal relationship of cigarette smoking and lung cancer has
probability. To judge or evaluate the causal significance of been based on three points : (a) relative risk (b) dose­
an association, all the above criteria must be utilized, no one response relationship, and (c) the decrease in risk on
of which by itself is self-sufficient or sine qua-non for cessation of smoking. Table 26 presents data showing
drawing causal inferences from statistical associations, but relative risk and dose-response relationship. Such high
each adds to the quantum of evidence, and all put together relative risks are rarely seen in epidemiological studies. It has
contribute to a probability of the association being causal. been stated that the relationship between lung cancer and
smoking is one of the most impressive demonstrations of a
ASSOCIATION BETWEEN CIGARETTE dose-response relationship that can be found in
SMOKING AND LUNG CANCER epidemiology (3). The dose-response relationship has, in
fact, played a major role in acceptance of relationship as
Cigarette smoking and lung cancer hypothesis provides causal (13). If there has been no dose-response relationship,
an excellent example to illustrate the epidemiological criteria that would have been a strong argument against the causal
by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

hypothesis. Another factor that has added to the weight of association, reflecting a definite causal association. In short,
evidence is the fact that lung cancer death rates among specificity supports causal interpretation but lack of
moderate smokers were intermediate between those among specificity does not negate it.
light smokers and heavy smokers. TABLE 28
TABLE 26 Expected and observed deaths for smokers of cigarettes
Death rate and relative risk for smokers and non-smokers compared to non-smokers; Seven prospective studies
combined, for selected causes of death
Daily average Death rate per 1000
cigarettes Relative risk Underlying Expected Observed Mortality
smoked Smokers Non-smokers cause of death deaths (E) deaths (O) ratio (O/E)

1-14 0.47 0.07 6.7 Cancer of lung 170.3 1,833 10.8

15-24 0.86 0.07 12.3 Bronchitis and emphysema 89.5 546 6.1
25 + 1 66 0.07 23.7 Cancer of larynx 14.0 75 5.4
Source : (62J Cancer oesophagus 37.0 152 4.1
\ Cessation experiment) Peptic ulcer 105.1 294 2.8
Cancer bladder 111.6 216 1.9
(Another piece of evidence is provided by the cessation
experiment. Table 27 shows the mortality ratios in ex­ CHD 6,430.7 11,177 1.7
cigarette smokers by number of years stopped smoking Cancer rectum 207.8 213 1.0
among British doctors. The results confirmed that the All causes of death 15,653.9 23,223 1.7
mortality ratios were reduced in a way that would be
expected if smoking were the cause of the disease. This is a Source : (38)
strong point in the evidence favouring the hypothesis. The concept of specificity cannot be entirely dissociated
from the concept of association. It has been estimated that
TABLE 27
about 80-90 per cent of lung cancer can be attributed to
Lung cancer mortality ratios in ex-cigarette-smokers, by
cigarette smoking. To say this, it is assumed that the
number of years stopped smoking, British physicians
association between smoking and lung cancer is causal.

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Years stopped smoking Mortality ratio Under the heading of specificity, two more observations
require comment : (a) not everyone who smokes develops
Still smoking 15.8 cancer, and (b) not everyone who develops lung cancer has
1-4 16.0 smoked. The first apparent paradox is related to the
5-9 5.9 multifactorial nature of lung cancer. It may well be that there
10-14 53 are other factors as yet unidentified which must be present in
15 + 2.0 conjunction with smoking for lung cancer to develop. As for
Non-smokers 1.0 lung cancer in non-smokers, it is known that there are factors
Source : (60) other than smoking which increase the risk of lung cancer
such as occupational exposure to chromates, asbestos,
3. Specificity of the association nickel, uranium and exposure to air pollution. Deviations
The concept of specificity implies a “oqejxi-one” from one-to-one relationship between cigarette smoking and
relationship between the cause and effect. In the past, much lung cancer therefore, cannot be said to rule out a causal
of the controversy over cigarette smoking and lung cancer relationship.
centred round lack of specificity of the association. That is,
cigarette smoking is linked with not only lung cancer but
4. Consistency of the association
several others such as coronary heart disease, bronchitis, < The association is consistent if the results are^ replicated
emphysema, cancer cervix, etc. This was used, for several wRen studied in different settings and by different method.s.
years, as an argument against the acceptance of the That is, evidence from a single study is seldom sufficient to
association as causal. It is true that cigarette smoking is establish “causal” association. If there is no consistency, it
associated with so many diseases reflecting an apparent lack will weaken a causal interpretation)
of specificity, but that cannot be a strong argument, so as to A consistent association has been found between
dismiss the causal hypothesis. This is because the cigarette smoking and lung cancer. More than 50
requirement of specificity is a most difficult criterion to retrospective studies and at least nine prospective studies in
establish not only in chronic disease but also in acute different countries had shown a consistent association
diseases and conditions. The reasons are : first, a single between cigarette smoking and subsequent.development of
cause or factor can give rise to more than one disease. lung cancer, lending support to a causal association.
Secondly, most diseases are due to multiple factors with no
possibility of demonstrating one-to-one relationship. 5. Biological plausibility
The lack of specificity can be further explained by the fact ^Causal association is supported if there is biological
that tobacco smoke is a complex of substances containing credibility to the association, that is, the association agrees
several harmful ingredients or factors such as nicotine, with current understanding of the response of cells, tissues,
carbon monoxide, benzpyrene, particulate matter and many organs, and systems to stimuli^ For example, the notion that
other ingredients with possible additive and synergistic food intake and cancer are interrelated is an old one. The
action. The different components of tobacco smoke could as positive association of intestine, rectum and breast cancers is
well be responsible for different states. In spite of this, it can biologically logical, whereas the positive association of food
be seen from Table 28 that the association of lung cancer and skin cancer makes no biological sense suggesting that
with cigarette smoking is far more striking than any other strength of association by itself does not imply causality.
by R△J
 USES OF EPIDEMIOLOGY —99
This is one of the pitfalls of correlation studies. Further, the 1. To study historically the rise and fall of
criterion of biological plausibility should not be applied disease in the population
rigidly. That is, even if a biological mechanism cannot be
Winston Churchill said : “The farther back you look, the
postulated, it does not rule out the possibility of a cause and
farther forward you can see”. The first use of epidemiology
effect relationship, for it may be merely due to the limits of
relates to this aspect, that is, study of the history of disease
current knowledge. in human population. It is well known that the health and
The cigarette smoking and lung cancer hypothesis is disease pattern in a community is never constant. There are
biologically plausible. It is not hard to visualize the fluctuations both over short and long periods of time. For
inhalation of hot smoke into the lungs and deposition of a example, the first contribution of epidemiology to the study
chemical carcinogen over a period of time probablybuilding of coronary heart disease was that it was an “epidemic”.
itself up to a threshold level and initiatmgneoplastic changes Later many others such as accidents, cancer and diabetes
in the lungs. Experimental studies in animals have were found to be “epidemic”. As old diseases (e.g.,
strengthenecrthe evidence for the aetiological role of smallpox) are conquered, new ones (e.g., Legionnaires’
cigarette smoking, although one cannot directly translate the disease, Lassa fever, AIDS) have been identified, in which
results of such studies in humans. Many such studies have epidemiology has played a major role. Epidemiology
shown that lung cancer can be produced by provides a means to study disease profiles and time trends in
tracheobronchial implantation of tobacco extracts or by human population. By a study of these trends, we can make
inhalation of cigarette smoke or of aerosols of its useful projections into the future and identify emerging
constituents. ^Carcinogenic substances have been isolated health problems and their correlates.
from cigarette^srhbke, although the precise carcinogens
responsible for lung cancer in man are unknown7~The 2. Community diagnosis
biological credibility, in fact, provides a convincing evidence One of the uses of epidemiology is community diagnosis.
in favour of a causal association. Community diagnosis generally refers to the identification
6. Coherence of the association arid quantification of health problems in a community in
terms o' mortality and morbidity rates and ratios, and
CAlinal criterion for the appraisal of causal significance of idefHTTication of their correlates for the purpose of defining
an association is its coherence with known facts that are those individuals or groups at risk or those in need of health

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thought to be relevant. For example, the historical evidence care. By quantification of health problems, we lay down
of the rising consumption of tobacco in the form of priorities in disease control and prevention. Secondly,
cigarettes and the rising incidence of lung cancer are quantification of morbidity and mortality can serve as a
coherent. Male and female differences in trends of lung benchmark for the evaluation of health services at a later
cancer death rates are also coherent with the more recent date. Thirdly, the quantification of health problems can be a
adoption of cigarette smoking by wonien. Death rates rose source of new knowledge about disease distribution,
first in males and are now increasing relatively more rapidly causation and prevention. Community diagnosis has also
in females. The fall in the relative risk of lung cancer when been effectively extended beyond population distributions
cigarette smoking Ts~~stopped? and the occurrence of lung and profiles of illness to include an understanding of the
cancer from occupational exposure to other carcinogens social, cultural and environmental characteristics of the
such as asbestos and uranium and the demonstrated community (93). Epidemiology, therefore, has been
increase in lung cancer risk when workers exposed to these described as a “diagnostic tool” of community medicine.
substances also smoked, enhance the significance of a
causal association^ 3. (Planning and evaluation)
(m conclusion, it may be stated that the association Planning is essential for a rational allocation of the
between cigarette ..smoking and lung cancer can neverJbe-- limited resources. For example, in developing countries, too
proved by a direct experiment on humans. It is an illusory many hospitals have been built and equipped without
and virtually unattainable goal. It is well known that knowledge of the particular disease problems in the
epidemiology depends heavily on inferences drawn from community. Epidemiologic information about the
observations rather than on the ultimate experiment. The distribution of health problems over time and place provides
nearest approach to “scientific proof”, therefore is the vast the fundamental basis for planning and developing the
body of convincing evidence we have accumulated during needed health services and for assessing the impact of these
the past few years meeting all the criteria proposed for services on the people’s problems. The application of
judging the causality of such associations. epidemiological principles to problems of health care
constitutes the “new epidemiology” (94). (Examples of
USES OF EPIDEMIOLOGY planning include planning facilities for medical care (e.g.,
number of hospital beds required for patients with specific
While the study of disease distribution and causation
diseases, health manpower planning); planning facilities for
remains central to epidemiology; the techniques of
preventive services (e.g., screening programmes,
epidemiology have a wider application covering many more
immunization campaigns; provision of sanitary services);
important areas relating not only to disease but also health
and planning for research.
and health services. In more utilitarian terms, epidemiology
has been defined as “a means of learning, or asking (^Evaluation is an equally important concern of
questions....and getting answers that lead to further epidemiology. Any measures taken to control or prevent a
questions”. In this context, Morris (11) has identified seven disease must be followed by an evaluation to find out
distinct uses of epidemiology, five of which extend whether the measures undertaken are effective in reducing
epidemiology beyond the search for causes of disease and the frequency of the disease.\ Evaluation of a control method
bring it closer to day-to-day concerns of modern such as hepatitis vaccine requires more than the
medicine.These are : demonstration of its effectiveness in reducing disease

by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

frequency. We have to measure the cost of its large-scale tremendous impetus to the development of intensive
application in terms of the cost of the vaccine, trained coronary care units (99). Epidemiological investigations
personnel, storage, transport and other factors. The value of have yielded a large amount of data on risk factors in
one method in relation to others is assessed by cost­ relation to chronic disease. The impact of these findings on
effectiveness studies. It is now being recognized that not only our knowledge of the natural history of chronic disease
vaccines, but in time all health services will have to submit remains to be elucidated. Since the epidemiologist is
to evaluation (95). The development of randomized concerned with all cases in the defined population,
controlled trial has made it possible to evaluate treatment regardless of severity or source of medical care, his
modalities on a firm scientific basis. Such trials have raised perspective of disease is consequently the broadest.
doubts about the utility of multiphasic screening, certain
operative procedures (e.g., tonsillectomy, varicose vein, 7. Searching for causes and risk factors
stripping), prolonged hospitalization of patients with Epidemiology, by relating disease to interpopulation
myocardial infarction, etc. Clearly it is not enough to know differences and other attributes of the population or cohorts
that a programme provides some benefit; we need to know examined, tries to identify the causes of disease. The
how much benefit and at what risk and cost (95). contributions of epidemiology have been many in this regard.
Numerous examples can be cited : epidemiological studies
4. Evaluation of individual’s risks and chances have incriminated that rubella is the cause of congenital
One of the important tasks of epidemiologists is to make defects in the newborn, that thalidomide is a teratogenic
a statement about the degree of risk in a population. Besides agent, cigarette smoking is a cause of lung cancer, exposure
the incidence rate and specific rates which are measures of of premature babies to oxygen is the cause of retrolental
absolute risk, the epidemiologists calculate relative risk and fibroplasia, etc. in the case of chronic disease, hopes of
attributable risk for a factor related to or believed to be a finding a single cause remains unfulfilled, but an important
cause of the disease. The risk of bearing a mongol child and conceptual change has occurred - that is, search for risk
of some hereditary disorders are classic examples of factors. The concept of “risk factors” gave renewed impetus
evaluating individual’s risks and chances. The risk to epidemiological research. The search for causes and risk
assessment for smokers and non-smokers, for selected factors will be a ceaseless effort, as our ignorance about
causes of death (e.g., cancer CHD) is another well-known disease aetiology, particularly chronic disease, is profound,
example. not to speak of the “new” diseases which are appearing.

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5. Syndrome identification (infectious disease epidemiology
Medical syndromes are identified by observing frequently
associated findings in individual patients. It is worth Infectious disease epidemiology is a fundamental part of
recalling that, although approximately 3000 so-called the whole of epidemiology. In fact, the subject of
syndromes are described in the contemporary paediatric epidemiology originally developed from the study of
literature, a primary defect is known only in about 20 per epidemics of infectious diseases. There is a renaissance in
cent of these (96). Epidemiological investigations can be the study of communicable diseases, stimulated by
used to define and refine syndromes. By observation of (a) changes in the pattern of communicable diseases, (b) by
groups, such studies have been able to correct the discovery of “new” infections, and (c) by the possibility
misconceptions concerning many disease syndromes. For that some chronic diseases have an infective origin. The
example, there was less appreciation of the two main types development of vaccines and antibiotics was not followed,
of peptic ulcer (gastric and duodenal) till 1920. But the as predicted, by the virtual disappearance of infectious
“poverty” gradient in the certification of the gastric ulcer disease. Its prevention and control needs epidemiological
and its absence in duodenal ulcer led to differentiation of knowledge and experience (100). This section focuses on
gastric and duodenal ulcers. Another example is that of infectious disease epidemiology.
Patterson-Kelly syndrome of association between dysphagia Selected definitions
and iron-deficiency anaemia, but when the association was
tested by epidemiological methods, it was not found (11). Definitions are essential for any kind of epidemiological
Clinical studies using plasma renin levels have suggested activity, e.g., disease reporting, measurement of mortality
that aetiologically, prognostically and therapeutically distinct and morbidity, etc(J31ear-cut definitions of the terms such as
syndromes of essential hypertension may exist. It has been “infection”, “epidemic” and “surveillance” are needed in the
the subject of hot debate (97, 98). study of infectious diseases. A few selected definitions
pertaining to infectious disease epidemiology are given
6. Completing the natural history of disease below :
Epidemiology is concerned with the entire spectrum of INFECTION
disease in a population. The picture of disease constructed
on the basis of hospital patients is quite different from that Cjhe entry and development or multiplication of an
found in the community. The epidemiologist by studying infectious agent in an organism, including thg body of man
disease patterns in the community in relation to agent, host or "animals (4). It also implies that the body responds in
and environmental factors is in a better position to fill up the some'way to defend itself against the invader, either in the
gaps in the natural history of disease than the clinician. For form of an immune response (evidence of this may not be
example an outstanding contribution by epidemiology to the readily available) or disease. An infection does not always
natural history of atherosclerosis is the recognition that one- cause illness.
third to two-thirds of all deaths due to ischaemic heart There are several levels of infection : colonization (e.g.,
disease are sudden, i.e., occur in less than one hour. S. aureus in skin and normal nasopharynx'); subclinical or
Hospital studies could never have come to this conclusion, inapparent injection (e.g., polio); latent infection (e.g., virus
for most victims do not reach the hospital. This gave ofTierpes simplex); and manifest or clinical infection.

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 INFECTIOUS DISEASE EPIDEMIOLOGY i

CONTAMINATION (^A single case of a communicable disease__long absent

C_The presence of an infectious agent on a body surface; from a population or first invasion by a disease not
also on or in clothes, beddings, toys, surgical instruments or previously recognized in that area requires _immediate
dressings, or other inanimate articles or substances including reporting “and full field investigation; two cases of such
water, milk and food. (Pollution is distinct from disease associated in time and J?lace may be sufficient
contamination and implies the_presence of offensive, but not evidence to be considered an epidemic. The purpose of
necessarily infectious matter in the environment. surveillance systems is to identify epidemics as early as
Contamination on a body surface does not imply a carrier possible, so that effective control measure can be jjut in
state (100). h place; This remains the most important task for
epidemiology (4).
INFESTATION
ENDEMIC
(Fox persons or animals the lodgement, development_and
reproduction of arthropods on the surface of the body or in (En = in; demos=people). It refers to the constant
the clothing, e7g., lice, itch mite'YlOO). Some authorities use presence of a disease or infectious agent within a given
the term also to describe invasion of the gut by parasitic geographic area or population group, without importation
worms, e.g., ascariasis (100). from outside; may also refer to the “usual” or expected
frequency of the disease within such area or population
Infested articles or premises are those which harbour or group. For instance, common cold is endemic because
give shelter to animal forms, especially arthropods and somebody always has one.
rodents (100).
The term “hyperendemic” expresses that the disease is
HOST constantly present at a high incidence and/or prevalence
rate and affects all age groups equally; and the term
person or other living animal, including birds and “holoendemic” a high level of infection beginning early in
arthropods, that affords subsistence or lodgement to an life and affecting most of the child population, leading to a
infectious agentjunder natural Jas opposed to experimental) state of equilibrium such that the adult population shows
condnibnsjAni obligate hostTneans the only host, e.g., man evidence ol the disease much less commonly than do the
in measles and typhoid lever. Hosts in which the parasite
children, as in the case of malaria (100).

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attains~~maturity or passes its sexual stage are primary or
((d^initivehp^)those in which the parasife~is in a larval or (An endemic disease when conditions are favourable may
asexual__jstatg, are secondary ox (intermediate hosts. A burst into an epidemic (e.g., hepatitis A, typhoid fever). As
Ctronsport host) is a carrier in wF'icl’i'tTTe .organism remains new control or preventive measures are applied, the
alive but does not undergo development (100) endemic status of a disease may change.

INFECTIOUS DISEASE SPORADIC

A disease due to an infectious agent. While some The word sporadic means scattered____________
about. The cases
infectious diseases are contagious, others are non- occur irregularly, haphazardly from time to time, and
contagious. All infectious diseases and infestations are generally infrequently (100). The cases are so few and
communicable diseases (4). separate I widely in space and time that they show little or
no connection with each other, nor a recognizable common
CONTAGIOUS DISEASE source of infection, e.g., tetanus, herpes-zoster and
(^A disease that is transmitted through contact (100). meningococcal meningitis A sporadky disease may be the
Examples include scabies, trachoma, STD and leprosy _J starting point of an epidemic when conditions are
favourable for its spread. Many zoonotic diseases are
COMMUNICABLE DISEASE characterised by sporadic transmission to man^
(An illness due to a specific infectious agent or its toxic PANDEMIC
products that arises through transmission of that agent or its
products from an infected person, animal, or reservoir to a An epidemic occurring over a very wide area, crossing
susceptible host, either TTirectly or indirectly through an international boundaries, and usually affecting a large
intermediate plant or animal host, vector, or the inanimate number oi people. Only some pandemics cause severe
environment (100). disease in some individuals or at a population level.
Characteristics of an infectious agent influencing the
EPIDEMIC causation of a pandemic include : the agent must be able to
infecKhumans, to cause disease in human? and to spread
[Epi (upon), demos (people)].Cjhe occurrence in a
easily from human to_human (4). Examples arejnfluenza
community or region of cases of an illness, specific health-
pandemics and cholera pandemics.
related behaviour, or other health-related events^clearly in
excess of normal expectanc1, The communftyFor region and EXOTIC
the period in which the cases occur must be specified
precisely. The number of cases indicating the presence of an Diseases which are imported into a country in which they
epidemic varies according to the agent, size, and type of do not otherwise occur.
population exposed; previous experience or lack of exposure
jo the disease; and time and place of occurrence. ZOONOSES
Epidemicity is thus relative to usual frequency of the disease An infection or infectious disease transmissible under
Tn the same area, among the specified population, at the natural conditions from vertebrate animals to man. May be
same season of the yean) J enzootic or epizootic - e.g., rabies, plague, bovine

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MM PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

tuberculosis, anthrax, brucellosis, salmonellosis, endemic immunization or diagnostic procedures, e.g., reactions to
typhus, hydatidosis, kyasanur forest disease, monkeypox, penicillin and immunizing agents, aplastic anaemia
lassa fever, etc. following the use of chloramphenicol, childhood leukaemia
The term zoonoses has been further amplified as follows : due to prenatal X-rays, hepatitis B following blood
(a) anthropozoonoses : that is, infections transmitted to man transfusion, etc. These are all preventable. In short,
from vertebrate animals, e.gA raBies, plague, hydatid iatrogenic disease is a hazard of health care.
disease, anthrax and trichinosis; (b) zooanthroponoses : that SURVEILLANCE
is, infections transmitted from man to vertebrate animals,
e.g., human tuberculosis in cattle; and (c) amphixenoses : ((Continuous analysis, interpretation, and feedback of
that is infections maintained in both man and lower systematically collected data, generally using methods
vertebrate animals that may be transmitted in either distinguished by their practicality^ uniformity, and rapidity
direction, e.g., T.cruzi, and S.japonicum (100). rather than by accuracy or completeness. By observing
trends in time, place, and persons, changes can be observed
EPIZOOTIC or anticipated and appropriate action, including
An outbreak (epidemic) of disease in an animal investigative or control measures, can be taken. Sources of
population (often with the implication that it may also affect data may relate directly to disease or to factors influencing
human populations) (100). Only a few zoonotic agents disease. Thus they may include mortality and morbidity
cause major epidemics. Notable among these are the agents reports based on death certificates, hospital records, general
of anthrax, brucellosis, rabies, influenza, Rift valley fever, practice sentinels, or notifications; laboratory diagnosis;
Q fever, Japanese encephalitis and equine encephalitis. The outbreak reports; vaccine uptake and side effects; sickness
study of epizootic diseases is given the name of absence records; changes in disease agents, vectors, or
epizootiology. reservoirs; serological surveillance through serum banks (4).

EPORNITHIC ERADICATION
An outbreak (epidemic) of disease in a bird population ^Termination of all transmission of infection by
(100). extermination of the infectious agent through surveillance
and containment (4, 100). Eradication is an absolute
ENZOOTIC process, an “all or none” phenomenon, restricted to

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An endemic occurring in animals e.g., anthrax, rabies, termination of an infection from the whole world. It implies
brucellosis, bovine tuberculosis, endemic typhus and tick that disease will no longer occur in a population. To-date,
typhus. only one disease has been eradicated, that is smallpox. 4
(^The term elimination is sometimes used to describe
NOSOCOMIAL INFECTION “eradication” of disease (e.g., measles) from a___________ larue
( Nosocomial (hospital acquired) infection is an infection geographic region or political jurisdiction (lQOi. In the state
originating in a patient while in a hospital or other health oi~ouFpfesent knowledge, diseases which are amenable to
care facility. It denotes a new disorder (unrelated to the eradication are measles, diphtheria, polio and guinea worm.
patient’s primary condition) associated with being in a
hospital (100). That is, it was not present_or incubating at DYNAMICS OF DISEASE TRANSMISSION
the time of admission or the residual of an infection acquired
during a previous admission. It includes infections acquired Communicable diseases are transmitted from the
in the hospital but appearing after discharge, and also such reservoir/source of infection to susceptible host. Fig. 16
infections among the staff of the facility (100). Examples illustrates the medical model of an infectious disease.
include infection of surgical wounds, hepatitis B and urinary Basically there are three links in the chain of transmission, viz,
the reservoir, modes of transmission and the susceptible host.
tract infections.
(^Sources and reservoir '
OPPORTUNISTIC INFECTION
(^The starting point for the occurrence of a communicable
(infection with organism(s) that are normally innocuous
disease is the existence of a reservoir or source of infection.
(e.g. commensals in the human) but become pathogenic
The source^of infection is defined as “the person, animal,
when the body’s immunological defenses are compromised,
object or_substance from which an infectious agent passes or
as in AIDS (4AJ
is disseminated to the host” (100). A reservoir is defined as
IATROGENIC DISEASE “any person, animal, arthropod, plant, soil or substance (or
combination of these) in which an infectious agent lives and
Literally, “doctor-generated”; often, broadly used to refer multiplies,which it depends primarily for survival, and
to adverse effects of preventive, diagnostic, therapeutic, where ityreproduces itself in such inanneFTHat it can be
surgical, and other medical, biotechnical, cosmetic, sanitary, transmitted to a susceptible host” (100). In short, ffie
and public health products, services, procedures, reservoir is the natural habitat in which the organism
interventions, or policies. QTie process through which a metabolizes and replicates.
professional activity generates an adverse health effect.
The terms^reservoir and source are not always
There is a natural plurality of views on what constitutes
synonymous.tyFor example, in hookworm infection^ the
iatrogengsis and its scope. Medicine and public health are
reservoir is man, but/the source of infection is the , soil
obviously not the only professions j:hat cause adverse health
cornaminated with infective larvae. In tetanus, the reservoir
effgcts (4).
and source are the same, that is soil. In typhoid fever, the—
The disease may be serious enough to prolong the reservoir of infection may be a case or carrier, but the source
hospital stay, require special treatment or actually threaten of infection may be faeces or urine of patients or
life. Most of the episodes are related to drug therapy, contaminated food, milk or water. Thus the term “source”

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 DYNAMICS OF DISEASE TRANSMISSION

SOURCE MODES
SUSCEPTIBLE

J
OR OF
HOST
RESERVOIR TRANSMISSION

FIG. 16
Chain of Infection

refers to the immediate source of infection and may or may Barring a few (e.g., measles), subclinical infection occurs
not be a part of reservoir. in most infectious diseases. In some diseases (e.g., rubella,
( The term homologous reservoir is applied_when another mumps, polio, hepatitis A and B, Japanese encephalitis,
member of the same species is the victim, as for example influenza, diphtheria), a great deal of subclinical infection
man is the principal reservoir for some enteric pathogens, occurs. Since subclinical infections occur frequently during a
e.g., vibrio cholerae. The term heterologous is applied when person’s life time, they are responsible for the immunity
the infection is derived from a reservoir other than man, as shown by adult humans to a variety of disease-producing
for example animals and birds infected with salmonella. microbes.
The reservoir may be of three types : (3) The term latent infection must be distinguished from
subclinical infection. In latent infection ,_the host does notshed
1. Human reservoir the infectious agent wEich lies dormant within the host
2. Animal reservoir, and without symptoms (and often without demonstrable presence
3. Reservoir in non-living things. in blood, tissues or bodily secretions of the host). For example,
latent infection occurs in herpes simplex, Brill-Zinser disease,
1. Human reservoir infections due to slow viruses, ancylostomiasis, eicCthe role of
latent infection in the perpetuation of certain infectious agents
By far the most important source or reservoir of infection appears to be great. \
for humans is man himself. He may be a case or carrier. Man
is often described as his own enemy because most of the In epidemiological terminology, the term primary case

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communicable diseases of which man is heir to are refers to the first case of a communicable disease introduced
contracted from human sources. into the population unit being studied. The term index
case refers to the first case to come to the attention of the
a. CASES investigator; it is not always the primary case. Secondary
cases are those developing from contact with primary case.
A case is defined as “a person in the population or study A suspect case is an individual (or a group ot individuals)
group identified as having the particular disease, health who has all ot the signs and symptoms of a disease or
disorder-or condition under investigation” (100). A variety condition, yet has not been diagnosed as having the disease
oFcriteria (e.g., clinical, biochemical, laboratory registries or’ had the cause of the symptoms connected to the
and notifications, abstracts of clinical records, surveys of the suspecteTT pathogen.
general population, population screening andu^porting of
defects etc.) may be used to identify cases.yBroadly, the Whatever may be the “gradient of infection”, all infected
presence of infection in a host may be clinicak suBclinical or persons, whether clinical or subclinical, are potential sources
latenEThese variations inThe manifestations of disease are of infection, because the disease agent is leaving the body
through frequent stools, vomiting, coughing, sneezing or
referred to as “spectrum of disease” or “gradient of
other means and is potentially available for transfer to a new
infection” (see page 45).
host.
(1) The clinical illness may be mild or moderate, typical
or atypical, severe or fatal depending upon the gradient of b. CARRIERS
involvement. Epidemiologically, mild cases may be more In some diseases, either due to inadequate treatment or
important sources of infection than severe cases because immune response, the disease agent is not completely
they are ambulant and spread the infection wherever they eliminated, leading to a carrier state. A carrier is defined as
go, whereas severe cases are usually confined to bed. “an infected person or animal that harbours a specific
(2) The subclinical cases are variously referred to as infectious agent in the absence of discernible clinical disease
inapparent, covert, missed or abortive .cases. They are and serves as a potential source of infectiornbr others”
equally important as sources of infection. The disease agent (100). As a rule carriers are less infectious than cases, but
may multiply in the host but does not manifest itself by signs epidemiologically, they are more dangerous than cases
and symptoms. The disease agent is, eliminated and because they escape recognition, and continuing as they do
contaminates the environment in the same way as clinical to live a normal life among the population or community,
cases. Persons who are thus sick (unbeknown to themselves they readily infect the susceptible individuals over a wider
and others) contribute more than symptomatic patients to area and longer period of time, under favourable conditions.
the transmission of infection to others and. what is more, The “Typhoid Mary” is a classic example of a carrier.
they do not appear in any of the statistics(Subclinical cases The elements in a carrier state are : (a) fhe^ presence in
play a dominant role in maintaining the chain of infection the body of the disease agent (b) the absence of
(endemicity) in the community} recognizable symptoms and signs of disease, and (c) the
Subclinical infection can be detected only by laboratory shedding of the disease agent in the discharges or
tests, e.g., recovery of the organism, antibody response, excretions, thus acting as a source of infection for other
biochemical and skin sensitivity tests. persons.

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 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS _________________

Carriers may be classified as below : Carriers of avirulent organisms are called pseudo-carriers.
A. Type Pseudo-carriers are not important epidemiologically.
(a) Incubatory C. By portal of exit : Carriers may also be classified
(b) Convalescent according to the portal of exit of the infectious agent. Thus
(c) Healthy we have urinary carriers, intestinal carriers, respiratory
carriers, nasal carriers, etc. Skin eruptions, open wounds
B. Duration and blood are also portals of exit. In typhoid fever, the
(a) Temporary urinary carrier is more dangerous than an intestinal carrier.
(b) Chrome A typhoid carrier working in a food establishment or water
C. Portal of exit works is more dangerous than a typhoid carrier working in
(a) Urinary an office establishment. Thus the portal of exit and the
(b) Intestinal occupational status of the carrier are important
(c) Respiratory epidemiological considerations.
(d) Others 2. Animal reservoir
A. By type : (a) INCUBATORY CARRIERS : Incubatory (JEhelsource of infection may sometimes be ^animals and
carriers are those who shed the infectious agent during the birds.. These, like the human sources of infechon/mayFte
incubation period of disease. That is, they are capable of cases or carriers. The diseases and infections which are
infecting others before the onset of illness. This usually transmissible to man from vertebrates are called zoonoses.
occurs during the last few days of the incubation period, There are over 100 zoonotic diseases which may be
e.g., measles, mumps, polio, pertussis, influenza, diphtheria conveyed to man from animals and birds. The best known
and hepatitis B. (b) CONVALESCENT CARRIERS : That is, examples are rabies, yellow fever and influenza. The role of
those who continue to shed the disease agent during the pigs and ducks in the spread of epidemic and pandemic
period of convalescence, e.g., typhoid fever, dysentery influenza both as reservoirs, carriers and “amplifying hosts”
(bacillary and amoebic), cholera, diphtheria and whooping is now well established. Pigeons in cities can lead to
cough. In these diseases, clinical recovery does_not coincide infection with chlamydia; dust mites from them carTcause
with bacteriological recovery. A convalescent carrier can allergy in man. Ornithosis and arboviruses can be
pose a serious threat to the unprotected household members transmitted to man from various birds. Wild birds, in

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and those in the immediate environment, as in the case of a particular, are important hosts in the transmission cycles of
typhoid fever patient who may excrete the bacilli for 6-8 most of the mosquito-borne encephalitis and several
weeks. This highlights the importance of bacteriological mosquito-borne undifferentiated febrile diseases (101).
surveillance of carriers, after clinical recovery, (c) HEALTHY CjTistojslasmosis is carried all over the world by_birds. As birds
CARRIERS : Healthy carriers emerge from subclinical cases. migrate from one locality to another they may carry ticks
They are victims of subclinical infection who have infected with viruses and rickettsiae that may cause disease
developed carrier state without suffering from overt disease, in humans._In short, the migrations and movements of
but are nevertheless shedding the disease agent, e.g., animals and birds mavx^rry serious epizootiological and
poliomyelitis, cholera, meningococcal meningitis, epidemiological risks.Clhere is evidence that genetic
salmonellosis, and diphtheria. It is well to remember that a recombination between animal and human viruses might
person whose infection remains subclinical may or may not produce “new” strains of viruses (e.g., influenza viruses).
be a carrier. For example, in polio the infection may remain
subclinical and the person may act as a temporary carrier by 3. Reservoir in non-living things
virtue of shedding the organism. On the other hand, in
Soil and inanimate matter can also act as reservoirs of
tuberculosis, most persons with positive tuberculin test do
not actively disseminate tubercle bacilli and therefore are infection. For example, soil may harbour agents that cause
tetanus, anthrax, coccidioidomycosis and mycetoma.
not labelled as carrier (38).
B. By duration : (a) TEMPORARY CARRIERS : MODES OF TRANSMISSION
Temporary carriers are those who shed the infectious agent
for short periods of time. In this category may be included Communicable diseases may be transmitted from the
the incubatory, convalescent and healthy carriers, reservoir or source of infection to a susceptible individual in
(b) CHRONIC CARRIERS : A chronic carrier is one who many different ways, depending upon the infectious agent,
excretes the infectious agent for indefinite periods. Chronic portal of entry and the local ecological conditions. As a rule,
carrier state occurs in a number of diseases, e?g., typhoid an infectious disease is transmitted by only one route, e.g.,
fever, hepatitis B, dysentery, cerebro-spinal meningitis, typhoid fever by vehicle transmission and common cold by
malaria, gonorrhoea, etc. Chronic carriers are far more direct contact. But there are others which may be
important sources of infection than cases. The longer the transmitted by several routes e.g., AIDS, salmonellosis,
carrier state, the greater the risk to the community. Some hepatitis B, brucellosis, Q fever, tularemia etc. The multiple
carriers excrete the infectious agent only intermittently and transmission routes enhance the survival of the infectious
some continuously. The duration of the carrier state varies agent. The mode of transmission of infectious diseases may
with the disease. In typhoid fever and hepatitis B, the be classified as below (2, 99).
chronic carrier state may last for several years; in chronic
dysentery, it may last for a year or longer. In diphtheria, the K DIRECT TRANSMISSION
carrier state is associated with infected tonsils; in typhoid 1. Direct contact
fever with gall bladder disease. Chronic carriers are known 2. Droplet infection
to reintroduce disease into areas which are otherwise free of 3. Contact with soil
infection (e.g., malaria). Therefore their early detection and 4. Inoculation into skin or mucosa
treatment are essential to limit the spread of infection. 5. Transplacental (vertical)

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 MODES OF TRANSMISSION _LQ5l
B INDIRECT TRANSMISSION larvae, tetanus, mycosis etc. (4) Inoculation into skin or
1. Vehiclfcborne mucosa : The disease agent may be inoculated directly into
2. Vector-borne the skin or mucosa e.g., rabies virus by dog bite, hepatitis B
a. Mechanical virus through contaminated needles and syringes etc., and
b. BiologicaF (5) (Transplacental (or vertical) transmission : Disease agents
3. Airsbome can he" transmitted transplacentallv (103, 104). This is
a. Droplet nuclei another form of direct transmission. Examples include the
b. Dust so-called TORCFFagents (Toxoplasma gondii, rubella virus,
4. Fomite-borne cytomegalovirus and herpes virus), varicella virus, syphi is,
5. Unclean hands and fingers hepatitis B, Coxsackie B and AIDS. Some of the non-living
agents (e.g., thalidomide, diethylstilbestrol) can also be
A. Direct transmission transmitted vertically. Tn these cases, the disease agent
(1) Directcontact: Infection may be transmitted by direct produces malformations of the embryo by disturbing its
contact from skin to skin, mucosa to mucosa, or mucosa to development.
kin of the same or another person. This implies direct and B. Indirect transmission
essentially immediate transfer of infectious agents from the
reservoir or source to a susceptible individual, without an This embraces^ variety of mechanisms including the
intermediate agency, e.g., skin-to-skin contact as by traditional 5 F’s -(“flies, fingers, fomites, food and fluid* An
touching, kissing or sexual intercourse or continued close essential requirement for indirect transmission is that the
contact. Direct contact not only reduces the period for which infectious agent must be capable of surviving outside the
the organism will have to survive outside the human host human host in the external environment and retain its basic
but also ensures a larger dose of infection. Diseases properties of pathogenesis and virulence till it finds a new
transmitted by direct contact include STD and AIDS, host. This depends upon the characteristics of the agent, the
leprosy, leptospirosis, skin and eye infections. (2){Droplet inanimate object and the influence of environmental factors
infection : This is direct projection of a spray of droplets of such as temperature and humidity.kJf the disease agent
saliva ^and nasopharyngeal secretions during coughing, acquires drug resistance, it will further facilitate its spread.
sneezing, (Fig. 17) or speaking and spitting, talking into the Indirect transmission can occur in a variety of settings
surrounding atmosphere. The expelled droplets may
impinge directly upon the conjunctiva, oro-respiratory
1. Vehicle-borne

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mucosa or skin of a close contact. Particles of 10 mmm or ^Vehicle-borne transmission implies transmission of the
greater in diameter are filtered off by nose. Those 5 mmm or infectious agent through the agency of water, food (including
less can penetrate deeply and reach the alveoli. The droplet raw vegetables, fruits, milk and milk products), ice, blood,
spread is usually, limited to a distance of 30-60 cm between serum, jnlasma or other biological products such as tissues
source and host (102). In infectious diseases, these droplets, and organs. Of these water and food are the most frequent
which may contain millions of bacteria and viruses can be a vehicles of transmission, because they are used by everyone.
source of infection to others. When a healthy susceptible ( The infectious agent may have multiplied or developed in the
person comes within the range of these infected droplets he vehicle (e.g., S.aureus in food) before being transmitted; or
is likely to inhale some of them and acquire infection. only passively transmitted in the vehicle (e.g., hepatitis A
Diseases transmitted by droplet spread include many virus in water). Diseases transmitted by water and food
respiratory infections, eruptive fevers, many infections of the include chiefly infections of the alimentary tract, e.g., acute
nervous system, common_coId?dTphtheria, whooping cough, diarrhoeas, typhoid fever, cholera, polio, hepatitis A, food
tuberculpsis, COVID-19, meningococcal meningitis, etc. The poisoning and intestinal parasites. Those transmitted by
potential for droplet spread is increased in conditions of blood include hepatitis B, malaria, syphilis, brucellosis,
close proximity, overcrowding and lack of ventilation. trypanasomes (Chaga’s disease), infectious mononucleosis
(3) Contact with soil: The disease agent may be acquired by and cytomegalovirus infection (105). Organ transplantation
direct exposure of susceptible tissue to the disease agent in may result in the introduction of the disease agent such as
soil, compost or decaying vegetable matter in which it cytomegalovirus in association with kidney transplants.
normally leads a saprophytic existence e.g., hookworm The epidemiological features of vehicle transmission are :
(a) if the dose of contamination is heavy, the outbreak may
be explosive as in the case of cholera and hepatitis A
epidemics (b) cases are initially confined to those who are
exposed to the contaminated vehicle, in some infections
(c) when secondary cases occur, the primary case may be
obscured (d) theTdistance travelled by the infectious agent
may be great, e.g., outbreaks of food poisoning (e) it is not
always possible to isolate the infectious agent in the
incriminated vehicle, e.g., typhoid bacilli in contaminated
water (f) when the vehicle is controlled or withdrawn, the
epidemic subsides, e.g., epidemics of cholera, and (g) the
common source of infection is often traceable.
2. Vector-borne
In infectious disease epidemiology, vector is defined as
an arthropocLor any living carrier (e.g., snail) that transports
Droplets sprayed into the air from a sneeze an infectious agent to a susceptible individual.^Transmission
(From : The Medical Clinics of North America, 1944 p. 1301) by a vector may be mechanical orj-jological. In the latter

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106 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

case, the disease agent passes through a developmental s^The factors which influence the ability of vectors to transmit
cycle or multiplication in the vector. disease are : (a) host feeding preerences (b) infectivity, that is
ability to transmifThe disease agent (c) susceptibility, that is
Epidemiological classification of vector-borne diseases ability to become infected (d) survival rate of vectors in the
environment (e) domesticity, thatisclegree oTassociation with
I. By vector
man, and (f) suitable environmental factors. Seasonal
a) Invertebrate type : Arthropod vectors fall into seven occurrence of some diseases (e.g., malaria) may be related to
orders largely intense breeding and thereby greater density of the insect
(1) Diptera - flies and mosquitoes vector during certain periods of the year.
(2) Siphonaptera - fleas
3. Airborne
(3) Orthoptera - cockroaches
(1) \Qroplet nuclei : “Droplet nuclei” are a type of
(4) Anoplura - sucking lice
particles implicated in the spread of airborne infection. They
(5) Hemiptera - bugs, including kissing bugs are tiny particles (1-10 microns range) that represent the
(6) Acarina - ticks and mites dried residue of droplets (100). They ma be formed by
(7) Copepoda - cyclops (a) evaporation of droplets coughed or sneezed into the air
b) Vertebrate type - Mice, rodents, bats. or (b) generated purposefully by a variety of atomizing
devices (aerosols). They may also be formed accidentally in
II. By transmission chain microbiological laboratories, in abattoirs, rendering plants or
autopsy rooms (106). The droplet nuclei may remain
Vector-borne diseases are classified under heterogeneous
airborne for long periods of time, some retaining and others
infection chain and involve three principal patterns :
losing infectivity or virulence. They not only keep floating in
a) Man and a non-vertebrate host the air but may be disseminated by air currentsHFrom the
1) Man-arthropod-man (malaria) point of their origin. Particles in the 1-5 micron range are
2) Man-snail-man (schistosomiasis). liable to be easily drawn into the alveoli of the lungs and
may be retained there. Diseases spread by droplet nuclei
b) Man, another vertebrate host, and a non-vertebrate
host include tuberculosis, influenza, chickenpox, measles,
Q fever. COVID-19, and many respiratory infectionsTTNot
1) Mammal-arthropod-man (plague)

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considered airborne are droplets and other large particles
2) Bird-arthropod-man (encephalitis). which promptly settle out). Mention must also be made of
c) Man and 2 intermediate hosts the role of airborne spread of toxic air pollutants including
“smog” resulting in air pollution epidemics.
1) Man-cyclops-fish-man (fish tape worm)
2) Man-snail-fish-man (Clonorchis sinensis) (2) Dust : Some of the larger droplets which are expelled
3) Man-snail-crab-man (Paragonimiasis). during talking, coughing or sneezing, settle down by their
sheer weight on the floor, carpets, furniture, clothes, bedding,
III. By methods in which vectors transmit agent linen and other objects in the immediate environment and
a) Biting become part of the dust. A variety of infectious agents (e.g.,
b) Regurgitation streptococci, ot' er pathogenic bacteria, viruses and fun: al
c) Scratching-in of infective faeces spores) "and skin squamae have been found in the dust of
hospital wards and living rooms. Some of them (e.g., tubercle
d) Contamination of host with body fluids of vectors. bacilli) may survive in the dust for considerable periods under
IV. By methods in which vectors are involved in the optimum conditions o! temperature and moisture. During the
transmission and propagation of parasites acFoTsweeping, dusting and bed-making, the dust is released
into the air and becomes once again airborne. Dust particles
(a) [Mechanical transmission : The infectious agent is may also be blown from the soil by wind; this “may include
mechanically transported by a crawling or fb.ing arthropod fungal spores. Coccidioidomycosis is an example of a disease
through~soiling of its feet or proboscis; or by passage of spread through airborne transmission of fungal spores (38).
organisms through its gastrointestinal tract and passively Other diseases carried by infected dust include streptococcal
excreted. There is no development or multiplication of the and staph lococcal infection, pneumonia, tuberculosis,
infectious agent on or within the vector, j Q fever and psittacosis. Airborne dust is primarily inhajecf,
(b) ^Biological transmission : The infectious agent but may settle on uncovered food and milk. This type of
undergoing replication or development or both, in vector and transmission is most common in hospital-acquired
requires an incubation period before vector can transmit. (nosocomial) infection.
Biological transmission is of three types : (itPropagative : The
agent merely multiplies in vector but no change in form, 4. Fomite-borne
e.g., plague bacilli in rat fleas, (ii) Cyclo-propagative : The CFomites (singular; fomes) are inanimate articles or
agent changes_inJorm and number, e.g., malaria parasites in substances other than water or food contaminateTby^the
mosquito, (iii) Cyclo-developmental : The disease aQent infectious discharges from_____ a patient and capable~of
undergoes only development but no multiplication, harbouring and transferring the infectious agent to a Healthy
e.g., microfilaria in mosquito. person. Fomites include soiled clothes, towels, linen,
When the infectious agent is transmitted vertically from handkerchigfs, cups, spoons, pencils, Hooks, toys, drinking
the infected female to her progeny in the vector, it is known glasses, door handles, taps, lavatory chains, syringes,
as (transovarial transmission} Transmission of the disease instruments and surgical dressings. (The fomites play an
ageni from onp stage of the life cycle to another as for important role in indirect infection. Diseases transmitted by
example nympH to adult is known as (^ransstadial fomites include diphtheria, typhoid fever, bacillary
transmission.^) dysentery, hepatitis A, eye ancLskin infections.

by R△J
 SUSCEPTIBLE HOST

5. Unclean hands and fingers explained in Fig. 18. The factors which determine the
incubation period include the generation time of the
ddands are the most common medium by which
particular >atho.;en, infective dose, portal of entry and
pathogenic agents are transferred to food from the skin, nose,
individual susceptibility. As a rule, infectious diseases are
bowel, etc as well as from other foods. The transmissiorrtakes
not communicable during the incubation period, but”there
place both directly (hemddp-mouth) and indirectly. Examples
are "exceptions, as for example, measles, chickenpox,
include staphylococcal and streptococcal infections, typhoid
whooping cough and hepatitis_A_are communicable during
fever, dysentery, hepatitis A and intestinal parasites. Unclean
thelater part of the incubation period.
hands_and_fingers imply lack of personal hygiene. Lack of
personal hygiene coupled with poor sanitation favour The length of the incubation period is characteristic of
i >erson-to-i.erson transmission of infection, an example is the each disease Jlhere is a minimum incubation period for every
1984 dysentery epidemic in India. disease before which no illness can occur.) That is, incubation
period varies for different infectious diseases, and also from
SUSCEPTIBLE HOST one person to another with the same disease. In some, the
incubation period is very short ranging from a few hours to
Successful parasitism 2-3 days, e.g., staphylococcal food poisoning, cholera,
bacillary dysentery and influenza. In some, the incubation
Four stages have been described in successful parasitism : period is of median length ranging from 10 days to 3 weeks;
(a) First, the infectious agent must find a PORTAL OF in this category, there are many examples : typhoid infections,
ENTRY by which it may enter the host. There are many virus diseases such as chickenpox, measles, COVID-19,
portals of entry, e.g., respiratory tract, alimentary tract, and mumps. Then there are infections with longer incubation
genitourinary tract, skin, etc. Some organisms may have periods (ranging from weeks to months or years) and whose
more than one portal of entry, e.g., hepatitis B, Q fever, incubation time is difficult to measure precisely, e.g., hepatitis
brucellosis, (b) On gaining entry into the host, the organisms A and B, rabies, leprosy and slow virus diseases.
must reach the appropriate tissue or “SITE OF ELECTION^
in the body of the host where it may find optimum CNon-infectious diseases such as cancer, heart disease and
conditions for its multiplication and survival, (c) Thirdly, the mental illness also have incubation ; eriods, which ma be
disease agent must find a way out of the body (PORTAL OF months or years. The term latent period is used in non-
EXITlJn order that it may reach a new host and propagate infectious diseases as the equivalent of incubation period in
infectious diseases (36). Latent period has been defined as

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its species. If there is no portal of exit, the infection becomes
a dead-end infection as in rabies^Jjubonic plague, tetanus “the period from disease initiation to disease detection” (2).
and trichinosis, (d) After leaving the human body, the In chronic disease, the agent-host interactions leading to a
organisrrTmust survive in the external environment for sequence of cellular changes are not well understood.
sufficient period till a new host is found. In addition, a Incubation period is of fundamental importance in
successTuTdisease agent should not cause the death of the epidemiological studies : (a) Tracing the source oj infection
host but produce only ajow-grade immunity so that the hostp and contacts : In the case of a disease with a short incubation
is vulnerable again and again to the same infection. The best period ranging from a few hours to a few days, it is relatively
example is common cold virus. simple to trace the source of infection and “follow the trail”_
of the spread of infection as in the case of food poisoning,
Incubation period bacillary dysentery or typhoid fever. The position is quite
(An infection becomes apparent only after a certain different with diseases whose incubation period is of medium
incubation period, which is defined as “the time interval length (10 days to 3 weeks) or longer. So many things will
between invasion by an infectious agent and appearance of have happened and such varied contacts taken place that the
the first sign or symptom of the disease in ue>tion” (2). cause-effect relationship becomes “djluted”. We will have a
During the incubation period, the infectious agent whole gamut of possible causes from among which we have
undergoes_jnultiphcation in the host. When a sufficient to single out the main cause. Once the source of infection is
density ofthe disease agent is built upin the host, the health traced, then only it will be possible to institute appropriate
equilibrium is disturbed and the disease becomes overt. Also control measures, (b) Period of surveillance : Incubation
of interest to the epidemiologist is the median incubation period is useful in determining the period of surveillance
period, defined as the time required Jql.50. per cent of the (or quarantine) which may be advisedJA in Fig. 18). This
cases to occur following exposure. \ These concepts are period is usually equal to the maximum incubation period of

Exposure FIG. 18
Showing incubation periods (Ref. 3)

by R△J
108 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

thg-disease, (c) Immunization : Prophylactically, a knowledge The denominator consists of all persons who are exposed
of incubation period helps us to prevent clinical illness by to the case. More specifically, the denominator may be
human immunoglobulins and antisera, (d) Identification of restricted only to “susceptible” contacts, if means are
point source or propagated epidemics : In a’point source available to distinguish the susceptible persons from the
epidemic, all the cases occur within one incubation period immune (5). The primary case is excluded from both the
of the disease; in a propagated epidemic, cases occur later numerator and denominator.
than the known length of the incubation period; and Supposing there is a family of 6 consisting of 2 parents
(e) Prognosis : Incubation period can also be used in (already immune) and 4 children who are susceptible to a
estimating the prognosis of a disease. In some diseases (e.g., specific disease, say measles. There occurs a primary case
tetanus, rabies), the shorter the incubation period, the worse and within a short time 2 secondary cases among the
the prognosis of the disease. Thus prognosis is related to the remaining children. The secondary attack rate is 2/3 or 66.6
incubation period of the disease (14). per cent. The primary case is excluded from both numerator
Serial interval and denominator.
In actual practice we seldom know precisely the Secondary attack rate is limited in its application to
incubation period of a disease. But we know, when an infectious diseases in which the primary case is infective for
outbreak of disease occurs, say in a family which is the only a short period of time measured in days (e.g., measles
smallest group and also a closed group, there is an initial and chickenpox). When the primary case is infective over a
primary case. The primary case is followed by 2 or 3 long period of time (e.g., tuberculosis), duration of exposure
secondary cases within a short time. The gap in time is an important factor in determining the extent of spread
between the onset of the primary case and the secondary (14). It is indicated by the formula :
case is called the “serial interval”. By collecting information Number of contacts developing
about a whole series of such onsets, we get a distribution of tuberculosis
secondary cases from which we can guess the incubation SAR = ------------------------------------------------- X 100
period of disease. Number of person-weeks (months
or years) of exposure
Generation time
Another concept in infectious disease epidemiology is Another limitation of secondary attack rate is to identify
“generation time”. It is defined as “the interval of time “susceptibles”. It is feasible only in diseases such as measles

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between receipt of infection by a host and maximal and chickenpox where history can be used as a basis for
infectivity of that host” (2). In general, generation time is identification; but in many others, susceptibles cannot be
roughly equal to the incubation period. However, these two readily identified (e.g., influenza). In such cases, secondary
terms are not the same. The time of maximum attack rate is based on all exposed family members and still
communicability may precede or follow the incubation remains a useful tool (14). Where there are numerous
period. For example, in mumps, communicability appears to subclinical cases, secondary attack rate has a limited
reach its height about 48 hours before the onset of swelling meaning. Further spread cannot be measured without
of the salivary glands (38). With person-to-person laboratory investigations (107).
transmission of infection, the interval between cases is An additional advantage of the secondary attack rate is
determined by the generation time (2). A further difference that vaccinees and non-vaccinees from several families can
is that the term “incubation period” can only be applied to be added to determine the overall attack rates in the
infections that result in manifest disease, whereas vaccinated and unvaccinated populations, provided the
“generation time” refers to transmissions of infection, same definitions for cases and immunization status are used.
whether clinical or subclinical (38). Secondary attack rate was initially developed to measure
Communicable period the spread of an infection within a family, household or any
closed aggregate of persons who have had contact with a
The communicable period is defined as “the time during case of disease. It is also useful to determine whether a
which an infectious agent may be transferred directly or
disease of unknown aetiology (e.g., Hodgkin’s disease) is
indirectly from an infected person to another person, from
communicable or not; and in evaluating the effectiveness of
an infected animal to man, or from an infected person to an
control measures such as isolation and immunization.
animal, including arthropods” (2). Communicability varies
in different diseases. Some diseases are more communicable
during the incubation period than during actual illness.
HOST DEFENCES
Communicability of some diseases can be reduced by early Host defences against infection are at once local and
diagnosis and treatment. An important measure of systemic, non-specific and specific, and humoral and
communicability is Secondary attack rate. cellular. It is difficult to identify any infectious agent that fails
Secondary attack rate to stimulate multiple host defence mechanisms. The concept
of overlapping host defences is crucial to our understanding
Secondary attack rate (SAR) is defined as “the number of of susceptibility to infection. This overlapping underlies the
exposed persons developing the disease within the range of reasonable measure of good health in the face of an
the incubation period, following exposure to the primary apparently significant host immune defect (108).
case” (5). It is given by the formula :
There is a phase of passive immunity transmitted to the
Number of exposed persons developing baby from the mother across the placenta. Maternal
the disease within the range of the
incubation period antibody transmitted to infant is gradually lost over a period
SAR = --------------------------------------------------- X 100 of 6 months. Thus a large proportion of infants remain free
Total number of exposed/“susceptible” from potent infection up to 3 months, or even longer. There
contacts is good evidence that this protective “biological shield” is

by R△J
 HOST DEFENCES

due to the presence of high levels of immunoglobulins IgM

and especially IgG in the cord blood and plasma of infants
born of immune mothers. It has been postulated that some
other factors (breast milk, presence of fetal haemoglobulin),
are also responsible for the transient protection of infants.

SPECIFIC DEFENCES
Specific defences come into play, once microorganisms
have breached local defence mechanisms. By virtue of these FIG. 19
The primary response
defences, the host is able to recognize, destroy and eliminate
antigenic material (e.g., bacteria, viruses, proteins, etc.) The nature and extent of primary response to an antigen
foreign to his own. A person is said to be immune when he is determined by a number of factors, e.g;, dose of antigen,
possesses “specific protective antibodies or cellular immunity nature of antigen, route of administration, adjuvants,
as a result of previous infection or immunization, or is so presence of maternal antibody, nutritional status of the host,
conditioned by such previous experience as to respond genetic and co-existing diseases etc (109). For example, with
adequately to prevent infection and/or clinical illness small doses of antigen, only IgM type of response may be
following exposure to a specific infectious agent” (106). induced, and successive small doses of antigen at suitable
intervals may also induce IgM antibody. The antigenic dose
The specific defences may be discussed for convenience
required for the induction of IgG is about 50 times that
under the following heads :
which is required to induce IgM antibody.
1. Active immunity
An important outcome of primary antigenic challenge is
(1) Humoral immunity education of the reticuloendothelial system of the body.
(2) Cellular immunity There is production of what are known as “memory cells” or
“primed cells” by both B and T lymphocytes. These cells are
(3) Combination of the above. responsible for the “immunological memory” which
2. Passive immunity becomes established after immunization. In fact, the purpose
of immunization is to develop immunological memory.

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(1) Normal human Ig
(2) Specific human Ig (b) SECONDARY (BOOSTER) RESPONSE: The response
to a booster dose differs in a number of ways from the
(3) Animal antitoxins or antisera. primary response : (1) shorter latent period. (2) production
1. Active immunity of antibody more rapid. (3) antibody more abundant.
(4) antibody response maintained at higher levels for a
It is the immunity which an individual develops as a result longer period of time, and (5) the antibody elicited tends to
of infection or by specific immunization and is usually have a greater avidity or capacity to bind to the antigen.
associated with presence of antibodies or cells having a
specific action on the microorganism concerned with a The secondary response also involves the production of
particular infectious disease or on its toxin (106). In other IgM and IgG antibody. Collaboration between B and T cells is
words, active immunity depends upon the humoral and necessary to initiate a secondary response. There is a brief
cellular responses of the host. The immunity produced is production of IgM antibody and much larger and more
specific for a particular disease, i.e., the individual in most prolonged production of IgG antibody. This accelerated
cases is immune to further infection with the same organism response is attributed to immunological memory. The immune
response (primary and secondary) and immunological
or antigenically related organism for varying periods
memory are the basis of vaccination and revaccination.
depending upon the particular disease.
Active immunity may be acquired in 3 ways : (1) Humoral immunity
(a) following clinical infection, e.g., chickenpox, rubella Humoral immunity comes from the B-cells (bone-marrow
and measles. derived lymphocytes) which proliferate and manufacture
(b) following subclinical or inapparent infection, e.g., specific antibodies after antigen presentation by
polio and diphtheria. macrophages. The antibodies are localized in the
immunoglobulin fraction of the serum. Immunoglobulins are
(c) following immunization with an antigen which may be divided into 5 main classes - IgG, IgM, IgA, IgD and IgE (and
a killed vaccine, a live attenuated vaccine or toxoid. sub-classes within them) - each class representing a different
The immune response functional group. These antibodies circulate in the body and
act directly by neutralizing the microbe, or its toxin or
(a) PRIMARY RESPONSE : When an antigen is rendering the microbe susceptible to attack by the
administered for the first time to an animal or human who polymorphonuclear leucocyte and the monocyte. The
has never been exposed to it, there is a latent period of complement system, together with antibodies is necessary for
induction of 3 to 10 days before antibodies appear in the efficient phagocytosis of bacteria (110).
blood (Fig. 19). The antibody that is elicited first is entirely The antibodies are specific, i.e., they react with the same
of the IgM type. The IgM antibody titre rises steadily during antigen which provoked their production, or a closely related
the next 2-3 days or more, reaches a peak level and then one. As a result of this specificity, host response mediated by
declines almost as fast as it developed. Meanwhile, if the antibodies is somewhat limited in that it will not provide
antigenic stimulus was sufficient, IgG antibody appears in a protection against more than one antigen (111). This
few days. IgG reaches a peak in 7-10 days and then specificity has been a formidable problem in the production
gradually falls over a period of weeks or months (Fig. 19). of vaccines. For example, there are numerous antigenic types
by R△J
no PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

of rhinoviruses, and it is not possible to expect a single develops. Many examples of this can be seen among individuals
vaccine to be effective against all these types (111). who, though immunized, nevertheless contact a typhoid or
paratyphoid infection, diphtheria, or some other disease.
(2) Cellular immunity Moreover, many factors are involved in the maintenance of
Although antibodies are quite effective in combating most immunity. Fatigue, strange surroundings, change of diet,
infectious diseases, humoral immunity does not cover all the ingestion of drugs, and emotional shock are examples of these
situation that one finds in infectious diseases (111). For factors that can produce a fall in immunity or a lowering of the
example, some pathogens (e.g., M. leprae, M. tuberculosis, threshold at which resistance to infection fails (114).
S. typhi, Candida albicans and many viruses) escape the
bactericidal action of leukocyte. They can even multiply in 2. Passive immunity
the mononuclear leukocyte (macrophage). However, these When antibodies produced in one body (human or animal)
macrophages can be stimulated by substances are transferred to another to induce protection against
(lymphokines) secreted by specific stimulated disease, it is known as passive immunity. In other words, the
T-lymphocytes (thymus - derived lymphocytes). The body does not produce its own antibodies but depends upon
activated macrophages perform a much more efficient ready-made antibodies. Passive immunity may be induced :
phagocytic function than non-activated macrophages (108).
(a) by administration of an antibody-containing
It is now well-recognized that cellular immunity plays a preparation (immune globulin or antiserum)
fundamental role in resistance to infection. It is mediated by the (b) by transfer of maternal antibodies across the placenta.
T-cells which differentiate into sub-populations able to help Human milk also contains protective antibodies, (IgA).
B-lymphocytes. The T-cells do not secrete antibody, but are (c) by transfer of lymphocytes, to induce passive cellular
responsible for recognition of antigen. On contact with antigen, immunity - this procedure is still experimental.
the T-cells initiate a chain of responses e.g., activation of
macrophages, release of cytotoxic factors, mononuclear Passive immunity differs from active immunity in the
inflammatory reactions, delayed hypersensitivity reactions, following respects : (a) immunity is rapidly established
secretion of immunological mediators (e.g., immune (b) immunity produced is only temporary (days to months)
interferon), etc. There is growing evidence that cellular till the antibody is eliminated from the body, and (c) there is
immunity is responsible for immunity against many diseases no education of the reticuloendothelial system.

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including tuberculosis, brucellosis and also for the body’s Passive immunization is useful for individual who cannot
rejection of foreign material, such as skin grafts. The importance form antibodies, or for the normal host who takes time to
of cell-mediated immunity can be appreciated from the fact develop antibodies following active immunization.
that a child born with a defect in humoral antibody production
may survive for as long as 6 years without replacement therapy, Herd immunity
but a severe defect in cell-mediated immunity will result in Herd immunity (or community immunity) describes a type
death within the first six months of life (112). of immunity that occurs when the vaccination of a portion of
population (or herd) provides protection to unprotected
(3) Combination of the above individuals. Herd immunity theory proposes that in diseases
In addition to the B and T lymphoid cells which are passed from individual to individual, it is difficult to maintain
responsible for recognizing self and non-self, very often, a chain of infection when large numbers of a population are
they cooperate with one another and with certain accessory immune. The higher the number of immune individuals, the
cells such as macrophages and human K (killer) cells, and lower the likelihood that a susceptible person will come in
their joint functions constitute the complex events of contact with an infectious agent (115).
immunity. For instance, one subset of T-cells (helper T-cells) Herd immunity provides an immunological barrier to the
are required for the optimal production of antibody to most spread of disease in the human herd. For example, when an
antigens. Another set of T-cells (suppressor T-cells) inhibit infectious disease is introduced into a “virgin” population,
immunoglobulin synthesis. Antibody-dependant cell- that is, population with a very low or no immunity, the
mediated (K) cytotoxic cells recognize membrane viral attack and case fatality rates tend to be very high involving
antigens through specific antibody, whereas natural killer practically all susceptibles as it had happened in the very
(NK) cells destroy non-specifically virus-infected target cells. severe measles epidemic in the Faroe islands, in 1854,
It is now increasingly recognized that vaccines to be effective where the population had no previous experience of
must elicit both humoral and cell-mediated responses (113). measles. The epidemic wave declined with a build-up of
Active immunity takes time to develop. It is superior to herd immunity following natural infection.
passive immunity because (a) the duration of protection, like Elements which contribute to herd immunity are
that of the natural infection is frequently long-lasting (a) occurrence of clinical and subclinical infection in the
(b) with few exceptions, severe reactions are rare (c) the herd, (b) immunization of the herd, and (c) herd structure.
protective efficacy of active immunization exceeds that of Herd structure is never constant. It is subject to constant
passive immunization, and in some instances, approaches variation because of new births, deaths and population
100 per cent, and (d) active immunization is less expensive mobility. An on-going immunization programme will keep up
than passive immunization. Vaccines are cheaper to produce the herd immunity at a very high level.
than are antisera. The herd structure includes not only the hosts
It is important to realize at this stage that an individual is (population) belonging to the herd species but also the
immunized only against small doses of pathogenic agents or presence and distribution of alternative animal hosts and
toxins. There exists a “threshold” at which resistance fails. possible insect vectors as well as those environmental and
Beyond a certain dosage, which here again varies with the social factors that favour or inhibit the spread of infection
individual, his physiological state and the micro-organism, from host to host. The herd structure thus plays a decisive
the immune systems are overwhelmed and the disease role in the immunity status of the herd.
by R△J
 IMMUNIZING AGENTS 111
If the herd immunity is sufficiently high, the occurrence of Vaccine is an immuno-biological substance designed to
an epidemic is regarded as highly unlikely. If that high level produce specific protection against a given disease. It
of immunity is maintained and stepped up, by an on-going stimulates the production of protective antibody and other
immunization programme, to the point where the immune mechanisms. Vaccines may be prepared from live
susceptible persons are reduced to a small proportion of the modified organisms, inactivated or killed organisms,
population, it may lead (but not necessarily) to elimination extracted cellular fractions, toxoids or combination of these.
of the disease in due course. This has been achieved in such
diseases as diphtheria and poliomyelitis. In the case of a. Live vaccines
smallpox, however, it may be mentioned that it was not herd Live vaccines (e.g., BCG, measles, oral polio) are
immunity (although important as it was) that played a prepared from live or wild (generally attenuated) organisms.
crucial role in its eradication, but elimination of the source These organisms have been passed repeatedly in the
of infection, by surveillance and containment measures. laboratory in tissue culture or chick embryos and have lost
With the abolition of vaccination against smallpox, the herd their capacity to induce full-blown disease but retain their
immunity in the case of smallpox will naturally tend to immunogenicity. In general, live vaccines are more potent
decline with the passage of time. In the case of tetanus, immunizing agents than killed vaccines, the reasons being :
however, herd immunity does not protect the individual. (i) live organisms multiply in the host and the resulting
Studies have shown that it is neither possible nor antigenic dose is larger than what is injected, (ii) live
necessary to achieve 100 per cent herd immunity in a vaccines have all the major and minor antigenic
population to halt an epidemic or control disease, as for components, (iii) live vaccines engage certain tissues of the
example, eradication of smallpox and poliomyelitis. Just body, as for example, intestinal mucosa by the oral polio
vaccine, and (iv) there may be other mechanisms such as
how much less than 100 per cent is required above which
the persistence of latent virus.
the disease may no longer exist, is a crucial question.
Live vaccines should not be administered to persons with
The proportion of immune individuals in a population,
immune deficiency diseases or to persons whose immune
above which a disease may no longer persist, is herd
response may be suppressed because of leukaemia,
immunity threshold. It's value varies with the virulence of the
lymphoma or malignancy or because of therapy with
disease, the efficacy of the vaccine and the contact
corticosteroids, alkylating agents, antimetabolic agents, or
parameter for the population.
radiation (117, 118). Pregnancy is another contraindication

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Herd immunity may be determined by serological surveys unless the risk of infection exceeds the risk of harm to the
(serological epidemiology). foetus of some live vaccines.
When two live vaccines are required they should be given
IMMUNIZING AGENTS either simultaneously at different sites or with an interval of
The immunizing agents may be classified as vaccines, atleast 3 weeks. In the case of live vaccines, protection is
immunoglobulins and antisera. generally achieved with a single dose of vaccine. An
additional dose is given to ensure seroconversion, e.g., 95 to
Vaccines 98 per cent of recipient will respond to single dose of
Over the last century, vaccination has been the most measles vaccine. The second dose is given to ensure that
effective medical strategy to control infectious diseases. 100 per cent of persons are immune. The other exception is
Smallpox has been eradicated world-wide and poliomyelitis polio vaccine which needs three or more doses to be given
has been almost eradicated. Most viral and bacterial at spaced intervals to produce effective immunity. Live
diseases traditionally affecting children world-wide are now vaccines usually produce a durable immunity, but not
preventable by vaccines. Vaccination is estimated to save at always as long as that of the natural infection.
least 2-3 million lives every year. The vaccines currently Live vaccines must be properly stored to retain
used are as shown in Table 29. effectiveness. Serious failures of measles and polio
TABLE 29
Vaccines currently in use

Live attenuated Killed whole organism Toxoid/Protem Polysaccharide Glycoconjugate Recombinant

Tuberculosis (BCG) Typhoid Diphtheria Pneumococcus Hib HBV
Yellow fever Cholera Tetanus Meningococcus Pneumococcus Lyme disease
Polio (OPV) Plague Acellular Pertussis Hib MenACWY Cholera toxin B
Measles Pertussis Anthrax Typhoid (Vi) HPV
Mumps Influenza Influenza subunit COVID-19
Rubella Typhus
Typhoid Polio (IPV)
Varicella Rabies
Rotavirus JE
Cholera TBE
Cold-adapted influenza HAV
Rotavirus reassortants COVID-19
Zoster
BCG - Bacille Calmette-Guerin: HAV - hepatitis A virus; HBV - hepatitis B virus; Hib - Haemophilus influenzae type b; IPV inactivated
polio vaccine; JE - Japanese encephalitis; Men - meningococcus, OPV - oral polio vaccine; TBE - tick-borne encephalitis.
Source : (116)
by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

immunization have resulted from inadequate refrigeration circulating antibody. They are often more stable than live
prior to use. attenuated vaccines.
b. Inactivated or killed vaccines Some features of attenuated vaccines versus inactivated
(killed) vaccines are listed in Table 30 and some of the very
Inactivated vaccines are produced by growing virus or important developments in the field of vaccines are listed in
bacteria in culture media and then inactivating them with Table 31.
heat or chemicals (usually formalin), when injected into the
TABLE 30
body they stimulate active immunity. They are usually safe
Comparison of characteristics of killed and live vaccines
but generally, less efficacious than live vaccines. For example,
cholera vaccine offers only 50 per cent protection. The Killed Live
Characteristic
efficacy of 3 doses of pertussis vaccine is about 80 per cent in vaccine vaccine
the first three years, and almost “nil” 12 years after Number of doses Mutiple Single
immunization. Killed vaccines usually require a primary series
Need for adjuvant Yes No
of 2 or 3 doses of vaccine to produce an adequate antibody
response, and in most cases “booster” injections are required. Duration of immunity Shorter Longer
The duration of immunity following the use of inactivated Effectiveness of protection Lower Greater
vaccines varies from months to many years. Inactivated polio (more closely mimics natural infection)
vaccine has been quite an effective vaccine, the widespread Immunoglobulins produced IgG IgA and IgG
use of which in certain countries has led to the elimination of Mucosal immunity produced Poor Yes
the disease. Killed vaccines are usually administered by Cell-mediated immunity produced Poor Yes
subcutaneous or intramuscular route. Residual virulent virus in vaccine Possible No
Because the vaccine is inactivated, the infective agent Reversion to virulence No Possible
cannot grow in the vaccinated individual and therefore, can Excretion of vaccine virus and No Possible
not cause the disease, even in an immunodeficient person. transmission to non-immune contacts
Interference by other viruses in host No Possible
The only absolute contraindication to their administration Stability at room temperature High Low
is a severe local or general reaction to a previous dose.
Unlike live antigens, inactivited antigens are not affected by Source : (119)

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TABLE 31
Milestones in vaccination

1798 Smallpox vaccine 1993 Japanese encephalitis vaccine.

1885 Rabies vaccine 1995 Varicella vaccine licensed.
1897 Plague vaccine 1995 Hepatitis A vaccine licensed.
1917 Cholera vaccine 1996 Acellular pertussis vaccine (DTaP) licensed for use
1917 Typhoid vaccine (parenteral) in young infants.
1923 Diphtheria toxoid 2000 Pneumococcal conjugate vaccine (Prevnar)
1926 Pertussis vaccine recommended for all young children
1927 Tuberculosis (BCG) 2003 First live attenuated influenza vaccine licensed (FIuMist)
1927 Tetanus toxoid for use in 5 to 49 year old persons.
1935 Yellow fever vaccine 2003 First Adult Immunization Schedule introduced.
1940s DTP 2004 Inactivated influenza vaccine recommended for all
1945 The first influenza vaccines children 6 to 23 months of age.
1955 Inactivated polio vaccine (IPV). 2004 Pediarix, a vaccine that combines the DTaP, IPV, and
1955 Tetanus and diphtheria toxoids adsorbed (adult use, Td) Hep B vaccines, into one shot, is approved.
1961 Monovalent oral polio vaccine 2005 Boostrix and Adacel, Tdap vaccines, are approved
1963 Trivalent oral polio vaccine (OPV) for teens.
1963 The first measles vaccine 2005 Menatra, a new menigococcal vaccine is approved for
1967 Mumps vaccine people between the age of 11 to 55 years.
1969 Rubella vaccine 2006 Rota Teq is a new rotavirus vaccine from Merck.
1970 Anthrax vaccine ProQuad is a new vaccine that combines
1971 Measles, Mumps, Rubella (MMR) vaccine licensed. the MMR and Varivax vaccines for measles, mumps,
1978 Fluzone, the current flu vaccine. rubella, and chicken pox into a single shot.
1980 Smallpox declared eradicated from the world 2006 Gardasil, the first HPV vaccine is approved.
1981 Meningococcal polysaccharide vaccine, 2007 A booster dose of Varivax, the chickenpox vaccine,
groups A, C, Y, W135 combined (Menomune) is recommended for all children.
1982 Hepatitis B vaccine 2007 The recommended age for Flumist, the nasal spray
1983 Pneumococcal vaccine, 23 valent flu vaccine, was lowered to two years.
1988 Worldwide Polio Eradication Initiative launched; 2008 Rotarix, a two dose rotavirus vaccine is approved
supported by Rotary International, CDC and others. 2009 Influenza-A (HjNJ vaccine approved.
1990 The Vaccine Adverse Reporting System (VAERS), a national 2011 FDA approved the first vaccine (Menactra) to prevent
programme monitoring the safety of vaccines established. meningococcal disease in infants and toddlers.
1990 Haemophilus influenzae type B (Hib) polysaccharide FDA approved Boostrix Tdap (Glaxo Smith Klin) to
conjugate vaccine licensed for infants. prevent tetanus, diphtheria and pertussis in older people
1990 Typhoid vaccine (oral) HPV vaccine for adolescent boys.
1991 Hepatitis B vaccine recommended for all infants. 2012 Approved quadrivalent formulation of fluarix.
1991 Acellular pertussis vaccine (DTaP) licensed for use in 2013 Inactivated and intranasal influenza vaccine-quadrivalent
older children aged 15 months to six years old. 2020 COVID-19
Source : (120)
by R△J
 IMMUNIZING AGENTS

c. Subunit vaccines (116) bacterial components from becoming a target of the host
A vaccine can be made of single or multiple antigenic immune response. Nevertheless, antibodies to bacterial
components of a microorganism that are capable of surface polysaccharides can clear the bacteria from the host
stimulating a specific immune response sufficient to protect by different mechanisms, such as complement-mediated
killing and opsonophagocytosis. Hence, stimulation of an
from the relevant pathogen infection or from the clinical
manifestation of the disease. Depending on the molecular antibody response against the surface polysaccharide of
pathogenic bacteria is a strategy for the development of
composition of the purified antigen used to prepare the
vaccines against capsulated bacteria. The chemical structure
vaccine, and on the techniques applied to obtain the final
or capsular polysaccharides varies not only between bacteria
material used as a vaccine, different types of subunit
of different species but also between different strains within
vaccines can be defined.
a single species, which are usually differentiated and typed
1. Toxoids based on their capsular polysaccharides. As a consequence,
a limitation of polysaccharide-based vaccine is that the
Certain organisms produce exotoxins, e.g., diphtheria immune responses they elicit are often serotype specific. In
and tetanus bacilli. The toxins produced by these organisms addition to S. pneumoniae, for which a vaccine against
are detoxicated and used in the preparation of vaccines. The 23 serotypes is available, polysaccharide-based vaccines
antibodies produced neutralize the toxic moiety produced have been developed for MenACWY, Hib, and Salmonella
during infection, rather than act upon the organisms. In typhimurium (116).
general, toxoid preparations are highly efficacious and safe
immunizing agents. 5. Conjugated vaccines
2. Protein vaccines Children under two years of age do not respond well to
antigens, such as polysaccharides, which produce antibodies
In case, immunization with a single protein or a via a T-cell independent mechanism. If these polysaccharide
combination of proteins from a pathogen is sufficient to antigens are chemically linked (conjugated) to a protein that
stimulate a protective immune response against that T-cells recognize, then these conjugate vaccines can elicit
particular microorganism, the approach of a protein-based strong immune responses and immune memory in young
vaccine is appropriate. Proteins can be purified from in-vitro children. Similar to the polysaccharide-based vaccines, the
cultures of a pathogenic microorganism. The resulting

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conjugate vaccines are also sero-type specific, and,
vaccine preparations contain different amounts of therefore, multivalent formulations are required to achieve
contaminants depending on the efficiency of the purification protection against multiple serotypes. Examples are
process. Licensed acellular pertussis vaccines currently S. pneumococcal and meningococcal vaccines (115).
available contain from two to four different proteins purified
from B. pertussis and are able to confer protection against d. Combinations
whooping cough comparable to that obtained with the If more than one kind of immunizing agent is included in
whole cell vaccine. One of the most widely used subunit the vaccine, it is called a mixed or combined vaccine. The
protein vaccines is the influenza vaccine composed of aim of combined vaccines is to simplify administration,
haemagglutinin (HA) and neuraminidase (NA) purified from reduce costs, minimize the number of contacts of the patient
the inactivated influenza virus. with the health system, reducing the storage cost, improving
timelines of vaccination, and facilitating the addition of new
3. Recombinant protein vaccines vaccine into immunization programme. No evidence exists
Development of the recombinant deoxyribonucleic acid that the administration of several antigens in combined
(DNA) technology has made possible the expression of vaccines increases the burden on the immune system which
protective protein antigens in heterologous expression is capable of responding to millions of antigens at a time.
systems such as E. coli, yeast, mammalian cells, or Combining antigens usually does not increase the risk of
baculovirus. This technology avoids the problems related to adverse reactions and can infact lead to an overall reduction
growing and manipulating large amounts of a pathogen in adverse reactions (115). The following are some of the
from which the antigen is purified. Moreover, recombinant well-known combinations :
proteins are generally better purified from cultured
DPT (Diphtheria-pertussis-tetanus)
microorganisms resulting in cleaner vaccine preparations
with a better safety profile. A drawback of a clean vaccine DT (Diphtheria-tetanus)
preparation containing pure recombinant protein(s) is their DP (Diphtheria-pertussis)
reduced immunogenicity that may require the addition of an DPT and typhoid vaccine
adjuvant to achieve enhanced efficacy. For example, the
hepatitis B vaccine is made by inserting a segment of the MMR (Measles, mumps and rubella)
hepatitis B virus gene into a yeast cell. The modified yeast DPTP (DPT plus inactivated polio)
cell produces large amounts of hepatitis B surface antigen, Hepatitis A, and B
which is purified and harvested and used to produce the Hepatitis A, and typhoid.
vaccine. The recombinant hepatitis B vaccine is identical to
the natural hepatitis B surface antigen, but does not contain DTwP (Diphtheria, tetanus, whole-cell pertussis)
virus DNA and is unable to produce infection. DPT-Hep B-Hib (Diphtheria, pertussis, tetanus, hepatitis
B and haemophilus influenzae type B).
4. Polysaccharide-based vaccines The term “polyvalent” is applied to vaccines (e.g., polio,
The surface of many pathogenic bacteria is covered by a influenza vaccines) which are prepared from two or more
capsular shell that is mainly assembled from polymeric strains of the same species. The term au^ or
glycans. This extensive polysaccharide coat entirely shields “autogenous” vaccine is applied when the organism in the
the bacteria outer membrane, preventing other surface vaccine is obtained from the same patient.
by R△J
114 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

OTHER COMPONENTS IN VACCINES (EXCIPIENTS) Different types of vaccine presentations (116A)

1. Single-dose vials (SDVs)
Adjuvant
A single-dose vial (SDV) contains one dose and is used
Sometimes a substance is added to a vaccine to enhance one time for one patient. Never combined leftover
the immune response by degree and/or duration, making it vaccine from one SDV with another to obtain a dose.
possible to reduce the amount of immunogen per dose or
2. Manufacturer-filled syringes
the total number of doses needed to achieve immunity. The
commonly used adjuvant are aluminium salts (aluminium A manufacturer-filled syringe (MFS) is prepared with a
hydroxide, aluminium phosphate or potassium aluminium single dose of vaccine and sealed under sterile conditions
sulfate) which primarily enhance the immune response to by the manufacturer. An MFS does not contain a
proteins. They have been shown to be safe over several preservative to help prevent the growth of microorganisms.
decades of use. Rarely, they may cause injection An MFS is intended for one patient and one injection. Once
site reactions, including subcutaneous nodules, sterile the sterile seal has been broken, the vaccine should be used
abscess, granulomatous inflammation or contact or discarded by the end of the workday.
hypersensitivity (115). 3. Multidose vials
Table 32 shows the approved human vaccine adjuvants A multidose vial (MDV) contains more than one dose of
in use, their class, components and the vaccines in which vaccine. MDVs canbe punctured more than once (using
they are used (116). sterile technique) because they typically contain a
preservative to help prevent the growth of microorganisms.
Antibiotics Only the number of doses indicated in the manufacturer’s
package insert should be withdrawn from the vial.
Antibiotics are used during the manufacturing phase to
prevent bacterial contamination of the tissue culture cells in Routes of administration
which the viruses are grown. For example, MMR vaccine and
IPV each contains less than 25 micrograms of neomycin per The routes of administration of vaccine varies to
dose (less than 0.000025g). Persons who are known to be maximise effectiveness of the vaccine. The routes of
allergic to neomycin should be closely observed after administration of vaccine are as follows :
vaccination so that any allergic reaction can be treated at 1. Intramuscular (IM) injection administers the vaccine

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once (115). into the muscle mass. Vaccine containing adjuvants should
be injected IM to reduce adverse local effects.
Preservatives 2. Subcutaneous (SC) injection administers the vaccine
These are chemicals (e.g. thiomersal, formaldehyde) into the subcutaneous layer above the muscle and below the
added to killed or subunit vaccines in order to inactivate skin.
viruses, detoxify bacterial toxins, and to prevent serious 3. Intradermal (ID) injection administers the vaccine in
secondary infections as a result of bacterial or fungal the topmost layer of the skin. BCG is the only vaccine with
contamination (115). this route of administration. Intradermal injection of BCG
vaccine reduces the risk of neurovascular injury.
Stabilizers
4. Oral administration of vaccine makes immunization
To confirm product quality or stability, compounds may easier by eliminating the need for a needle and syringe.
be added to vaccines for a variety of manufacture-related
issues: controlling acidity (pH); stabilizing antigens through 5. Intranasal spray application of a vaccine offers a needle
necessary steps in the manufacturing process, such as freeze free approach through the nasal mucosa of the vaccine.
drying; and preventing antigens from adhering to the sides The manufacturer’s usually recommend the route of
of glass vials with a resultant loss in immunogenicity. administration that limits best the adverse reactions of the
Examples of such additives include potassium or sodium respective vaccine. The recommended routes of different
salts, lactose, human serum albumin and a variety of animal vaccines are as shown on Fig. 20. The correct angle of the
proteins, such as gelatine and bovine serum albumin (115). needle while giving injection is shown in Fig. 21.

TABLE 32
Human vaccine adjuvants

Name Class Components Vaccine

Alum Mineral salts Aluminium phosphate, aluminium Diphtheria, tetanus, pneumococcus,
hydroxide HAV, HBV, anthrax, tick-borne
encephalitis, MenC, HPV
MF59 Oil-in-water emulsion Squalene, Tween 80, Span 85 Seasonal and pandemic influenza
AS03 Oil-in-water emulsion Squalene, Tween 80, a-tocopherol Pandemic influenza
AF03 Oil-in-water emulsion Squalene, Montane 80, Eumulgin Bl PH Pandemic influenza
Virosomes Liposomes Phospholipids, cholesterol, HA Seasonal influenza, HAV
AS04 Alum-adsorbed TLR4 agonist Aluminium hydroxide, MPL HBV, HPV
RC-529 Alum-adsorbed TLR4 agonist Aluminium hydroxide, synthetic MPL HBV
HAV - hepatitis A virus; HBV - hepatitis B virus; HPV - human papillomavirus; Men - meningococcus, MPL - monophosphoryl lipid A;
TLR - toll-like receptor
Source : (116)

by R△J
 IMMUNIZING AGENTS

Intranasal Intramuscular
Subcutaneous 90-degree angle
spray 45-degree angle
Live
attenuated
influenza
vaccine

Epidermis

Intradermal Dermis
10 to 15 degree
angle Sub­
cutaneous
tissue
Muscle

FIG. 20 FIG. 21
Recommended route of administration of vaccines Technique of giving vaccine injection
Source : (116A) Source : (116A)

peptides is considerably weaker than that induced by intact

Order of injections (116A) protein.
Frequently children and adults receive 2 or more (5) Development of edible vaccines whereby transgenic

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injections at an immunization encounter. Some vaccines are plants synthesizing antigens from pathogenic viruses may
associated with more pain than others. Because procedure provide new cost-effective ways of delivering vaccines.
pain can increase with each injection, the order of the
vaccines administered may effect the overall pain response. (6) Use of naked DNA vaccines-potentially simple,
Some vaccines cause a painful or stinging sensation; cheap, and safe-in which recombinant plasmids carrying the
examples include measles, mumps and rubella (MMR) and gene for the protein of interest are injected into hosts and
human papillomavirus (HPV) vaccines. Injecting the most the DNA produces the immunizing protein.
painful vaccine (e.g. MMR, PCV13 or HPV) last when (7) Administration of vaccine locally to stimulate
multiple injections are being administered can decrease the antibody at the portal of entry (such as aerosol vaccines for
pain associated with the injections. respiratory disease viruses).
FUTURE PROSPECTS (119) Immunoglobulins
Molecular biology and modern technologies are The human immunoglobulin system is composed of
combining to devise novel approaches to vaccine 5 major classes (IgG, IgM, IgA, IgD and IgE) and sub-classes
development. Many of these approaches avoid the within them. The various classes and sub-classes of
incorporation of viral nucleic acid in the final product, immunoglobulins represent different functional groups that
improving vaccine safety. Examples of what is ongoing in are required to meet different types of antigenic challenges.
this field can be listed as follows. The ultimate success of All antibodies are immunoglobulins, but it is still an
these new approaches remains to be determined. open question whether all immunoglobulins are
(1) Use of recombinant DNA techniques to insert the antibodies (108). The WHO recommends that the term
gene coding for the protein of interest into the genome of an “gamma globulin” should not be used as a synonym for
avirulent virus that can be administered as the vaccine (such “immunoglobulin” (121).
as vaccinia virus). IgG : IgG is the major immunoglobulin of serum,
(2) Including in the vaccine only those subviral comprising about 80 per cent of the total serum
components needed to stimulate protective antibody, thus immunoglobulins. Because of its relatively smaller molecular
minimizing the occurrence of adverse reactions to the weight (150,000), IgG can diffuse into the interstitial fluid.
vaccine. In other words, IgG is largely extravascular. IgG is the only
class of IgGs which is transported across the placenta.
(3) Use of purified proteins isolated from purified virus or Antibodies to gram-positive pyogenic bacteria, anti-viral
synthesized from cloned genes (a recombinant hepatitis B and anti-toxic antibodies are found exclusively among IgG
virus vaccine contains viral proteins synthesized in yeast globulins. Its half life is about 21 days. IgM : It accounts for
cells). Expression of cloned gene(s) sometimes results in about 6 per cent of normal serum immunoglobulins. It
formation of empty virus-like particles (VLPs). represents antibody that is promptly formed with exposure
(4) Use of synthetic peptides that correspond to antigenic to antigen (Fig. 19). Its presence may be indicative of recent
determinants on a viral protein, thus avoiding any possibility infection. IgM antibody has high agglutinating and
of reversion to virulence since no viral nucleic acid would be complement-fixing ability. Its half life is about 7 days. It can
present-although the immune response induced by synthetic be produced by a foetus undergoing an infection:
by R△J
U6 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

IgA : Constitutes about 13 per cent of the total serum administration has also become available (122). The
immunoglobulins. Antibody activity to a wide range of viral intramuscular injections are painful for some patients but can
and bacterial antigens has been reported in this class. IgA is be better tolerated if procaine 1 per cent is mixed at 1 part in
found relatively in large quantities in body secretions, e.g., 10 with the immunoglobulin (123). Doses larger than 5 ml must
saliva, milk, colostrum, tears, bronchial secretions, nasal be divided and injected into 4-6 intragluteal sites through a 18
mucosa, prostatic fluid, vaginal secretions and mucus or 20 gauge needle because the preparation is viscous.
secretions of the small intestine; it provides the primary Peak blood levels are reached in 2 days after
defence mechanism at the mucos membranes against local intramuscular injection. The half-life is 20-35 days.
infection. The half-life of IgA is approximately 6-8 days. Generally, immunoglobulins should not be given shortly
IgE : The serum level of IgE is <0.0005 miligrams per ml. before or after active immunization to avoid inhibiting the
Half-life is 2 days. IgE is concentrated in submucous tissues. immune response; tetanus and hepatitis B immunization are
It is the major antibody responsible for immediate allergic exceptions to this rule (122).
anaphylactic reactions. In persons with such antibody-
mediated allergic hypersensitivity, IgE concentration is The advantages of immunoglobulins are : (a) freedom
greatly increased, and IgE may appear in external secretions. from hepatitis B, (b) concentration of the antibodies into a
Serum IgE is also typically increased during helminth small volume for intramuscular use, and (c) stable antibody
infestations. IgD : IgD acts as an antigen receptor when content, if properly stored.
present on the surface of certain B lymphocytes. In serum it Adverse reactions to immunoglobulin can be local or
is present only in trace amount (<0.003 mg per ml). Its half­ systemic. Local reactions (e.g., pain, sterile abscesses) are
life is 2 days. relatively common when large volumes are injected
intramuscularly. Systemic reactions can be rapid or late.
Immunoglobulin preparations Rapid reactions occur during or within minutes of
Two types of immunoglobulin preparations are available administration, and are anaphylactic in type (flushing, flank
for passive immunization. These are (a) Normal human pain, rigor, dyspnoea, and signs of shock). Late reactions
immunoglobulin and (b) Specific (hyper-immune) human may occur within hours or days, are usually less severe, and
immunoglobulin. These are used in the prophylaxis of viral may include urticaria, arthralgia, pyrexia or diarrhoea.
and bacterial infections, and in replacement of antibodies in Systemic reactions are less common occurring once in every

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immunodeficient patients. 500-1000 injections. They are more common with
intravenous administration. Systemic reactions can
a. Normal human Ig be prevented by giving hydrocortisone before the
Normal human Ig is an antibody-rich fraction (Cohn injection (122).
fraction II), obtained from a pool of at least 1000 donors. The uses of human immunoglobulin are listed in
The WHO has laid down definite standards for its Table 33. Use is recommended only where the efficacy has
preparation. For example, the preparation should contain at been proved; where efficacy has not been established
least 90 per cent intact IgG; it should be as free as possible conclusively, use is listed as optional. The target populations
from IgG aggregates; all IgG sub-classes should be present; listed in the table have been well-defined in
there should be a low IgA concentration; the level of controlled studies, and use should be limited to these
antibody against at least two bacterial species and two individuals (122).
viruses should be ascertained etc. (122).
Normal human Ig is used to prevent measles in highly Antisera or antitoxins
susceptible individuals and to provide temporary protection The term antiserum is applied to materials prepared in
(upto 12 weeks) against hepatitis A infection for travellers to animals. Originally passive immunization was achieved by
endemic areas and to control institutional & household the administration of antisera or antitoxins prepared from
outbreaks of hepatitis A infection. non-human sources such as horses. Since human
Live vaccines should not normally be given for 12 weeks immunoglobulin preparations exist only for a small number
after an injection of normal human Ig, and if a live vaccine of diseases, antitoxins prepared from non-human sources
has already been given. NHIg injection should be deferred (against tetanus, diphtheria, botulism, gas gangrene and
for 2 weeks. snake bite) are still the mainstay of passive immunization.
Administration of antisera may occasionally give rise to
b. Specific human Ig serum sickness and anaphylactic shock due to abnormal
sensitivity of the recipient. The current trend is in favour of
The specific (hyperimmune) human Ig should contain at
least 5 times the antibody potential of the standard using immunoglobulins wherever possible. The uses of
antisera are listed in Table 34.
preparation per unit volume. These preparations are made
from the plasma of patients who have recently recovered
from an infection or are obtained from individuals who have THE COLD CHAIN •?
been immunized against a specific infection. They therefore \^The “cold chain” is a system of storage and transport of
have a high antibody content against an individual infection vaccines at low temperature from the manufacturer to the
and provide immediate protection e.g., specific human Igs actual vaccination site) The cold chain system is necessary
are used for chickenpox prophylaxis of highly susceptible because vaccine failure may occur due to failure to store and
individuals and for post-exposure prophylaxis of hepatitis B, transport under strict temperature controls. This is of
and rabies and for tetanus prophylaxis in the wounded. concern in view of the fairly frequent reports of vaccine-
Immunoglobulin is administered by intramuscular preventable disease occurrence in populations thought to
injection. Immunoglobulin suitable for intravenous have been well immunized. In other words - the success of

by R△J
 MJ in Ap?
*IMMUNOGLOBULINS
Gc© MW TABLE 33
Appropriate uses of human immunoglobulin in the prevention and treatment of disease
Agent/
Target population Preparation^ Dosec Status
Condition
Hepatitis A Family contacts IG (0.02 ml/kg of body weight) Recommended
Institutional outbreaks (3.2mg/kg of body weight) for prevention
Travellers exposed to IG 0 02-0.05 ml/kg of body weight
unhygienic conditions in (3.2-8.0 mg/kg of body weight)
tropical or developing every 4 months
countries
Hepatitis C Percutaneous or mucosal IG 0.05 ml/kg of body weight Optional for
exposure (8 mg/kg of body weight) prevention
Hepatitis B Percutaneous or mucosal HBIG 0.05-0.07 ml/kg of body weight Recommended for
exposure (8-11 mg/kg of body weight) prevention
Repeat in one month
Newborns of mothers with HBIG 0.05ml (8 mg) at birth, 3, Recommended for
HBsAg and 6 months prevention
Sexual contacts of acute HBIG 0.05 ml/kg of body weight Optional for
hepatitis B patients (8 mg/kg of body weight) prevention
Repeat after one month
Rubella Women exposed during IG 20 ml Optional for
early pregnancy prevention
Varicella-zoster Immuno-suppressed contacts VZIGd 15-25 units/kg body weight; Recommended for
of acute cases or minimum 125 units prevention
newborn contacts
Measles (rubeola) Infants less than 1 year old or IG 0.25 ml/kg of body weight Recommended for
immuno-suppressed contacts or 0 5 ml/kg of body weight prevention
of acute cases exposed if immuno-suppressed

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less than 6 days previously
Rabies Subjects exposed to rabid RIG 20 IU/kg of body weight Recommended for
animals prevention
Tetanus Following significant TIG 250 units for prophylaxis Recommended
exposure of unimmunized 3000-6000 units for therapy for prevention
or incompletely immunized or treatment
person or immediately on
diagnosis of disease
Rh isoimmunization Rh (D)-negative mother on RhIG 1 vial (200-300 pg) per 15 ml Recommended for
delivery of Rh-positive infant, of Rh (T) blood exposure prevention
or after uncompleted
pregnancy with Rh-positive
father, or after transfusion of
Rh-positive blood to
Rh-negative mother
a IG = immune globulin (human); HBIG = hepatitis B immune globulin; VZ1G = varicella-zoster immune globulin;
RIG = rabies immune globulin; TIG = tetanus immune globulin; RhIG = rhesus factor immune globulin.
b Hyperimmune immunoglobulins have also been used in prophylaxis of mumps and prophylaxis and treatment of pertussis and
diphtheria; there are no conclusive data available, and no recommendations can be given.
c Dose based on intramuscular administration of 16.5% solution
d Of limited availability at the present time

TABLE 34
Passive immunization procedures with antisera

Disease Passive immunization (ANTISERA)

1 Diphtheria A dose of 500-1,000 of IU of diphtheria antitoxin is given intramuscularly to susceptible contacts
immediately after exposure. Protection does not last more than 2-3 weeks.
2. Tetanus The usual prophylactic dose is 1,500 units of horse A.T.S. given subcutaneously or intramuscularly, soon
after injury.
3. Gas gangrene A polyvalent antitoxin is used. A patient who has sustained a wound possibly contaminated with spores of
gas gangrene should receive a dose of 10,000 IU of Cl. perfringens. (Cl. welchii) antitoxin, 5,000 units of
Cl. septicum antitoxin and 10,000 units of Cl. oedematiens antitoxin, intramuscularly, or in urgent cases
intravenously.
4. Rabies Antirabies serum in a dose of 40 IU per kg. of body weight should be given intramuscularly within 72 hours
and preferably within 24 hours of exposure. A part of the antiserum is applied locally to the wound.
5. Botulism When botulism is suspected, 10,000 units of polyvalent antitoxin is recommended every 3 to 4 hours

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118 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

national immunization programme is highly dependant on - Hepatitis B (Hep B)

supply chain system for delivery of vaccines and equipment, - Hib (liquid)
with a functional system that meets 6 rights of supply chain
- The right vaccine in the right quantity at the right place at - Human papillomavirus (HPV)
the right time in the right condition (no temperature breaks - Inactivated poliovirus (IPV)
in cold chain) and at the right cost (124). - Influenza
Temperature requirements for vaccines (125) - Pneumococcal
Vaccines are sensitive biological products. Some vaccines - Tetanus, DT, Td
are sensitive to freezing, some to heat and others to light. - Rotavirus (liquid and freeze-dried)
Vaccine potency, meaning its ability to adequately protect
the vaccinated patient, can diminish when the vaccine is Sensitivity to light (125)
exposed to inappropriate temperatures. Once lost, vaccine Some vaccines are very sensitive to light and lose
potency cannot be regained. To maintain quality, vaccines potency when exposed to it. Such vaccines should always be
must be protected from temperature extremes. Vaccine protected against sunlight and strong artificial light. Vaccines
quality is maintained using a cold chain that meets specific sensitive to light are BCG, measles, measles-rubella,
temperature requirements. It is essential that all those who measles-mumps-rubella and rubella. These vaccine
handle vaccines and diluents know the temperature are supplied in dark glass vials that give them some
sensitivities and the recommended storage temperature for protection; but they should be kept in their secondary
all the vaccines in the national schedule. packaging for as long as possible during storage and
transportation.
Sensitivity to heat and freezing
At the health facility level (usually health centres and
Fig. 22 shows the relative heat sensitivity of vaccines. health posts), health workers can adequately protect
These,vaccines are grouped into six categories. Within each vaccines by doing the following : (a) Keep vaccines in
of these six categories, the vaccines are arranged in appropriate vaccine refrigeration equipments; (b) Use a
alphabetical order, not in order of sensitivity to heat, within temperature monitoring device to ensure temperatures
the group. The most heat sensitive vaccines are in group A remain between +2°C and +8°C; (c) Transport vaccines to

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and the least heat sensitive vaccines are in group F. immunization sessions in a vaccine carrier, correctly packed,
The heat stability information shown for freeze-dried using coolant packs that have been properly prepared; and
vaccines applies only to unopened vials; most freeze-dried (d) During immunization sessions, fit a foam pad (if
vaccines rapidly lose potency after reconstitution. In available) at the top of the vaccine carrier.
addition, it is important to keep opened multi-dose vaccine At the health facility, one person must have overall
vials that do not contain preservative - whether lyophilized responsibility for managing the vaccine cold chain. A second
or liquid - cooled at temperature between +2°C and +8°C person can fill in when the primary person is absent. Their
during the immunization session, or used within 4 hours responsibilities should include : (a) checking and recording
after opening, whichever comes first. vaccine temperatures twice daily; typically in the morning
Vaccines that are sensitive to freezing and should be and at the end of the session or day; (b) properly storing
protected from sub-zero temperature are (125) : vaccines, diluents and water packs; and (c) handling
preventive maintenance of the cold chain equipment.
- Cholera
All health workers in a facility should know how to
- DTaP-hepatitis B-Hib-IPV (hexavalent)
monitor the cold chain and what to do if temperature is out
- DTwP or DTwP-hepatitis B-Hib (pentavalent) of range.

Most sensitive to heat ► Least sensitive to heat

Group F
Hepatitis B
Hib (freeze-dried)
Meningoccal A
Pneumococcal

FIG. 22
Vaccine heat sensitivity
Source : (125)

by R△J
 COLD CHAIN

Cold chain equipment (126) 3. Deep freezer (DF)

The cold chain equipment used in Universal The Deep freezer is an equipment, which operates on a
Immunization Programme are classified as follows : vapour compression system similar to any conventional type
of refrigerator operating on 220 volts A.C. mains supply.
Cold Chain Equipment However DF has top opening lid to prevent loss of cold air
during door opening.
The cabinet temperature is maintained between -15° to
-25°C. This is used for storing of OPV vaccine for 3 months
V v (district level and above only) and also for freezing of ice packs
Storage Transportation (at sub-district level only). Unlike the ice-lined refrigerator
(ILR), the DF has got little or limited hold-over time which is
dependent on the number of frozen ice packs in it and the
frequency of opening. These are available in different sizes.
The DF which is used for storing vaccines should not be
used for preparation of icepacks, as it may increase the
cabinet temperature and can be potentially harmful to the
vaccines (OPV). However adequate frozen icepacks can be
kept permanently inside the vaccine storing DF for
increasing the hold-over time.

4. Ice lined refrigerator (ILR)

One of the most important link in the cold chain is ice
lined refrigerator (ILR). This is an equipment which operates
on a vapour compression system similar to any conventional
type of refrigerator operating on 220 volts A.C. mains
supply. ILRs are to maintain a cabinet temperature between
+2°C to + 8°C and are used to store vaccines at district and

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sub-district level. These type of refrigerators are top opening
because they can hold the cold air inside better than a
Electrical Cold Chain Equipment refrigerator with a front opening. It can keep vaccine safe
There are equipments of different capacity for storage of with minimum 8 hours continuous electricity supply in a
vaccines at different levels, which are dependant on electric 24-hour period. The ILRs are categorized on the basis of
supply to maintain the recommended temperature. vaccine storage capacity. These are available in different
sizes. Usually the larger ILR is supplied to district
1. Walk-in-freezers (WIF)
headquarters and smaller ILR to PHC headquarters, based
The Walk-in-freezer is a pre-fabricated modular on the size and population.
polyurethane foam (PUF) insulated panel assembled cold
Inside the ILR there is a lining of water containers (ice
room with two identical refrigeration units and a standby
packs or tubes) fitted all around the walls and held in place
generator set to provide uninterruprted power supply. The
generator set starts automatically as soon as the power cuts by a frame.
off. It maintains a temperature between - 15°C to - 25°C. When the refrigerator is functioning the water in the
WIF are usually installed at national, state and regional containers freezes and cools the cabinet. When the
vaccine stores. It is used for bulk storage of OPV vaccine and electricity supply fails, then the ice lining maintains the
for preparation of frozen ice packs for vaccine inside temperature of the refrigerator at a safe level for
transportation. vaccines. Therefore, the temperature is maintained in ILR
for much longer duration than in the deep freezers and
2. Walk-in-coolers (WIC) domestic refrigerator. Thus ILR is an ideal option for safe
The Walk-in-cooler is a pre-fabricated modular storage of vaccines.
polyurethane (PUF) insulated panel assembled cold room. Based on the temperature zone, inside of the ILR can be
They maintain a temperature of +2°C to +8°C. In India, divided into 2 parts, upper part and lower part. In most of
under UIP usually WIC with capacity of 16.5, 32 and the ILR models, the lower part is cooler compared to the
40 Cubic meter are in use. upper part, as the cooler air is heavier and settles down at
These are used for storage of large quantities of all UIP the bottom of ILR. Hence upper part is preferred location for
vaccines like BCG, hepatitis B, DPT, pentavalent, IPV, storing the freeze sensitive vaccines.
measles and TT. They have two identical cooling units and a All the vaccines should be kept in the basket provided
standby generator with automatic start and stop function. with the ILR. Vaccines like OPV, BCG, measles, and JE (in
These Walk-in-coolers are installed at government the sub-district stores, OPV is kept in ILR, unlike higher level
medical store depots, state and regional vaccine stores. The vaccine stores, where it is kept in DF) can be kept at bottom
WICs have been installed in some district vaccine stores of the basket while DPT, TT, hep B, IPV and pentavalent
based on the target beneficiary and requirement. vaccines and diluents are kept in upper part of the basket.
WIC and WIF come with continuous temperature These vaccines should never be kept directly on the floor of
recorder and alarm system. Once the temperature of WIC/ the refrigerator as they can freeze and get damaged. In case
WIF exceeds the recommended storage temperature the basket is not available, two layers of empty ice-packs can be
alarm system gives alarm loudly. laid flat on the bottom of the ILR.

by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Hold-over time of the equipment (126) chain. Return the unused vaccine vials from session site to
In the event of power failure, hold-over time is defined as the PHC on the same day in the cold chain through
the “time taken by the equipment to raise the inside cabinet alternative vaccine delivery. Keep the box labeled
temperature from its temperature at the time of power cut, to “returned unused” in the ILR for all unused vaccines that
maximum temperature limit of its recommended range.” For can be used in the subsequent session, but discard vaccines
example, in case of ILR if the cabinet temperature is +4°C that have been returned unopened more than three
at the time of power-cut, then the time taken to reach +8°C times (127).
from +4°C will be hold-over time for that ILR.
6. Cold boxes
Hold-over time depends on the following factors :
(a) Ambient temperature: More the ambient temperature less Cold boxes are supplied to all peripheral centres. These
will be the hold-over time; (b) Frequency of opening of lid are used mainly for transportation of the vaccines. Before
and use of basket; (c) Quantity of vaccines kept inside with the vaccines are placed in the cold boxes, fully frozen ice
adequate space between the containers (Equipment empty/ packs are placed at the bottom and sides. The vaccines are
loaded); and (d) Condition of ice-pack lining (Frozen/ first kept in cartons or polythene bags. The vials of DPT,
partially frozen/melted). DT, TT, vaccines and diluents should not be placed in direct
'Contact with the frozen ice packs.
5. Domestic refrigerator (front load refrigerator)
7. Vaccine carriers
Domestic refrigerators can also maintain the cabinet
temperature between + 2°C to +8°C, but the hold-over time Vaccine carriers are used to carry small quantities of
and capacity to store vaccines/freeze icepacks is limited. vaccines (16-20 vials) for the out of reach sessions. 4 fully
They can be used for storage of vaccine at private clinics frozen ice-packs are used for lining the sides, and vials of
and nursing homes, provided continuous power supply is DPT, DT, TT and diluents should not be placed in direct
ensured. contact with frozen ice-packs. The carriers should be closed
tightly.
Load a domestic refrigerator as following : (a) Freeze and
store ice-packs in the freezer compartment, they should be 8. Day carriers
kept vertically to avoid leaking with a space of at least 2 mm.
Ice-packs should be taken out from the left; (b) All the Day carriers are used to carry small quantities of

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vaccines and diluents are stored in the refrigerator vaccines (6-8 vials) to a nearby session. Two fully frozen
compartment. Arrange the boxes of vaccine in stacks so air packs are to be used. It is used only for few hours period.
can pass between them. Placement of vaccines in the
refrigerator with freezer on top is as follows: measles, BCG, 9. Ice packs
rota virus vaccine and OPV on the top shelf. DPT, The ice packs contain water and no salt should be added
pentavalent vaccine, TT, IPV, hepatitis B, and JE vaccine on to it. The water should be filled upto the level marked on
the middle shelf and diluents next to vaccine with which they the side. If there is any leakage such ice-packs should be
are supplied; (c) Keep ice-packs filled with water on the discarded.
bottom shelf and in the door of the refrigerator. They help to
The risk of cold chain failure is greatest at sub-centre
maintain temperature in case of power-cut; and (d) Closer
and village level. For this reason, vaccines are not stored at
expiry date vaccines should be kept in front.
the sub-centre level and must be supplied on the day of
A dial thermometer should be kept in the ILR and use.
temperature recorded twice a day. At the time of defrosting
the vaccines are shifted to the cold boxes containing Solar cold chain equipment (126)
required number of frozen ice packs. In case of equipment Solar systems used in UIP are mainly of two types.
failure or electric supply failure, vaccines should be
transferred to ice boxes and then to alternate vaccine 1. Solar refrigerators battery drive.
storage. 2. Solar refrigerators direct drive.
There are some DOs and DONTs for the use of ILR/
freezer. DOs: keep the equipment in cool room away from 1. Solar refrigerator battery drive
direct sunlight and at least 10 cms away from the wall; keep A solar refrigerator operates on the same principle as
the equipment levelled; fix the equipment through voltage normal compression refrigerator but incorporates low voltage
stabilizer; keep vaccines neatly with space between the (12 or 24V) DC compressors in place of mains AC voltage
stacks for circulation of air; keep the equipment locked and operated compressors. The battery is charged by solar
open only when necessary; defrost periodically, supervise energy. A solar refrigerator has good PUF insulation around
the temperature record; and if vaccines are kept in cartons, the storage compartments to maximize energy efficiency.
make holes on the sides of the cartons for cold air Battery, charge controller and solar panels are the major
circulation. DONTs : do not keep any object on these additional components associated with solar refrigerator.
equipments; do not store any other drug; do not keep Vaccine refrigerator/freezer :
drinking water or food in them; do not keep more than one It is a refrigerator cum freezer having basket for storing of
months requirements at PHC level; and do not keep date vaccine and freezing of ice-packs. It has two separate
expired vaccines. Reconstituted BCG, Rota virus vaccine compartments :
and measles vaccines can be kept at 4-2°C to +8°C for
maximum of 4 hours and JE vaccine for 2 hours. To be on 1. Vaccine storage compartment maintains temperature
safe side, write the time of reconstitution on the label of range of +2°C to +. 8°C.
these vaccine vials and discard them after 4 hours (2 hours 2. Freezer compartment is for storing frozen ice-pack
for JE vaccine). Do not keep any used vials in the cold maintaining temperature upto -7°C.

by R△J
 OPEN VIAL POLICY

For each refrigerator and freezer compartment, it has during night and cloudy days. These refrigerators are wired
separate DC compressor. The refrigerator is designed for directly to the photovolatic generators.
continuous operation, therefore an ON/OFF switch is not
provided, as it is not necessary. The freezer however, does OPEN VIAL POLICY (2015)
have an ON/OFF switch to allow for defrosting. Implementation of open vial policy allows reuse of
partially used multidose vials of applicable vaccines under
2. Solar refrigerator direct drive UIP in subsequent session (both fixed and outreach) upto
The “direct drive” technology uses the sun’s energy to four weeks (28 days) subject to meeting certain conditions
freeze water or other phase change material and then uses and thus reduce vaccine wastage. The guidelines on open
the cooling from that “ice bank” to keep the refrigerator cold vial policy 2015 are summarized in Fig. 23.

Open Vial Policy

X____________________________________________________ /

ENSURE SAFETY
PRESERVE LIFE

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J Open Vial policy applies only for DPT,
TT, Hepatitis B, Oral Polio Vaccine (OPV),
Liquid Pentavalent, PCV and injectable IPV.

X Does not apply to Measles/MR,

BCG, Japanese Encephalitis (JE)
vaccines, Rota virus

S Vaccine vials opened in session-site can be used in more

than one immunization session upto four weeks provided:-
• Expiry date has not passed.
• Vaccines are stored strictly under appropriate temperature range
both during transportation & storage at cold chain point.
• Vaccine vial septum has not submerged in water or
contaminated in any way.
• Aseptic technique has been used to withdraw all doses.
• Vaccine vial monitor (VVM), has not reached discard point.
X Open vials should never be submerged in water
(e.g. Water accumulated in vaccine carrier) as it increases the risk of
contamination of the vial septum.
J Ensure all open vials have recorded date and time of opening.
• At the end of the session, all open vials should be returned to Cold
Chain Point.
• At Cold Chain Point, open vials should be segregated into :
- Re-usable DPT, TT. Hep B and Pentavalent vaccine vials
fulfilling the above mentioned criteria.
- Non-reusable open vials of Measles/MR, BCG & JE
• All open vials of BCG, Measles and JE should be destroyed after
48 hours or before next session, whichever is earlier.
• In case of any AEFI reported, all open vials (usable & non-usable)
should not be discarded or used. All open vials should be stored
under proper cold chain till investigation is complete.
J All vials (open or unopened) should be transported in a zipper bag in
the vaccine carrier and recorded in the stock register.
J Well-sealed conditioned ice-packs should be used in vaccine carriers
and water should not be allowed to accumulate where vaccine vials
and diluents are stored.

FIG. 23
Open Vial Policy 2015
Source : (126)
by R△J
122 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Monitoring heat exposure immunization session or within six hours of opening,

using vaccine vial monitors whichever comes first. This is regardless of the
formulation of the product (liquid or freeze-dried).
Vaccine vial monitors (VVMs) are the only temperature
monitoring devices that routinely accompany vaccines
throughout the entire supply chain. A VVM is a chemical
indicator label attached to the vaccine container (vial,
ampoule or dropper) by the vaccine manufacturer. As the
container moves through the supply chain, the VVM records
its cumulative heat exposure through a gradual change in
colour. If the colour of the inner square is the same colour or
darker than the outer circle, the vaccine has been exposed to
too much heat and should be discarded. Fig. 24 shows the
colour change sequence.
There are currently four types of VVM, chosen to match
the heat sensitivity of the vaccine. These four types are
VVM2, VVM7, VVM14 and VVM30. The VVM number is the
time in days that it takes for the inner square to reach the
colour indicating a discard point, if the vial is exposed to a
constant temperature of 37°C.
The main purpose of VVMs is to ensure that heat­
damaged vaccines are not administered. The VVM status is
also used to decide which vaccines can safely be kept after a
cold chain break occurs thus minimizing unnecessary
vaccine wastage. In addition, VVM status helps the user to
decide which vaccine should be used first - a batch of
vaccine showing significant heat exposure should be
Source : (125)

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distributed and used before a batch that shows lower heat
exposure, even if its expiry date is longer. VVMs do not Freeze damage to the vaccine
measure exposure to freezing temperature.
The vaccines that are freeze sensitive will get spoiled
There are two different locations for VVMs (Fig. 25) and if they get frozen. The causes of vaccine freezing are :
each is associated with specific guidance for handling (a) Improper storage in ILR; (b) Cold climates and if ambient
opened multi-dose vials of vaccine : temperature is less than 0°C; (c) Storage and transport with
1. WHO-prequalified vaccines, where the VVM, if attached, non-conditioned frozen ice-packs; (d) Defective ILR;
is on the label of the vaccine. The vaccine vial, once (e) Incorrect thermostat adjustment; and (f) Untrained or
opened, can be kept for subsequent immunization improperly trained staff handling vaccine/cold chain.
sessions up to 28 days, regardless of the formulation of The “Shake Test” is used to check whether freeze
the product (liquid or freeze-dried). sensitive vaccines have been damaged by exposure to
2. WHO-prequalified vaccines where the VVM is attached temperature below 0°C. After it has thawed, a vial of
in a location other than on the label (e.g., cap or neck of vaccine that has been frozen no longer has the apperance of
ampoule). In this instance, the vaccine vial, once a cloudy liquid, but tends to form flakes that settle down at
opened, must be discarded at the end of the the bottom of the vial.

Cumulative heat exposure >

VVM start colour Discard Point

The VVM start colour of the inner square is never pure-white, it Beyond discard point.
is always slightly purple and begins lighter in colour than the Square colour is darker
outer circle. From this point forward, the inner square starts to than the outer circle.
darken in colour, until the temperature and/or duration of heat
.reaches a level which degrades the vaccine, at which time the
VVM's discard point will be evident.
Do not use this vaccine __________________________
— Use This Vaccine ►
inform your supervisor

FIG. 24
VVM showing colour change sequence and interpretation.
Source : (128)
by R△J
 ADVERSE EVENTS FOLLOWING IMMUNIZATION 123
Shake Test (125, 126) the death of some or all the essential live organisms in the
vaccine. Store the diluents and droppers with the vaccines in
There is only one way to conduct a Shake Test. The
the vaccine carrier during transportation. Diluents should
protocol must not be altered. The procedure is as follows :
not come in direct contact with the ice-pack.
Test Vial
ADVERSE EVENTS FOLLOWING
- Take a vaccine vial you suspect that may have been
frozen - This is “TEST” vial. IMMUNIZATION
Vaccines used in national immunization programmes are
Frozen control vial extremely safe and effective. However, no immune response
- Take a vaccine vial of the same antigen, same is entirely free from the risk of adverse reactions or remote
manufacturer, and same batch number as the suspect sequelae.
vaccine vial you want to test, An AEFI is any untoward medical occurrence which
- Freeze solid this vial at - 20°C overnight in the DF. This follows immunization and which does not necessarily have a
is the “frozen control” vial, and label it accordingly to causal relationship with the usage of the vaccine. The adverse
avoid its usage. event may be any unfavourable or unintended sign,
- Let it thaw. Do NOT heat it. abnormal laboratory finding, symptom or disease. Reported
- Hold the Control and the Test vials together between adverse events can either be true adverse events, i.e. really a
thumb and forefinger, and vigorously shake the vials for result of the vaccine or immunization process, or coincidental
10-15 seconds. events that are not due to the vaccine or immunization
- Place both vials to rest on a flat surface, side-by-side process but are temporally associated with immunization.
observe them for 30 minutes. In 2012, the Council for International Organizations of
- Compare for rate of sedimentation as shown in Fig. 26. Medical Sciences (CIOMS) and WHO revised the existing
- If the sedimentation in the “Test vial” is slower than in classification relevant to cause-specific categorization
the “Frozen control vial”, the vaccine has not been of AEFIs and a new categorization has been introduced
damaged, it passes the shake test. Use the vaccine batch which is as follows :
- it is not damaged. 1. Vaccine product-related reaction

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- If the sedimentation is similar in both vials or if
An AEFI that is caused or precipitated by a vaccine due
sedimentation is faster in the “Test” vial than in the
to one or more of the inherent properties of the vaccine
“Frozen” vial, the vaccine is damaged, it failed in shake
product.
test. Do NOT use. Notify your supervisor.
Example : Extensive limb swelling following DTP
vaccination.
Use this
Vaccine 2. Vaccine quality defect-related reaction
If the sediments An AEFI that is caused or precipitated by a vaccine that
in the suspect is due to one or more quality defects of the vaccine
vial settle more product, including its administration device as provided
slowly, the by the manufacturer.
Almost suspect vaccine
clear may be used. Example : Failure by the manufacturer to completely
Thick Do not use
inactivate a lot of inactivated polio vaccine leads to cases
sediment^. this vaccine of paralytic polio.
If the sediments 3. Immunization error-related reaction
Control vial in the suspect
vial settle at the
An AEFI that is caused by inappropriate vaccine
same rate, the handling, prescribing or administration and thus by its
suspect vaccine nature is preventable.
can NOT be
Test vial used. Example : Transmission of infection by contaminated
multidose vial.
4. Immunization anxiety-related reaction
FIG. 26 An AEFI arising from anxiety about the immunization.
Comparison of deliberately frozen vial next to the suspect test vial.
Source : (125) Example : Vasovagal syncope in an adolescent during/
following vaccination.
Correct Storage and Use of Diluents (124, 127) 5. Coincidental event
Only use the diluents supplied and packaged by the An AEFI that is caused by something other than the
manufacturer with the vaccine, since the diluent is vaccine product, immunization error or immunization
specifically designed for the needs of that vaccine, with anxiety.
respect to volume, pH level and chemical properties. Example : A fever occurs at the time of the vaccination
Store the diluents, between +2° to + 8° C in the ILR. If (temporal association) but is in fact caused by malaria.
there are constraints of space, then store diluents outside the Coincidental events reflect the natural occurrence of
cold chain. However, remember to cool diluents for at least health problems in the community with common
24 hours before use to ensure that vaccines and diluents are problems being frequently reported.
at the same temperature ( + 2° to +8°C) when being
reconstituted. Otherwise, it can lead to thermal shock i.e. Source : (128A)
by R△J
124 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

1. Vaccine reactions (115, 128, 130) TABLE 35

Summary of common minor vaccine reactions
The new cause-specific categorization is important for
decision-making on a vaccine-product, since it clearly Vaccine Possible minor Expected
differentiates the two types of possible vaccine reactions. adverse reaction frequency
The first, vaccine product-related reaction, is a BCG Local reaction Common
reaction in an individual's response to the inherent (pain, swelling, redness)
properties of the vaccine, even when the vaccine has been Cholera Oral presentation-none
prepared, handled and administered correctly. The second, DTP Local reaction Upto 50% a
vaccine quality defect-related reaction, is the defect in (pain, swelling, redness)
a vaccine that occurred during manufacturing process. Such Fever Upto 50%
a defect may have an impact on an individual's response Hepatitis A Local reaction Upto 50%
and thus increase the risk of adverse vaccine reactions. In (pain, swelling, redness)
early years of immunization programmes, a few major Hepatitis B Local reaction Adults up to
incidences of vaccine quality defect-related reactions were (pain, swelling, redness) 30%, Children
upto 5%
reported (e.g. Cutter case study). However, due to Fever 1-6%
introduction of improved Good Manufacturing Practices
Hib Local reaction 5-15%
(GMP), such defects are now very rare. (pain, swelling, redness)
Fever 2-10%
Vaccine reactions may be classified into common, minor
reactions or rare, more serious reactions. Most vaccine Japanese Local reaction, Upto 20%
encephalitis low-grade fever, myalgia,
reactions are minor and settle on their own. More serious gastrointestinal upset
reactions are very rare and, in general, do not result in
Measles/ Local reaction Upto 10%
long-term problems. MMR (pain, swelling, redness)
Irritability, malaise and Upto 5%
COMMON, MINOR VACCINE REACTIONS non-specific symptoms, fever
Pneumococcal Local reaction 30-50%

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The purpose of a vaccine is to induce immunity by (pain, swelling, redness)
causing the recipient's immune system to react to the Poliomyelitis None
vaccine. Local reaction, fever and systemic symptoms can (OPV)
result as part of the immune response. In addition, some of Poliomyelitis None
the vaccine's components (e.g. aluminium adjuvant, (IPV)
stabilizers or preservatives) can lead to reactions. A Rabies Local and/or general reaction 15-25%
successful vaccine reduces these reactions to a minimum depending on type of vaccine
while producing the best possible immunity. (see product information)
Meningococcal Mild local reactions Upto 71%
The local reactions include pain, swelling and/or redness disease
at the injection site and can be expected in about 10% of
Tetanus/Td Local reaction Upto 10%
vaccinees, except for those injected with DTP (whole cell), (pain, swelling, redness)b
or tetanus boosters, where up to half can be affected. BCG Malaise and non-specific Upto 25%
causes a specific local reaction that starts as a papule symptoms
(lump) two or more weeks after immunization, that then Tick-borne Local reaction Upto 10%
becomes ulcerated and heals after several months, encephalitis (pain, swelling, redness)
leaving a scar. Keloid (thickened scar tissue) from the BCG Typhoid fever Depends on type of vaccine -
lesion is more common among asian and african use (see product information)
populations. Yellow fever Headache 10%
Influenza-like symptoms 22%
The systemic reactions include fever and occur in about Local reaction 5%
10% or less of vaccinees, except for DTP where it is again (pain, swelling, redness)
about half. Other common systemic reactions (e.g., a With whole-cell pertussis vaccine. Rates for acellular pertussis
irritability, malaise, 'off-colour', loss of appetite) can also vaccine are lower.
b Rate of local reactions likely to increase with booster doses,
occur after DTP For measles/MMR and OPV the sytemic
up to 50-85%.
reactions arise from vaccine virus infection. Measles vaccine
causes fever, rash and/or conjunctivitis, and affects 5-15% Source : (129)
of vaccinees. It is very mild compared to 'wild' measles, but
for severely immunocompromised individuals, it can be RARE, MORE SERIOUS VACCINE REACTIONS (115)
severe, even fatal. Vaccine reactions for mumps (swollen ‘Serious’ and ‘severe’ are often used as interchangeable
parotid gland) and rubella (joint pains and swollen lymph terms but they are not. An AEFI will be considered serious,
nodes) affect less than 1% of children. Rubella vaccine if it results in death, is life-threatening, requires in-patient
causes symptoms more often in adults, with 15% suffering hospitalization or prolongation of existing hospitalization,
from joint pains. Systemic reactions from OPV affect less results in persistent or significant disability/incapacity, is a
than 1% of vaccinees with diarrhoea, headache and/or congenital anomaly/birth defect, or required intervention to
muscle pain. prevent permanent impairment or damage. Severe is used
to describe the intensity of a specification event (as in mild,
The common minor vaccine reactions and their expected moderate or severe). The event itself, however, may be of
frequency are as shown in Table 35. relatively minor medical significance. (For example, fever is
by R△J
 ADVERSE EVENTS FOLLOWING IMMUNIZATION 125
a common relatively minor medical event, but according to thrombocytopenia, HHEs, persistent inconsolable
its severity it can be graded as mild fever or moderate fever. screaming) do not lead to long-term problems. Anaphylaxis,
Anaphylaxis is always a serious event and life-threatening.) while potentially fatal, is treatable without leaving any long­
Table 36 details the rare vaccine reactions; the onset term effects. Although encephalopthy is included as a rare
interval, the rate per doses and the case definitions. Most of reaction to measles or DTP vaccine, it is not certain that
the rare and more serious vaccine reactions (e.g. seizures, these vaccines in fact cause encephalopathy.

TABLE 36
Rare vaccine reactions, onset interval and rate per doses

Vaccine Reaction Onset interval Rate/doses

BCG Suppurative lymphadenitis 2-6 months 1-10/104

BCG osteitis 1-12 months 1-700/106
Disseminated BCG infection 1-12 months 0.19-1 56/106

Hib None
Hepatitis B Anaphylaxis 0-1 hour 1.1/106

Influenza Anaphylaxis 0.7/106

(inactivated) Guillain-Barre syndrome (GBS) 1-2/106
Oculo-respiratory syndrome 76/106

Influenza (live- Anaphylaxis 2/106

attenuated) Wheezing (children 6-11 months age) 14/100

Japanese Neurologic events (encephalitis, 1-2.3/106

encephalitis encephalopathy $,
(inactivated) peripheral neuropathy)

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Measles/MMR/MR Febrile seizures 6-12 days 3/103
Thrombocytopenia 15-35 days 3/104
Anaphylaxis 0-1 hour -1/106
Encephalopathy $ 6-12 days <l/106
Oral poliomyelitis VAPP 4-30 days 2-4/106t
Pertussis (DTwP) Persistent (>3 hours) inconsolable screaming 0-24 hours <1/100
Seizures tt 0-3 days <1/100
Hypotonic, hypo responsive episode (HHE) 0-48 hours 1-2/103
Anaphylaxis 0-1 hour 20/106
Encephalopathy $ 0-2 days 0-1/106
Pneumococcal None proven 1
Rotavirus None known "
Tetanus toxoid, DT Brachial neuritis 2-28 days 5-10/106
Anaphylaxis 0-1 hour 1-6/106
Yellow fever Vaccine-associated viscerotropic disease 1/106
Varicella Febrile seizures 4-9/104tt

Notes.
Reactions (except anaphylaxis) do not occur if already immune (—90% of those receiving a second dose are immune): children over six
years unlikely to have febrile seizures.
VAPP Risk is higher following the first dose (1 in 750,000 compared to 1 in 5.1 million for subsequent doses), and for adults and
immunocompromised.
± No proven risk of severe febrile or anaphylactic reactions or neurological disorders (e.g. Guillain-Barre syndrome)
Post-marketing surveillance of currently available rotavirus vaccines has detected a small increased risk of intussusception (—1-2 cases per
100,000 infants vaccinated) in some settings shortly after the first dose of rotavirus vaccine.
Very rare in children
++Seizures are mostly febrile and the risk depends on age, with much lower risk in infants under the age of four months
$Although encephalopathy is included as a rare possible reaction to measles, JE or DTP vaccines, it is not certain that these vaccines in fact
cause encephalopathy. Hence, further scientific evaluation is necessary
Although other serious events have been reported following immunization, it is likely that these events are coincidental, not true reactions.

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 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

The case definitions and treatments of adverse events following immunization are as follows (115, 130) :

Adverse event Case definition Treatment Vaccines

Acute flaccid Acute onset of flaccid paralysis within 4 to 30 days of receipt No specific treatment OPV
paralysis (vaccine of oral poliovirus (OPV), or within 4 to 75 days after contact available; supportive
associated paralytic with a vaccine recipient with isolation of vaccine virus and care.
poliomyelitis) absence of wild polio virus in the stool, and neurological
deficits remaining 60 days after onset, or death.

Anaphylactoid Exaggerated acute allergic reaction, occurring within 2 hours Self-limiting; All
reaction (acute after immunization, characterized by one or more of the anti-histamines
hypersensitivity following: may be helpful.
reaction) • wheezing and shortness of breath due to bronchospasm
• laryngospasm/laryngeal oedema
• one or more skin manifestations, e.g. hives, facial oedema,
or generalized oedema.
Less severe allergic reactions do not need to be reported.

Anaphylaxis Severe immediate (within 1 hour) allergic reaction leading to Adrenaline injection All
circulatory failure with or without bronchospasm and/or
laryngospasm/laryngeal oedema

Arthralgia Joint pain usually including the small peripheral joints. Self-limiting; Rubella,
Persistent, if lasting longer than 10 days, transient; if lasting analgesics MMR
up to 10 days.

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Brachial neuritis Dysfunction of nerves supplying the arm/shoulder without Symptomatic only; Tetanus
other involvement of nervous system. A deep steady, often analgesics.
severe aching pain in the shoulder and upper arm followed
in days or weeks by weakness and wasting in arm/shoulder
muscles. Sensory loss may be present, but is less prominent.
May present on the same or the opposite side to the injection
and sometimes affects both arms.

Disseminated BCG Widespread infection occurring within 1 to 12 months after Should be treated BCG
infections BCG vaccination and confirmed by isolation of with anti-tuberculous
Mycobacterium bouts BCG strain. Usually in regimens including
immunocompromised individuals. isoniazid and rifampicin.

Encephalopathy Acute onset of major illness characterized by any two of the No specific treatment Measles,
following three conditions: available; supportive Pertussis
• seizures care.
• severe alteration in level of consciousness lasting for
one day or more
• distinct change in behaviour lasting one day or more.
Needs to occur within 48 hours of DTP vaccine or from
7 to 12 days after measles or MMR vaccine, to be related
to immunization.

Fever The fever can be classified (based on rectal temperature) Symptomatic; AU

as mild (38 to 38.9°C), high (39 to 40.4°C) and paracetamol.
extreme (40.5°C or higher). Fever on its own does not
need to be reported.

Hypotonic, Event of sudden onset occurring within 48 (usually less The episode is Mainly
hyporesponsive than 12) hours of vaccination and lasting from one minute transient and DTP,
episode (HHE or to several hours, in children younger than 10 years of age. self-limiting, and does rarely
shock-collapse) All of the following must be present: not require specific others
• limpness (hypotonic) treatment. It is not
• reduced responsiveness (hyporesponsive) a contraindication to
• pallor or cyanosis - or failure to observed/recall. further doses of the
vaccine.
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 ADVERSE EVENTS FOLLOWING IMMUNIZATION 127

Adverse event Case definition Treatment Vaccines

Injection site Fluctuant or draining fluid-filled lesion at the site of injection. Incise and drain; All
abscess Bacterial if evidence of infection (e.g. purulent, inflammatory antibiotics if
signs, fever, culture), sterile abscess if not. bacterial.

Lymphadenitis Either at least one lymph nodes enlarged to >1.5 cm in size Heals spontaneously BCG
(includes (one adult finger width), or a draining sinus over a lymph (over months) and
suppurative node. Almost exclusively caused by BCG and then occurring best not to treat
lymphadenitis) within 2 to 6 months after receipt of BCG vaccine, on the unless lesion is
same side as inoculation (mostly axilliary). sticking to skin. If
so,or already draining,
surgical drainage and
local instillation of
anti-tuberculous drug.
Systemic treatment
with anti-tuberculous
drugs is ineffective.

Osteitis/ Inflammation of the bone with isolation of Mycobacterium Should be treated with BCG
Osteomyelitis bovis BCG strain. anti-tuberculous
regimens including
isoniazid and rifampicin.

Persistent Inconsolable continuous crying lasting 3 hours or longer Settles within a day or DTP,
inconsolable accompanied by high-pitched screaming. so; analgesics may Pertussis

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screaming help

Seizures Occurrence of generalized convulsions that are not Self-limiting supportive All,
accompanied by focal neurological signs or symptoms. care; paracetamol and especially
Febrile seizures: if temperature elevated >38°C (rectal) cooling if febrile; rarely Pertussis,
Afebrile seizures : if temperature normal. anticonvulsants. Measles

Sepsis Acute onset of severe generalized illness due to bacterial Critical to recognize All
infection and confirmed (if possible) by positive blood and treat early. Urgent
culture. Needs to be reported as possible indicator of transfer to hospital for
programme error. parenteral antibiotics
and fluids

Severe local Redness and/or swelling centred at the site of injection Settles spontaneously All
reaction and one or more of the following: within a few days to
• swelling beyond the nearest joint a week. Symptomatic
• pain, redness, and swelling of more than 3 days duration treatment with
• requires hospitalization. analgesics. Antibiotics
Local reactions of lesser intensity occur commonly and are are inappropriate.
trivial and do not need to be reported.

Thrombocytopenia Serum platelet count of less than 50,000/ml leading to Usually mild and MMR
bruising and/or bleeding. self-limiting;
occasionally may need
steroid or platelets.

Toxic shock Abrupt onset of fever, vomiting and watery diarrhoea within a Critical to recognize All
syndrome (TSS) few hours of immunization. Often leading to death within and treat early. Urgent
24 to 48 hours. Needs to be reported as possible indicator of transfer to hospital
programme error. for parenteral
antibiotics and fluids.

RECOGNITION OF ANAPHYLAXIS (115, 130) antibiotic which it contains.

Administration of antisera may occasionally give rise to Anaphylaxis is a severe reaction of rapid onset,
anaphylactic shock and serum sickness. Many viral vaccines characterized by circulatory collapse. The early signs of
contain traces of various antibiotics used in their anaphylaxis are generalized erythema and urticaria with
preparation and some individuals may be sensitive to the upper and/or lower respiratory tract obstruction. In more

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128 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

severe cases, limpness, pallor, loss of consciousness and • Generalized itching of skin especially
hypotension may also become evident. Vaccinators should hands, forehead and eyes in children
be able to recognize the following signs and symptoms of Note : Skin changes alone without life
anaphylaxis: threatening cardio-respiratory signs do
not signify an anaphylactic reaction
Diagnostic features of anaphylaxis Gastrointestinal • Diarrhoea
Respiratory Airway • Colic abdominal pain
• Throat and tongue swelling (pharyngeal/ • Vomiting
laryngeal oedema) - the patient has • Incontinence
difficulty in breathing and swallowing and In general, the more severe the reaction, the more rapid the
feels that the throat is closing up.
onset. Most life-threatening reactions begin within 10 minutes
• Hoarse voice.
of immunization. It is advisable to keep the recipient under
• Stridor
observation for at least 20 minutes after the injection.
Breathing Symptoms limited to only one system can occur, leading to
• Bronchospasm delay in diagnosis. Biphasic reactions where symptoms recur
• Respiratory distress 2 or more of the 8 to 12 hours after onset of the original attack and prolonged
following: attacks lasting up to 48 hours have been described.
- Tachypnoea
Time Scale Signs and symptoms Severity
- Increased use of accessory respiratory
of anaphylaxis
muscles
- Recession Early warning Dizziness, perineal burning, Mild
signs warmth, pruritus
- Cyanosis
• Grunting Flushing, urticaria, nasal congestion, Mild to
• Respiratory arrest sneezing, lacrimation, angioedema moderate
Cardiovascular • Hypotension Hoarseness, nausea, vomiting, Moderate
sub-sternal pressure
• Clinical diagnosis of uncompensated
shock, indicated by the combination of V Laryngeal oedema, dyspnoea,
abdominal pain
Moderate
to severe
at least three of the following:

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- Tachycardia Late, life-threat­ Bronchospasm, stridor, collapse, Severe
- Capillary refill time >3 seconds ening symptoms hypotension, dysrhythmias
- Reduced central pulse volume
- Decreased level of consciousness or 2. Immunization error-related reactions (115,130)
loss of consciousness “Immunization” means the usage of a vaccine for the
• Cardiac arrest purpose of immunizing individuals. “Usage” includes all
• Bradycardia (a slow pulse) is usually a processes that occur after a vaccine product has left the
late feature, often preceding cardiac manufacturing/packaging site, i.e. handling, prescribing and
arrest administration of the vaccine.
CNS • Confusion/Agitation
An immunization error-related reaction may lead to a
• Headache
cluster of events associated with immunization. These
• Loss of consciousness
clusters are usually associated with a particular provider, or
Dermatologic or • Tingling of lips health facility, or even a single vial of vaccine that has been
mucosal • Generalized urticaria or generalized inappropriately prepared or contaminated. Immunization
erythema
errors-related reactions can also affect many vials. For
• Angioedema, localized or generalized
(angioedema is similar to urticaria but
example, freezing vaccine during transport may lead to an
involves swelling of deeper tissues, most increase in local reactions.
commonly in the eyelids and lips, and Table 37 shows the immunization error-related reactions
sometimes in the mouth and throat) (115).
TABLE 37
Immunization error-related reactions
Immunization error Related reaction
Error in vaccine Exposure to excess heat or cold as a result of Systemic or local reactions due to changes m the physical
handling inappropriate transport, storage or handling of nature of the vaccine such as agglutination of aluminium-
the vaccine (and its diluent) where applicable. based excipients in freeze-sensitive vaccines.
Use of a product after the expiry date. Failure to vaccinate as a result of loss of potency or non­
viability of an attenuated product.
Error in vaccine prescribing Failure to adhere to a contraindication. Anaphylaxis, disseminated infection with an attenuated
or non-adherence to live, VAPR
recommendations for use Failure to adhere to vaccine indications or Systemic and/or local reactions, neurologic, muscular,
prescription (dose or schedule). vascular or bony injury due to incorrect injection site,
equipment or technique.
Error in administration Use of an incorrect diluent or injection of a Failure to vaccinate due to incorrect diluent. Reaction due
product other than the intended vaccine. to the inherent properties of whatever was administered
other than the intended vaccine or diluent.
Incorrect sterile technique or inappropriate Infection at the site of injection/beyond the site of
procedure with a multidose vial. injection.

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 ADVERSE EVENTS FOLLOWING IMMUNIZATION 129
In the past, the most common immunization error was an 4. Coincidental events
infection (including bloodborne virus) as a result of non- Occasionally following immunization there may occur a
sterile-injection. The infection could manifest as a local disease totally unconnected with the immunizing agent.
reaction (e.g. suppuration, abscess), systemic effect (e.g. Vaccines are normally scheduled early in life, when
sepsis or toxic shock syndrome), or blood-borne virus infections and other illnesses are common, including
infection (e.g. HIV, hepatitis B or hepatitis C). However, with manifestations of an underlying congenital or neurological
the introduction of auto disabled (AD) syringes, infection condition. The mechanism seems to be that the individual is
occurrence has reduced significantly. Still, infection can
harbouring the infectious agent and the administration of
occur in cases of mass vaccination or disaster stituations,
the vaccine shortens the incubation period and produces the
particularly if there is any shortage or problems with logistics
disease or what may have been otherwise only a latent
and supplies. This can be avoided by proper planning and
infection is converted into a clinical attack.
preparedness of programme managers.
The symptoms arising from an immunization error may PRECAUTIONS TO BE TAKEN
help to identify the likely cause. For example, children Before administration of the antiserum or antitoxin, it is
immunized with contaminated vaccine (usually the
necessary to test for sensitivity reaction. This can be done in
bacterium Staphylococcus aureus) become sick within a few
2 ways: (a) instilling a drop of the preparation into the
hours; local tenderness and tissue infiltration, vomiting,
conjunctival sac. A sensitized person will develop pricking of
diarrhoea, cyanosis and a high temperature are the most
the conjunctiva, (b) a more reliable way of testing is by
frequent symptoms. Bacteriological examination of the vial,
intradermal injection of 0.2 ml of antiserum diluted 1 : 10
if still available, can confirm the source of the infection.
with saline. A sensitized patient will develop a wheal and
3. Immunization stress-related-response flare within 10 minutes at the site of injection. It should be
(115, 115A) borne in mind that these tests are not infallible.
Previously it was known as immunization anxiety-related Adrenaline (1:1000 solution) should be kept ready when
reaction. Individuals and groups can react in anticipation to giving foreign serum. In the event of anaphylaxis, for an
and as a result of an injection of any kind. This reaction is adult, 0.5 ml of adrenaline solution should be injected
unrelated to content of the vaccine. Fainting is relatively intramuscularly immediately, followed by 0.5 ml every
20 minutes if the systolic blood pressure is below 100 mm of

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common. During fainting, the individual suddenly becomes
pale, loses consciousness and collapses to the ground. mercury. An injection of antihistaminic drug should also be
Fainting is sometimes accompanied by brief clonic seizure given, e.g., 10-20 mg of chlorpheniramine maleate by the
activity (i.e. rhythmic jerking of the limbs), but this requires intramuscular route, to minimize the after-effects such as
no specific treatment or investigation. Fainting is relatively urticaria or oedema. The patient should be observed for
common after immunization of adults and adolescents, but 30 minutes after any serum injection.
very rare in young children. It is managed by simply placing The risk of adverse reactions can be reduced by proper
the patient in a recumbent position. Recovery of sterilization of syringes and needles, by proper selection of
consciousness occurs within a minute or two, but patients the subject and the product, and if due care is exercised in
may take some more time to recover fully. Table 38 shows carrying out the procedure. Measles and BCG vaccines
the difference between fainting attack and anaphylaxis. should be reconstituted only with the diluent supplied by the
An anxiety spell can lead to pale, fearful appearance and manufacturer. Reconstituted vaccine should be discarded at
symptoms of hyperventilation (light-headedness, dizziness, the end of each immunization session and NEVER retained
tingling in the hands and around the mouth). Breath-holding for use in subsequent sessions. In the refrigerator of the
occurs in young children and will lead to facial flushing and immunization centre, no other drug and substances should
cyanosis. It can end in unconsciousness, during which be stored beside vaccines. Training of immunization worker
breathing resumes. Anaphylaxis develops over several and their close supervision to ensure that proper procedures
minutes upto a few hours and usually involves multiple body are being followed are essential to prevent complications
systems. Unconsciousness is rarely the sole manifestation of and deaths following immunization. Careful epidemiological
anaphylaxis - it only occurs as a late event in severe cases. investigation should be carried out when an adverse event
A strong central pulse (e.g. carotid) is maintained during a following immunization occurs to pinpoint the cause of the
faint, but not in anaphylaxis. incident and to correct immunization practices (131, 115)
TABLE 38
Difference between a fainting attack and anaphylaxis

Clinical features Fainting Anaphylaxis

Timing Before, during or few minutes after injection A short time, upto a few hours
Skin Generalized pallor, cold clammy skin Itching, generalized erythema, urticaria, swelling of
lips, face, tingling around lips
Respiratory system Normal breathing Tachypnoea, difficulty in breathing, wheezing, stridor,
Shallow breathing hoarseness, cyanosis, recession of intercostal spaces
Cardiovascular Bradycardia, weak pulse, carotid pulse felt, hypotension Tachycardia, weak pulse, carotid pulse may be weak,
may occur-reversed by supine position hypotension - not reversed by supine position
GIT Vomiting Vomiting, diarrhoea, abdominal cramps
CNS Faintishness, light-headedness relieved by supine posture Anxiety and distress, loss of consciousness not
relieved by supine posture

Panic attack - no hypotension, pallor, wheeze, or urticarial rash or swelling. May have flushing or blotchy skin.
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 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Investigating adverse events • Brachial neuritis (2-28 days after

following immunization (115) tetanus containing vaccine)
• Thrombocytopenia (15-35 days
The suggested reportable events believed by the public or
after measles/MMR)
health workers to be caused by immunization are listed
• Intussusception commonly after
below and could be considered for inclusion in the AEFI
rotavirus
surveillance system. There is no point in reporting common
minor reactions such as local reactions, fever and self­
limiting systemic symptoms. Occurring between • Lymphadenitis
1 and 12 months • Disseminated BCG infection
Events that should be reported after after BCG • Osteitis/Osteomyelitis
immunization immunization

Occurring within • Anaphylactoid reaction (acute No time limit Any death, hospitalization, disability
24-48 hours of hypersensitivity reaction) or other severe and unusual events that
immunization • Anaphylaxis are thought by health workers or the
• Persistent (more than 3 hours) public to be related to immunization
inconsolable screaming
• Hypotonic hyporesponsive episode Once the report has been received, an assessment should be
(HHE) made to determine whether or not an investigation is needed.
• Toxic shock syndrome (TSS) The urgency of the investigation depends on the situation.

Occurring within
Investigating AEFI clusters
• Severe local reaction
7 days of • Sepsis A cluster of AEFI is defined as two or more cases of the
immunization • Injection site abscess (bacterial/sterile) same adverse event related in time, place or vaccine
administration. Cluster investigation begins by establishing
the case definition and identifying all cases that meet the
Occurring within • Seizures, including febrile seizures case definition.

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14 days of (6-12 days for measles/MMR;
immunization A cluster of similar adverse events is likely to arise from
0-2 days for DTP)
programme errors. If the event also occured in unimmunized
• Encephalopathy (6-12 days for people, it may be coincidental. If all cases received the same
measles/MMR; 0-2 days for DTP) vaccine or lot, and there are no similar cases in the
community, a problem with the vaccine is likely. If the event
Occurring within • Acute flaccid paralysis (4-30 days for is a known vaccine reaction but occurring at an increased
3 months of OPV recipient; 4-75 days for rate, a programme error or a vaccine problem are likely
immunization contact) causes (Fig. 27).

Yes Yes
Vaccine product
Coincidental event
related reaction
Source : (115) FIG. 27
Identifying cause of AEFI cluster
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 DISEASE PREVENTION AND CONTROL

Investigation of an AEFI (115) 4. Formulate a •On the likely/possible cause(s) of the

AN AEFI investigation follows standard epidemiological working event.
investigation principles. In addition, investigation of the hypothesis:
vaccine(s), immunization techniques and procedures, and 5. Test working • Does case distribution match working
service in action needs to be conducted. hypothesis hypothesis ?
STEPS IN AN AEFI INVESTIGATION • Occasionally, laboratory tests may help.

Step Actions 6. Conclude • Reach a conclusion on the cause.

investigation • Complete AEFI Investigation Form.
1. Confirm • Obtain patient’s medical file
• Take corrective action, and recommend
information (or other clinical record).
further action
in report • Check details about patient and event
from medical file and document
A series of cases without comparison of disease and
information.
exposure among controls is not likely to reveal the cause of
• Identify any other cases that need to be
the AEFI, except in the case of programme errors. Clear case
included in the investigation.
definitions, from the guidelines on reporting or defined
2. Investigate • Immunization history. during the investigation, are essential. The investigation
and collect • Previous medical history, including prior needs to identify all cases in the community and find out the
data: history of similar reaction or other outcomes for all those who received the suspect vaccine.
About the allergies. A working hypothesis should be established as soon as there
patient: • Family history of similar events. is sufficient information. Laboratory testing may sometimes
confirm or rule out the suspected cause. The vaccine may be
About the • History, clinical description, any relevant tested for sterility and adjuvant (e.g. aluminium content);
event: laboratory results about the AEFI and the diluent for sterility and chemical composition; and the
diagnosis of the event. needles and syringe for sterility. Testing should be requested
• Treatment, whether hospitalized, and on a clear suspicion and not as a routine, and never before
outcome. the working hypothesis has been formulated.

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About the • Conditions under which the vaccine was Contraindications to vaccination
suspected shipped, its present storage condition,
vaccine(s): state of vaccine vial monitor, and Vaccines are very rarely contraindicated. However, it is
temperature record of refrigerator. important to check for contraindications to avoid serious
• Storage of vaccine before it arrived at reactions. For example, vaccines are contraindicated if there
health facility, where it has come from is serious allergy to the vaccine or its components. Live
higher up the cold chain, vaccine vaccines should not be given to immune-deficient children.
monitor card. The main contraindication to the administration of
vaccines are summarized in Table 39.
About • Whether others received the same
other vaccine and developed illness. DISEASE PREVENTION AND CONTROL
people: • Whether others had similar illness (may
Every disease has certain weak points susceptible to
need case definition); if so exposure of
attack. The basic approach in controlling disease is to
cases of suspect vaccine(s).
identify these weak points and break the weakest links in the
• Investigate the local immunization
chain of transmission (Fig. 16). This requires sound
service.
epidemiological knowledge of the disease - that is its
3. Assess the • Vaccine storage (including open vials), magnitude, distribution in time, place and person,
service by: distribution, and disposal. multifactorial causation, sources of infection and dynamics
asking • Diluent storage and distribution. of transmission.
about: • Reconstitution (process and time kept). Frequently it may be necessary to institute more than one
• Use and sterilization of syringes and method of control simultaneously. The choice of methods
needles. will depend upon factors such as availability of proper tools
• Details of training in immunization and techniques, relative cost effectiveness, efficiency and
practice, supervision and vaccinator(s). acceptability. Although effective control of a disease requires
• Number of immunizations greater than knowledge of its multifactorial causation, removal or
normal ? elimination of a single known essential link or the weakest
Observing link may be sufficient to control a disease, even if complete
• Refrigerator - what else is stored (note if
knowledge about the aetiology of the disease in question is
the service similar containers stored next to vaccine
lacking. The classic example is that of John Snow controlling
in action: vials which could be confused); which the cholera epidemic in London, by removing the handle of
vaccines/diluents stored with other
the incriminated water pump.
drugs; whether any vials have lost their
label. Disease control involves all the measures designed to
• Immunization procedures (reconstitution, prevent or reduce as much as possible the incidence,
drawing up vaccine, injection prevalence and consequences of disease (132). This
technique, safety of needles and includes community participation, political support and
syringes; disposal of opened vials). intersectoral coordination (133). Control measures should
• Do any open vials look contaminated ? not be delayed because of incomplete or lack of accurate
knowledge of the aetiological agent.
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132 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

TABLE 39
Contraindications to vaccines
Vaccine Contraindications

All An anaphylactic reaction3 following a previous dose of a particular vaccine is a true contraindication to further
immunization with the antigen concerned and a subsequent dose should not be given, OR, Current serious illness.
Live vaccines (MMR, Pregnancy.
BCG, yellow fever) Radiation therapy (i.e. total-body radiation)
Yellow fever Egg allergy.
Immunodeficiency (from medication, disease or symptomatic HIV infection6)
BCG Symptomatic HIV infection.
Influenza, yellow fever History of anaphylactic reactions3 following egg ingestion. No vaccines prepared in hen's egg tissues (i.e. yellow
fever and influenza vaccines) should be given. (Vaccine viruses propagated in chicken fibroblast cells, e.g.
measles or MMR vaccines, can however usually be given.)
Pertussis-containing Anaphylactic reaction to a previous dose.
Evolving neurological disease (e.g. uncontrolled epilepsy or progressive encephalopathy). Vaccines containing
the whole-cell pertussis component should not be given to children with this problem. Acellular vaccine is less
reactogenic and is used in many industrialized countries instead of whole-cell pertussis vaccine.
a Generalized urticaria, difficulty in breathing, swelling of the mouth and throat, hypotension or shock.
b In many industrialized countries yellow fever vaccine is administered to individuals with symptomatic HIV infection or who are suffering
from other immunodeficiency diseases, provided that their CD4 count is at least 400 cells/mm3 and if they plan to visit areas where
epidemic or endemic yellow fever actually occurs.
Source : (129)

Broadly these are measures, pending results of suspected), it should be notified to the local health authority,
epidemiologic investigation. whose responsibility is to put into operation control
1. The reservoir or source of infection measures, including the provision of medical care to

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2. The route(s) of transmission patients, perhaps in a hospital.
3. The susceptible host (people at risk). Certain diseases are statutorily notifiable. The diseases to
The activities of disease prevention and control are now be notified vary from country to country; and even within
included in primary health care - it requires community the same country. Usually, diseases which are considered to
participation (involvement), political support and inter­ be serious menaces to public health are included in the list
sectoral coordination (133). of notifiable diseases. Notifiable diseases may also include
non-communicable diseases and conditions such as cancer,
1. Controlling the reservoir congenital defects, accidents, etc.
If the first link in the chain of causation (i.e., the disease Notification is an important source of epidemiological
agent) is deemed to be the weakest link, logically, the most information. It enables early detection of disease outbreaks,
desirable control measure would be to eliminate the which permits immediate action to be taken by the health
reservoir or source, if that could be possible. Elimination of authority to control their spread. The other uses of
the reservoir may be pretty easy with the animal reservoir notification are discussed elsewhere.
(e.g., bovine tuberculosis, brucellosis), but is not possible in Notification of infectious diseases is often made by the
humans in whom the general measures of reservoir control attending physician or the head of the family, but any one,
comprise : early diagnosis, notification, isolation, treatment, including the lay people (e.g., religious, political and
quarantine, surveillance and disinfection - all directed to administrative leaders, teachers and others) can report, even
reduce the quantity of the agent available for dissemination. on suspicion. In all cases, the diagnosis is verified by the
(1) EARLY DIAGNOSIS local health authority.
Under the International Health Regulations (IHR),
The first step in the control of a communicable disease is
certain prescribed diseases are notified by the national
its rapid identification. It is the cornerstone on which the
health authority to WHO. These can be divided into :
edifice of disease control is built. It has been aptly said that
prompt detection of cases (and carriers) and their treatment (a) Those diseases subject to International Health
is like stamping out the “spark” rather than calling the fire Regulations (1969), Third Annotated Edition, 1983 -
brigade to put out the fire caused by the spark. Frequently, cholera, plague and yellow fever.
laboratory procedures may be required to confirm the (b) Diseases under surveillance by WHO - louse-borne
diagnosis. typhus fever, relapsing fever, paralytic polio, malaria,
Early diagnosis is needed for (a) the treatment of patients viral influenza-A, SARS, smallpox etc.
(b) for epidemiological investigations, e.g., to trace the Health administrations are required to notify to WHO
source of infection from the known or index case to the Geneva for any notification of communicable diseases under
unknown or the primary source of infection (c) to study the international surveillance and International Health
time, place and person distribution (descriptive Regulations.
epidemiology) and (d) for the institution of prevention and
control measures. (3) EPIDEMIOLOGICAL INVESTIGATIONS
An epidemiological investigation is called for whenever
(2) NOTIFICATION there is a disease outbreak, the methodology for which is
Once an infectious disease has been detected (or even given elsewhere (see page 147). Broadly, the investigation
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 DISEASE PREVENTION AND CONTROL
133
covers the identification of the source of infection and of the TABLE 40
factors influencing its spread in the community. These may Periods of isolation recommended
include geographical situation, climatic condition, social,
Disease Duration of isolation
cultural and behavioural patterns, and more importantly the
character of the agent, reservoir, the vectors and vehicles, Chickenpox Until all lesions crusted; usually about 6
and the susceptible host populations. days after onset of rash.
Measles From the onset of catarrhal stage through
(4) ISOLATION 3rd day of rash.
Isolation is the oldest communicable disease control German measles None, except that women in the first
trimester or sexually active, non
measure. It is defined as “separation, for the period of immune women in child-bearing years
communicability of infected persons or animals from others not using contraceptive measures should
in such places and under such conditions, as to prevent or not be exposed.
limit the direct or indirect transmission of the infectious Cholera, Diphtheria 3 days after tetracyclines started, until 48
agent from those infected to those who are susceptible, or hours of antibiotics (or negative cultures
who may spread the agent to others” (106). In general, after treatment).
infections from human/animal sources can be controlled by Shigellosis 1 Until 3 consecutive negative stool cultures.
physical isolation of the case or carrier, and if necessary, Salmonellosis J
treatment until free from infection, provided cases and Hepatitis A 3 weeks.
carriers can be easily identified and carrier rates are low. Influenza 3 days after onset.
Polio 2 weeks adult, 6 weeks paediatric.
The purpose of isolation is to protect the community by
Tuberculosis Until 3 weeks of effective chemotherapy.
preventing transfer of infection from the reservoir to the
(sputum +)
possible susceptible hosts. The type of isolation varies with
Herpes zoster 6 days after onset of rash.
the mode of spread and severity of the disease. There are
Mumps Until swelling subsides.
several types of isolation - standard isolation, strict
Pertussis 4 weeks or until paroxysms cease.
isolation, protective isolation, high security isolation (134).
For each patient, the relative risks to the patient and to Meningococcal
meningitis Until the first 6 hours of effective
others should be assessed and the appropriate type of

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Streptococcal antibiotic therapy are completed.
isolation determined. Hospital isolation, wherever possible, pharyngitis
is better than home isolation. Isolation is particularly difficult
in rural areas. In some situations (e.g., cholera outbreaks) Source : (136, 137)
the entire village or rural community may have to be
isolated. Isolation may also be achieved in some diseases by (5) TREATMENT
“ring immunization”, that is encircling the infected persons Many communicable diseases have been tamed by
with a barrier of immune persons through whom the effective drugs. The object of treatment is to kill the
infection is unable to spread. This method when applied infectious agent when it is still in the reservoir, i.e., before it
worldwide in the 1960s and 1970s eradicated smallpox. In is disseminated. Treatment reduces the communicability of
North America, ring immunization is being applied in disease, cuts short the duration of illness and prevents
measles control and eradication. The duration of isolation is development of secondary cases. In some diseases (e.g.,
determined by the duration of communicability of syphilis, tuberculosis, and leprosy), early diagnosis and
the disease and the effect of chemotherapy on infectivity treatment is of primary importance in interrupting
(Table 40). transmission. Treatment is also extended to carriers.
Isolation has a distinctive value in the control of some Treatment can take the form of individual treatment or
infectious diseases, e.g., diphtheria, cholera, streptococcal mass treatment. In the latter category, all the people in the
respiratory disease, pneumonic plague, etc. In some community are administered the drugs whether they have
diseases where there is a large component of subclinical the disease or not (e.g., trachoma). If the treatment is
infection and carrier state (polio, hepatitis A, and typhoid inadequate or inappropriate, it may induce drug resistance
fever), even the most rigid isolation will not prevent the in the infectious agent and may frustrate attempts to control
spread of the disease. It is also futile to impose isolation if the disease by chemotherapy. It is well to remember that no
the disease is highly infectious before it is diagnosed as in disease has ever been conquered through attempting to treat
the case of mumps. Isolation has failed in the control of every affected individual (138). Yaws is a shining example.
diseases such as leprosy, tuberculosis and STD. In the
control of these diseases, the concept of physical isolation (6) QUARANTINE
has been replaced by chemical isolation, i.e., rapid
treatment of cases in their own homes and rendering them Quarantine has been defined as “the limitation of
non-infectious as quickly as possible. Lastly, cases are freedom of movement of such well persons or domestic
usually reported after the disease has spread widely. Taking animals exposed to communicable disease for a period of
all these limitations into consideration, it may be stated that time not longer than the longest usual incubation period of
isolation which is a “barrier approach” to the prevention the disease, in such manner as to prevent effective contact
and control of infectious disease is not as successful as one with those not so exposed” (139). Quarantine measures are
would imagine and may well give rise to a false sense of also “applied by a health authority to a ship, an aircraft, a
security (135). In modern-day disease control, isolation is train, road vehicle, other means of transport or container, to
more judiciously applied and in most cases replaced by prevent the spread of disease, reservoirs of disease or
surveillance because of improvements in epidemiological vectors of disease” (140).
and disease control technologies. Today, isolation is Quarantine may comprise (a) absolute quarantine, as
recommended only when the risk of transmission of the defined above; (b) modified quarantine, e.g., a selective
infection is exceptionally serious. partial limitation of freedom of movement, such as exclusion
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134 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

of children from school; and (c) segregation which has been equilibrium between host and environment through
defined as “the separation for special consideration, control encouraging some ecological influences and inhibiting
of observation of some part of a group of persons (or others (138).
domestic animals) from the others to facilitate control of a
communicable disease, e.g., removal of susceptible children 3. The susceptible host
to homes of immune persons” (2). The third link in the chain of transmission is the
In contrast to isolation, quarantine applies to restrictions susceptible host or people at risk. They may be protected by
on the healthy contacts of an infectious disease. Quarantine one or more of the following strategies.
which was once a popular method of disease control has (1) ACTIVE IMMUNIZATION
now declined in popularity (135). With better techniques of
early diagnosis and treatment, quarantine, as a method of One effective way of controlling the spread of infection is to
disease control, has become outdated. It has been replaced strengthen the host defences. Under certain circumstances this
by active surveillance. may be accomplished by active immunization, which is one of
the most powerful and cost-effective weapons of modern
2. Interruption of transmission medicine. There are some infectious diseases whose control is
solely based on active immunization, e.g., polio, tetanus,
A major aspect of communicable disease control relates
diphtheria and measles. Vaccination against these diseases is
to “breaking the chain of transmission” or interruption of
given as a routine during infancy and early childhood
transmission (Fig. 16). This may mean changing some
(Table 42), with periodic boosters to maintain adequate levels
components of man’s environment to prevent the infective of immunity. Then there are immunizations against certain
agent from a patient or carrier from entering the body of
diseases (Table 41) which are offered to high-risk groups or
susceptible person. For example, water can be a medium for
restricted to definite geographic areas where the disease is
the transmission of many diseases such as typhoid,
endemic or a public health problem (e.g., yellow fever).
dysentery, hepatitis A, cholera and gastroenteritis. Water
Unfortunately we do not have vaccines for every infectious
treatment will eliminate these diseases. Depending upon the disease (e.g., malaria, diarrhoeal diseases). Diseases for which
level of pollution, this may vary from simple chlorination to
improved or less costly vaccines are needed include
complex treatment. However, control of the source of
tuberculosis, pertussis, meningococcal meningitis, hepatitis B,
contamination is an important long-term measure. Food-

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rabies, Japanese encephalitis, etc. (142).
borne disease is particularly prevalent in areas having low
standards of sanitation. Clean practices such as hand­ Immunization is a mass means of protecting the greatest
washing, adequate cooking, prompt refrigeration of number of people. By reducing the number of susceptibles
prepared foods and withdrawal of contaminated foods will in the community, it augments “herd immunity” making the
prevent most food-borne illnesses (141). When the disease infection more difficult to spread. It also reduces the risk for
is vector-borne, control measures should be directed those individuals who have escaped vaccination or those
primarily at the vector and its breeding places. Vector who have not developed satisfactory protection. It is well to
control also includes destruction of stray dogs, control of bear in mind that immunizations are not all 100 per cent
cattle, pets and other animals to minimize spread of effective, particularly when an individual is exposed to a
infection among them, and from them to man. On the other large dose of pathogenic organisms.
hand, episodes of infection either by droplets or droplet Immunization has to be planned according to the needs
nuclei are not usually controlled effectively by attempting to of the situation. Every country has its own immunization
interrupt their mode of spread; reliance is placed on early schedule, so does each medical society and each paediatric
diagnosis and treatment of patients, personal hygiene and society, adding to confusion. Thus there is an infinite
proper handling of secretions and excretions. In short, number of immunization schedules, each having its merits
blocking the routes of transmission imply an attack on and demerits. If each vaccine were to be given separately, a
environmental factors, that is, to bring about an adjusted minimum of at least 14 visits would be needed to the

TABLE 41
Active Immunization recommended under special circumstances
Disease Immunization
1. Cholera Two types of safe and effective oral cholera vaccines currently available Given orally in two doses
between seven days and six weeks apart.
2. Plague Given subcutaneously or intramuscularly in 2 doses at an interval of 7 to 14 days Immunity
starts 5 to 7 days after inoculation and lasts for about 6 months.
3. Typhoid fever Two vaccines are available for prevention of typhoid. Typhoid polysaccharide vaccine is injectable given
subcutaneously or intramuscularly One dose is required. Confers protection after 7 days The other
is oral Ty21a vaccine, administered on 1, 3 and 5th day. Protective immunity achieved 7 days after
3rd dose.

4. Influenza Inactivated vaccines are widely used. Two adequately spaced doses (1.0 ml each) of an aqueous
or saline vaccine are recommended for primary immunization, although one dose may be given
when an epidemic is threatened. The immunity lasts for about 3 to 6 months. Oil-adjuvanted
vaccines give immunity of longer duration, but they tend to produce unpleasant local reaction.
5. Yellow fever The dose of the vaccine (17 D vaccine) is 0.5 ml given subcutaneously. Immunity begins 10-12
days after vaccination, and extends upto 10 years.
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 IMMUNIZATION SCHEDULES
135
immunization clinic. The current trend is to combine DPT - 6 weeks, 10 weeks and 14 weeks;
immunizing agents into small packages and thus reduce the 16-18 months and 5 years
number of injections an individual must receive. Hepatitis B - Birth, 6 weeks and 14 weeks or
A well thought-out immunization schedule must be 6 weeks, 10 weeks and 14 weeks
(a) epidemiologically relevant, that is, vaccinations should be Hib Conjugate - 6 weeks, 10 weeks and 14 weeks
included only against diseases which are public health Measles - 9 months, 16-24 months
problems and against which an effective vaccine exists MMR - 15 months
(b) immunologically effective : children must be vaccinated at Typhoid - 2 years, 5 years, 8 years, 12 years
an age when they can benefit from it, i.e., when they are TT/Td - 10 years, 16 years
capable of forming defences and when they have lost the TT - 2 doses one month apart for pregnant
antibodies transmitted by the mother. Above all, children women, or booster dose if previously
must be vaccinated at the right time, that is before they are immunized.
exposed to possible infection. An immunization may not be
Pneumococcal - 6 weeks, 14 weeks and booster dose
effective if given within too short an interval between
conjugate at 9-12 months.
subsequent doses (c) operationally feasible : this includes cost
vaccine
and ability to achieve a high percentage of coverage which is
a key factor in an effective immunization programme. The Pentavalent vaccine has replaced DPT, Hepatitis B and
schedule must minimize the number of visits, by simultaneous Hib conjugate vaccine in NIS, therefore DPT, Hepatitis and
administration of vaccines, and (d) socially acceptable : the Hib conjugate vaccine should not be given at 6, 10, and
schedule must take into account the local customs, beliefs and 14 weeks if pentavalent vaccine is being used.
practices, seasonal and climatic factors and daily work
pattern of the community. One important factor is to reduce Vaccines that can be given after discussion with
long waiting time for patients whose sole purpose in visiting parents
the clinic was to be immunized. Varicella - 15 months (or after 1 year)
Universal Immunization Programme (UIP) Hepatitis A - high-risk selected infants,
18 months, and 6 months later
In May 1974, the WHO officially launched a global

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Influenza vaccine - 6 months of age to high risk
immunization programme, known as Expanded Programme selected infants annually
on Immunization (EPI) to protect all children of the world
against six vaccine-preventable diseases, namely - 2. WHO EPI Schedule
diphtheria, whooping cough, tetanus, polio, tuberculosis and
measles by the year 2000. EPI was launched in India in Table 44 summarizes the WHO recommendations for
January 1978 (143). routine vaccination for children. The purpose is to assist
health planners to develop an appropriate country specific
The Programme is now called Universal Child immunization schedule based on local conditions. The
Immunization, 1990-that’s the name given to a declaration health care workers should refer to their national
sponsored by UNICEF as part of the United Nations’ 40th immunization schedules.
anniversary in October 1985. It is aimed at adding impetus
to the global programme of EPI. The WHO EPI Global Advisory Committee has strongly
recommended BCG and Polio vaccine to be given at birth or
The Indian version, the Universal Immunization at first contact, in countries where tuberculosis and polio have
Programme, was launched on November 19, 1985 and was not been controlled. In all countries routine immunization
dedicated to the memory of Smt. Indira Gandhi. The with DPT and oral polio vaccine can be safely and effectively
National Health Policy was aimed at achieving universal initiated at 6 weeks of age. New vaccines are being added for
immunization coverage of the eligible population by 1990. the vaccination schedule e.g., hepatitis B, rubella, Rota virus
vaccine Hib, pneumococcal and Japanese encephalitis
IMMUNIZATION SCHEDULES vaccines are now included in several country's programmes.
The immunization schedule may be altered to suit the local
1. National Immunization Schedule needs of individuals and groups. Interruption of the schedule
The National Immunization Schedule is given in Table with a delay between doses does not interfere with the final
43. The first visit may be made when the infant is 6 weeks immunity achieved. There is no basis for the mistaken belief
old; the second and third visits, at intervals of 1-2 months. that if a second (or third) dose in an immunization is delayed,
Oral polio vaccine may be given concurrently with the immunization schedule must be started all over again
pentavalent vaccine. BCG can be given with any of the three (109). The ages shown in Table 43 for the various
doses but the site for the injection should be different. The immunizations are considered the best. However, if there is
schedule also covers immunization of women during any delay in starting the first dose the site for the injection
pregnancy against tetanus. should be different, the periods may be adjusted accordingly.
The Indian Academy of Paediatrics recommends Immunization is frequently postponed if children are ill or
inclusion of more vaccines in the immunization schedule. malnourished. This is not acceptable in the light of present
These vaccines are not included in the UIP because of knowledge. In fact, it is particularly important to immunize
financial constraints. The immunization schedule approved children with malnutrition. Low grade fever, mild respiratory
by the IAP is as follows : infections or diarrhoea and other minor illnesses should not
be considered as contraindications to immunization. These
BCG - Birth - 2 weeks are the very children who are most in need of immunization.
OPV - Birth; 6 weeks, 10 weeks and 14 weeks; They are most likely to die should they acquire a vaccine-
16-18 months, 5 years preventable disease (145).
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136 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

TABLE 42
National Immunization Schedule (NIS) for infants,
children and pregnant women (vaccine-wise), India (2020)

Vaccine When to give Dose Route Site

For Pregnant Women

Tetanus Toxoid (TT)/ Early in pregnancy 0.5 ml Intra-muscular Upper Arm
Tetanus & adult
Diphtheria (Td)-l

TT/Td-2 4 weeks after TT-1 0.5 ml Intra-muscular Upper Arm

TT/Td-Booster If received 2 TT doses in a pregnancy 0.5 ml Intra-muscular Upper Arm

within the last 3 years*

For Infants
Bacillus Calmette At birth or as early as possible 0.1ml (0.05ml Intra-dermal Left Upper Arm
Guerin (BCG) till one year of age until 1 month age)

Hepatitis B - At birth or as early as possible 0.5 ml Intra-muscular Antero-lateral

Birth dose within 24 hours side of mid-thigh

Oral Polio Vaccine At birth or as early as possible 2 drops Oral Oral

(OPV)-O within the first 15 days

OPV1,2&3 At 6 weeks, 10 weeks & 14 weeks 2 drops Oral Oral

(OPV can be given till 5 years of age)

Pentavalent 1, 2 & 3 At 6 weeks, 10 weeks & 14 weeks 0.5 ml Intra-muscular Antero-lateral

(can be given till one year of age) side of mid-thigh

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Pneumococcal Two primary doses at 6 and 14 weeks 0.5 ml Intra-muscular Antero-lateral
Conjugate followed by booster dose at 9-12 months side of mid-thigh
Vaccine (PCV)
Rotavirus (RW)# At 6 weeks, 10 weeks & 14 weeks Oral Oral
5 drops Rotavac (liquid vaccine) or
2.5 ml Rotasill (lyophilized vaccine)
(can be given till one year of age)

Inactivated Polio Two fractional dose at 6 and 14 weeks 0 1 ml ID Intra dermal, two Right Upper
Vaccine (IPV) of age fractional dose Arm

Measles Rubella 9 completed months-12 months. 0.5 ml Sub-cutaneous Right Upper

(MR) 1st dose (Measles can be given till 5 years of age) Arm

Japanese 9 completed months-12 months. 0.5 ml Sub-cutaneous Left Upper Arm

Encephelitis
(JE)-l**
Vitamin A (1st dose) At 9 completed months with 1ml Oral Oral
Measles-Rubella ( 1 lakh IU)
For Children
Diphtheria, 16-24 months 0.5 ml Intra-muscular Antero-lateral
Pertussis & side of mid-thigh
Tetanus (DPT)
booster-1
MR 2nd dose 16-24 months 0.5 ml Sub-cutaneous Right Upper Arm
OPV Booster 16-24 months 2 drops Oral Oral
JE-2 16-24 months 0.5 ml Sub-cutaneous Left Upper Arm

Vitamin A*** 16-18 months. Then one dose every 2 ml Oral Oral
(2nd to 9th dose) 6 months upto the age of 5 years (2 lakh IU)
DPT Booster-2 5-6 years 0.5 ml. Intra-muscular Upper Arm

TT/Td 10 years & 16 years 0.5 ml Intra-muscular Upper Arm

* One dose if previously vaccinated within 3 years

** JE Vaccine is introduced in select endemic districts after the campaign.
*** 2nd to 9th doses of Vitamin A can be administered to children 1-5 years old during bi-annual rounds, in collaboration with ICDS.
# Rotavirus vaccine : lyophilized vaccine in all states/UT (D&N Haveli, Daman & Diu, Goa, Gujarat, Jharkhand, Karnataka, Kerala,
Maharashtra, Puducherry, Telangana, West Bengal), Liquid vaccine in remaining 25 states/UT.
Source : (143A)
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 IMMUNIZATION SCHEDULES

TABLE 43
WHO Recommendations for Routine Immunizations for Children (updated April 2018)
Doses in Interval Between Doses Booster
Antigen Primary Series 1st to 2nd 2nd to 3rd 3rd to 4th Dose
Recommendations for all children
BCG ' As soon as possible after birth 1
As soon as possible 3 4 weeks (min) 4 weeks (min)
Option 1 after birth (<24h) with DTPCV1 with DTPCV2
Hepatitis B As soon as possible 4 4 weeks (mm) 4 weeks (min) 4 weeks (min)
Option 2 after birth (<24h) with DTPCV1 with DTPCV2 with DTPCV3
bOPV 4- 1PV 6 weeks 4 (IPV dose to be 4 weeks (mm) 4 weeks (mm)
given with bOPV with DTPCV2 with DTPCV3
dose from 14 weeks)
Polio IPV/bOPV 8 weeks (IPV 1st) 1-2 IPV 4-8 weeks 4-8 weeks 4-8 weeks
Sequential 2 bOPV
IPV 8 weeks 3 4-8 weeks 4-8 weeks
3 Boosters 12-23
4 weeks (min) 4 weeks (min) months (DTP-
DTP-containing vaccine 6 weeks (min) 3 containmg vaccince)
- 8 weeks - 8 weeks 4-7 years (Td), and
9-15 years (Td)
4 weeks (min) 4 weeks (min)
Option 1 3 with DTPCV2 with DTPCV3
Haemophilus 6 weeks (min)
influenzae 59 months (max.) 8 weeks (mm) if only 4 weeks (min) At least 6 months
type b Option 2 2-3 2 doses, 4 weeks if 3 doses (min) after
(min) if 3 doses last dose
Option 1 6 weeks (min) 3 4 weeks (min) 4 weeks
Pneumococcal
(Conjugate) Option 2 6 weeks (mm) 2 8 weeks (mm) 9-15 months
6 weeks (min) 2 4 weeks (min)
Rotarix with DTPCV2
with DTP1
Rotavirus
6 weeks (mm) 3 4 weeks (min)- 10 4 weeks (mm)
Rota Teq with DTP1 weeks with DTPCV2 with DTPCV3
Measles 9 or 12 months (6 months mm) 2 4 weeks (mm)

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9 or 12 months with measles
Rubella containing vaccine 1
As soon as possible from 6 months
HPV 9 years of age (females only) 2 (min 5 months)
Recommendations for children residing in certain regions
Inactivated 2 4 weeks
Vero cell-derived 6 months generally (generally)
Japanese
Encephalitis Live attentuated 8 months 1
Live recombinant 9 months 1
9-12 months with measles
Yellow Fever containing vaccine 1
1-3 months 5-12 months
> 1 yr FSME-Immune FSME-lmmun FSME-lmmun
Tick-borne Encephalitis and Encepur and Encepur and Encepur At least 1
3 1-7 months 12 months Every 3 years
> 3 yrs TBE-Moscow TBE-Moscow TBE-Moscow
and EnceVir and EnceVir and EnceVir
Recommendations for children in some high-risk populations
TCV (Typbar) > 6 months 1
Typhoid Vi PS 2 years (mm) 1 Every 3 years
Ty21a Capsules 5 years (min) 3or4 1 day 1 day 1 day Every 3-7 years
Dukoral 3 (2-5 years) > 7 days (min) > 7 days (min) Every 6 months
(WC-rBS) 2 years (mm) 2 (> 6 years) < 6 weeks (max ) < 6 weeks (max) Every 2 years
Cholera
Shanchol,
Euvchol 1 year (min) 2 14 days After 2 years
and mORCVAX
MenA conjugate 9-18 months (5 jig) 1
Meningococcal 2-11 months 2 8 weeks After 1 year
MenC conjugate
> 12 months 1
Quadrivalent 9-23 months 2 12 weeks
conjugate £ 2 years 1
Hepatitis A 1 year At least 1
Rabies As required 2 7 days
Dengue (CYD-TDV) 9 years (min) 3 6 months 6 months
Recommendations for children receiving vaccinations from immunization programmes with certain characteristics
12-18 months with measles 1 month (mm)
Mumps containing vaccine 2 to school entry
Seasonal Influenza Revaccinate
2 (< 9 years) annually
(inactivated 6 months (min) 1 (> 9 years) 4 weeks
tri- and quadri-valent) 1 dose only
4 weeks to 3 months
Varicella 12-18 months 1-2 per manufacturer
recommendations
Source : (144)

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138 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Since the success of EPI is now being seen to have services or as part of disease elimination or eradication
important long-term effects on the traditional epidemiological measure.
patterns of major infectious diseases, often raising the average Adolescence presents certain challenges for immunization
age of incidence, the adolescent age group of 10-19 years in relation to lifestyle and other social issues, while also
represent an important additional target group for offering special opportunities, such as a vaccine delivery in
immunization. In the pre-immunization era, large proportion the setting of educational institutions. The vaccines of
of adults had disease induced immunity to common interest are MR and MMR as part of measles outbreak
infections, now majority of individuals have vaccine induced prevention or elimination campaign, Td as booster dose for
immunity, which may or may not have the same long-term neonatal tetanus elimination, hepatitis B, influenza, varicella
stability. Questions therefore arise as to policy and strategy and HPV vaccines etc.
implications for post-infancy immunization programmes. Immunization of health care workers : The information in
The WHO Scientific Advisory Group of Experts to EPI Table 44 is provided by WHO to assist countries to develop
has indicated the need to expand immunization activities policies for the vaccination of health care workers, as per the
beyond infancy, either as part of routine immunization national vaccination schedule in use in their countries.
TABLE 44
Immunization of health care workers
Antigen Vaccination of Health Care Workers recommended
BCG BCG vaccination is recommended for unvaccinated TST- or IGRA-negative persons at risk of occupational exposure
in low and high TB incidence areas (e.g. health-care workers, laboratory workers, medical students, prison workers,
other individuals with occupational exposure)
Hepatitis B Immunization is suggested for groups at risk of acquiring infection who have not been vaccinated previously (for
example HCWs who may be exposed to blood and blood products at work).
Polio All HCWs should have completed a full course of primary vaccination against polio.
Diphtheria HCWs who may have occupational exposure to C diphtheriae. All health-care workers should be upto date with
immunization as recommended in their national immunization schedules
Measles All HCWs should be immune to measles and proof/documentation of immunity or immunization should be required as
a condition of enrollment into training and employment.

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Rubella If rubella vaccine has been introduced into the national programme, all HCWs should be immune to rubella and proof/
documentation of immunity or immunization should be required as a condition of enrollment into training and
employment.
Meningococcal One booster dose 3-5 years after the primary dose may be given to persons considered to be at continued risk of
exposure, including HCWs.
Influenza HCWs are an important group for influenza vaccination. Annual immunization with a single dose is recommended.
Varicella Countries should consider vaccination of potentially susceptible health-care workers (i.e. unvaccinated and with no
history of varicella) with 2 doses of varicella vaccine
Pertussis HWCs should be prioritized as a group to receive pertussis vaccine.
Antigen No current recommendation for vaccination of Health Care Workers
Tetanus There is currently no recommendation regarding HCWs.
Haemophilus The main burden of disease lies in infants under 5 years of age. Work in a health care setting is not indicated as a
influenzae type b factor for increased risk. There is currently no recommendation regarding HCWs.
Pneumococcal The main burden of disease lies in infants under 5 years of age. Immunocompetent adults are not at an increased risk for
serious pneumococcal disease HCWs are not indicated as a group at increased risk of pneumococcal disease.
Rotavirus Children are the target group for rotavirus vaccination as they have the greatest burden of disease. Adults including
HCWs are not at increased risk of severe disease.
HPV HCWs are not at increased risk of HPV. The primary target group for vaccination is girls aged 9-14.
Japanese Health-care workers are generally not at special risk of contracting JE. Workers at high-risk in endemic areas, such as
Encephalitis those involved in vector control, should be vaccinated.
Yellow Fever Individuals in endemic countries and travellers to these countries should receive a single dose of yellow fever vaccine.
Work in a health care setting is not indicated as a factor for increased risk. There is currently no recommendation
regarding HCWs.
Tick-borne Health-care workers are generally not at special risk of contracting JE. Workers at high-risk in endemic areas, such as
Encepalitis those involved in vector control, should be vaccinated.
Typhoid Typhoid vaccines should be employed as part of comprehensive control strategies in areas where the disease is endemic.
Work in a health care setting is not indicated as a factor for increased risk. There is currently no recommendation
regarding HCWs.
Cholera Cholera vaccines may be employed as part of comprehensive control strategies in areas where the disease is endemic as
well as to prevent and respond to cholera outbreaks. There is currently no recommendation regarding HCWs
Hepatitis A Hepatitis A is transmitted through contaminated food and water or direct contact with an infectious person. HCWs are
not indicated as a group at increased risk of hepatitis A infection
Rabies PrEP may be considered for medical professionals who regularly provide care to persons with rabies
Mumps Routine mumps vaccination is recommended in countries with a well-established, effective childhood vaccination
programme and the capacity to maintain high level vaccination coverage with measles and rubella vaccination. HCWs
are not indicated as a group at increased risk.
Dengue (CYD-TDV) HCWs are not at increased risk of dengue
Source : (144A)

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 IMMUNIZATION SCHEDULES 139
(2) PASSIVE IMMUNIZATION (5) NON-SPECIFIC MEASURES
Three types of preparations are available for passive Most of the non-specific measures to interrupt pathways
immunity - (a) Normal human immunoglobulin, (b) Specific of transmission are of general applicability. Improvements in
(hyperimmune) human immunoglobulin, and (c) antisera or the quality of life (e.g., better housing, water supply,
anti-toxins. sanitation, nutrition, education) fall into this category. Non­
Passive immunization is a short-term expedient useful only specific measures will also include “legislative measures”,
when exposure to infection has just occurred or is imminent wherever needed, to formulate integrated programme and
within the next few days. The duration of immunity induced permit effective programme implementation. In fact, these
is short and variable (1-6 weeks). Undesirable reactions may non-specific factors have played a dominant role in the
occur, especially if antiserum is of non-human origin. decline of tuberculosis, cholera, leprosy and child mortality
Passive immunization has a limited value in the mass control in the industrialized world, long before the introduction of
of disease. It is recommended for non-immune persons under specific control measures. Another important non-specific
special circumstances. The commonly employed passive measure is community involvement in disease surveillance,
immunization procedures are listed in Table 33 and 34. disease control and other public health activities. If
community involvement is not an integral part of public
(3) COMBINED PASSIVE AND ACTIVE health programmes, they are unlikely to succeed. Laws,
IMMUNIZATION regulations and policy measures alone will not bring the
In some diseases (e.g., tetanus, diphtheria, rabies) desired results (101).
passive immunization is often undertaken in conjunction It is well worth considering some obstacles and new
with inactivated vaccine products, to provide both developments in the control of infectious diseases in
immediate (but temporary) passive immunity and slowly developing countries. First and foremost is the scarcity of
developing active immunity. If the injections are given at funds, lack of an effective health infrastructure, public health
separate sites, the immune response to the active agent, may laboratory facilities, equipment, supplies, trained personnel
or may not be impaired by immunoglobulin (108). (e.g., epidemiologists) and public awareness needed for the
But, according to current recommendations investigation and control of communicable diseases. This
immunoglobulin should not be given within 3 weeks before, handicap is shared by all developing countries. A
or until 2 weeks after administration of a live attenuated development which has been supported by WHO is

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vaccine (146). For example, the antibody response to live integration of communicable disease control into primary
attenuated measles vaccine is diminished in persons who health care. This integration has been successfully carried
receive immunoglobulin concurrently (147). However, there out. Some authorities emphasize the need for maintaining
are exceptions to this rule, as for example, the simultaneous intensive vertical programmes for the control of the highly
administration of hepatitis B vaccine and hepatitis B prevalent and controllable diseases such as malaria,
immunoglobulin (122). tuberculosis and leprosy until their frequency has been
reduced to low levels. The failure of the malaria eradication
(4) CHEMOPROPHYLAXIS programmes emphasize this point.
Chemoprophylaxis implies the protection from, or Finally a major obstacle to disease control is human
prevention of, disease. This may be achieved by causal behaviour. Medical technology is often ineffective in
prophylaxis, or by clinical prophylaxis : changing behaviour. In this regard, health education
(i) Causal prophylaxis implies the complete prevention of remains the only approach to enlist public co-operation and
infection by the early elimination of the invading or to induce relevant changes in the behaviour and life-styles of
migrating causal agent. For example, there is causal people. Such changes could, in themselves, be powerful
prophylaxis available against malaria. methods of disease control.
(ii) Clinical prophylaxis implies the prevention of clinical
symptoms; it does not necessarily mean elimination of Surveillance
infection. Surveillance must follow control measures. It has been
The indications for chemoprophylaxis are given as in defined as “the continuous scrutiny of all aspects of
Table 45. occurrence and spread of disease that are pertinent to
TABLE 45 effective control” (106). Surveillance goes beyond the
Indications for chemoprophylaxis passive reporting of cases. It includes laboratory
confirmation of presumptive diagnosis; finding out the
Disease Chemoprophylaxis source of infection, routes of transmission, identification of
Cholera Tetracycline or furazolidone for all cases and susceptible contacts; and still others who are at
house-hold contacts risk in order finally to prevent the further spread of the
Conjunctivitis, Erythromycin ophthalmic ointment disease. Serological surveillance identifies patterns of
bacterial (no effect on viral conjunctivitis) current and past infection. Included in surveillance are
Diphtheria Erythromycin (and first dose of vaccine) systematic collection of pertinent morbidity and mortality
Influenza Oseltamivir (effective only for type A) data, the orderly consolidation of these data, special field
for contacts suffering from chronic diseases investigations and rapid dissemination of this information to
Malaria See Chapter 5 those responsible for control or prevention. Once control
Meningitis, Ciprofloxacin and minocycline, for household
measures have been instituted, their effectiveness should be
meningococcal and close community contacts; immunization evaluated. If they have not been successful, the reason(s) for
should be initiated in all cases (against failure should be identified, the existing measures modified
serogroups A and C). and evaluation continued (102). The ultimate objective of
Plague Tetracycline for contacts of pneumonic plague surveillance is prevention.

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140 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

Surveillance may comprise : (a) Individual surveillance : immunoglobulin in a dose of 0.02-0.05 mg/kg of body
This is surveillance of infected persons until they are no weight has been recommended every 4 months. Ideally
longer a significant risk to other individuals, (b) Local immunoglobulin should not be given within 3 weeks before,
population surveillance : e.g., surveillance of malaria, or until 2 weeks after administration of a live vaccine.
(c) National population surveillance : e.g., surveillance of A highly safe, inactivated HAV vaccine is available in several
smallpox after the disease has been eradicated, and European countries. (6) Hepatitis E : There is no vaccine
(d) International surveillance : At the international level, the against hepatitis E and immunoglobulin prepared in Europe
WHO maintains surveillance of important diseases (e.g., and USA does not give much of protection. Avoidance of
influenza, malaria, polio, etc.) and gives timely warning to contaminated food and water is the only effective protective
all national governments. Surveillance, if properly pursued, measure. (7) Hepatitis B : Hepatitis B vaccines are available
can provide the health agencies with an overall intelligence and are safe. Three doses of vaccine constitute the complete
and disease-accounting capability. Surveillance is an course. The first two doses are given one month apart and
essential pre-requisite to the rational design and evaluation the third dose about 6 months later. (8) STD and HIV :
of any disease control programme. Measures for preventing STD are the same whether the
individual is travelling abroad or not, i.e., avoidance of sex
HEALTH ADVICE TO TRAVELLERS altogether or limit it to a single faithful, uninfected partner.
Use of condom is an important preventive measure. To
Emporiatrics is the term coined to describe the science of reduce the risk of acquiring HIV and hepatitis B from
the health of travellers (148). Travellers face special health syringes and needles, travellers should avoid injectable
risks. In the age of jet travel, international travellers are drugs and if an injection is essential they should make sure
subject to various forms of stress that may reduce their that the needle and syringe come from sterile pack.
resistance to disease, e.g., crowding, long hours of waiting, (9) Yellow fever: Vaccination certificate for yellow fever is
disruption of eating habit, change in the climate and time the only certificate required for international travel. Yellow
zone. These factors may in themselves provoke nausea, fever vaccine is recommended for travellers to countries
indigestion, extreme fatigue and insomnia. designated as yellow fever endemic zone. (10) Tetanus : It is
Secondly, in developing countries, they are exposed to a wise precaution for the traveller to have a booster dose of
diseases which are not covered by International Health tetanus toxoid if 10 years or more have elapsed since the
Regulations (IHR), e.g., malaria, giardiasis, dengue, last injection of a complete course or booster.

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influenza, filariasis, STD and AIDS, intestinal parasites, Medical kit for travellers should contain a disinfectant and
typhoid and paratyphoid fever, viral hepatitis, etc. Many of dressing that can be applied easily. Sun cream, mosquito
these may not manifest themselves immediately but occur repellent, oral rehydration salts and first-aid articles are
during a varying period after the traveller returns to his basic necessities. Patients with chronic diseases like
normal way of life. Poor hygiene by food handler, poor diabetes, cardiac problems etc. should carry enough
water quality and improper disposal of wastes are other medicines to avoid the risk of break in medication (150). It is
important causes of disease transfer (149). International advisable to carry a card with noting of their blood group,
travellers have a personal responsibility to recognize these drug sensitivity if any and name of any chronic disease he or
risks of travel, which can be minimized by immunization and she is suffering from.
chemoprophylaxis or chemotherapy. Thirdly, travellers For the benefit of travellers, the WHO publishes every
are separated from familiar and accessible sources of year a booklet, now entitled “International Travel and
medical care. Health, Vaccination requirements and Health advice It
Some of the recommendations pertain to the following : provides guidance on some of the main health risks to which
(1) Avoid bathing with polluted water as this may result in travellers may be exposed in different parts of the world and
ear, eye and skin infections. Excessive heat and humidity or advice on precautions that may be taken against them.
over-exertion in these conditions may lead to exhaustion
from loss of water and salt. (2) The measures for prevention DISINFECTION
of insect bites. (3) Diarrhoeal Diseases : “Be careful what
you eat” is common advice to travellers, but very few truely Semmelweis (1818—1865) demonstrated the value of
understand its implications. Diarrhoea affects an estimated handwashing with antiseptic solutions, when he obtained
20-50 per cent of all travellers. Contaminated food drinks considerable reduction in the death rate from puerperal
are the most common source of these infections. Careful fever. Lister (1827-1912) was also successful in reducing the
selection and preparation of food and drink offer the best number of wound infections by prophylactic application of
protection. Unfortunately appearance of food is no guide as an antiseptic (carbolic acid) to wounds. The importance of
to its safety. The main personal protection is to consider antiseptics and disinfectants has not diminished in this
unpasteurized milk, non-bottled drinks, uncooked food “golden age of antibiotics”. Their uses range from control of
(apart from the fruits and vegetables that can be peeled or communicable diseases to sterilization of sophisticated
shelled), as likely to be contaminated and therefore unsafe. instruments, and treatment of fungal and bacterial infections
The food should be thoroughly and freshly cooked. Use of the skin and mucous membrane.
boiled water or bottled mineral water (now available Definitions
everywhere). Travellers should be aware of the importance
of oral rehydration fluids containing salt and glucose for Disinfectant : Usually a chemical agent (but sometimes
countering dehydration. (4) Malaria : There is a high risk of a physical agent) that destroys disease causing pathogens or
acquiring malaria in endemic areas. Travellers are advised to other harmful microorganisms, but might not kill bacterial
protect themselves by chemoprophylaxis. Drug prophylaxis spores. It refers to substances applied to inanimate objects.
should begin at the latest on the day of arrival in the Disinfection : Thermal or chemical destruction of
malarious areas and continued for 4-6 weeks after leaving pathogen and other types of microorganisms. Disinfection is
the malarious areas. (5) Hepatitis A : Normal human less lethal than sterilization because it destroys most

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 DISINFECTION ^141
recognized pathogenic microorganisms but not necessarily 9. Economical: should not be prohibitively high in cost.
all microbial forms (e.g., bacterial spores). 10. Solubility: should be soluble in water.
Sterilization : Validated process used to render a 11. Stability: should be stable in concentrate and use­
product free of all forms of viable microorganisms including dilution.
bacterial spores. Sterilizer is the apparatus used to sterilize 12. Cleaner: should have good cleaning properties.
medical devices, equipment or supplies by direct exposure 13. Environmentally friendly: should not damage the
to the sterilizing agent. environment on disposal.
Antiseptic : Substance that prevents or arrests the
growth or action of micro-organisms by inhibiting their Types of disinfection
activity or by destroying them. The term is used especially (a) Concurrent disinfection : It is the application of
for preparations applied topically to living tissue. disinfective measures as soon as possible after the discharge
Asepsis : Prevention of contact with micro-organism. of infectious material from the body of an infected person,
Sanitizer : Agent that reduces the number of bacterial or after the soiling of articles with such infectious discharges
contaminants to safe levels as judged by public health (2). In other words, the disease agent is destroyed as soon as
requirements. Commonly used with substances applied to it is released from the body, and in this way further spread of
inanimate objects. the agent is stopped. Concurrent disinfection consists of
usually disinfection of urine, faeces, vomit, contaminated
Sterile : State of being free from all living micro­ linen, clothes, hands, dressings, aprons, gloves, etc
organisms. throughout the course of an illness, (b) Terminal
Hospital disinfectant : Disinfectant registered for use disinfection : It is the application of disinfective measures
in hospitals, clinics, dental offices or any other medical- after the patient has been removed by death or to a hospital
related facility. Efficacy is demonstrated against Salmonella or has ceased to be a source of infection or after other
choleraesuis, Staphylococcus aureus, and Pseudomonas hospital isolation practices have been discontinued (10,
aeruginosa. 106). Terminal disinfection is now scarcely practised;
Germicide : Agent that destroys micro-organisms, terminal cleaning is considered adequate, along with airing
especially pathogenic organisms. and sunning of rooms, furniture and bedding (10, 106).
(c) Precurrent (prophylactic) disinfection : Disinfection

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Detergent : Surface cleaning agent that makes no of water by chlorine, pasteurization of milk and
antimicrobial claims on the label. They comprise a handwashing may be cited as examples of precurrent
hydrophilic component and a lipohilic component. It acts by disinfection.
lowering surface tension e.g. soap which removes bacteria
along with dirt. Natural agents
Cleaning : Removal, usually with detergent and water (1) Sunlight: Direct and continuous exposure to sunlight
or enzyme cleaner and water, of adherent visible soil, blood, is destructive to many disease producing organisms. The
protein substances, micro-organisms and other debris from ultraviolet rays of sunlight (these do not penetrate through
the surfaces, crevices, serrations, joints, and lumens of glass) are particularly lethal to bacteria and some viruses.
instruments, devices and equipment by a manual or Articles such as linen, bedding, and furniture may be
mechanical process that prepares the items for safe handling disinfected by exposure to direct sunlight for several hours
and/or further decontamination. (2) Air ; Exposure to open air (airing) acts by drying or
Deodorant : Deodarant is a substance which suppresses evaporation of moisture which is lethal to most bacteria. In
or neutralizes bad odours, e.g., lime and bleaching powder. general, natural agents such as sunlight and air, because of
their vagaries, cannot be totally depended upon for
Properties of an ideal disinfectant (151) disinfection.
An ideal disinfectant fulfils the following criteria : Physical agents
1. Broad spectrum: should have a wide antimicrobial (1) Burning : Burning or incineration is an excellent
spectrum. method of disinfection. Inexpensive articles such as
2. Fast acting: should produce a rapid kill. contaminated dressings, rags and swabs can be disposed off
3. Not affected by environmental factors: should be by burning. Addition of sawdust, paper, kerosene or other
active in the presence of organic matter (e.g., blood, combustible material aid in burning. Faeces can be disposed
sputum, faeces) and compatible with soaps, off by burning. Burning should not be done in open air; it is
detergents, and other chemicals encountered in use. best done in an incinerator. (2) Hot air : Hot air is very
4. Nontoxic: should not be harmful to the user or useful for sterilizing articles such as glassware, syringes,
patient. swabs, dressings, french chalk, oils, vaseline and sharp
5. Surface compatibility: should not corrode instruments. The drawback of hot air is that it has no
instruments and metallic surfaces, and should not penetrating power, and is therefore not suitable for
cause the deterioration of cloth, rubber, plastics, and disinfection of bulky articles such as mattresses. Hot air
other materials. sterilization is usually done in a hot air oven. The
temperature of the air in the oven should be maintained at
6. Residual effect on treated surfaces: should leave an 160-180 deg C for at least one hour to kill spores.
antimicrobial film on the treated surface. Unfortunately, such elevated temperatures destroy plastic,
7. Easy to use with clear label directions. rubber and other delicate substances. (3) Boiling : Boiling is
8. Odourless: should have a pleasant odour or no an effective method of disinfection. It provides an
odour to facilitate its routine use. atmosphere of boiling and steam. Boiling for 5—10 minutes

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 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

(rolling boil) will kill bacteria, but not spores or viruses. negative bacteria, but only slowly effective against spores
Boilers provide temperature well above 90 deg C in an and acid-fast bacteria. It is also effective against certain
atmosphere of steam, which is exposed to open air. To viruses. Phenol disinfectants are not readily inactivated by
ensure destruction of spores, temperatures above 100 deg C organic matter. Its effect is greatly weakened by dilution.
would be required which cannot be achieved in boilers. Therefore, it should not be used in less than 10 per cent
Boiling is suitable for disinfection of small instruments, tools strength for disinfection of faeces. In 5 per cent strength, it
which are not used for subcutaneous insertion, linen and may be used for mopping floors and cleaning drains.
rubber goods such as gloves. Linen stained with faeces, pus Aqueous solutions of 0.2 to 1 per cent are bacteriostatic.
or blood should be first washed in cold water (preferably (3) Cresol : Cresol is an excellent coal-tar disinfectant. It is
with a disinfectant such as 2V2 per cent cresol) and then 3 to 10 times as powerful as phenol, yet no more toxic.
subjected to boiling, with frequent stirring because linen and Cresol is best used in 5 to 10 per cent strength for
clothes are poor conductors of heat. Addition of 1 per cent disinfection of faeces and urine. A 5 per cent solution may
soap and 0.3 per cent of washing soda enhances the effect be prepared by adding 8 ounces of cresol to one gallon of
of boiling. Boiling for about 30 minutes is adequate to water (or 50 ml to one litre of water). Cresol is an all-
disinfect linen, utensils and bedpans. The drawbacks of purpose general disinfectant. (4) Cresol emulsions : Cresol
boiling are that it is a slow process, unsuitable for thick emulsified with soap is known as “saponified cresol”. Lysol,
beddings and woollen materials as they shrink, and it fixes izal and cyllin are cresol emulsions. Lysol contains 50-60
albuminous stains. (4) Autoclaving : Sterilizers which per cent cresol. They are very powerful disinfectants. A 2 per
operate at high temperatures (in excess of 100 deg C) and cent solution of lysol may be used for disinfection of faeces.
pressure are called autoclaves. They generate steam under (5) Chlorhexidine (hibitane) : This is one of the most useful
pressure (saturated steam) which is the most effective skin antiseptics. Highly active against vegetative gram­
sterilizing agent. Autoclaves fall into two categories - gravity positive organisms, and moderately active against gram­
displacement autoclaves and the high-speed prevaccum positive microbes. It is soluble in water and alcohol. It is
sterilizers. Basically, the autoclave works on the same inactivated by soaps and detergents. 0.5 per cent alcoholic
principle as the domestic pressure cooker. Autoclaving is or aqueous solutions can be used as effective handlotions.
widely used in hospital and laboratory practice. It destroys Creams and lotions containing 1 per cent chlorhexidine are
all forms of life, including spores. Steam attains a higher recommended for burns and hand disinfection.

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temperature under pressure, and has greater powers of (6) Hexachlorphane : This antiseptic is highly active against
penetration than ordinary steam. For example, it attains a gram-positive organisms, but less active against gram­
temperature of 122 deg C under 15 lbs/sq. inch (1 kg/sq. negative organisms. It is slow in action, but shows a
cm.) pressure. It acts by giving off its latent heat. Absolute cumulative effect on the skin and is compatible with soaps.
sterility can be obtained only by raising the temperature of Thus it may be incorporated in soap preparations without
articles to over 135 deg C. Autoclaving is the most effective loss of activity. (7) Dettol : Dettol (chloroxylenol) is a
method for sterilization of linen, dressings, gloves, syringes, relatively non-toxic antiseptic and can be used safely in high
certain instruments and culture media. It is not suitable for concentrations. It is more easily inactivated by organic
sterilization of plastics and sharp instruments. (5) Radiation : matter than many other phenolic disinfectants. It is active
Ionizing radiation is being increasingly used for sterilization against streptococci, but worthless against some gram­
of bandages, dressings, catgut and surgical instruments. The negative bacteria. Dettol (5%) is suitable for disinfection of
objects to be sterilized are placed in plastic bags before instruments and plastic equipment; a contact of at least
radiation, and they will remain sterile until opened. Ionizing 15 minutes will be required for disinfection.
radiation has great penetrating powers with little or no
heating effect. This method is most effective, but very costly. 2. Quaternary ammonia compounds
Commercial methods of sterilization are normally carried (1) Cetrimide : It is manufactured under the trade name
out by gamma radiation (atomic). This technique requires “cetavlon”. It is actively bactericidal against vegetative
special packing and equipment. It is now one of the most gram-positive organisms, but much less so against gram­
viable, safe and economic methods used today. negative organisms. Cetavlon is soluble in water; it has a
soapy feel. It may be used in 1-2 per cent strength.
Chemical agents (2) Savlon : Savlon is a combination of cetavlon and
Articles which cannot be sterilized by boiling or hibitane. Plastic appliances may be disinfected by keeping
autoclaving may be immersed in chemical disinfectants. them in normal strength savlon for 20 minutes. Savlon 1 in 6
Chemical agents may also be used for the disinfection of in spirit is more effective than savlon 1 in 20 aqueous
faeces, urine and other contaminated material. There are a solution. Clinical thermometers may be best disinfected in
wide range of chemical disinfectants, each with its savlon 1 in 6 in spirit in just under 3 minutes.
advantages and disadvantages. These are discussed below :
3. Halogens and their compounds
1. Phenol and related compounds a. Chlorine and chlorine compounds : They are potent
(1) Phenol : Pure phenol or carbolic acid is the best bactericidal, fungicidal, sporicidal, tuberculocidal and
known member of this group. On exposure to air, the virucidal. Since long time chlorine has been used as
colourless crystals of phenol become pinkish, and on longer disinfectant in water treatment.
exposure, the colour deepens to dark red. Pure phenol is not (1) Bleaching powder : Bleaching powder or chlorinated
an effective disinfectant. It is used as a standard to compare lime (CaOCl2) is a white amorphous powder with a pungent
the germicidal activity of disinfectants. (2) Crude phenol : smell of chlorine. A good sample of bleaching powder
The phenol that is commonly used for disinfection is “crude contains about 33 per cent of “available chlorine”. It kills
phenol”, which is a mixture of phenol and cresol. It is a dark most of the organisms when used in the strength of 1 to 3
oily liquid. It is effective against gram-positive and gram­ per cent. Bleaching powder is widely used in public health
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 DISINFECTION
143
practice in India for disinfection of water, faeces and urine; extended exposure time difficult to achieve unless the items
and as a deodorant. The chief drawback of bleaching are immersed (151).
powder is that it is an unstable compound and loses its
chlorine content on storage. Its action is rapid but brief. A 5 5. Formaldehyde
per cent solution (3 to 4 rounded tablespoons to 1 litre of More commonly known in solution as formalin,
water) is suitable for disinfection of faeces and urine formaldehyde is a highly toxic and irritant gas which
allowing a period of one hour for disinfection. precipitates and destroys protein. It is effective against
(2) Hypochlorites : Hypochlorites are the most widely used vegetative bacteria, fungi and many viruses but only slowly
chlorine disinfectant, available as liquid (e.g. sodium effective against bacterial spores (e.g., tetanus spores) and
hypochlorite) or solid (e.g. calcium hypochlorite). The most acid-fast bacteria. It does not injure fabrics and metals. It
prevalent chlorine products are aqueous solutions of 5.25- may be used as a 2-3 per cent solution (20-30 ml of 40 per
6.15 per cent of sodium hypochlorite, usually called cent formalin in one litre of water) for spraying rooms, walls
household bleach. They have a broad spectrum of and furniture.
antimicrobial activity, do not leave toxic residues, are
unaffected by water hardness, are inexpensive and fast Formaldehyde gas is most commonly used for
acting, remove dried or fixed organisms and biofilms from disinfection of rooms. The gas is most effective at a high
surfaces (151). (3) Chlorine tablets : Under various trade temperature and a relative humidity of 80-90 per cent. The
names (viz., halazone tablets) they are available in the gas may also be used for disinfection of blankets, beds,
market. They are quite good in disinfecting small quantities books and other valuable articles which cannot be boiled.
of water. (4) Alternative compounds that release chlorine
and are used in the health-care setting include demand­ 6. Oxidizing agents
release chlorine dioxide, sodium dichloroisocyanurate, and a. Potassium permanganate : It is a purplish black
chloramine-T. The advantage of these compounds over crystelline powder that colours everything it touches through
hypochlorites is that they retain chlorine longer and so exert strong oxidizing action, which limits its use. It is used to
a more prolonged bactericidal effect. (5) The microbicidal disinfect aquariums and is also widely used in community
activity of a new disinfectant, “superoxidized water” has swimming pools to disinfect ones feet before entering the
been examined. The concept of electrolyzing saline to create pool. It is also used to disinfect fruits and vegetables.

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a disinfectant or antiseptic is appealing because the basic b. Hydrogen peroxide : Hydrogen peroxide is
materials of saline and electricity are inexpensive and the bactericidal, virucidal, sporicidal and fungicidal. It is used in
end product (i.e., water) does not damage the environment. hospital setting to disinfect surfaces. It is used as solution
The main products of this water are hypochlorous acid (e.g., alone or in combination with other chemicals as a high level
at a concentration of about 144 mg/L) and chlorine. disinfectant. A 0.5 per cent accelerated hydrogen peroxide
b. Iodine : (1) Iodine solutions or tinctures have been demonstrated bactericidal and virucidal activity in 1 minute
used by health professionals primarily as antiseptic on skin and mycobactericidal and fungicidal activity in 5 minutes. A
(e.g.to prepare incision site prior to surgery) or tissue since 3 per cent solution is also used as an antiseptic and for
long time. Iodine is bactericidal, fungicidal, virucidal and cleaning wounds and discharging ulcers.
lethal to spore-bearing organisms. Iodine is cheap, readily
c. Paracetic acid : It is a disinfectant produced by reacting
available and quick in action. (2) Iodophores : An iodophore
hydrogen peroxide with acetic acid. It is broadly effective
is a combination of iodine and a solubilizing agent or carrier;
against microorganisms and is not deactivated by catalase
the resulting complex provides a sustained-release reservoir
and peroxidase, the enzymes that break down hydrogen
of iodine and releases small amounts of free iodine in
peroxide. It inactivates gram-positive and gram-negative
aqueous solution. The best known and most widely used
bacteria, fungi and yeast in less than 5 minutes at less than
iodophore is povidone-iodine (Betadine). They are non­
100 ppm. In the presence of organic matter, 200-250 ppm is
irritant and do not stain the skin. Besides their use as an
required. For viruses, the dose range is wide (12-2250 ppm).
antiseptic, iodophores have been used for disinfecting blood
culture bottles and medical equipment. It breaks down to environment friendly residue (acetic acid
and hydrogen peroxide) and therefore can be used in
4. Alcohols non-rinse applications.
Ethyl and isopropyl alcohols are commonly used as 7. Metals as microbicides
antiseptics and disinfectants. Ethyl alcohol in the form of
industrial methylated spirit is the alcohol most commonly Anti-infective activity of some heavy metals has been
used for skin disinfection and hand washing. Pure alcohol known since antiquity. Heavy metals such as silver have
has no powers of disinfection but when diluted with water to been used for prophylaxis of conjunctivitis of the new-born,
60-90 per cent vol/vol, it is potent bactericidal, fungicidal, topical therapy for burn wounds, and bonding to indwelling
virucidal and tuberculocidal, but does not destroy bacterial catheters. Inactivation of bacteria on stainless steel surfaces
spores (151). Its activity decreases rapidly below 50 per cent by zeolite ceramic coating containing silver and zinc ions has
concentration. 70 per cent alcohol is lethal in a period of also been demonstrated. Metals such as silver, iron, and
seconds to all types of non-sporing bacteria, but when copper could be used for environmental control, disinfection
applied to the skin and other surfaces, its activity disappears of water or reusable medical devices, or incorporated into
as the alcohol dries off. Because of expense and medical devices.
flammability, its use is limited to small article disinfection.
Available evidence suggests that the most effective skin 8. Lime
antiseptics are alcoholic solutions of chlorhexidine and Lime is the cheapest of all disinfectants. It is used in the
iodine. Alcohols are inflammable and consequently must be form of fresh quick lime or 10-20 per cent aqueous
stored in cool areas. They also evaporate rapidly, making suspension known as “milk of lime”. Faeces and urine can

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1M_ PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

be disinfected by mixing 10-20 per cent aqueous Factors affecting the efficacy of sterilization (151)
suspension of lime and allowing the disinfectant to act for Following factors should be kept in mind while sterilizing
2 hours. As lime wash, it is used for treating walls. As a the medical equipment:
deodorant, lime is sprinkled in cattle sheds and stables and
in public places where urinals and latrines are located. Factors Effect
1. Cleaning Failure to adequately clean instruments
9. Ethylene oxide results in higher bioburden, protein
Heat-sensitive articles may be sterilized at 55-60 deg.C load, and salt concentration. These will
by ethylene oxide which kills bacteria, spores (e.g., tetanus decrease sterilization efficacy.
spores) and also viruses. Ethylene oxide is explosive, 2. Pathogen type Spore-forming organisms are most
therefore, it is mixed with carbon dioxide (12 per cent). resistant to sterilization. However, the
Water vapour is also often added to the mixture (relative contaminating microflora on surgical
humidity 33 per cent) since it increases the efficiency of the instruments consists mainly of
gas. Ethylene oxide has been effectively used to sterilize vegetative bacteria.
fabrics, plastic equipment, cardiac catheters, books, etc; but 3. Biofilm Biofilm accumulation reduces efficacy
the process is difficult to control. Therefore ethylene oxide
disinfection is discouraged when alternatives are available. accumulation of sterilization by impairing exposure of
the sterilant to the microbial cell.
10. Miscellaneous inactivating agents 4. Luman length Increasing lumen length and decreasing
a. Pasteurization : Pasteurization is not a sterilization and luman lumen diameter impairs sterilant
process; its purpose is to destroy all pathogenic
diameter penetration. May require forced flow
microorganisms. However, pasteurization does not destroy
through lumen to achieve sterilization.
bacterial spores. The time-temperature relation for hot-water
pasteurization is generally 70°C (158°F) for 30 minutes. 5. Restricted flow Sterilant must come into contact with
microorganisms. Device designs that
b. Microwave : Microwaves are used in medicine for
prevent or inhibit this contact (e.g.
disinfection of soft contact lenses, dental instruments,
sharp bends, blind lumens) will
dentures, milk, and urinary catheters for intermittent self­ decrease sterilization efficacy.

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catheterization. However, microwaves must only be used
with products that are compatible (e.g., do not melt). 6. Device design Materials used in construction may
Microwaves are radio-frequency waves, which are usually and affect compatibility with different
used at a frequency of 2450 MHz. The microwaves produce construction sterilization processes.
friction of water molecules in an alternating electrical field.
The intermolecular friction derived from the vibrations Recommended disinfection procedures
generates heat. The microwaves produced by a “home­
1. Faeces and urine
type” microwave oven (2.45 GHz) completely inactivate
bacterial cultures, mycobacteria viruses, and Faeces and urine should be collected in impervious
G. stearothermophilus spores within 60 seconds to vessels and disinfected by adding an equal volume of one of
5 minutes depending on the challenge organism. the disinfectants listed in Table 46 and allowed to stand for
1-2 hours. Faeces should be broken up with a stick to allow
c. Flushing and Washer Disinfectors : Flushing and
proper disinfection. If the disinfectants listed in Table 47 are
washer-disinfectors are automated and closed equipment
not available, an equal amount of quicklime or freshly
that clean and disinfect objects from bedpans, urinals and
prepared milk of lime (1 of lime to 4 of water) may be
washbowls to surgical instruments and anesthesia tubes. added, mixed and left for 2 hours. If none is available, a
They have a short cycle of a few minutes. They clean by bucket of boiling water may be added to the faeces which is
flushing with warm water, possibly with a detergent, and then covered and allowed to stand until cool. After
then disinfect by flushing the items with hot water or with disinfection, the excretal matter may be emptied into water
steam. Because this machine empties, cleans, and disinfects, closet or buried in ground. Bedpans and urinals should
manual cleaning is eliminated, fewer disposable items are ideally be steam disinfected. Alternatively, they may be
needed, and fewer chemical gemicides are used. disinfected with 2V2 per cent cresol for an hour after
d. Ultraviolet radiation : The wavelength of UV radiation cleaning.
ranges from 328 nm to 210 nm. Its maximum bactericidal
effect occurs at 240-280 nm. Mercury vapour lamps emit TABLE 46
more than 90 per cent of their radiation at 253.7 nm, which Agents suitable for disinfection of faeces and urine
is near the maximum microbicidal activity (155). UV
radiation has been employed in the disinfection of drinking
water, air, titanium implants and contact lenses. Bacteria
and viruses are more easily killed by UV light than the
bacterial spores.
e. Ozone : Ozone has been used for years as a drinking
water disinfectant. Ozone is produced when O2 is energized
and split into two monatomic (Ox) molecules. The
monatomic oxygen molecules then collide with O2 molecules 2. Sputum
to form ozone, which is O3. Ozone is a powerful oxidant that This is best received in gauze or paper handkerchiefs
destroys microorganisms but it is highly unstable (i.e. half­ and destroyed by burning. If the amount is considerable (as
life of 22 minutes of room temperature). in TB hospitals), it may be disinfected by boiling or
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 SPECIAL DISINFECTION PROCEDURE 145
autoclaving for 20 minutes at 20 lbs pressure. Alternatively, Presently, WHO advises against the use of tunnel for
the patient may be asked to spit in a sputum cup half filled human use, as it can cause skin irritation and respiratory
with 5 per cent cresol. When the cup is full, it is allowed to tract allergy; and it does not give protection from the
stand for an hour and the contents may be emptied and infective agent in the respiratory tract.
disposed off. 5 per cent phenol or 4.8 per cent chloroxylenol
is also used for safe disposal of sputum. Guidelines on disinfection of common public
places including offices (156)
3. Room
It provides interim guidance about the environmental
Usually thorough cleaning, airing and exposure to direct cleaning/decontamiation of common public places including
sunlight, when possible, for several hours will be sufficient. If
offices in areas reporting COVID-19.
necessary, floors and hard surfaces in the room should be
prohibited for 48 hours (152). For chemical disinfection,
1. Indoor areas including office spaces
floors and hard surfaces should be sprayed or mopped with
one of the following disinfectants : chlorine preparations Office spaces, including conference rooms should be
such as chlorinated lime in concentrations that leave 25 ppm cleaned every evening after office hours or early in the
or more of free chlorine; formaldehyde solution at a morning before the rooms are occupied. If contact surface is
concentration of 1 per cent or more; phenolic disinfectants visibly dirty, it should be cleaned with soap and water prior
such as 2V2 per cent cresol. The solution should remain in to disinfection. Prior to cleaning, the worker should wear
contact with the surface for at least 4 hours before final disposable rubber boots, gloves (heavy duty), and a triple
washing (152). layer mask.
On rare occasions, when fumigation is required, the gas • Start cleaning from cleaner areas and proceed towards
most commonly used is formaldehyde. It may be generated dirtier areas.
by boiling commercial formalin in 2 volumes of water (500
• All indoor areas such as entrance lobbies, corridors and
ml of formalin plus 1 litre of water per 30 cu. metres of
staircases, escalators, elevators, security guard booths,
space) in a stainless steel vessel, over an electric hot plate or
by adding potassium permanganate to commercial formalin office rooms, meeting rooms, cafeteria should be
in large jars (170-200 gram to 500 ml of formalin plus 1 litre mopped with a disinfectent with 1% sodium hypochlorite
or phenolic disinfectants.

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of water per 30 cu. metres) (152). There is vigorous boiling
and liberation of formaldehyde gas. The room is kept closed • High contact surfaces such as elevator buttons,
for 6-12 hours to allow disinfection. Formaldehyde handrails/handles and call buttons, escalator handrails,
disinfection is most effective at a high temperature and a public counters, intercom systems, equipment like
relative humidity of 80-90 per cent. telephone, printers/scanners, and other office machines
should be cleaned twice daily by mopping with a linen/
Special Disinfection Procedures absorbable cloth soaked in 1% sodium hypochloride.
(In COVID-19 context) Frequently touched areas like table tops, chair handles,
pens, diary files, keyboards, mouse, mouse pad, tea/
Sanitization tunnel
coffee dispensing machines etc. should specially be
It is a tunnel or gateway for the sanitization and cleaned.
decontamination of items and people when combined with
appropriately atomized biocides and/or virucide spray. • For metallic surfaces like door handles, security locks,
These sanitary and decontamination tunnels and gates keys etc., 70% alcohol can be used to wipe down
represent a safe protection and entry for everyone, in surfaces where the use of bleach is not suitable.
particular for those who work in close contact with groups • Hand sanitizing stations should be installed in office
and are therefore at higher risk. It can be installed at the premises (specially at the entry) and near high contact
entrance of public offices, pharmacies, supermarkets, surfaces.
airports, hospitals, ports, stations and for companies who
• In a meeting/conference/office room, if someone is
need to sanitize the workforce, goods, vehicles and
coughing, without following respiratory etiquettes or
materials.
mask, the areas around his/her seat should be vacated
The tunnel creates an obligatory passage and is equipped and cleaned with 1% sodium hypochlorite.
with internal arc-shaped atomizing nozzles that saturate the
environment. The nebulization system is connected to • Carefully clean the equipment used in cleaning at the
control system capable of automatically mixing and end of the cleaning process.
sanitizing products at percentage indicated by the • Remove PPE, discard in a yellow disposable bag and
manufacturer. The liquid is sprayed in the form of mist for wash hands with soap and water.
6-8 seconds on the person walking through the tunnel.
Access to the tunnel is regulated by a traffic light with In addition, all employees should consider cleaning the
motion detection. By placing a barrier floor inside the work area in front of them with a disinfecting wipe prior to
sanitary gate, it is possible to sanitize the surface in contact use and sit one seat further away from others, if possible.
with the ground.
The chemical used is : (a) hydrogen peroxide and
2. Outdoor areas
isopropyl alcohol with distilled water; (b) sodium Outdoor areas have less risk then indoor areas due to air
hypochlorite for material sanitization; (c) sodium currents and exposure to sunlight. These include bus stops,
hypochlorite for humans under PPE protection; and railway platforms, park, roads, etc. Cleaning and
(d) concentrated chemical free and alcohol free ayurvedic disinfection efforts should be targeted to frequently touched/
solution with enriched 100 per cent silver nano particles. contaminated surfaces as already detailed above.

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146 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

3. Public toilets Guidelines for preparation of 1% sodium

Sanitary workers must use separate set of cleaning hypochlorite solution
equipment for toilets (mops, nylon scrubber) and seperate Product Available chlorine lper cent solution
set for sink and commode). They should always wear
disposable protective gloves while cleaning a toilet. Sodium hypochlorite 3.5% 1 part bleach to
- liquid bleach 2.5 parts water
Areas Agents / Procedure Sodium hypochlorite 5% 1 part bleach to
Toilet cleaner - liquid 4 parts water
NaDCC (sodium 60% 17 grams to
Toilet pot/ Sodium hypochlorite • Inside of toilet pot/commode. dichloro-isocyanurate) 1 litre water
commode 1 %/detergent Scrub with the recommended powder
Soap powder/long agents and the long handle NaDCC (1.5 g/tablet) 60% 11 tablets to
handle angular brush angular brush - tablets 1 litre water
• Outside: clean with
Chloramine - powder 25% 80 g to 1 litre water
recommended agents;
use a scrubber. Bleaching powder 70% 7 g to 1 litre water
Any other As per manufacturer’s Instructions
Lid/ Nylon scrubber • Wet and scrub with soap
commode and soap powder and the nylon 4. Personal Protective Equipment (PPE)
powder/detergent scrubber inside and outside.
1% Sodium • Wipe with 1% Sodium Wear appropriate PPE which would include the following
Hypochlorite Hypochlorite while carrying out cleaning and disinfection work.
• Wear disposable rubber boots, gloves (heavy duty), and
Toilet floor Soap powder / • Scrub floor with soap powder a triple layer mask
detergent and and the scrubbing brush
scrubbing brush/ • Wash with water • Gloves should be removed and discarded/damaged, and
nylon broom 1% • Use sodium hypochlorite a new pair worn.
Sodium Hypochlorite 1% dilution. • All disposable PPE should be removed and discarded
Sink Soap powder / • Scrub with the nylon after cleaning activities are completed.

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detergent and scrubber. • Hands should be washed with soap and water
nylon scrubber 1% • Wipe with 1% sodium immediately after each piece of PPE is removed,
Sodium, Hypochlorite hypochlorite. following completion of cleaning.
Showers Warm water • Thoroughly scrub the floors/ Masks are effective if worn according to instructions and
area / Detergent powder tiles with warm water and properly fitted. Masks should be discarded and changed if
Taps and Nylon Scrubber detergent. they become physically damaged or soaked.
fittings 1% Sodium • Wipe over taps and fittings
Hypochlorite/ with a damp cloth and Hand washing technique
70% alcohol detergent. Fig. 28 shows steps of hand washing technique with soap
• Care should be taken to clean and water (156).
the underside of taps and
fittings.
• Wipe with 1% sodium
hypochlorite/ 70% alcohol.

Soap Detergent and • Should be cleaned daily with

dispensers water detergent and water and Rub back of each hand
with water cover all hand surfaces palm to palm with palm of other hand
dried with fingers interlocked

- 70% Alcohol can be used to wipe down surfaces where the use
of bleach is not suitable, e.g. metal. Chloroxylenol (4.5-5.5%)/
Benzalkonium Chloride or any other disinfectants found to be
effective against coronavirus may be used as per
manufacturer’s instructions. Rub palm to palm with Rub with back of fingers Rub each thumb clasped Rub tips of fingers in
fingers interlocked to opposing palms with in oppsite hand using a opposite palm in a
- Always use freshly prepared 1% sodium hypochlorite. fingers interlocked rotational movement circular motion

• Do not use disinfectants spray on potentially highly

jr>. z
contaminated areas (such as toilet bowl or surrounding
surfaces) as it may create splashes which can further /■/
spread the virus. Rub each wrist with Rinse hands Use elbow to Dry thoroughly with a
opposite hand with water turn off tap single-use towel
• To prevent cross contamination, discard cleaning
material made of cloth (mop and wiping cloth) in
appropriate bags after cleaning and disinfecting. Wear
new pair of glove and fasten the bag.
• Disinfect all cleaning equipment after use and before Hand washing should
using in other areas. take 15-30 seconds

• Disinfect buckets by soaking in bleach solution or rinse in FIG. 28

hot water. Hand washing technique with soap and water

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 INVESTIGATION OF AN EPIDEMIC
-147
Guidelines for use of mask (156) may be spurious, and arise from misinterpretation of signs
The correct procedure of wearing triple layer surgical and symptoms by the lay public. It is therefore necessary to
have the verification of diagnosis on the spot, as quickly as
mask is as follows :
possible. It is not necessary to examine all the cases to arrive
1. Perform hand hygiene at a diagnosis. A clinical examination of a sample of cases
2. Unfold the pleats; make sure that they are facing down. may well suffice. Laboratory investigations wherever
3. Place over nose, mouth and chin. applicable, are most useful to confirm the diagnosis but the
4. Fit flexible nose piece over nose bridge. epidemiological investigations should not be delayed until
5. Secure with tie strings (upper string to be tied on top of the laboratory results are available.
head above the ears - lower string at the back of the
neck.) 2. Confirmation of the existence of an epidemic
6. Ensure there are no gaps on either side of the mask,
The next step is to confirm if epidemic exists. This is done
adjust to fit. by comparing the disease frequencies during the same
7. Do not let the mask hanging from the neck. period of previous years. An epidemic is said to exist when
8. Change the mask after six hours or as soon as they the number of cases (observed frequency) is in excess of the
become wet. expected frequency for that population, based on past
9. Disposable masks are never to be reused and should be experience An arbitrary limit of two standard errors from
disposed off. the endemic occurrence is used to define the epidemic
10. While removing the mask great care must be taken not threshold for common diseases such as influenza (3). Often
to touch the potentialy infected outer surface of the the existence of an epidemic is obvious needing no such
mask. comparison, as in the case of common-source epidemics of
11. To remove mask first untie the string below and then the cholera, food poisoning and hepatitis A. These epidemics
string above and handle the mask using the upper are easily recognized. In contrast the existence of modern
strings. epidemics (e.g., cancer, cardiovascular diseases) is not easily
12. Disposal of used masks: Used mask should be considered recognized unless comparison is made with previous
as potentially infected medical waste. Discard the mask experience.
in a closed bin immediately after use.

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3. Defining the population at-risk
INVESTIGATION OF AN EPIDEMIC
(a) Obtaining a map of the area : Before beginning the
Ghe occurrence of an epidemic always signals some investigation, it is necessary to have a detailed and current
significant shift in the existing balance between the agenT, map of the area. If this is not available, it may be necessary
ost and environment^ It calls for a prompt and thorough to prepare such a map. It should contain information
investigation of the cases to uncover the factor(s) concerning natural landmarks, roads and the location of all
responsible and to guide in advocating control measures to dwelling units along each road or in isolated areas. The area
prevent further spread. (Emergencies caused by epidemics may be divided into segments, using natural landmarks as
remain one of the most important challenges to national boundaries. This may again be dividecfinto smaller sections.
health administrations. Epidemiology has an important role Within each section, the dwelling units (houses) may be
t6“play in the investigation of epidemics. The objectives of designated by numbers.
an epidemic investigation are (3, 22, 153). (b) Counting the population : The denominator may be
a. to define the magnitude of the epidemic outbreak or related to the entire population or sub-groups of
involvement in terms of time, place and person. a population. It may also be related to total events (sec
b. to determine the particular conditions and factors page 45 for more details). For example, if the denominator is
responsible for the occurrence of the epidemic. the entire population a complete census of the population
by age and sex should be carried out in the defined area by
c. to identify the cause, source(s) of infection, and
house-to-house visits. For this purpose lay health workers
modes of transmission to determine measures
in sufficient numbers may be employed. Using this
necessary to control the epidemic; and
technique it is possible to establish the size of the
d. to make recommendations to prevent recurrence^ population. The population census will help in computing
the much-needed attack rates in various groups and
An epidemic investigation calls for inference as well as
description. Frequently, epidemic investigations are called subgroups of the population later on. Without an
for after the peak of the epidemic has occurred; in such appropriate denominator of “population at risk” attack rates
cases, the investigation is mainly retrospective. No step by cannot be calculated.
step approach applicable in all situations can be described
like a “cook-book” (153). However, in investigating an 4{Rapid search for all cases and their
epidemic . it is desired to have an orderly procedure or characteristics \
practical guidelines as outlined below which are applicable (a) Medical survey : Concurrently, a medical survey
for almost any epidemic study. Some of the steps can be should be carried out in the defined area to identify all cases
done concurrently. including those who have not sought medical care, and
those possibly_exposed to risk. Ideally, the complete survey
1. Verification of diagnosis (screening each member of the population for the presence
Verification of diagnosis is the first step in an epidemic of the disease in question) will vdek up all affected
investigation, as it may happen sometimes that the report individuals with symptoms or signs of the disorder. Lay

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148 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

health workers may be trained ^to administer the outbreaks, food-specific attack rates must be calculated for
“e: i'‘emioic-jT al case sheet” or questionnaire to collect each food eaten to determine the source of infection.
relevant data. . /The purpose of data analysis is to identify common event
(b) Epidemiological case sheet : The epidemiologist or experience, and to delineate the group involved in the
should be armed with an “epidemiological case sheet” for common experience.
collecting data from cases and from persons apparently
exposed but unaffected. The epidemiological case sheet or 6. Formulation of hypothesis
(Vase interview formy should be carefully designed (based On the basis of time, place and person distribution or the
on the findings of a rapid preliminary inquiry) to collect Agent-Host-Environment model, formulate hypothesis to
relevant information. This includes : name, age, sex, explain the epidemic in terms of (a) possible source
occupation, social class, travel, history of previous exposure, (b) causative agent (c) possible modes of spread, and (d) the
time of onset of disease, signs and symptoms of illness, environmental factors which enabled it to occur. These
personal contacts at home, work, school and other places; hypothesis should be placed in order of relative likelihood.
special events such as parties attended, foods eaten and Formulation of a tentative hypothesis should guide further
exposure to common vehicles such as water, food and milk; investigation.
visits out of the community, history of receiving injections or
blood products, attendance at large gathering, etc. (The 7. Testing of hypothesis
information collected should be relevant to the disease All reasonable hypothesis need to be considered and
under study. For example, if the disease is food-borne, weighed by comparing the attack rates in various groups for
detailed food histories are necessary. A case review form will those exposed and those not exposed to each suspected
ensure completeness and consistency of data collection. factor. This will enable the epidemiologist to ascertain which
Gf the outbreak is large, it may not be possible to hypothesis is consistent with all the known facts. When
interview all the cases (e.g., influenza). In such cases, a divergent theories are presented, it is not easy to distinguish
random sample should be examined and data collected. I immediately between those which are sound and those
which are merely plausible. Therefore it is instructive to turn
(c) (Searching for more cases : The patient may be asked back to arguments which have been tested by the
if he knew of other cases in the home, family,

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subsequent course of events (154).
neighbourhood, school, work place having an onset within
the incubation of the index case.({Dases admitted to the local 8. Evaluation of ecological factors
hospitals should also be taken into consideration. This may
revea’ not only additional cases but also person-to-i erson An investigation of the circumstances involved should be
spread. The search for new cases (secondary cases) should carried out to undertake appropriate measures to prevent
be carried out everyday, till the area is declared free of further transmission of the disease .(Ecological factors which
epidemic. This period is usually taken as twice the have made the epidemic possible should be investigated
incubation period of the disease since the occurrence of last such as sanitary status of eating establishments, water and
case. milk supply; breakdown in the water supply system;
movements of the human population, atmospheric changes
such as temperature, humidity and air pollution, population
5. Data analysis dynamics of insects and animal reservoirs jThe outbreak can,
The data collected should be analyzed on ongoing basis, be studied in a case control fashion. One of the primary
using the classical epidemiological parameters - time, place concerns of the epidemiologist is to relate the disease to
and person. If the disease agent is known, the characteristics environmental factors to know the source(s) of infection,
of time, place and person may be rearranged into Agent- reservoirs and modes of transmission.
Host-Environment model (3).
9. Further investigation of population at risk
a. Time : (Prepare a chronological distribution of dates of
onset and construct an “epidemic curve”. Look for time Astudy of the population at risk or a sample of it may be
clustering of cases. An epidemic curve may suggest : (a) a needed to obtain additional information. This may involve
time relationship with exposure to u suspected source medical examination, screening tests, examination of
(Fig. 4), (b) whether it is a common-source or propagated suspected food, faeces or blood samples, biochemical
epidemic, and (c) whether it is a seasonal or cyclic pattern studies, assessment of immunity status, etc. The approach
suggestive of a particular infection. \ may be retrospective or prospective. For example,
serological study may reveal clinically inapparent cases and
b. Place : Prepare a “spot map” (geographic distribution) throw light on the pathogenesis of the condition. Healthy
of cases, and if possible, their relation to possible sources of individuals (those who are not ill) from the same universe
infection, e.g., water supply, air pollution, foods eaten, may be studied in a case control fashion. This will permit
occupation, etc. Clustering of cases may indicate ^common classification of all members as to :
source of infection. Analysis of geographic distribution may
provide evidence of the source of disease and its mode of a. exposure to specific potential vehicles.
spread. This was demonstrated by John Snow in the cholera b. whether ill or not.
outbreak in the Golden Square district, London (Figure 6).
c. Person : Analyze the data by age, sex, occupation and 10. Writing the report
other possible risk factors. Determine the attack rates/case The report should be complete and convincing.
fatality rates, for those exposed and those not exposed and Information to be included in the final report on an
according to host factors. For example, in most food-borne epidemic is given in Table 47 (155).

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 REFERENCES

TABLE 47 References
Information to be included in the final report on an epidemic 1. Acheson, R.M. (1978). Brit. Med. J., 2 : 1737.
2. Last, JohnM.ed. (1983). A Dictionary of Epidemiology, A Handbook
Section Contents sponsored by the IEA, Oxford Univ. Press.
3. Roht, L.H. et al (1982). Principles of Epidemiology, A. self-teaching
1. Background guide, London, Academic Press.
Geographical location 4. IEA (2014), A Dictionary of Epidemiology, 6th ed., Edited by Miquel
Climatic conditions Porta, Oxford University Press.
Demographic status (population pyramid) 5. Lilienfeld, A.M. and Lilienfeld, D.E. (1980) Foundations of
Socio-economic situation Epidemiology, 2nd ed., Oxford University Press.
Organization of health services 6. Lowe, C.R. and J. Kostrzewski (1973). Epidemiology, A guide to
Surveillance and early warning systems teaching methods, Churchill Livingstone.
Normal disease prevalence 7. Alderson, M. (1983). An Introduction to Epidemiology, 2nd ed.,
London, Macmillan.
2. Historical data 8. Lilienfeld, A.M. (1973). Am. J. Epi., 97 :135.
Previous occurrence of epidemics 9. Langmuir, A.D. (1975). Int. J. Epi., 4 (4) 253.
- of the same disease, 10. Roberts, C.J. (1977) Epidemiology for Clinicians, London, Pitam
- locally or elsewhere Medical.
Occurrence of related diseases, if any 11. Morris, J.N. (1975). Uses of Epidemiology, 3rd ed., London,
- in the same area Churchill Livingstone.
- in other areas 12. WHO (1982). The Place of Epidemiology in Local Health Work,
Discovery of the first cases of the present outbreak Offset Pub. No. 70, Geneva, WHO.
13. Macmahon, B. and T.F. Pugh (1970). Epidemiology : Principles and
3. Methodology of investigations Methods, Boston, Little, Brown.
Case definition 14. Fox, J.P. et al (1970). Epidemiology : Man and Disease, New York,
Questionnaire used in epidemiological Macmillan.
investigation 15. WHO (1981). Health for All, Sr. No. 4.
Survey teams 16. Hall, David J. (1984). The Islamic World Med.J., April 84 p. 22.
Household survey 17. Rose, G and D.J.P. Barker (1979). Epidemiology for the Uninitiated,
British Medical Association, London.
Retrospective survey 18. WHO (1959). Techn. Rep. Ser., No.164.
Prospective surveillance 19. WHO (1968). Techn. Rep. Ser., No. 389.
Collection of laboratory specimens 20. Hogarth, J. (1978). Glossary of Health Care Terminology, Geneva,
Laboratory techniques. WHO.

telegram-@Cherry_2412
4. Analysis of data 21. Lowe, C.R. andS.K. Lwanga (1978). Health Statistics, A manual for
Clinical data : teachers of medical students, IEA/WHO handbook, Oxford Medical
- frequency of signs and symptoms Publications.
- course of disease 22. Barker, D.J.P. and G. Rose (1976). Epidemiology in Medical
Practice, Churchill Livingstone.
- differential diagnosis 23. WHO (1993), Basic Epidemiology by R. Beaglehole R. Bonita,
- death or sequelae rates T.Kjelistrom.
Epidemiological data : 24. Austin, D.F. and Werner, S.B. (1970). Epidemiology for the Health
- mode of occurrence Sciences, Illionis, C.C. Thomas.
- in time 25. Fraser, D.W. et al (1977). N. Eng. Med. J., 299 : 1189.
- by place 26. WHO (2008). Health Situation in South East Asia Region, 2001-2007.
- by population groups 27. Herbst, A.L. et al (1971). N. Eng. J. Med., 284 : 878.
Modes of transmission . 28. Marmot, M.G. (1979). Bull WHO, 57 (3) 332.
- source(s) of infection 29. WHO (1967). Techn. Rep. Ser., No. 365.
- route(s) of excretion and portal(s) of entry 30. Austin-Seymour, Mary M et al (1984). Ann. Int. Med., 100 : 17.
- factors influencing transmission 31. MacMahon, B. (1981). In : Preventive and Community Medicine,
Laboratory data . 2nd ed., Duncan Clark (ed) Boston, Little, Brown & Co.
- isolation of agent(s) 32. WHO (2006). Basic Epidemiology, 2nd Ed., R. Bonita, R.
Beaglehole and T. Kjellstrom.
- serological confirmation 33. WHO (1972). Techn. Rep. Ser., No. 510, P 20.
- significance of results 34. Thompson, D.W. et al (1982). Am. J. Epid., 116 (5) 840.
Interpretation of data : 35. Karon, J.M. and Kupper, L.L. (1982). Am. J. Epi., 116 (5) 852.
- comprehensive picture of the outbreak 36. Doll, R. and Hill, A.B. (1950). Brit. Med. J., 2 : 739.
- hypotheses as to cause(s) 37. Schlesselman, J.J. (1982). Case Control Studies, New York, Oxford
- formulation and testing of hypotheses by statistical University Press.
analysis. 38. Mausner, J.S. and Bahn, A.K. (1974). Epidemiology : An
Introductory Text, Philadelphia, Saunders.
5. Control measures 39. Wynder, E.L. and Graham, E.A. (1950). JAMA, 143 : 329.
Definition of strategies and 40. Levin, M.I. et al (1950). JAMA 143 : 336-338.
methodology of implementation 41. Kelsey, J.K. et al (1978). J. Epi. and Comm. Hlth. 32 : 102-107
- constraints 42. Linos, A. et al (1980). N. Eng. J. Med., 302 : 1101.
- results 43. Rooks, J.B. et al (1979). JAMA, 242 : 644-648.
Evaluation • 44. Adour, K.K. et al (1975). JAMA. 233 : 527-539.
- significance of results 45. Kline, J. et al (1978). Am. J. Epi., 107 : 290-298.
- cost/effectiveness 46. Hennekens, C.H. et al (1977). Int. J. Epi., 6 : 243-246.
Preventive measures. 47. Hoover, R.N. and P.H. Strasser (1980). Lancet, 1 : 837-840.
48. Vassey, M.P. and R.Doll (1968). Brit. Med. J., 2 : 199.
It may be necessary to implement temporary control 49. Vassey, M.P. and R.Doll (1969). Brit. Med. J., 2 : 651.
measures at the commencement of an epidemic on the basis 50. Speirs, A.L. (1962). Lancet, 1: 303.
of known facts of the disease. These measures may be 51. Dawber, T.R. et al (1951). Am. J. Pub. Hlth, 41 : 249.
52. Doll, R. and A.B.Hill (1964). Brit. Med. J. 1:1399-1410;1460-1467.
modified or replaced in the light of new knowledge acquired 53. Royal College of General Practitioners (1974). Oral Contraceptives
by the epidemic investigation. As Frost (154) observed, an and Health, London, Pitman Medical.
epidemiological investigation is more than the collection of 54. Neutra, R.R. et al (1978). N. Eng. J. Med., 299 : 324-326.
established facts. It includes their orderly arrangement into 55. Lee, A.M. etal (1969). J. Natl. Cancer Inst., 42 : 1045.
chains of inference, which extend more or less beyond the 56. Wagoner, J.K. et al (1965). N. Eng. J. Med., 273 : 181-188.
57. Selter, R. and PE. Sartwell (1965). Am. J. Epi., 81 : 2-22.
bounds of direct observation. 58. Makka, L. et al (1974). JAMA, 230 : 64.
by R△J
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS

59. Court-Brown, W.M. and R. Doll (1957). Leukaemia and Aplastic 113. McConnel, I. et al (1981). The Immune System, a Course on the
anaemia in patients irradiated for ankylosing spondylitis, MRC Spl moleculer and cellular basis of immunity, 2nd ed. Oxford, Blackwell.
Res.Ser.No.295, London, HMSO. 114. WHO (1976). Public Health Papers, No.62.
60. Doll, R. and Peto (1976). Brit. Med. J., 2 : 1525. 115. WHO (2013), Immunization Safety Surveillance, Guidelines for
61. Dorn, H.F. (1959). Pub. Health Rep., 74: 581-593, Washington DC, managers of immunization programmes on reporting and
Govt. Printing Press. investigating adverse events following immunization, 2nd ed.
62. Doll, R. and A.B. Hill (1956). Brit.Med.J., 2 : 1071-1081. 115A.WHO (2019). Weekly Epidemiological Record, No.22/23, 2019.
63. Selikoff, I.J. etal (1968). JAMA, 204 : 106-112. 116. William E. Paul (2013), Fundamental Immunology, Seventh ed.
64. Mann, J.I. (1977). In : Proceedings of an International Symposium 116A.Centre for Disease Control and Prevention(2020), Epidemiology
on CHD in young women, Edinburgh, 30 June-2 July 1977, and prevention of vaccine - preventable diseases.
Edinburgh, Churchill Livingstone. 117. Galazka, A.M. etal (1984). World Health Forum, 5 (3).
65. Doll, R. and A.B. Hill (1956). Brit. Med. J., 2 : 1071. 118. Galazka, A.M. etal (1984). Bull WHO, 62:357
66. Doll, R. and A.B. Hill (1954). Brit. Med. J., 1 : 1451-1455. 119. Jawetz, Melnick and Adelberg's Medical Microbiology, 24th edition
67. Hammond, E.C. and D.Horn (1954). JAMA, 155 :1316-1328. (2007), A Lange medical book.
68. Hammond, E.C. etal (1958). JAMA, 116 :1159-1172; 1294-1308. 120. Internet.
69. Editorial (1977). Lancet, 2 : 747. 121. WHO (1983). Bull WHO, 61 (1) Directions to Contributors to
70. WHO (1980). Medical Experimentation and the protection of Bulletin.
Human Rights. 122. WHO (1982). Bull WHO, 60 (1) 43-47.
71. Weser, J.K. et al (1984). N. Eng. J. Med., 310:830. 123. WHO (1978) Techn. Rep. Ser. No. 630.
72. Smithells, R.W. et al (1983). Lancet, 1: 1027-31. 124. Govt, of India (2011), Immunization Handbook for Health Workers,
73. Paradise, J.L. et al (1984). N. Eng. J. Med., 310:674. Ministry of Health and Family Welfare, New Delhi.
74. Coronary Artery Surgery Study Randomized Trial (1984). N. Eng. J. 125. WHO (2015), Vaccine Cold Chain Module 2, 2015.
Med., 310 : 750. 126. Govt, of India (2016), Hand book for vaccine and Cold Chain
75. Schoenberg, B.S. (1982). Neuroepidemiology, 1 : 85-101. handlers, 2nd edition, Ministry of Health and Family Welfare, New
76. Medical Research Council (1951), Brit. Med. J., 2:1463-71. Delhi.
77. WHO cooperative Trial on Primary Prevention of IHD (1980) Lancet, 127. Govt, of India (2008), Immunization Handbook for Medical Officers,
Ministry of Health and Family Welfare, New Delhi.
2:379.
78. Rose, G. and P.J.S. Hamilton (1978). J. Epi and Community Health, 128. Govt, of India (2015), AEFI - Adverse Events Following
32:275-81. Immunization, Surveillance and Response Operational Guidelines,
2015, Ministry of Health and Family Welfare, New Delhi.-
79. Terry, T.L. (1942). Am. J. Ophthalmology, 25:203-204; 1409-1423 128A.WHO (2020), Module 3, Adverse events following immunization.
80. Kinsey, V.E. and F.M. Hemphill (1955). Am. J. Oph, 56:481. 129. WHO (2006), International travel and Health 2006.
81. Kinsey, V.E. (1956). Archives of Oph, 56, 481-543. 130. Govt, of India (2017), Immunization Handbook for Medical Officers,
82. South-East London Screening Study Group (1977). Inj. J. Epi., 6 (4) Ministry of Health and Family Welfare, New Delhi.
357-63. 131. WHO (1996), Weekly Epidemiological Record No. 32,9 August 1996.

telegram-@Cherry_2412
83. Bennet, A.E. (1978). Recent Advances in Community Medicine, 132. WHO (1984). Health for All, Sr.No.9.
Churchill Livingstone. 133. WHO (1978). Health for All, Sr.No.l, pp 24-25.
84. Sackett, D.L. et al (1974). Ann. Int. Med., 80 : 137. 134. Bagshawe, K.D. etal (1978). Brit.Med.J., 2:879-881.
85. Trichopoulos, D. etal (1983). Lancet, 1:441-443. 135. WHO (1978). WHO Chronicle, 32:439-447.
86. Moses, L.E. etal (1984). Annual Rev. P. H., 5:267-92. 136. Clark Duncan, W and B. MacMahon (1981). Preventive and
87. Yudkin, J.Roddy, J. (1964). Lancet, 2:6. Community Medicine, 2nd ed., Boston, Little Brown & Co.
88. Bennet, A.E. etal (1970). Lancet, 1:1012. 137. American Academy of Paediatrics (1977). Report of Committee on
89. US Public Health Service (1964). Smoking and Health, PH. Service infectious Diseases (Red Book, 18th ed).
Pub; No. 1103 Washington, US Govt. Printing Press. 138. Le Riche and J. Milner (1971). Epidemiology as Medical Ecology,
90. Hill, A.B. (1965). Proc. Roy. Soc. Med., 58:295-300. Churchill, Livingstone.
91. Hill, A.B. (1971). Principles of Medical Statistics, 9th ed., Oxford 139. Council for International Organizations of Medical Sciences (1973).
University Press. Communicable Diseases, Provisional International Nomenclature,
92. Susser, M.W. (1977). Am. J. Epi., 105:1-15 CIOMS/WHO, Geneva.
93. Noble, John (1976). Primary Care and the Practice of Medicine, 140. WHO (1983). International Health Regulations, 1969. 3rd
Boston, Little Brown. Annotated edition, WHO, Geneva.
94. White, K.L. (1978). In : Basic Health Care in Developing Countries, 141. Salvato, J.A. (1976). Guide to Sanitation in Tourist Establishments,
An Epidemiological perspective, Basil S. Hetzel (ed). IEA/WHO WHO Geneva.
Handbook, Oxford Med. Publications. 142. WHO (1984). The Work of WHO, 1982-83.
95. Mckeown, T and C.R. Lowe (1974). An Introduction to Social 143. WHO (1978). Expanded Programme on Immunization, Report and
Medicine, 2nd ed., Blackwell. Working Papers, 31st Session of the WHO Reg. Committee,
96. WHO (1980). Early Detection of Handicap in Children, EURO Rep Mongolia, 21-28 Aug, 1978, SEARO.
and Studies, 30 Reg.Office WHO, Copenhagen. 143A.Govt. of India (2022), Annual Report 2021 -2022, Ministry of Health
97. Melby. J.C. (1975). JAMA, 231: 399. and Family Welfare, New Delhi.
98. Finnerty, F.A. (1975). JAMA, 231 : 402. 144. WHO (2016), WHO recommendations for routine immunizations,
99. WHO (1972). WHO Chr., 26 (1) 7-11. Immunization, Vaccines and Biologicals.
100. IEA (2001), A Dictionary of Epidemiology, 4th ed., Edited by John 144A.WHO (2020), Immunization, Vaccines and Biologicals, WHO
M. Last. recommendations for immunization, summary tables.
101. WHO (1982). Techn. Rep. Ser., No.682. 145. Galazka, A.M. et al (1984). Bull WHO, 62 (3) 357.
102. Brachman, P.S. (1984). In : Oxford Textbook of Public Health, Vol II. 146. Centre for Disease Control (1982). Health Information for
103. Waterson, A.P (1979). Brit. Med. J., 2:564. International Travel, Washington DC. Govt. Printing Office (H.H.S.
Publication (CDC) 82-8280), p.64.
104. Dudgeon, J.A. (1976). Brit. Med. Bull, 32:77-85. 147. Krugman, S. et al (1963). Pediatrics, 31:919-928.
105. WHO (1978). Techn. Rep. Ser., No.626. 148. Editorial (1982). Brit.Med.J., 285:582.
106. Benenson, A.S. ed (1981). Control of Communicable Diseases in 149. WHO (1983). WHO Chronicle, 37 (6) 210.
Man, 13th ed. American P.H. Association, New York. 150. WHO (1996), International Travel and Health, Vaccination
107. Last, J.M. (1980). Maxcy-Rosenau Public Health and Preventive Requirements and Health Advice.
Medicine, 11th ed., Appleton Century Crofts. 151. William A. Rutala, David J. Weber and Health Care Infection Control
108. Fudenberg, H.H. et al (1976). Basic and Clinical Immunology, Los Advisory Committee (2008), Guidelines for Disinfection and
Altos, Ca, Lange Sterilization in Healthcare Facilities, CDC.
109. Gell, PG.H. et al (1975). Clinical Aspects of Immunology, 3rd ed., 152. WHO (1972). Techn.Rep.Ser., No.493, p. 58.
Blackwell, Oxford. 153. Friedman, G.D. (1974). Primer of Epidemiology, McGraw Hill.
110. Mims, C.A. (1977). The Pathogenesis of Infectious Disease, London, 154. Frost, W.H. (1936). In Snow on Cholera, New York,
Academic Press. Commonwealth Fund, p.ix.
111. Youmans, G.P et al (1980). The Biological and Clinical Basis of 155. Bres, P (1986). Public Health action in Emergencies caused by
Infectious Diseases, 2nd ed., Saunders. Epidemics, WHO, Geneva.
112. Turk, J.L. (1975). In : Clinical Aspects of Immunology, PG.H. Cellet 156. COVID-19 : Guidelines on disinfection of common public places
al (eds), 3rd ed., Blackwell, Oxford. including offices, 2020.

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 Screening for Disease

“Health should mean a lot more than escape from death or, for that matter, escape from disease. ”

Iceberg phenomenon of disease 3) requires little physician-time. In fact the physician is

not required to administer the test, but only to
Epidemiologist and others who study disease find that the interpret it.
pattern of disease in hospitals is quite different from that in a
community. That is, a far larger proportion of disease (e.g., Screening and diagnostic tests
diabetes, hypertension) is hidden from view in the
community than is evident to physicians or to the general A screening test is not intended to be a diagnostic test. It
public. The analogy of an iceberg, only the tip of which is is only an initial examination. Those who are found to have
seen, is widely used to describe disease in the community. positive test results are referred to a physician for further
diagnostic work-up and treatment. Screening and diagnostic
The concept of the “iceberg phenomenon of disease” tests may be contrasted as in Table 1
(Page 46) gives a better idea of the progress of a disease
from its sub-clinical stages to overt or apparent disease than TABLE 1

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the familiar spectrum of disease. The submerged portion Screening and diagnostic tests contrasted
of the iceberg represents the hidden mass of disease (e.g.,
sub-clinical cases, carriers, undiagnosed cases). The floating Screening test Diagnostic test
tip represents what the physician sees in his practice. The 1 Done on apparently healthy Done on those with
hidden part of the iceberg thus constitutes the mass of indications or sick.
unrecognized disease in the community, and its detection 2 Applied to groups Applied to single patients,
and control is a challenge to modern techniques in all diseases are considered.
preventive medicine.
3 Test results are Diagnosis is not final but
arbitrary and final modified in light of new
Concept of screening evidence, diagnosis is
The active search for disease among apparently healthy the sum of all evidence.
people is a fundamental aspect of prevention. This is 4 Based on one criterion Based on evaluation of a
embodied in screening, which has been defined as “the or cut-off point number of symptoms, signs
search for unrecognized disease or defect by means of (e.g., diabetes) and
rapidly applied tests, examinations or other procedures in laboratory findings.
apparently healthy individuals.” 5 Less accurate More accurate.
Historically, the annual health examinations were meant 6 Less expensive More expensive.
for the early detection of “hidden” disease. To bring such 7 Not a basis for treatment Used as a basis for treatment.
examinations within the reach of large masses of people with 8 The initiative comes from The initiative comes from
minimal expenditures of time and money, a number of the investigator or agency a patient with a complaint.
alternative approaches have come into use. They are based providing care.
primarily on conserving the physician-time for diagnosis
and treatment and having technicians to administer simple, Source : (2)
inexpensive laboratory tests and operate other measuring
devices. This is the genesis of screening programmes. The However, the criteria in Table 1 are not hard and fast.
original screening programmes were for individual diseases There are some tests which are used both for screening and
such as tuberculosis, syphilis or selected groups such as diagnosis, e.g., test for anaemia and glucose tolerance test.
antenatal mothers, school children and occupational groups. Screening and diagnosis are not competing, and different
Over the years, the screening tests have steadily grown in criteria apply to each.
number (Table 8). Screening is considered a preventive care
function, and some consider it a logical extension of health Concept of “lead time”
care. Fig. 1 shows the possible outcomes for a given disease
Screening differs from periodic health examinations process. There is nothing to be gained in screening for
in the following respects (1): diseases whose onset is quite obvious. Detection
programmes should be restricted to those conditions in
1) capable of wide application which there is considerable time lag between disease onset
2) relatively inexpensive, and and the usual time of diagnosis. In this period, there are

by R△J
152 SCREENING FOR DISEASE

usually a number of critical points which determine both the b. Case-finding

severity of the disease and the success of any treatment in
This is use of clinical and/or laboratory tests to detect
reversing the disease process. There is clearly little value in
disease in individuals seeking health care for other reasons;
detecting disease in advance of the usual time of diagnosis
for example, the use of VDRL test to detect syphilis in
unless such detection precedes the final critical point beyond
pregnant women. Other diseases include pulmonary
which treatment would be unsuccessful and/or permanent
tuberculosis in chest symptomatics, hypertension, cervical
damage would be done. Detection programmes should,
therefore, concentrate on those conditions where the time cancer, breast cancer, diabetes mellitus, etc.
lag between the disease’s onset and its final critical point is c. Diagnostic tests
sufficiently long to be suitable for population screening (3).
Use of clinical and/or laboratory procedures to confirm or
Disease First Final Usual OUTCOME refute the existence of disease or true abnormality in
onset possible critical time of patients with signs and symptoms presumed to be caused by
detection point diagnosis diagnosis the disease; for example, VDRL testing of patients with
-----i------- lesions suggestive of secondary syphilis; endocervical culture
for TV. gonorrhoea.
Screening time The distinction between screening, case-finding or
diagnosis should be clear-cut. Often, however, it is blurred
Lead time by the multiplicity of tests used and the haphazard nature of
FIG.l diagnostic decision-making. Thus the same test may be used
Model for early detection programmes in different contexts for both screening and diagnosis. Each
“Lead time” is the advantage gained by screening, i.e., step may involve multiple tests as in the case of syphilis.
the period between diagnosis by early detection and In evaluating a test, then, one must consider whether it is
diagnosis by other means. In Fig.l, A is the usual outcome for screening or diagnosis, alone or in conjunction with
of the disease, and B is the outcome to be expected when other tests (19).
the disease is detected at the earliest possible moment. The
benefits of the programme are therefore B-A. The benefits
Uses of screening

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of the programme must be seen in terms of its outcomes. It is Four main uses have been described:
also necessary for the complexities and costs of any
detection programme to be viewed against the benefits a. Case detection
accruing therefrom (3). This is also known as “prescriptive screening”. It is
defined as the presumptive identification of unrecognized
Aims and objectives disease, which does not arise from a patient’s request, e.g.,
The basic purpose of screening is to sort out from a large neonatal screening. In other words, people are screened
group of apparently healthy persons those likely to have the primarily for their own benefit. Specific diseases sought by
disease or at increased risk of the disease under study, to this method have included bacteriuria in pregnancy, breast
bring those who are “apparently abnormal” under medical cancer, cervical cancer, deafness in children, diabetes
supervision and treatment (Fig.2). Screening is carried out in mellitus, iron deficiency anaemia, PKU, pulmonary
the hope that earlier diagnosis and subsequent treatment tuberculosis, haemolytic disease of the newborn, etc. (5).
favourably alters the natural history of the disease in Since disease detection is initiated by medical and public
a significant proportion of those who are identified as health personnel, they are under special obligation to make
“positive” (4). sure that appropriate treatment is started early.
Apparently healthy
(Screening tests) b. Control of disease
1 This is also known as “prospective screening”. People are
examined for the benefit of others, e.g., screening of
Apparently normal Apparently abnormal immigrants from infectious diseases such as tuberculosis and
(Periodic re-screening) syphilis to protect the home population; and screening for
(a) Normal - periodic
re-screening streptococcal infection to prevent rheumatic fever. The
(b) Intermediate - screening programme may, by leading to early diagnosis
surveillance permit more effective treatment and reduce the spread of
(c) Abnormal - infectious disease and/or mortality from the disease.
treatment
c. Research purposes
FIG.2
Possible outcomes of screening Screening may sometimes be performed for research
purposes. For example, there are many chronic diseases
Explanation of terms whose natural history is not fully known (e.g., cancer,
hypertension). Screening may aid in obtaining more basic
a. Screening knowledge about the natural history of such diseases, as for
Strictly speaking, screening is testing for infection or example, initial screening provides a prevalence estimate
disease in populations or in individuals who are not seeking and subsequent screening, an incidence figure. Where
health care; for example, serological testing for AIDS virus in screening is done for research purposes, the investigator
blood donors, neonatal screening, premarital screening for should inform the study participants that no follow-up
syphilis. therapy will be available.

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 CRITERIA FOR SCREENING 153
d. Educational opportunities Multiphasic screening has enjoyed considerable
popularity, and evidence from randomized controlled
Apart from possible benefits to the individual and the
studies in UK and USA suggested that multiphasic screening
acquisition of information of public health relevance,
has not shown any benefit accruing to the population in
screening programmes (as for example, screening for
terms of mortality and morbidity reduction (9). On the other
diabetes) provide opportunities for creating public
hand, it has increased the cost of health services without any
awarendss and for educating health professionals.
observable benefit. Furthermore, in multiphasic screening,
as currently practised, most of the tests have not been
Types of screening
validated. These observations have cast doubts on the utility
Three types of screening have been described: of multiphasic screening (10, 11).
a. Mass screening
b. High-risk or selective screening CRITERIA FOR SCREENING
c. Multiphasic screening. Before a screening programme is initiated, a decision
must be made whether it is worthwhile, which requires
a. Mass screening ethical, scientific, and, if possible financial justification (4).
Mass screening simply means the screening of a whole The criteria for screening are based on two considerations:
population (6) or a sub-group, as for example, all adults (7). the DISEASE to be screened, and the TEST to be applied
It is' offered to all, irrespective of the particular risk (12,13,14,15).
individual may run of contracting the disease in question
(e.g., tuberculosis). Disease
The disease to be screened should fulfil the following
Mass screening for disease received enthusiastic support
criteria before it is considered suitable for screening:
in rhe past. However, when a number of mass screening
procedures were subjected to critical review, there appeared 1. the condition sought should be an important health
to be little justification for their use in many instances (8). problem (in general, prevalence should be high);
Indiscriminate mass screening, therefore, is not a useful 2. there should be a recognizable latent or early
preventive measure unless it is backed up by suitable asymptomatic stage;
treatment that will reduce the duration of illness or alter its 3. the natural history of the condition, including

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final outcome. development from latent to declared disease, should
be adequately understood (so that we can know at
b. High-risk or selective screening what stage the process ceases to be reversible);
Screening will be most productive if applied selectively to 4. there is a test that can detect the disease prior to the
Ijlgh-risk groups, the groups defined on the basis of onset of signs and symptoms;
epidemiological research (7). For example, since cancer 5. facilities should be available for confirmation of the
cervix tends to occur relatively less often *in the upper social diagnosis;
groups, screening for cancer cervix in the lower social 6. there is an effective treatment;
groups could increase the yield of new cases. One 7. there should be an agreed-on policy concerning
population sub-group where certain diseases (e.g., diabetes, whom to treat as patients (e.g., lower ranges of blood
hypertension, breast cancer) tend to be aggregated in the pressure; border-line diabetes);
family. By screening the other members of the family (and 8. there is good evidence that early detection and
close relatives), the physician can detect additional cases. treatment reduces morbidity and mortality;
Epidemiologists have extended the concept of screening 9. the expected benefits (e.g., the number of lives saved)
for disease to screening for “risk factors”, as these factors of early detection exceed the risks and costs.
/ apparently antedate the development of actual disease. For
example, elevated serum cholesterol is associated with a When the above criteria are satisfied, then only, it would
high risk of developing coronary heart disease. Risk factors, be appropriate to consider a suitable screening test.
particularly those of a patho-physiological nature such as
serum cholesterol and blood pressure are amenable to Screening test
2 interventions. In this way, preventive measures can The test must satisfy the criteria of acceptability,
• applied before the disease occurs. Besides effectiveness, repeatability and validity, besides others such as yield,
economical use of resources will also occur if the screening simplicity, safety, rapidity, ease of administration and cost.
tests are selectively applied to individuals in high-risk group. Tests most likely to fulfil one condition may however, be
least likely to fulfil another - for example, tests with greater
c. Multiphasic screening accuracy may be more expensive and time consuming. The
It has been defined as the application of two or more choice of the test must therefore often be based on
screening tests in combination to a large number of people compromise.
at one time than to carry out separate screening tests for
single diseases. The procedure may also include a health 1. Acceptability
questionnaire, clinical examination and a range of Since a high rate of cooperation is necessary, it is
measurements and investigations (e.g., chemical and important that the test should be acceptable to the people at
haematological tests on blood and urine specimens, lung whom it is aimed. In general, tests that are painful,
function assessment, audiometry and measurement of visual discomforting or embarrassing (e.g., rectal or vaginal
acuity) - all of which can be performed rapidly with the examinations) are not likely to be acceptable to the
appropriate staffing organization and equipment (7). population in mass campaigns.

by R△J
•154____ SCREENING FOR DISEASE

2. Repeatability of histopathological specimens. Observer errors can be

An attribute of an ideal screening test or any minimized by (a) standardization of procedures for obtaining
measurement (e.g., height, weight) is its repeatability measurements and classifications (b) intensive training of all
(sometimes called reliability, precision or reproducibility). the observers (c) making use of two or more observers for
That is, the test must give consistent results when repeated independent assessment, etc. It is probable that these errors
more than once on the same individual or material, under can never be eliminated absolutely.
the same conditions. The repeatability of the test depends
B. Biological (subject) variation
upon three major factors, namely observer variation,
biological (or subject) variation and errors relating to There is a biological variability associated with many
technical methods. For example, the measurement of blood physiological variables such as blood pressure, blood sugar,
pressure is poorly reproducible because it is subjected to all serum cholesterol, etc. The fluctuation in the 'variate
these three major factors. measured in the same individual may be due to: (a) Changes
in the parameters observed: This is a frequent phenomena in
A. Observer variation clinical presentation. For example, cervical smears taken
All observations are subjected to variation (or error). from the same woman may be normal one day, and
These may be of two types: abnormal on another day. Myocardial infarction may occur
without pain. Subject variation of blood pressure is a
a. Intra-observer variation common phenomenon, (b) Variations in the way patients
perceive their symptoms and answer: This is a common
If a single observer takes two measurements (e.g., blood subject variation. There may be errors in recollection of past
pressure, chest expansion) in the same subject, at the same events when a questionnaire is administered. When the
time and each time, he obtained a different result, this is subject is aware that he is being probed, he may not give
termed as intra-observer or within-observer variation. correct replies. In short, subject variation can be a potential
This is variation between repeated observations by the same source of error in epidemiological studies, (c) Regression to
observer on the same subject or material at the same time. the mean: An important example of biological variability is
Intra-observer variation may often be minimized by taking regression to the mean. There is a tendency for values at the
the average of several replicate measurements at the same
extremes of a distribution, either very high or low, to regress
time.
towards the mean or average on repeat measurements.

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b. Inter-observer variation Many features of disease states vary considerably over time,
for example, the pain of rheumatoid arthritis, stopl
This is variation between different observers on the same frequency in ulcerative colitis, blood pressure in
subject or material, also known as between-observer hypertension or the blood glucose in diabetes. This concept
variation. Inter-observer variation has occurred if one is particularly important to remember in evaluating the
observer examines a blood-smear and finds malaria effects of a specific therapy on a variable such as the use df
parasite, while a second observer examines the same slide
a specific drug - to reduce blood pressure or serum
and finds it normal.
cholesterol.
Table 2 shows the results when 14,867 chest X-ray films Whereas observer variation may be checked by repeat
were each read independently by the same eight measurements at the same time, biological variation is tested
radiologists. by repeat measurements over time. This is due to the fact
TABLE 2 that measurement is done only on a tiny sample of the
normal distribution of the physiological variable.
Showing observer variation among radiologists
C. Errors relating to technical methods
“Positive” No.of films Per cent
readings Lastly, repeatability may be affected by variations
inherent in the method, e.g., defective instruments,
0/8 13,560 91.21 erroneous calibration, faulty reagents; or the test itself might
1/8 877 5.90 be inappropriate or unreliable. Where these errors are large,
2/8 168 1.13 repeatability will be reduced, and a single test result may be
3/8 66 44 unreliable.
4/8 42 .28 3. Validity (accuracy)
5/8 28 .19
The term validity refers to what extent the test
6/8 23 .16 accurately measures which it purports to measure. In other
7/8 39 26 words, validity expresses, the ability of a test to separate or
8/8 64 .43 distinguish those who have the disease from those who do
not. For example, glycosuria is a useful screening test for
14,867 100.00
diabetes, but a more valid or accurate test is the glucose
Source : (16) tolerance test. Accuracy refers to the closeness with which
measured values agree with “true” values.
The results shown in Table 2 are sobering and instructive. Validity has two components - sensitivity and specificity.
There was concurrence of all 8 readers that 91.21 per cent of When assessing the accuracy of a diagnostic test, one must
the films had one or more positive readings. consider both these components. Both measurements are
Observational errors are common in the interpretation of expressed as percentages. Sensitivity and specificity are
X-rays, ECG tracings, readings of blood pressure and studies usually determined by applying the test to one group of

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 CRITERIA FOR SCREENING 155
persons having the disease, and to a reference group not Sensitivity
having the disease (Table 3). Sensitivity and specificity, The term sensitivity was introduced by Yerushalmy. (17)
together with “predictive accuracy” are inherent properties in 1940s as a statistical index of diagnostic accuracy. It has
of a screening test. These are discussed below. been defined as the ability of a test to identify correctly all
TABLE 3-A those who have the disease, that is “true-positive”. A 90 per
cent sensitivity means that 90 per cent of the diseased
Screening test result by diagnosis people screened by the test will give a “true-positive” result
Diagnosis Total and the remaining 10 per cent a “false-negative” result.
Screening
test results Diseased Not diseased Specificity
Positive a (True-positive) b (False-positive) a+b It is defined as the ability of a test to identify correctly
those who do not have the disease, that is, “true-negatives”.
Negative c (False-negative) d (True-negative) c+d
A 90 per cent specificity means that 90 per cent of the non­
Total a+c b+d a+b+c+d diseased persons will give “true-negative” result, 10 per cent
of non-diseased people screened by the test will be wrongly
The letter “a” (Table 3-A) denotes those individuals classified as “diseased” when they are not.
found positive on the test who have the condition or To illustrate, let us compare the sensitivity and specificity
disorder being studied (i.e., true-positives). The group of EEG and CAT screening for diagnosis of brain tumours
labelled “b” includes those who have a positive test result (Tables 4 and 5).
but who do not have the disease (i.e., false-positives).
Group “c” includes those with negative test results but who It can be seen from Tables 4 and 5, the CAT screening test
havQ the disease (i.e., false-negatives). Finally, those with is both more sensitive and more specific than EEG in the
negative results who do not have the disease are included in diagnosis of brain tumours.
group “d” (i.e., true-negatives). In dealing with diagnostic tests that yield a quantitative
result (e.g., blood sugar, blood pressure) the situation is
Evaluation of a screening test different. There will be overlapping of the distributions of an
The following measures are used to evaluate a screening attribute for diseased and non-diseased persons (Fig. 3).
test: False positives and false negatives comprise the area of the

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overlap. When the distributions overlap, it is not possible to
(a) Sensitivity = a/ (a + c) x 100 correctly assign individuals with these values to either the
fb) Specificity = d/(b + d) x 100 normal or the diseased group on the basis of screening alone.
(c) Predictive value of a positive test = a/(a + b) x 100 For example, if we decide to use the 2-hour post-prandial
Jd) Predictive value of a negative test = d/(c + d) x 100 blood glucose level of 180 mg/100 ml as an index of the
presence of diabetes mellitus, the sensitivity and specificity
• (e) Percentage of false-negatives = c/(a 4- c) x 100 are 50 and 99.8 per cent respectively (Table 6). In other
(f) Percentage of false-positive = b/(b + d) x 100 words, sensitivity is low, but specificity very high. Further it
will be seen from Table 6 that sensitivity and specificity are
Let us rewrite Table 3-A substituting hypothetical figures inversely related. That is, sensitivity may be increased only
(Table 3-B) and calculate the above measures: at the expense of specificity and vice versa. An ideal
screening test should be 100 per cent sensitive and
TABLE 3-B 100 per cent specific. In practice, this seldom occurs.
Screening test result by diagnosis TABLE 4
Diagnosis of brain tumours by EEG
Screening Diagnosis
j. Brain tumour
test results Diseased Not diseased EEG results
Present Absent
Positive 40 20 60 ■
(a) (b) (a+b) Positive 36 54,000
Negative 100 Negative 4 306,000
9,840 9,940
(C) (d) (c + d) 40 360,000
r
140 9,860 10,000 Sensitivity = 36/40 x 100 = 90 per cent
(a + c) (b + d) (a + b + c + d) Specificity = 306,000/360,000 x 100 = 85 per cent
TABLE 5
(a) Sensitivity = (40/140) x 100 = 28.57%
Diagnosis of brain tumours by computer assisted axial
(true-positive)
tomography
(b) Specificity = (9840/9860) x 100 = 99.79%
(true-negative) Brain tumour
CAT results
(c) False-negative = (100/140) x 100 = 71.4% Present Absent
Positive 39 18,000
(d) False-positive = (20/9860) x 100 = 0.20% 342,000
Negative 1
(e) Predictive value ■■= (40/60) x 100 = 66.66% 40 360,000
of a positive test
(f) Predictive value ■ = (9840/9940) x 100 = 98.9% > Sensitivity = 39/40 x 100 = 97.5 per cent
of a negative test Specificity = 342,000/360,000 x 100 = 95 per cent

by R△J
156 SCREENING FOR DISEASE

TABLE 6 False negatives and positives

Sensitivity and specificity of a 2-hour postprandial blood Whereas the epidemiologist thinks in terms of sensitivity
test for glucose for 70 true diabetics and 510 true non­ and specificity, the clinician thinks in terms of false negatives
diabetics at different levels of blood glucose and false positives.
Blood glucose Sensitivity Specificity False-negatives: The term “false-negative” means that
level (mg/100 ml) patients who actually have the disease are told that they do
not have the disease. It amounts to giving them a “false
80 100.0 1.2 reassurance”. The patient with a “false-negative” test result
90 98.6 7.3 might ignore the development of signs and symptoms and
100 97.1 25.3 may postpone the treatment. This could be detrimental if the
110 92.9 48.4 disease in question is a serious one and the screening test is
120 88.6 68.2 unlikely to be repeated within a short period of time. A
130 81.4 82.4 screening test which is very sensitive has few “false
140 74.3 91.2 negatives”. The lower the sensitivity, the larger will be the
150 64.3 number of false negatives.
96.1
160 55.7 98.6 False-positives: The term “false-positive” means that
170 52.9 99.6 patients who do not have the disease are told that they have
180 50 0
the disease. In this case, normal healthy people may be
99.8
subjected to further diagnostic tests, at some inconvenience,
190 44.3 99.8
discomfort, anxiety and expense - until their freedom from
200 37 1 100.0 disease is established. A screening test with a high specificity
Source : (18) will have few false positives. False-positives not only bilrden
the diagnostic facilities, but they also bring discredit to
Predictive accuracy screening programmes.
In addition to sensitivity and specificity, the performance In fact, no screening test is perfect, i.e., 100 per cent
of a screening test is measured by its “predictive value” sensitive and 100 per cent specific.
which reflects the diagnostic power of the test. The predictive
accuracy depends upon sensitivity, specificity and disease Yield

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prevalence. The “predictive value of a positive test” indicates “Yield” is the amount of previously unrecognized disease
the probability that a patient with a positive test result has, in that is diagnosed as a result of the screening efforts It
fact, the disease in question. The more prevalent a disease is depends upon many factors, viz. sensitivity and specificity of
in a given population, the more accurate will be the the test, prevalence of the disease, the participation of the
predictive value of a positive screening test. The predictive individuals in the detection programme. For example, by
value of a positive result falls as disease prevalence declines. limiting a diabetes screening programme to persons over
Table 7 shows the predictive value of positive Gram’s 40 years, we can increase the yield of the screening test.
stained cervical smear test to detect gonorrhoea at High-risk populations are usually selected for screening, thus
prevalences of 5,15 and 25 per cent. In this example, the increasing yield.
predictive value of a positive test was calculated to be 21, 47
Combination of tests
and 63 per cent respectively. Thus in female populations in
which the gonorrhoea is low (5 per cent prevalence), only Two or more tests can be used in combination to enhance
21 per cent of patients with positive results really have the specificity or sensitivity of screening. For example, syphilis
gonorrhoea; the remaining 79 per cent have false-positive screening affords an example whereby all screenees are first
results. Furthermore, as the sensitivity of this test is only evaluated by an RPR test. This test has high sensitivity, yet will
50 per cent, half of the cases are not detected, which greatly yield false positives. However, all those positive to RPR are
reduces the impact of the detection programme on disease then submitted to FTA-ABS, which is a more specific test, and
transmission. the resultant positives now truly have syphilis.

TABLE 7
Predictive value of a positive gram-stained cervical smear test
(with constant sensitivity of 50% and specificity of 90%) at three levels of prevalence

Prevalence 5% Prevalence 15% Prevalence 25%

Culture Culture Culture

+ - Total + - Total + - Total

Smear + 25 95 120 Smear + 75 85 160 Smear + 125 75 200

-25 855 880 -75 765 840 -125 675 800

Total 50 950 1000 Total 150 850 1000 Total 250 750 1000

Positive 25 X 100 21% Positive 75 Positive 125

predictive = predictive ttk X 47% predictive y100_ 63%
120 X1‘
value value 160 value ZUU

by R△J
 CRITERIA FOR SCREENING
157
The problem of the borderline (20) blood glucose is lowered to detect diabetes (say less than
120 mg per cent), the sensitivity of the test is increased at
The question arises which of the two qualities (sensitivity
the cost of specificity. If the cut-off point is raised (say to
or specificity) is more important in screening? No categorical
180 mg per cent), the sensitivity is decreased (Table 6). In
answer can be given. Figure 3 illustrates graphically the
other words, there is no blood sugar level which will ensure
concepts of sensitivity and specificity.
the separation of all those with the disease from those
Figure 3-a is a bimodal distribution of a variable in the without the disease.
“normal” /and “diseased” populations. Note that the two
In screening for disease, a prior decision is made about
curves overlap. If the disease is bimodal, as may be
the cut-off point, on the basis of which individuals are
expected in certain genetically transmitted characteristics
classified as “normal” or “diseased”. In making this decision,
such as phenylketonuria, the shaded area or the “border­
the following factors are taken into consideration:
line” group will comprise a mixture of persons with the
(a) Disease prevalence: When the prevalence is high in the
disease and persons without the disease (i.e., a mixture of
community, the screening level is set at a lower level, which
false positives and false negatives). The point at which the
will increase sensitivity, (b) The disease: If the disease is very
distributions intersect (i.e., at level E) is frequently used as lethal (e.g., cervical cancer, breast cancer) and early
the cut-off point between the “normal” and “diseased” detection markedly improves prognosis, a greater degree of
persons, because it will generally minimize the false positives sensitivity, even at the expense of specificity, is desired. In
and false negatives. these cases, subsequent diagnostic work-up can be relied on
Figure 3-b is a unimodal distribution. Many physiological to rule out the disease in the false-positives. That is, a
variables such as blood pressure, blood sugar and serum proportion of false-positives is tolerable but not false-
cholesterol show this type of distribution. Their values are negatives. On the other hand, in a prevalent disease like
continuously distributed around the mean, confirming to a diabetes for which treatment does not markedly alter
normal or skewed distribution. In these observations, there outcome, specificity must be high and early cases may be
is no sharp dividing line between the “normal” and missed, but false-positives should be limited; otherwise the
“diseased”. The “borderline” group (C-D) will comprise a health system will be overburdened with diagnostic
homogeneous sample of persons. The question arises demands on the positives, both true and false. That is, high
whether the cut-off point between “disease” and “normality” specificity is necessary when false-positive errors must be
should be set at C or D as in Figure 3-b. If the cut-off point avoided. A useful index in making this decision is the

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is set at the level of A or C, it will render the test highly predictive value of a positive test. This index measures the
sensitive, missing few cases but yielding many false percentage of positive results that are true positives; it is a
positives. If the cut-off point is set at B or D, it will increase function of the sensitivity and specificity as well as the
specificity of the test. Furthermore, in the unimodal frequency of the disease.
distribution, once a cut-off point level has been adopted, There are various other points which must also be taken
all persons above that level (i.e., above level C or D in into account in screening. First, people who participate in
Figure 3-b) would be regarded as “diseased”. the screening programme may not be those who have most
Taking diabetes as our example, if the cut-off point for to gain from it, as for example, those at greatest risk of
cancer of the cervix uteri are least likely to attend for
(a) BIMODAL DISTRIBUTION
cervical cytology. Therefore screening must be applied
selectively to those people most likely to benefit. Selection
might be based on a person’s age, sex, medical history,
occupation, family history or other factors. Secondly, tests
with greater accuracy may be more expensive and time­
consuming, and the choice of the test therefore often be
based on compromise. Thirdly, screening should not be
developed in isolation; it should be integrated into the
existing health services. Lastly, the risks as well as the
expected benefits must be explained to the people to be
screened. These risks include any possible complications of
the examination procedures, and the possibility of false­
positive and false-negative test results.
Regardless of the approach taken to screening tests,
(b) UNIMODAL DISTRIBUTION regular patient follow-up visits are important (not to leave
the patients high and dry) if effective health and medical
care are to result from the effort. Garfield (21) has stressed
the need to meet demands for medical care by separating
screenees into well, asymptomatic-sick, and sick groups.
This separation makes possible the optimal use of health
care services.
Evaluation of screening programmes
Many screening tests (Table 8) were introduced in the
past without subjecting them to rigid scrutiny. They were
introduced because it was thought a good thing to detect
and treat cases before they should reach an advanced stage.
The modern view is that new screening programmes should
be introduced only after proper evaluation.

by R△J
158 SCREENING FOR DISEASE

TABLE 8 uncontrolled studies of cervical cancer screening which

Some screening tests indicated that deaths from that disease could be very much
reduced if every woman was examined periodically.
Pregnancy Infancy
(3) Other methods: There are also other methods of
Anaemia LCB evaluation such as case control studies and comparison in
Hypertension Toxaemia Congenital dislocation of hip
trends between areas with different degrees of screening
coverage. Thus it can be determined whether intervention
Rh status Congenital heart disease by screening is any better than the conventional method of
Syphilis (VDRL Test) Spina bifida managing the disease.
*
Diabetes Cerebral palsy To conclude, the screening concept, filled with potential
Cardiovascular disease Hearing defects has been overburdened with problems, many of which
remain unsolved. The construction of accurate tests that are
Neural tube defects Visual defects
both sensitive and specific is a key obstacle to the wide
Down’s syndrome Hypothyroidism application of screening. Scientific and technical puzzles
HIV Developmental screening tests abound.
Haemoglobinopathies
References
Middle-aged men and women Sickle cell anaemia
1. Reiser, S.J. (1980). World Health Forum, 1 (1 and 2) 99-103.
Hypertension Undescended testis 2. Blumberg, M.S. (1966). In: Chronic Diseases and Public Health, A.M.
Cancer Elderly Lilienfeld, et al (eds). Johns Hopkins.
3. WHO (1980). Early detection of handicap in children, EURO Reports
Diabetes mellitus Nutritional disorders and Studies No.30.
Serum cholesterol Cancer 4. Cochrane, A.L. and Holland, W.w. (1971). Br.Med.Bull, 27:3.
5. McKeown, T. et al (1968). Screening in Medical Care, Reviewing the
Obesity Tuberculosis evidence for Nuffield Provincial Hospital Trust, London and Oxford.
Chronic bronchitis 6. Last, J.M. ed (1980). A Dictionary of Epidemiology, Oxford University
Press.
Glaucoma
7. Whitby, L.G. (1974), Lancet, 2:819-821.

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Cataract 8. Rakel, R.E. (1977). Principles of Family Medicine, Saunders.
9. WHO (19S1).WorldHealth Forum, 2:294.
(1) Randomized controlled trials: Ideally evaluation 10. South-East London Screening Study Group (1977).
should be done by a randomized controlled trial in which Int. J.Epidemiology, 6:357.
one group (randomly selected) receives the screening test, 11. Collen, M. (1978). Multiphasic health testing services, New York,
and a control which receives no such test. Ideally RCT Wiley.
should be performed in the setting where the screening 12. Wilson, J.M.G. and Jungner, G. (1968). Principles and Practice-or
Screening for Disease, Pub. Hlth. Paper No.34, Geneva; WHO.
programme will be implemented, and should employ the 13. WHO (1971). Mass Health Examinations, P.H. Paper No.45.
same type of personnel, equipment and procedures that will 14. Roberts, C.J. (1977). Epidemiology for Clinicians, Pitman Medical.
be used in that programme. If the disease has a low 15. WHO (1980). World Health Forum, 1:105..
frequency in the population, and a long incubation period 16. Yerushalmy, J. (1956). BullInt.Union Tuberculosis, 26:110-124.
(e.g., cancer) RCT may require following tens of thousands 17. Yerushalmy, J. (1947). Pub.Hlth.Rep.,62:1432.
of people for 10-20 years with virtually perfect record 18. Lilienfeld, A.M. and D.Lilienfeld (1979). Foundations of
keeping. The cost and logistics are often prohibitive. Epidemiology, 2nd ed. New York, Oxford Publications.
19. Grant, A and Mohide, P (1982). In: Effectiveness and Satisfaction in
(2) Uncontrolled trials: Sometimes, uncontrolled trials are Antenatal Care, M. Ekin and I. Chalmers (eds). Heinemann, London.
used to see if people with disease detected through 20. Le Riche, W.H. and Jean Milner (1971). Epidemiology as Medical
screening appear to live longer after diagnosis and treatment Ecology, Churchill Livingstone.
than patients who were not screened. One such example is 21. Garfield, S.R. (1970). N. Eng. J. Med., 283:1087.

by R△J
1 5 Epidemiology of
Communicable Diseases
“Infectious diseases will last as long as humanity itself”

(i.e. all are vesicles or all are pustules) on any given part of
I. RESPIRATORY INFECTIONS the body (e.g. the face or arm)
AND
SMALLPOX No alternative diagnosis explaining the illness
(VARIOLA)
AND
An acute infectious disease caused by variola virus, and Laboratory confirmation.
clinically characterized by a sudden onset of fever,
headache, backache, vomiting and sometimes convulsions, Smallpox eradication surveillance
especially in children. On the third day of fever, a typical
rash appears which is centrifugal in distribution and passes Despite the absence of smallpox, surveillance of
“rumours” continues in order to sustain public confidence in

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through successive stages of macule, papule, vesicle,
pustule, and scab with subsequent scarring. the eradication of the disease. However, the final chapter of
the smallpox story remains to be written, as the smallpox
Previously, it was one of the greatest killer disease. In virus has not been completely destroyed. Stocks are still held
1967, WHO began an intensified worldwide campaign to at government research centres in the Russian Federation
eradicate smallpox, based on the technique of surveillance
and at the United States.
and containment. The last known case of smallpox in India
occurred on 24th May 1975. India was declared smallpox References
free on 5th July 1975. The eradication of smallpox was
1. WHO (1980), The Global Eradication of Smallpox, Final Report,
confirmed in April 1977 by an international commission. Geneva.
The World Health Assembly confirmed the global 2. WHO (2009), Weekly Epidemiological Record, No. 7, Feb 13, 2009.
eradication of smallpox in May 1980. All countries have
discontinued routine vaccination against smallpox.
However, WHO maintains a reserve stock of smallpox HUMAN MONKEYPOX
vaccine and vaccination needles - sufficient to protect more
than 200 million people, should an emergency arise (1). Monkeypox is a viral zoonosis (a virus transmitted to
humans from animals) with symptoms similar to those seen
Case definition for notification of smallpox under in the past in smallpox patients, although it is clinically less
the International Health Regulations, 2005 (2) severe. With the eradication of smallpox in 1980 and
Member states to the IHR (2005) are required to notify to subsequent cessation of smallpox vaccination, monkeypox
WHO immediately of any confirmed case of smallpox. The has emerged as the most important orthopoxvirus for public
case definition for a confirmed smallpox case includes the health. Monkeypox primarily occurs in central and west
following : Africa, often in proximity to tropical rainforests, and
has been increasingly appearing in urban areas. Animal
Confirmed case of smallpox hosts include a range of rodents and non-human
An individual of any age presenting with acute onset of primates (1).
fever (>38.3°C/101°F), malaise, and severe prostration
with headache and backache occurring 2-4 days before Problem statement
onset of rash Monkeypox is a disease of global public health
AND importance as it not only affects countries in west and
central Africa, but also the rest of the world. In 2003, the first
Subsequent development of a maculopapular rash
monkeypox outbreak outside of Africa was in the United
starting on the face and forearms then spreading to the trunk
States of America and was linked to contact with infected
and legs, and evolving within 48 hours to deep-seated, firm
or hard and round well-circumscribed vesicles, and later pet prairie dogs. This outbreak led to over 70 cases of
pustules, which may become umbilicated or confluent monkeypox in the U.S. Monkeypox has also been reported
in travelers from Nigeria to Israel in September 2018, to the
AND United Kingdom in September 2018, December 2019, May
Lesions that appear at the same stage of development 2021 and May 2022, to Singapore in May 2019, and to the

by R△J
160 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

United States of America in July and November 2021. In asthenia. Lymphadenopathy is a distinctive feature of
May 2022, multiple cases of monkeypox were identified in monkeypox compared to other diseases that may initially
several non-endemic countries. Studies are currently appear similar (chickenpox, measles, smallpox).
underway to further understand the epidemiology, sources • the skin eruption usually begins within 1-3 days of
of infection, and transmission patterns. appearance of fever. The rash tends to be more
concentrated on the face and extremities rather than on
Agent factor the trunk. It affects the face (in 95 per cent of c&ses), and
Monkeypox virus is an enveloped double-stranded DNA palms of the hands and soles of the feet (in 75 per cent
virus that belongs to the Orthopoxvirus genus of the of cases). Also affected are oral mucous membranes (in
Poxuiridae family. There are two distinct genetic clades of 70 per cent of cases), genitalia (30 per cent), and
the monkeypox virus : the. central African (Congo Basin) conjunctivae (20 per cent), as well as the cornea. The
clade and the west African clade. The Congo Basin clade rash evolves sequentially from macules (lesions with a
has historically caused more severe disease and was thought flat base) to papules (slightly raised firm lesions), vesicles
to be more transmissible. The geographical division between (lesions filled with clear fluid), pustules (lesions filled
the two clades has so far been in Cameroon, the only with yellowish fluid), and crusts which dry up and fall off.
country where both virus clades have been found. The number of lesions varies from a few to several
thousand. In severe cases, lesions can coalesce until
Natural host large sections of skin slough off.
Various animal species have been identified as Monkeypox is usually a self-limited disease with the
susceptible to monkeypox virus. This includes rope squirrels, symptoms lasting from 2 to 4 weeks. Severe cases qccur
tree squirrels, Gambian pouched rats, dormice, non-human more commonly among children and are related to the
primates and other species. Uncertainty remains on the extent of virus exposure, patient health status and nature of
natural history of monkeypox virus and further studies are complications. Underlying immune deficiencies may lead to
needed to identify the exact reservoir(s) and how virus worse outcomes. Although vaccination against smallpox was
circulation is maintained in nature. protective in the past, today persons younger than 40 to 50
years of age (depending on the country) may be more

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Transmission of disease (1, 2) susceptible to monkeypox due to cessation of smallpox
Animal-to-human (zoonotic) transmission can occur from vaccination campaigns globally after eradication of the
direct contact with the blood, bodily fluids, or cutaneous or disease. Complications of monkeypox can include
mucosal lesions of infected animals. Eating inadequately secondary infections, bronchopneumonia, sepsis,
cooked meat and other animal products of infected animals encephalitis, and infection of the cornea with ensuing loss of
is a possible risk factor. People living in or near forested vision. The extent to which asymptomatic infection may
areas may have indirect or low-level exposure to infected occur is unknown. The case fatality ratio has been around
animals. 3-6 per cent (1).
Human-to-human transmission can result from close
contact with respiratory secretions, skin lesions of an Diagnosis
infected person, or recently contaminated objects. Polymerase chain reaction (PCR) is the preferred
Transmission via droplet respiratory particles usually laboratory test given its accuracy and sensitivity. For this,
requires prolonged face-to-face contact, which puts health optimal diagnostic samples for monkeypox are from skin
workers, household members and other close contacts of lesions - the roof or fluid from vesicles and pustules, and dry
active cases at greater risk. However, the longest crusts. Where feasible, biopsy is an option.
documented chain of transmission in a community has risen
in recent years from 6 to 9 successive person-to-person Treatment
infections. This may reflect declining immunity in all Clinical care for monkeypox should be fully optimized to
communities due to cessation of smallpox vaccination. alleviate symptoms, manage complications and prevent
Transmission can also occur via the placenta from mother to long-term sequelae. Patients should be offered fluids and
fetus (which can lead to congenital monkeypox) or during food to maintain adequate nutritional status. Secondary
close contact during and after birth. While close physical bacterial infections should be treated as indicated. An
contact is a well-known risk factor for transmission, studies antiviral agent known as tecovirimat that was developed for
are needed to better understand this risk, if monkeypox can smallpox was licensed by the European Medical Association
be transmitted specifically through sexual transmission (EMA) for monkeypox in 2022 based on data in animal and
routes (1,2). human studies. It is not yet widely available.
Incubation period
Vaccination
The incubation period of monkeypox is usually from 6 to
13 days, but can range from 5 to 21 days. Vaccination against smallpox was demonstrated through
several observational studies to be about 85 per cent
Clinical picture effective in preventing monkeypox. Prior smallpox
vaccination may result in milder illness. A still newer vaccine
The infection can be divided into two periods : based on a modified attenuated vaccinia virus (Ankara
• the invasion period (lasts between 0-5 days) strain) was approved for the prevention of monkeypox in
characterized by fever, intense headache, 2019 (1). This is a two-dose vaccine for which availability is
lymphadenopathy, back pain, myalgia and intense limited.
by R△J
 CHICKENPOX

Prevention (1) In India, during the year 2020, about 29,481 cases of
chickenpox were reported with 15 deaths. The case fatality
Raising awareness of risk factors and educating people
rate was about 0.050 per cent. Kerala reported the highest
about the measures they can take to reduce exposure to the
number of cases (17,086) and West Bengal reported the
virus is the main prevention strategy for monkeypox. maximum number of deaths (8) due to chickenpox (3).
Scientific studies are now underway to assess the feasibility
and appropriateness of vaccination for the prevention and Epidemiological determinants
control of monkeypox. Some countries have, or are
developing, policies to offer vaccine to persons who may be Agent factors
at risk such as laboratory personnel, rapid response teams (a) AGENT : The causative agent of chickenpox, V-Z virus
and health workers. is also called “Human (alpha) herpes virus 3”. Primary
infection causes chickenpox. Recovery from primary
Reducing the risk of human-to-human infection is commonly followed by the establishment of latent
transmission (1) infection in the cranial nerves, sensory, ganglia, and spinal
Surveillance and rapid identification of new cases is dorsal root ganglia, often for decades, without clinical
critical for outbreak containment. During human manifestations. When the cell-mediated immunity wanes with
monkeypox outbreaks, close contact with infected persons is age or following immuno-suppressive therapy, the virus may
the most significant risk factor for monkeypox virus reactivate, resulting in herpes zoster in about 10-30 per cent
infection. Health workers and household members are at a of persons (4). It is, a painful, vesicular, pustular eruption in
greater risk of infection. Health workers caring for patients the distribution of one or more sensory nerve roots. The virus
with suspected or confirmed monkeypox virus infection, or can be grown in tissue culture, (b) SOURCE OF INFECTION:
handling specimens from them, should implement standard Usually a case of chickenpox. The virus occurs in the
infection control precautions. If possible, persons previously oropharyngeal secretions and lesions of skin and mucosa.
vaccinated against smallpox should be selected to care for Rarely the source of infection may be a patient with herpes
the patient. zoster. The virus can be readily isolated from the vesicular
fluid during the first 3 days of illness. The scabs however are
References not infective (5). (c) INFECTIVITY: The period of
communicability of patients with varicella is estimated to

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1. WHO (2022), Fact sheet on Monkeypox, 19th May 2022.
2. CDC (2022), Monkeypox, How it spreads.
range from 1 to 2 days before the appearance of rash, and
4 to 5 days thereafter (5). The virus tends to die out before the
pustular stage (6). The patient ceases to be infectious once
CHICKENPOX the lesions have crusted, (d) SECONDARY ATTACK
(VARICELLA) RATE: Varicella is a highly contagious disease with secondary
attack ratio of approximately 85 per cent (range between
Chickenpox or varicella is an acute, highly infectious 61 per cent to 100 per cent) in susceptible household
disease caused by varicella-zoster (V-Z) virus. It is contacts. Herpes zoster is approximately 20 per cent as
characterized by vesicular rash that may be accompanied by infectious as chickenpox; in susceptible people, contact with
fever and malaise. It is worldwide in distribution and occurs herpes zoster rash causes varicella, not herpes zoster (9).
in both epidemic and endemic forms. Chickenpox and Host factors
herpes zoster are now regarded as different host responses to
the same aetiological agent. Inoculation of zoster vesicle (a) AGE : Chickenpox occurs primarily among children
fluid into children produces chickenpox, and children who under 10 years of age. Few persons escape infection until
have recovered from zoster virus related infection are adulthood. The disease can be severe in normal adults,
resistant to varicella (1). (b) IMMUNITY : One attack gives durable immunity; second
attacks are rare. The acquisition of maternal antibody
Problem Statement protects the infant during the first few months of life. No
age, however, is exempt in the absence of immunity. The
Based on conservative estimates, the global annual IgG antibodies persist for life and their presence is correlated
chickenpox disease burden includes 4.2 million severe with protection against varicella. The cell-mediated
complications leading to hospitalization and 4,200 deaths. immunity appears to be important in recovery from V-Z
In the pre-vaccine era in high-income developed countries, infections and in protection against the reactivation of latent
case fatality rate was about 3 per lac cases compared to V-Z virus (8). (c) PREGNANCY : Infection during pregnancy
1-3 per 1000 cases for measles. Factors which influence the presents a risk for the foetus leading to congenital varicella
severity of disease and outcome in populations include the syndrome. It occurs in 0.4-2.0 per cent of children born to
proportion of cases among infants, pregnant women and mothers who become infected with VZV during the first 20
other adults, the prevalence of immunocompromising weeks of gestation. Infants, whose mothers had chickenpox
conditions including HIV infections and the extent of access during pregnancy, have a higher risk of developing herpes
to care and appropriate treatment. In otherwise healthy zoster in the first years of life (2).
children, the disease is usually self-limiting (2).
The incidence and severity of herpes-zoster disease Environmental factors
increases with age, with marked increase after 50 years of Chickenpox shows a seasonal trend in temperate settings
age, which correlates with ageing related decline in cell- and in most tropical settings, with peak incidence during
mediated immunity. Among adults who reach 85 years of winter and spring, or in coolest, driest months in the tropics.
age, it is estimated that approximately half will have suffered Periodic large outbreaks occur with an inter-epidemic cycle
atleast one episode of herpes zoster (2). of 2-5 years (2)

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

VZV is heat labile. Outside host cell, the virus survives in TABLE 1
the external environment for only a few hours, occasionally Differences between smallpox and chickenpox
for a day or two, and it is readily inactivated by lipid
Smallpox Chickenpox
solvents, detergents, and proteases (2).
1. Incubation:
Transmission About 12 days About 15 days
(range: 7-17 days). (range 7-21 days)
Chickenpox is transmitted from person to person by
droplet infection and by droplet nuclei. Most patients are 2. Prodromal symptoms:
infected by “face-to-face” (personal) contact. The portal of Severe. Usually mild.
entry of the virus is the upper respiratory tract or the 3. Distribution of rash :
conjunctiva. Since the virus is extremely labile, it is unlikely (a) centrifugal (a) centripetal
that fomites play a significant role in its transmission. (b) palms and soles frequently (b) seldom affected
Contact infection undoubtedly plays a role when an involved
individual with herpes zoster is an index case. The virus can (c) axilla usually free (c) axilla affected
cross the placental barrier and infect the foetus, a condition (d) rash predominant on (d) rash mostly on flexor
extensor surfaces and surfaces.
known as congenital varicella. bony prominences.
Incubation period 4. Characteristics of the rash:
(a) deep-seated (a) superficial
Usually 14 to 16 days, although extremes as wide as 10 to (b) vesicles multilocular and (b) unilocular; dew-drop like
21 days have been reported. umbilicated appearance
(c) only one stage of rash may (c) rash pleomorphic, i.e.,
Clinical features be seen at one time different stages of the rash
The clinical spectrum of chickenpox may vary from a evident at one given time,
because rash appears in
mild illness with only a few scattered lesions to a severe
successive crops
febrile illness with widespread rash. Inapparent infection is (d) an area of inflammation is
(d) No area of inflammation is
estimated to occur in no more than 5 per cent of susceptible seen around the vesicles. seen around the vesicles.
children (7). In the majority of cases, the disease tends to be

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mild and typical (6). The clinical course of chickenpox may 5. Evolution of rash ■
(a) evolution of rash is slow, (a) evolution of rash very rapid
be divided into two stages : deliberate and majestic,
(A) PRE-ERUPTIVE STAGE : Onset is sudden with mild passing through definite
or moderate fever, pain in the back, shivering and malaise. stages of macule, papule,
vesicle and pustule.
This stage is very brief, lasting about 24 hours. In adults, the
prodromal illness is usually more severe and may last for (b) scabs begin to form 10-14 (b) scabs begin to form 4-7
days after the rash appears days after the rash appears
2-3 days before the rash comes out (6).
6. Fever:
(B) ERUPTIVE STAGE : In children the rash is often the Fever subsides with the Temperature rises with each
first sign. It comes on the day the fever starts. The distinctive appearance of rash, but fresh crop of rash.
features of the rash are : may rise again in the
(a) Distribution : The rash is symmetrical. It first appears pustular stage (secondary
rise of fever)
on the trunk where it is abundant, and then comes on the
face, arms and legs where it is less abundant. Mucosal Complications
surfaces (e.g., buccal, pharyngeal) are generally involved.
In most cases, chickenpox is a mild, self-limiting disease.
Axilla may be affected, but palms and soles are not usually
The mortality is less than 1 per cent in uncomplicated cases.
affected. The density of the eruption diminishes
centrifugally. However, varicella may be accompanied by severe
complications particularly in immunosuppressed patients and
(b) Rapid evolution : The rash advances quickly through may also occur in normal children and adults. These include
the stages of macule, papule, vesicle and scab. In fact, the haemorrhages (varicella haemorrhagical), pneumonia,
first to attract attention are often the vesicles filled with clear encephalitis, acute cerebellar ataxia and Reye’s syndrome
fluid and looking like “dew-drops” on the skin. They are (acute encephalopathy associated with fatty degeneration of
superficial in site, with easily ruptured walls and surrounded the viscera especially liver) (10). Varicella pneumonia is rare in
by an area of inflammation. Usually they are not healthy children but is the most common complication in
umbilicated. The vesicles may form crusts without going neonates, adults and immuno-compromised patients. It is
through the pustular stage. Many of the lesions may abort. related to many varicella-related deaths. Maternal varicella
Scabbing begins 4 to 7 days after the rash appears. during pregnancy may cause foetal wastage and birth defects
(c) Pleomorphism : A characteristic feature of the rash in such as cutaneous scars, atrophied limbs, microcephaly and
chickenpox is its pleomorphism, that is, all stages of the rash low birth weight, cataract, microphthalmia, chorioretinitis,
(papules, vesicles and crusts) may be seen simultaneously at deafness and cerebro-cortical atrophy. If varicella develops in
one time, in the same area. This is due to the rash appearing a mother within 5 days after delivery, the newborn is at risk of
in successive crops for 4 to 5 days in the same area. disseminated disease and should receive varicella-zoster
immunoglobulin (4). The virus has a potential for oncogenicity.
(d) Fever : The fever does not run high but shows
exacerbations with each fresh crop of eruption. Varicella-zoster virus is the major virus associated with
acute retinal necrosis and progressive outer retinal necrosis,
The main points of difference between chickenpox and both of which occur with increased frequency among AIDS
smallpox are given in Table 1. patients (4).

by R△J
 CHICKENPOX

Secondary bacterial infections, particularly with group A currently recommended for children between 12-18 months
P-haemolytic streptococci and staphylococcus aureus are of age who have not had chickenpox.
common. Cellulitis, erysipelas, epiglottitis, osteomyelitis, Recommendations on dosage and interval between doses
scarlet fever and rarely meningitis are observed. Pitted scars vary by manufacturer. Monovalent vaccine can be
are frequent sequelae. administered following one or two dose schedule (0.5 ml
Immunocompromised patients are at increased risk of each by subcutaneous injection. A 2 dose schedule is
complications of varicella, including those with recommended for all persons aged >13 years. When 2 doses
malignancies, organ transplants or HIV infection and those are administered, the minimum interval between doses is
receiving high doses of corticosteroids. Disseminated from 4 weeks to 3 months for children (12 months to
intravascular coagulation may occur which is rapidly fatal. 12 years of age inclusive), and 4 or 6 weeks for adolescents
Children with leukaemia are especially prone to develop and adults (13 years of age and older).
severe disseminated varicella-zoster virus disease (1). Combination vaccines (MMRV) can be administered to
children from 9 months to 12 years. If 2 doses of MMRV are
Laboratory diagnosis used, the minimum interval between doses should be
During the smallpox post-eradication era the diagnosis of 4 weeks. It is preferred that the 2nd dose be administered
chickenpox is of great importance because of its from 6 weeks to 3 months after the first dose or at 4-6 years
resemblance to mild smallpox. Laboratory diagnosis is rarely of age (2).
required as clinical signs are usually clear-cut. The duration of immunity is not known but is probably 10
Laboratory confirmation of varicella or herpes zoster years. Although the vaccine is very effective in preventing
(HZ) is by detecting VZV DNA using polymerase chain disease, breakthrough infections do occur - but are much
reaction (PCR) or isolating VZV in cell culture from vesicular milder than in unvaccinated individuals (usually less than 50
fluid, crusts, saliva, cerebrospinal fluid or other specimens. lesions, with milder systemic symptoms). Although the
Direct immunofluorescence can also be used for rapid vaccine is very safe, adverse reactions can occur as late as
testing though this method has lower sensitivity than PCR. 4-6 weeks after vaccination. Tenderness and erythema at the
Detection of VZV-specific serum IgM antibody is injection site are seen in 25%, fever in 10-15%, and a
considerably less sensitive than PCR and is not the method localized maculopapular or vesicular rash in 5%; a smaller
of choice for confirming varicella. Detection of serum IgM percentage develops a diffuse rash, usually with five, or fewer

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and PCR are of limited value for the confirmation of HZ. vesicular lesions.
Serologic screening of serum for IgG antibodies is used to Spread of virus from vaccinees to susceptible individuals
assess immunity or susceptibility to varicella in unvaccinated is possible, but the risk of such transmission even to
persons, e.g. in health-care workers (2). immuno-compromised patients is small, and disease, when it
develops, is mild and treatable with acyclovir. Nonetheless,
Control the vaccine, being a live attenuated virus, should not be
The usual control measures are notifications, isolation of given to immunocompromised individuals. The use of
cases for about 6 days after onset of rash and disinfection of varicella vaccine may be considered in clinically stable HIV-
articles soiled by nose and throat discharges (11). infected children or adults with CD4+ T-cell levels > 15 per
Several antiviral compounds provide effective therapy for cent including those receiving highly active antiretroviral
varicella including acyclovir, valaciclovir, famiciclovir and therapy. HIV testing is not a prerequisite for varicella
foscarnet. Acyclovir can prevent the development of systemic vaccination (2). It is contraindicated in persons allergic to
disease in varicella-infected immunosuppressed patients and neomycin. For theoretic reasons, it is recommended that
can halt the progression of zoster in adults. Acyclovir does not following vaccination, salicylates should be avoided for 6
appear to prevent post herpic neuralgia (1). weeks (to prevent Reye’s syndrome).
Varicella vaccination is contraindicated during pregnancy
Prevention and pregnancy should be delayed for 4 weeks after vaccination.
Termination of pregnancy is not indicated if vaccination was
1. VARICELLA-ZOSTER IMMUNOGLOBULIN (VZIG) carried out inadvertently during pregnancy (9).
Varicella-Zoster Immunoglobulin (VZIG) given within
72 hours of exposure has been recommended for prevention POST-EXPOSURE PROPHYLAXIS
of chickenpox in exposed susceptible individuals particularly Vaccine: Varicella vaccine is recommended for post
in immunosuppressed persons. These include (a) susceptible exposure administration to un-vaccinated healthy people
persons receiving immunosuppressive therapy; (b) persons aged >12 months and without other evidence of immunity, to
with congenital cellular immunodeficiency; (c) persons prevent or modify the disease. The vaccine should be
with acquired immunodeficiency including HIV/AIDS; administered as soon as possible within 5 days after exposure
(d) susceptible and exposed persons, in particular pregnant to rash, if there is no contraindication to use. Among
women; (e) newborns; and (f) premature infants of low birth children, protective efficacy was reported as >90 per cent
weight. It has no therapeutic value in established disease. when vaccination occurred within 3 days of exposure.
VZIG is given by intramuscular injection in a dose of However, administration of a second dose is recommended
12.5 units/kg body weight up to a maximum of 625 units, for exposed people to bring them up-to-date on vaccination
with a repeat dose in 3 weeks, if a high-risk patient remains and for best protection against future exposure (9).
exposed. Because VZIG appears to bind the varicella Several unresolved issues remain, including the need for
vaccine, the two should not be given concomitantly (4). booster doses, whether universal childhood vaccination will
shift the incidence of disease to adolescence or adulthood
2. VACCINE
with the possibility of more severe disease, and whether
A live attenuated varicella virus vaccine is safe and vaccination might prevent development of herpes zoster.

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

References (3) reduce measles mortality by >95 per cent in comparison

1. Jawetz, Melnick and Adelberg's Medical Microbiology, (2007), 24th with the estimated level in the year 2000 (5).
Ed., A Lange Publication. The Global Measles and Rubella Strategic Plan 2012-20
2. WHO (2014), Weekly Epidemiological Record, No. 25, June 20,2014. period saw a significant reduction in the measles and rubella
3. Govt, of India (2021), National Health Profile of India 2021, Ministry disease burden, a steep increase in the introduction of a
of Health and Family Welfare, New Delhi. second dose of measles-containing (MCV2) and rubella
4. Lawrence, M., Tierney, Jr. (2008), Current Medical Diagnosis and
Treatment, (2008), 47th Ed., A Lange Publication. vaccines, and improvements in surveillance. An increase in
5. Weller, Thomas H. (1977). in Viral Infections of Humans: measles cases in January and February 2022 is a worrying sign
Epidemiology and Control, Evans Alfred, S. et al (eds), 2nd ed., of a heightened risk for the spread of vaccine-preventable
Plenum Medical, New York. diseases and could trigger large outbreaks. Pandemic-related
6. Christie, A.B. (1980). Infectious Diseases: Epidemiology and Clinical disruptions, increasing inequalities in access to vaccines and
Practice, 3rd ed., Churchil Livingstone. the diversion of resources from routine immunization are
7. Stephen, RPreblud and A.R. Hinman (1980), Maxey-Rosenau: Public leaving too many children without protection against measles.
Health and Preventive Medicine, Last, J.M. (ed), 11th ed, Appleton - In addition, with millions of people being displaced due to
Century - Crofts.
8. WHO (1985) Bull WHO 63 : 433.
conflicts and crises, disruptions of routine immunization and
9. CDC Pink Book (2019), Epidemiology and Prevention of Vaccine- COVID-19 vaccine services, lack of clean water, sanitation
Preventable Diseases. and overcrowding increase the risk of disease outbreak.
10. WHO (1985) Techn. Rep. Ser., No.725. Almost 17,338 measles cases were reported globally in
11. Bres, P. (1986) Public Health Action in Emergencies caused by January and February 2022, compared to 9,665 during the
Epidemics. Geneva, WHO. first two months of 2021. As measles is very contageous, cases
tend to show up quickly when vaccination level declines (In
MEASLES 2020, 23 million children missed out on basic childhood
vaccines through health services).
__ ____________ (RUBEOLA) ___________________
Based on updated annual data, the estimated number of
An acute highly infectious disease of childhood caused by measles cases decreased 79 per cent, from 3,67,63,000 in
a specific virus of the group myxoviruses. It is clinically year 2000 to 75,49,000 in 2020; and estimated annual
characterized by fever and catarrhal symptoms of the upper measles deaths decreased 94 per cent from 10,72,800 to
respiratory tract (coryza, cough), followed by a typical rash. 60,700 in year 2020. During 2000-2020, measles

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Measles is associated with high morbidity and mortality in vaccination prevented an estimated 31.7 million deaths
developing countries. Measles occurs only in humans. There globally compared with no measles vaccination (6).
is no animal reservoir of infection.
In India, measles is a significant cause of childhood
Problem statement morbidity. Prior to the immunization programme, cyclical
increase in the incidence of measles were recorded every
Measles is endemic virtually in all parts of the world. It third year. With the increase in immunization coverage levels,
tends to occur in epidemics when the proportion of the intervals between cyclical peaks has increased and the
susceptible children reaches about 40 per cent (1). When the intensity of the peak minimized. However, several outbreaks
disease is introduced into a virgin community more than 90 are reported in tribal and remote areas. The retrospective
per cent of that community will be infected (2). While data indicate a declining trend of measles in the country.
measles is now rare in industrialized countries, it remains a During 1987 about 2.47 lakh cases were reported, whereas,
common illness in many developing countries. The primary after implementation of UIP, the number of cases has come
reason for continuing high childhood measles mortality and down to 12,081 with 1 death during the year 2020.
morbidity is the failure to deliver at least one dose of
measles vaccine to all infants (3). The states majorly affected were West Bengal (4,863
cases and 1 death), Odisha (3,151 cases, no deaths), Uttar
The challenges for measles elimination include : (1) weak Pradesh (1,372 cases without any death), Assam (931 cases,
immunization systems; (2) high infectious nature of measles; no deaths), Andhra Pradesh (373 cases, no deaths), and
(3) populations that are inaccessible due to conflict; (4) the Gujarat (254 cases and no deaths) (7). The country is
increasing refusal of immunization by some populations; making significant progress towards the goal of measles
(5) the changing epidemiology of measles which has led to elimination and rubella/congenital rubella syndrome control.
increased transmission among adolescents and adults; The strategies for measles and rubella elimination include :
(6) the gaps in human and financial resources at the country, (1) 95 per cent coverage with measles and rubella
regional and global levels (6). vaccination; (2) Case-based measles-rubella surveillance
In 1980, before widespread use of measles vaccine, an with adequate laboratory support; (3) Linkage with other
estimated 2.6 million measles deaths occurred worldwide. child health interventions; and (4) Increased public
Recognizing this burden, WHO and UNICEF developed an confidence and demand for immunization (8)
accelerated measles mortality reduction strategy of
delivering 2 doses of measles containing vaccine (MCV) to Epidemiological determinants
all children through routine services and supplementary
immunizing activities (SIAs), and improving disease Agent factors
surveillance. Implementation of this strategy began in 2001. (a) AGENT : Measles is caused by an RNA paramyxovirus.
At the 2010 World Health Assembly, member states So far as is known, there is only one serotype. The virus
endorsed the following targets to be met by 2015 as cannot survive outside the human body for any length of
milestones towards eventual global measles eradication : time, but retains infectivity when stored at sub-zero
(1) raise routine coverage with the first dose of MCV (MCVJ temperature. The virus has been grown in cell cultures,
to >90 per cent nationally, and >80 per cent in every district (b) SOURCE OF INFECTION : The only source of infection is
or equivalent administrative unit; (2) reduce and maintain a case of measles. Carriers are not known to occur. There is
annual measles incidence to <5 cases per million; and some evidence to suggest that subclinical measles occurs

by R△J
 MEASLES

more often than previously thought, (c) INFECTIVE respiratory tract (as with injection of live measles vaccine), the
MATERIAL : Secretions of the nose, throat and respiratory incubation period is somewhat shortened, averaging 7 days.
tract of a case of measles during the prodromal period and the
early stages of the rash, (d) COMMUNICABILITY : Measles is Clinical features
highly infectious during the prodromal period and at the time There are three stages in the natural history of measles,
of eruption. Communicability declines rapidly after the viz. the prodromal or pre-eruptive stage, eruptive stage and
appearance of the rash. The period of communicability is post-measles stage.
approximately 4 days before and 4 days after the appearance
of the rash. Isolation of the patient for a week from the onset 1. PRODROMAL STAGE
of rash more than covers the period of communicability (9). It begins 10 days after infection, and lasts until day 14. It
(e) SECOND ATTACK RATE : There is only one antigenic is characterized by fever, coryza with sneezing and nasal
type of measles virus. Infection confers life long immunity. discharge, cough, redness of the eyes, lacrimation and often
Most so-called second attacks represent errors in diagnosis photophobia. There may be vomiting or diarrhoea. A day or
either in initial or second illness (10). two before the appearance of the rash Koplik’s spots like
table salt crystals appear on the buccal mucosa opposite the
Host factors first and second lower molars. They are small, bluish-white
(a) AGE : Affects virtually everyone in infancy or spots on a red base, smaller than the head of a pin (10).
childhood - between 6 months and 3 years of age in Their presence is pathognomonic of measles.
developing countries where environmental conditions are
generally poor, and older children usually over 5 years in 2. ERUPTIVE PHASE
developed countries (11). Following the use of measles This phase is characterized by a typical, dusky-red,
vaccine, the disease is now seen in somewhat older age- macular or maculo-papular rash which begins behind the ears
groups (12). This highlights the importance of periodic and spreads rapidly in a few hours over the face and neck,
serological checking of the immunity status of the susceptible and extends down the body taking 2 to 3 days to progress to
population, (b) SEX : Incidence equal, (c) IMMUNITY : No the lower extremities. The rash may remain discrete, but often
age is immune if there was no previous immunity. One attack it becomes confluent and blotchy. In the absence of
of measles generally confers life-long immunity. Second complications, the lesions and fever disappear in another 3 or
attacks are rare. Infants are protected by maternal antibodies

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4 days signalling the end of the disease. The rash fades in the
up to 6 months of age; in some, maternal immunity may same order of appearance leaving a brownish discoloration
persist beyond 9 months. Immunity after vaccination is quite which may persist for 2 months or more.
solid and long-lasting, (d) NUTRITION : Measles tends to be
very severe in the malnourished child, carrying a mortality During the prodromal phase (2-4 days) and the first 2-5
upto 400 times higher than in well-nourished children having days of rash, virus is present in tears, nasal and throat
measles (13). This may possibly be related to poor cell- secretions, urine and blood. Just as the maculo-papular rash
mediated immunity response, secondary to malnutrition appears, the circulating antibodies become detectable, the
(14). Additionally, severely malnourished children have been viraemia disappears and the fever falls. The rash develops
shown to excrete measles virus for longer periods than better as a result of interaction of immune T cells with virus-
nourished children indicating prolonged risk to themselves, infected cells in the small blood vessels. In patients with
and of intensity of spread to others (15). Even in a healthy defective cell-mediated immunity, no rash develops (10).
child, an attack of severe measles may be followed by weight Diagnosis of measles is based on the typical rash and
loss, precipitating the child into malnutrition. Koplik’s spots seen in oral mucosa. The diagnosis would
normally be incorrect in any febrile exanthem in which red
Environmental factors eyes and cough are absent. In developed countries, where
Given a chance, the virus can spread in any season (10). measles is uncommon, specific IgM antibodies by ELISA, or
In tropical zones, most cases of measles occur during the dry the detection of measles virus RNA by RT-PCR (reverse
season. In temperate climates, measles is a winter disease, transcriptase polymerase chain reaction) in throat swabs,
probably because people crowd together indoors. Epidemics oral fluid or nasopharyngeal mucus; or urine are being used
of measles are common in India during winter and early for diagnosis (18).
spring (January to April). Population density and movement
do affect epidemicity (16). In general, the less favourable the 3. POST-MEASLES STAGE
prevailing socio-economic conditions, the lower the average The child will have lost weight and will remain weak for a
age at which children are attacked. number of days. There may be failure to recover and a
gradual deterioration into chronic illness - due to increased
Transmission susceptibility to other bacterial and viral infections,
Transmission occurs directly from person to person nutritional and metabolic effects and the tissue destructive
mainly by droplet infection and droplet nuclei, from 4 days effects of the virus. There may be growth retardation and
before onset of rash until 4 days thereafter. The portal of diarrhoea, cancrum oris, pyogenic infections, candidosis,
entry is the respiratory tract. Infection through conjunctiva is reactivation of pulmonary tuberculosis etc.
also considered likely as the virus instilled into the
conjunctiva can cause infection. Recipients of measles Complications (18)
vaccine are not contagious to others (17). The severity of measles varies widely, depending on
several host and environmental factors. The risk of
Incubation period developing severe or fatal measles increases for children
Incubation period is commonly 10 days from exposure to aged <5 years, and persons living in overcrowded
onset of fever, and 14 days to appearance of rash. When conditions, those who are malnourished especially with
measles infection is artificially induced bypassing the vitamin A deficiency, and those with immunological

by R△J
 EPIDEMIOLOGY of communicable diseases

disorders, such as AIDS. Complications occur in infection may diminish the severity of the rash of the second
approximately 30% of reported cases depending on age and infection (21).
predisposing conditions. Relatively common complications
of measles include otitis media, laryngotracheo-bronchitis Prevention of measles
(croup), diarrhoea and pneumonia. In children in developed The following guidelines are important in combating
countries, otitis media occurs in 7-9% of cases, diarrhoea in measles:
8% of cases, and pneumonia in 1-6%. Post-infectious
a. achieving an immunization rate of over 95 per cent,
measles encephalitis occurs in about 1-4 per 1000-2000
and
cases, and sub-acute sclerosing panencephalitis (SSPE)
develops several years after the infection in about 1 per b. on-going immunization against measles through
10,000-100,000 cases. Particularly severe complications of successive generations of children.
measles which occur in immunocompromised individuals
are an acute progressive encephalitis (measles inclusion­ 1. Measles vaccination
body encephalitis), and a characteristic giant cell Measles is best prevented by active immunization.
pneumonia. In developing countries, persistent diarrhoea VACCINE : Only live attenuated vaccines are
with protein-losing enteropathy may ensue, particularly in recommended for use; they are both safe and effective, and
infants. In these countries, where malnutrition, particularly may be used interchangeably within immunization
vitamin A deficiency, and exposure to other infectious programmes. Person to person transmission of measles
diseases are common, the case-fatality rate for measles is vaccine strains has never been documented. The vaccine is
usually 3-6%, but can be as high as 30% particularly among presented as a freeze-dried product. Before use, the
displaced or isolated, immunologically naive populations. In lyophilized vaccine is reconstituted with sterile diluent. Each
developed countries death due to measles is rare and the dose of 0.5 ml contains >1000 viral infective units of the
case-fatality rate is usually 0.01-0.1%. The greatest risk of vaccine strain; this is also true when it is presented as an
death is in children younger than 1 year and in adults older MCV combination. Measles vaccine may also contain
than 30 years. In HIV-infected children, the case-fatality rate sorbitol and hydrolysed gelatin as stabilizers, as well as a
has been reported to be as high as 50% (18). small amount of neomycin, but it does not contain
Measles during pregnancy is not known to cause thiomersal. In general, it is recommended that freeze-dried
congenital abnormalities of the foetus. However, it is vaccine be stored in a refrigerated condition (20). The

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associated with spontaneous abortion and premature diluent must not be frozen but should be cooled before
delivery. Measles in the offspring of mothers with measles reconstitution. Reconstituted measles vaccine loses about
ranges from mild to severe; therefore, it is recommended 50 per cent of its potency after 1 hour at 20°C; it loses
that infants born to such mothers be passively immunized almost all potency after 1 hour at 37°C. The vaccine is also
with immunoglobulin at birth (19). sensitive to sunlight, hence it is kept in coloured glass vials.
After reconstitution, the vaccine must be stored in the dark
Treatment (18) at 2-8°C and used within 4 hours.
There is no specific treatment for measles. Case Measles vaccine is available in monovalent (measles only)
management of measles focuses on supportive care as well
form and in combination : measles-rubella (MR), measles­
as the prevention and treatment of measles complications
mumps-rubella (MMR) vaccine, and measles-mumps-
and secondary infections. Supportive care should be
rubella-varicella (MMRV) vaccine.
provided, including relieving common symptoms such as
fever, cough, nasal congestion or rhinorrhea, conjunctivitis, Reaching all children with 2 doses of measles containing
and sore mouth. Nutritional support is recommended to vaccine (MCV) should be the standard for all national
reduce the risk of malnutrition due to diarrhoea, vomiting immunization programmes. In countries with ongoing
and poor appetite associated with measles. Breast-feeding transmission in which the risk of measles mortality remains
should be encouraged where appropriate. Oral rehydration high, MCVX should be given at age 9 months. MCV2 should
salts should be used as needed to prevent dehydration. be given between 15-18 months, as providing MCV2 in the
Since measles is highly contagious, patient isolation is an 2nd year of life reduces the rate of accumulation of
important intervention to prevent further spread of the virus. susceptible children and the risk of an outbreak. The
However, increasing population immunity through minimum interval between MCVT and MCV2 is 4 weeks.
vaccination is the most effective way to prevent outbreaks. Every opportunity (e.g. when children come into contact
with health services) should be taken to vaccinate all
All cases of severe measles, and all cases of measles in
children that missed one or both MCV routine doses,
areas with high case-fatality rates should be treated with
particularly those under 15 years of age. Policies which
vitamin A, as many children develop acute deficiency of
vitamin A, which may lead to keratomalacia and blindness prohibit use of vaccine in children >1 year of age, older
from corneal scarring. A high dose of vitamin A is given children and teenagers should be changed to allow these
immediately on diagnosis and repeated the next day. The individuals to be vaccinated.
recommended age-specific daily doses are 50,000 IU for In countries with low levels of measles transmission
infants aged <6 months, 100,000 IU for infants aged 6-11 (i.e. those that are near elimination or verified as having
months, and 200,000 IU for children aged > 12 months. If the eliminated endemic measles virus transmission), and
child has clinical signs of vitamin A deficiency (such as Bitot’s therefore the risk of measles virus infection among infants is
spots) a third dose should be given 4-6 weeks later (20). low, MCVX may be administered at 12 months of age to take
advantage of the higher sero-conversion rates achieved at
Measles and chickenpox this age. In these countries, the optimal age for delivering
It has been noted that sometimes measles and MCV2 is based on programmatic considerations to achieve
chickenpox may occur together and one most remarkable the highest coverage of MCV2 and, hence, the highest
finding in these cases of double infection is that the first population immunity. Administration of MCV2 at 15-18

by R△J
 MEASLES 167
months of age ensures early protection of the individual, Replication of vaccine viruses can be prolonged in
slows accumulation of susceptible young children, and may persons who are immunosuppressed or immunodeficient.
correspond to the schedule for other routine immunizations Severe immunosuppression can be due to a variety of
(for example, a DTP-containing booster, PCV, or conditions, including congenital immunodeficiency, HIV
meningococcal vaccines). This measure also supports the infection, leukaemia, lymphoma, generalized malignancy, or
establishment of a policy on immunization and other health therapy with alkylating agents, antimetabolites, radiation, or
interventions in the second year of life. If MCV2 coverage is large doses of corticosteroids. For this reason, persons who
high (>90%) and school enrolment is high (>95%), are severely immunocompromised for any reason should not
administration of routine MCV2 at school entry may prove be given measles containing vaccine.
an effective strategy for achieving high coverage and Women known to be pregnant should not receive measles
preventing outbreaks in schools (22). vaccine. Pregnancy should be avoided for 4 weeks following
MCV administered before 9 months of age should be MMR vaccine. Close contact with a pregnant woman is not a
considered a supplementary dose and recorded on the contraindication to MMR vaccination of the contact.
child’s vaccination record as “MCV0”. Children who receive Breastfeeding is not a contraindication to vaccination of
MCV0 should also receive MCV1 and MCV2 at the either the woman or a breastfeeding child.
recommended ages according to the national schedule. A Do tuberculin skin testing (TST) at the same visit as MMR
supplementary dose of MCV should be given to infants from vaccination, or delay TST at least 4 weeks if MMR is given
6 months of age : (1) during a measles outbreak as part of first. The least favoured option is to do TST first and
intensified service delivery; (2) during campaigns in settings administer MMR when TST is read as it delays the
where the risk of measles among infants < 9 months of age vaccination. TST has no effect on the response to MMR
remains high (e.g. in endemic countries experiencing regular vaccination. However, measles containing vaccines may
outbreaks); (3) for internally displaced populations and transiently suppress the response to TST in a person infected
refugees, and populations in conflict zones; (4) for individual with M. tuberculosis (23).
infants at high risk of contracting measles (e.g. contacts of
known measles cases or in settings with increased risk of ADMINISTRATION : The reconstituted vaccine is
exposure during outbreaks such as day-care facilities); generally injected subcutaneously, but it is also effective
(5) for infants travelling to countries experiencing measles when administered intramuscularly.
outbreaks; (6) for infants known to be HIV-infected or REACTIONS When injected into the body, the

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exposed (i.e. born to an HIV-infected woman) (22). attenuated virus multiplies and induces a mild “measles”
Given the severe course of measles in patients with AIDS, illness (fever and rash) 5 to 10 days after immunization, but
measles vaccination should be routinely administered to in reduced frequency and severity. This may occur in 15 to
potentially susceptible, asymptomatic HIV infected children 20 per cent of vaccinees. The fever may last for 1-2 days
and adults. Vaccination may even be considered for those and the rash for 1-3 days. There is no cause for alarm. The
with symptomatic HIV infection if they are not severely vaccines now given rarely cause severe reaction (10). There
immuno-suppressed according to conventional definitions. is no spread of the virus from the vaccinees to contacts.
In areas where there is a high incidence of both HIV IMMUNITY : The vaccine has convincingly demonstrated
infection and measles, an initial dose of MCV may be to provide immunity to even severely malnourished
offered as early as age 6 months (recorded as MCV0). The 2 children. Immunity develops 11 to 12 days after vaccination
routine doses of MCV (MCVX and MCV2) should then be and appears to be of long duration, probably for life. One
administered to these children according to the national dose of the vaccine given at 11-12 months of age appears to
immunization schedule (22). give 95 per cent protection and with two doses 98 per cent
CONTRAINDICATIONS TO VACCINATION (23) : MMR protection. Infants vaccinated at the age of 9 months show
and other measles-containing vaccines are not recommended sero-conversion of about 90 per cent (20).
for HIV-infected persons with evidence of severe CONTACTS : Susceptible contacts over the age of
immunosuppression. MMRV is not approved for and should 9-12 months may be protected against measles with
not be administered to a person known to be infected with HIV. measles vaccine, provided that this is given within 3 days of
Persons with moderate or severe acute illness should not exposure. This is because, the incubation period of measles
be vaccinated until the patient has improved. This induced by the vaccine is about 7 days, compared with
precaution is intended to prevent complicating the 10 days for the naturally acquired measles.
management of an ill patient with a potential vaccine ADVERSE EFFECTS OF VACCINE : Toxic shock
adverse reaction, such as fever. Minor illness (e.g., otitis syndrome (TSS) occurs when measles vaccine is
media, mild upper respiratory infections), concurrent contaminated or the same vial is used for more than one
antibiotic therapy, and exposure to or recovery from other session on the same day or next day. The vaccine should not
illness are not contraindications to measles vaccination. be used after 4 hours of opening the vial. TSS is totally
Receipt of antibody-containing blood products preventable and reflects poor quality of immunization
(e.g., immune globulin, whole blood or packed red blood services. The symptoms of TSS are typical. Severe watery
cells, intravenous immune globulin) may interfere with diarrhoea, vomiting and high fever are reported within few
sero-conversion after measles vaccine. The length of time hours of measles vaccination. There are usually a cluster of
that such passively acquired antibody persists depends on cases as all infants vaccinated from contaminated vial will be
the concentration and quantity of blood product received. affected. This may cause death within 48 hours. Case
For instance, it is recommended that vaccination be delayed fatality rates are high (20).
for 3 months following receipt of immune globulin for
prophylaxis of hepatitis A; a 7 to 11 months delay is 2. Immunoglobulin
recommended following administration of intravenous Measles may be prevented by administration of
immune globulin, depending on the dose. immunoglobulin (human) early in the incubation period.

by R△J
168 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The dose recommended by WHO is 0.25 ml per kg of body that only two doses are needed, and that a measles vaccine
weight (see Table 33 on page 116). It should be given within has now been developed which is more heat stable. It
3-4 days of exposure. The person passively immunized requires (a) achieving an immunization coverage of at least
should be given live measles vaccine 8-12 weeks later. The 96 per cent of children under one year of age, and that
need for immunoglobulin is now much reduced because of (b) the cumulation in the immunity gap be prevented.
the availability of an effective live attenuated vaccine.
References
Global measles and rubella strategic framework 1. Coovidia H. (1988). Med. Int. 53 : 2177.
2021-2030 (MRSF) (24) 2. Morley David (1975). Trans.Roy.Soc.trop.Med.Hyg., 69:22.
The measles and rubella strategic framework 2021-2030 3. WHO (2006), Fact Sheet No. 286, WHO Website.
aims to provide a high-level framework that will guide the 4. WHO (2011), Weekly Epidemiological Record, No. 1-2, 2011.
5. WHO (2018), Fact sheet on measles, March 2018.
regional and national strategies and operational plans,
6. UNICEF and WHO. (2022), UNICEF and WHO warn of perfect storm
within the umbrella of the Immunization Agenda 2030 of conditions for measles outbreak affecting children, 27th April, 2022.
structure. It aims to establish convergence with other key 7. Govt, of India 2021, National Health Profile of India-2021, Central
agency strategy documents. It envisions “A world free from Bureau of Health Intelligence, Ministry of Health and Family Welfare,
measles and rubella”. The goal for the 2021-2030 period is New Delhi.
to “achieve and sustain the regional measles and rubella 8. WHO 2014, World Health Statistics 2014.
elimination goals”. 9. Govt, of India (2020), Annua!Report 2019-20, Ministry of Health and
Family Welfare, New Delhi.
The core strategies identified in the 2012-20 MRSP will 10. Jawetz, Melnick, and Adelberg's Medical Microbiology, 24th ed.
remain relevant in the post 2020 period. The strategic (2007), A Lange publication.
priorities are as follows : 11. WHO (1978), Tech.Rep.Ser., 629.
1. Incorporate all measles and rubella activities, including 12. Pan American Health Organization (1978). BulIPAHO, 12 (2): 162.
surveillance and case management, as key components 13. Morley David (1973). Paediatric Priorities in the Developing World,
Butterworths.
of effective PHC system in support of universal health
14. Katz, M and Stiehm, E.R. (1977). Pediatrics, 59 : 490.
coverage. 15. Dossetor, J et al (1977) B MJ 1 : 1633 - 35.
2. Improve ownership and accountability of measles and 16. Last, John M. (1980). Maxey-Rosenau : Public Health and Preventive
rubella goals and targets at all levels and improve Medicine, 11th ed., Appleton-Century-Crofts, New York.

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community demand for uptake of measles and rubella 17. Gershon, A. A. (1979). In Principles and Practice of Infectious Diseases,
containing vaccines. Mandell, G.L. et al (eds), Wiley.
3. Identify and close immunity gaps to measles and rubella 18. WHO (2017), Weekly Epidemiological Record, No. 17, 2017.
by effectively utilizing all relevant contacts between 19. Lawrence, M. etal. Current Medical Diagnosis and Treatment, 47th Ed.
(2008), A Lange Medical Publication.
individuals and the health system, establishing or
20. WHO 2009, Weekly Epidemiological Record, No. 35, 28 Aug. 2009.
strengthening new contact points where required, and
21. Alter Milton (1976). Lancet, 1:456.
using targeted approaches to reach under-served 22. WHO (2020), Summary of WHO position papers - Recommended
populations. Routine Immunization for Children.
4. Leverage the life-course approach for delivery of the 23. CDC (2019), Epidemiology and Prevention of Vaccine Preventable
second routine dose of measles and rubella containing Diseases, Yellow Book.
vaccines and for catch-up vaccination; and integrate 24. Measles and Rubella Initiative (2020), Measles and Rubella Strategic
measles and rubella activities with other health and non­ Framework, 2021-2030.
health activities.
5. Ensure outbreak preparedness for timely detection and RUBELLA
effective response to limit the spread of measles and (GERMAN MEASLES)
rubella and reduce related morbidity and mortality.
Rubella or german measles is an acute childhood infection,
6. Ensure continued, timely and quality supply of measles usually mild, of short duration (approximately 3 days) and
and rubella containing vaccines, vaccination supplies and accompanied by low-grade fever, lymphadenopathy and a
laboratory reagents and that measles and rubella maculopapular rash. Infection in early pregnancy may result
activities, including surveillance, are sustainably financed. in serious congenital defects, including death of the foetus.
7. Foster research and innovation to overcome barriers to The disease is worldwide in distribution and tends to occur in
achieve high measles and rubella population immunity epidemics. In pre- vaccination era epidemics occurred every
and to generate and use high quality disease and 5 to 9 years. However, extent and periodicity of rubella are
programme data. highly variable in industrialized and developing countries.
Worldwide over 100,000 babies are born with congenital
Outbreak control measures rubella syndrome every year (1,2).
The following control measures have been
recommended : (a) isolation for 7 days after onset of rash, History
(b) immunization of contacts within 2 days of exposure Rubella was considered a mild and benign disease until
(if vaccine is contraindicated, immunoglobulin should be 1941 when Norman Gregg, an ophthalmologist reported an
given within 3-4 days of exposure), and (c) prompt epidemic of congenital cataracts associated with other
immunization at the beginning of an epidemic is essential to congenital defects in children born to mothers who had
limit the spread. rubella during their pregnancies (3). This discovery changed
the concept that rubella is not merely a benign disease of
Eradication of measles childhood but also one with teratogenic potential. In 1962,
It is believed that measles, like smallpox, is amenable to the virus was isolated; in 1967, an attenuated vaccine was
eradication. Measles immunization has in its favour the fact developed.

by R△J
 RUBELLA

Epidemiological determinants for 10 to 14 days after the rash, (c) RASH: The rash is often
the first indication of the disease in children. It appears first
Agent factors on the face, usually within 24 hours of the onset of
(a) AGENT : Rubella is caused by an RNA virus of the prodromal symptoms. It is a minute, discrete, pinkish,
togavirus family. Only one antigenic type of the virus seems macular rash and not confluent as the rash of measles and it
to exist. The virus has been recovered from the naso­ may be pruritic. Conjunctivitis may occur. The rash spreads
pharynx, throat, blood, CSF and urine. It can be propagated rapidly to the trunk and extremities, by which time it is often
in cell culture, (b) SOURCE OF INFECTION : Clinical or no longer apparent on the face. The rash spreads much
subclinical cases of rubella. A large number of rubella faster and clears more rapidly than the rash of measles. It
infections are, in fact, subclinical. This represents one of the disappears altogether by the third day. The rash is an
major differences between measles and rubella. There is no inconstant feature of the disease; it is absent in subclinical
known carrier state for postnatally acquired rubella. Infants cases. The incidence of rubella infection without rash may
born with congenital rubella may shed the virus for many be upto 25 per cent (4), (d) COMPLICATIONS : In rare
months. The vaccine virus is not communicable, (c) PERIOD instances arthralgia may occur in several joints in adults,
OF COMMUNICABILITY: Rubella is much less especially young women. Encephalitis is very rare.
communicable than measles, probably because of the Thrombocytopenic purpura has also been observed as a
absence of coughing in rubella. It is difficult to state the exact complication. Mention has been made already about the
period of infectivity. It probably extends from a week before congenital malformations.
symptoms to about a week after rash appears. Infectivity is
greatest 1-5 days after the appearance of rash (1). Diagnosis
Because of its mildness and variability of symptoms, the
Host factors disease can go unrecognized unless it is an epidemic. A
(a) AGE: Mainly a disease of childhood particularly in the definitive diagnosis of rubella is possible only through virus
age group 3 to 10 years. Persons older than 15 years now isolation and serology. Throat swabs should be cultured for
account for over 70 per cent cases in developed countries - virus isolation; it takes longer than serological diagnosis. The
this is similar to the changing epidemiological pattern with haemagglutination inhibition (HI) test is a standard
measles, following widespread immunization campaigns serological test for rubella. However, serum must be

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against the disease, (b) IMMUNITY : One attack results in pretreated to remove non-specific inhibitors before testing.
life-long immunity; second attacks are rare. Infants of ELISA tests are preferred because serum pretreatment is not
immune mothers are protected for 4 to 6 months. It is required and they can be adapted to detect specific IgM.
estimated that 10 to 40 per cent of the population could Detection of IgG is evidence of immunity because there is
reach adulthood without experiencing rubella infection in only one serotype of rubella virus. To accurately confirm a
the absence of immunization. recent rubella infection, either a rise in antibody titer must
be demonstrated between two serum samples taken at least
Environmental factors 10 days apart or rubella-specific IgM must be detected in a
Disease usually occurs in a seasonal pattern i.e. in single specimen. It is critically important in a pregnant
temperate zones during the late winter and spring, with woman (6).
epidemics every 4-9 years.
CONGENITAL RUBELLA SYNDROME (CRS)
Transmission Congenital rubella syndrome (CRS) refers to infants born
The virus is transmitted directly from person to person by with defects secondary to intrauterine infection or who
droplets from nose and throat, and droplet nuclei (aerosols), manifest symptoms or signs of intrauterine infection
from one week before onset of rash to one week after it has sometime after birth (5). Congenital infection is considered
faded. The portal of entry is via the respiratory route. The to have occurred if the infant has IgM rubella antibodies
virus is maintained in human population by chain shortly after birth (as IgM antibodies do not cross the
transmission. The virus can cross the placenta (vertical placenta, their presence indicate that they must have been
transmission) and infect the foetus in utero, leading to synthesized by the infant in utero) or if IgG antibodies persist
congenital rubella in the newborn. for more than 6 months, by which time maternally derived
antibodies would have disappeared. Intrauterine infection
Incubation period with rubella is associated with chronic persistence of the
2 to 3 weeks; average 18 days. virus in the newborn. At birth, virus is easily detectable in
pharyngeal secretions, multiple organs, cerebrospinal fluid,
Clinical features urine, and rectal swabs. Viral excretion may last for 12-18
months after birth, but the level of shedding gradually
A large percentage of infections (20-50 per cent) are decreases with age (6).
asymptomatic (2). In a typical case, the clinical features
comprise the following: (a) PRODROMAL : The prodromal Rubella infection inhibits cell division, and this is
symptoms (coryza, sore throat, low-grade fever) herald the probably the reason for congenital malformations, and low
onset of viraemia. They are generally mild and insignificant, birth weight (7). The classic triad of congenital defects are
and less frequent in children, (b) LYMPHADENOPATHY : In deafness, cardiac malformations and cataracts.
susceptible individuals, the enlargement of the post- Rubella infection in a woman who becomes infected (i.e.
auricular, occipital and posterior cervical lymph nodes with asymptomatic or symptomatic disease) just before
appears as early as 5-10 days before the appearance of the conception and upto the first 8-10 weeks of gestation causes
rash. This, however, is not pathognomonic since cases of multiple congenital abnormalities in upto 90% of infections,
clinical rubella without enlargement of lymph nodes have and may result in miscarriage or stillbirth. Congenital
been documented (2). The glands may be found enlarged anomalies associated with maternal rubella infection are rare
by R△J
17Q EPIDEMIOLOGY OF COMMUNICABLE DISEASES

after the 16th week of pregnancy, although sensorineural Rubella vaccination should be avoided in pregnancy
hearing deficits may occur after exposure upto week 20 of because of a theoretical (but never demonstrated) risk of
gestation. The defects associated with CRS include teratogenic outcomes. Women planning a pregnancy are
ophthalmic (e.g. cataracts, microphthalmia, glaucoma, advised to avoid pregnancy for 1 month after rubella
pigmentary retinopathy, chorioretinitis), auditory (e.g. vaccination. Inadvertent vaccination with RCV during
sensorineural deafness), cardiac (e.g. peripheral pulmonary pregnancy is not an indication for terminating the
artery stenosis, patent ductus arteriosus or ventricular septal pregnancy. People who receive blood products wait at least
defects) and craniofacial (e.g. microcephaly) anomalies. CRS 3 months before vaccination with RCV, and, if possible,
can also present with other manifestations, such as avoid administration of blood products for 2 weeks after
meningoencephalitis, hepatosplenomegaly, hepatitis, vaccination (2).
thrombocytopenia, interstitial pneumonitis and radio-
lucency in the long bones (a characteristic radiological Global measles and rubella strategic framework
pattern of CRS). Infants who survive the neonatal period (2021-2030)
may have serious developmental disabilities (such as autism, Refer to page 168 for the details.
visual and hearing impairment), and developmental delay.
Viral shedding can continue in CRS cases beyond 1 year of References
age, which may result in virus transmission (2).
1. WHO (2016), Rubella Fact sheet, March 2016.
Prevention 2. WHO (2020), Weekly Epidemiological Record, No. 27, 3rd July 2020.
3. Fovbes, J.A. (1969). American J. Dis.Child., 118 :5.
The currently used rubella vaccines are based on the live 4. Valman, H.B. (1981), Brit.Med.J. 283 : 1038.
attenuated RA 27/3 strain. Most rubella vaccines are 5. Walter, A.O. et al (1984). JAMA 251 : 1988.
available in combination with other vaccine antigens such as 6. Jewetz, Melnick and Adelberg’s Medical Microbiology, 28th ed., 2019.
measles, mumps and varicella (MR, MMR, MMRV, 7. Dudgeon, J.A. (1969). Am.J.Dis.Child, 118:35.
respectively) and also in a monovalent formulation. Each 8. WHO (2020), Summary of WHO Position Papers - Recommended
dose of an RCV contains a minimum number of infectious Routine Immunization for Children.
units (>1000 plaque-forming units or 50% cell culture
infectious dose). When stored at 4°C, most RCVs have a MUMPS

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shelf-life of 2-3 years. Monovalent rubella, MR and MMR
vaccines should be stored at 2-8°C, protected from light. An acute infectious disease caused by an RNA virus
Diluent vials may be stored at ambient temperatures but classified as genus Rubulavirus of the family
must never be frozen. The standard volume of a single dose paramyxoviridae which has a predilection for glandular and
of RCV is 0.5 ml, and the vaccine is usually injected nervous tissues. Clinically, the disease is recognized by non­
subcutaneously. The preferred site of injection is the suppurative enlargement and tenderness of one or both the
anterolateral thigh or outer aspect of upper arm, depending parotid glands. Other organs may also be involved.
on the age of the individual (2). Constitutional symptoms vary, or may be inapparent. The
Because rubella is not as highly infectious as measles and disease occurs throughout the world. Although morbidity
because the effectiveness of 1 dose of an RCV is >95%, rate tends to be high, mortality rate is negligible.
even at 9 months of age, only 1 dose of rubella vaccine is In most parts of the world, the annual incidence of
required to achieve rubella elimination if high coverage is mumps in the absence of immunization is in the range of
achieved. However, when combined with measles 100-1000 cases/100,000 population with epidemic peak
vaccination, it may be easier to implement a second dose of every 2-5 years. Natural infection with this virus is thought
RCV’s using the same combined MR vaccine or MMR to confer lifelong protection (1).
vaccine for both doses. RCV’s can be administered
concurrently with inactivated vaccines. As a general rule, Agent factors
live vaccines should be given either simultaneously with
(a) AGENT : The causative agent, Myxovirus parotiditis is
RCV’s, or at least 4 weeks apart. An exception to this is oral
a RNA virus of the myxovirus family. The virus can be grown
polio vaccine, which can be given at any time before or after
readily in chick embryo or tissue culture. There is only one
RCV’s without interfering in the response to either vaccine.
serotype, (b) SOURCE OF INFECTION : Both clinical and
Interference may occur between MMR and yellow fever subclinical cases. Subclinical cases which account for 30-40
vaccines if they are simultaneously administered to children per cent of all cases (2) appear to be responsible for
<2 years of age (8). maintaining the cycle of infection. The virus can be isolated
The vaccine induced immunity persists for life time. In from the saliva or from swabs taken from the surface of
order to provide direct protection against rubella, all non­ Stenson’s duct. Virus has also been found in the blood,
pregnant women of reproductive age who are not already urine, human milk and on occasion in the CSF. (c) PERIOD
vaccinated or who are sero-negative for rubella receive one OF COMMUNICABILITY : Usually 4-6 days before the
dose of RCV (2). onset of symptoms and a week or more thereafter. The
period of maximum infectivity is just before and at the onset
Precautions and contraindications of parotitis. Once the swelling of the glands has subsided,
RCVs should not be given to anyone who has the case may be regarded as no longer infectious,
experienced a severe allergic reaction after a previous (d) SECONDARY ATTACK RATE : Estimated to be about
vaccine dose or vaccine component. It is recommended not 86 per cent.
to provide the vaccine to those with active TB or severe
immunodeficiency (including individuals with symptomatic Host factors
HIV infection, AIDS, congenital immune disorders, (a) AGE AND SEX : Mumps is the most frequent cause of
malignancies or aggressive immunosuppressive therapy). parotitis in children in the age group 5-9 years. The average
by R△J
 MUMPS

age of incidence of mumps is higher than with measles, although congenital malformations following mumps
chickenpox or whooping cough. However, no age is exempt infection in pregnancy have not been reported (6).
if there is no previous immunity. The disease tends to be
more severe in adults than in children, (b) IMMUNITY : One Prevention
attack, clinical or subclinical, is assumed to induce lifelong VACCINATION : Highly effective live attenuated vaccine
immunity. There is only one antigenic type of mumps virus, is now available for the prevention of mumps. Widely-used
and it does not exhibit significant antigenic variation (3). live attenuated mumps vaccine strains include the Jeryl-
Most infants below the age of 6 months are immune because Lynn, RIT 4385, Leningrad-3, L-Zagreb and Urabe strains.
of maternal antibodies. Live attenuated mumps vaccine strains used only on a
limited scale include the Hoshino, Torii and NKM-46
Environmental factors strains. The WHO recommends that the Rubini
Mumps is largely an endemic disease. Cases occur mumps vaccine strain should not be used in national
throughout the year, but the peak incidence is in winter and immunization programmes because of its demonstrated low
spring. Epidemics are often associated with overcrowding. effectiveness (6).
A single dose (0.5 ml) intramuscularly produces
Mode of transmission detectable antibodies in 95 per cent of vaccinees. The
The disease is spread mainly by droplet infection and duration of long-term immunity is not known. It is
after direct contact with an infected person. recommended for routine immunization for children over
1 year of age, either alone or in combination with other virus
Incubation period vaccines, eg. in MMR vaccine or as a quadrivalent vaccine
Varies from 2 to 4 weeks, usually 14-18 days. with varicella. A second dose is recommended for children at
4-6 years of age i.e., before starting the school. The current
Clinical features mumps strain (Jeryl Lynm) has the lowest associated
incidence of post vaccine aseptic meningitis (from 1 in
Mumps is a generalized virus infection. In 30-40 per cent 150,000 to 1 in 1.8 million). There are no known cases of
of cases mumps infection is clinically non-apparent. In long-term sequelae associated with mumps vaccination (4).
clinically apparent cases, it is characterized by pain and
swelling in either one or both the parotid glands but may also Countries including mumps vaccines in their national

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involve the sublingual and submandibular glands. Often the immunization programme are advised by WHO to set
child complains of “ear ache” on the affected side prior to disease control targets (control or elimination) and to design
the onset of swelling. There may be pain and stiffness on their mumps immunization strategy accordingly. Strategies
opening the mouth before the swelling of the gland is to achieve mumps elimination include very high coverage
evident. Mumps may also affect the testes, pancreas, CNS, with the first dose of mumps vaccine, ensuring a second
ovaries, prostate, etc. In severe cases, there may be fever, opportunity for vaccination and conducting catch-up
headache and other constitutional symptoms which may last immunization of susceptible cohorts (6).
from 3-5 days. The swelling subsides slowly over 1-2 weeks. As with most other live virus vaccines, mumps vaccine
COMPLICATIONS : Though frequent, are not serious. should not be administered to pregnant women, patients
These include orchitis, ovaritis, pancreatitis, meningo­ receiving immunosuppressive therapy or those who are
encephalitis, thyroiditis, neuritis, hepatitis and myocarditis. severely ill. For further details, please refer to page 164.
Testicular swelling and tenderness denote orchitis, which is
the most common extrasalivary gland manifestation of Mumps surveillance (6)
mumps in adults. It is unilateral in about 75 per cent of Case definitions : WHO recommends the following case
cases. High fever usually accompanies orchitis, which definitions for mumps surveillance :
develops typically 7-10 days after the onset of parotitis in a. Clinical mumps : acute onset of unilateral or bilateral
about 25-40 per cent of post-pubertal men (4). Bilateral tender, self-limited swelling of the parotid or other
orchitis is rare and the assumption that mumps orchitis may salivary gland, lasting 2 or more days and without
lead to sterility is ill-founded (5). Upper abdominal pain, other apparent cause.
nausea and vomiting suggest pancreatitis. Mumps is a
leading cause of pancreatitis in children. It occurs in about b. Laboratory confirmed mumps : a patient with clinical
4 per cent of patients (6). Lower abdominal pain and mumps and laboratory confirmation by positive­
ovarian enlargement suggest oophoritis which occurs in mumps IgM antibody (without mumps immunization in
5 per cent of post pubertal women, usually unilateral (4). the previous 6 weeks) or; sero-conversion with
While some instances of diabetes have occurred in children 4-fold or greater rise in mumps IgG titre; or isolation of
following mumps infection, a causal relationship has yet to mumps virus from saliva, urine or cerebrospinal fluid.
be demonstrated (5). Rarer complications include nerve c. Epidemiologically-confirmed mumps : a patient with
deafness, polyarthritis, hydrocephalus, encephalitis, clinical mumps who is epidemiologically linked to a
cerebellar ataxia, facial palsy and transverse myelitis. laboratory-confirmed mumps case.
Encephalitis is associated with cerebral oedema, serious
neurologic manifestations and sometimes death (4). Upto Control
15% of mumps patients may develop meningitis, and a The control of mumps is difficult because the disease is
much smaller proportion (0.02-0.03%) may develop infectious before a diagnosis can be made. The long and
encephalitis. Mumps is one of the main infectious causes of variable incubation period, and the occurrence of subclinical
sensorineural deafness, which affects approximately 5 per cases make the control of spread difficult. However, cases
100,000 mumps cases (6). should be isolated till the clinical manifestations subside.
Mumps infection in the first trimester of pregnancy is Steps should be taken to disinfect the articles used by the
associated with a 25% incidence of spontaneous abortion, patient. Contacts should be kept under surveillance.
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

References At present three types of influenza virus are circulating in

1. WHO (2007), Weekly Epidemiological Record, 16th Feb, No. 7, 2007. the world: AfHjNJ, A(H3N2) and B viruses. Influenza A
2. Christie, A.B. (1980). Infectious Disease : Epidemiology and Clinical predominated in most countries accounting for 59 per cent
Practice, 3rd ed., Churchill Livingstone. of all influenza viruses detected.
3. Jawetz, E. etal (2007), Medical Microbiology, 24th ed., Lange Medical
Book. SEASONAL INFLUENZA
4. Stephen, J. McPhee et al (2008), Current Medical Diagnosis and
Treatment, 47th ed., A Lange Medical Book.
5. Feldman, Harry A (1977) in Viral Infections of Humans: Epidemiology Epidemiological determinants
and Control, Evans Alfred, S. et al (eds), 2nd ed., Plenum Medical,
New York and London. Agent factors
6. WHO (2005), Weekly Epidemiological Record, No. 48,2nd Dec. 2005. (a) AGENT : Influenza viruses are classified within the
family Orthomyxoviridae. There are four viral subtypes,
INFLUENZA namely influenza type A, type B, type C and type D. These
four viruses are antigenically distinct. There is no cross
Influenza is an acute respiratory tract infection caused by immunity between them. Of importance are the influenza A
influenza virus, of which there are 4 types - A, B, C and D. and B viruses which are responsible for epidemics of disease
All known epidemics are caused by influenza A and B throughout the world (4). Influenza A virus has 2 distinct
strains. The disease is characterized by sudden onset of surface antigens - the haemagglutinin (H) and the
chills, malaise, fever, muscular pains and cough. neuraminidase (N) antigens. The H antigen initiates infection
following attachment of the virus to susceptible cells. The N
Problem statement antigen is responsible for the release of the virus from the
infected cell. The currently identified subtypes are 18 HA
Influenza is truly an international disease. It occurs in all and 11 NA. Humans are generally infected by viruses of the
countries and affects millions of people every year. Its subtype Hl, H2 or H3, and N1 or N2. Type B virus does not
behaviour is unpredictable. It may occur in several forms. It exhibit antigenic shifts and is not divided into subtypes.
may smoulder in a community without clinical recognition,
being manifest only by serological surveys. It may occur in The influenza A virus is unique among the viruses
pandemics every 10-40 years due to major antigenic because it is frequently subject to antigenic variation, both

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changes, as occurred in 1918 (Spanish influenza), 1957 major and minor. When there is a sudden complete or major
(Asian influenza) and 1968 (Hong Kong influenza) (1). change, it is called a shift, and when the antigenic change is
More recently, influenza A (H^J virus of swine origin gradual over a period of time, it is called a drift. Antigenic
emerged in Mexico during the spring of 2009 and was given shift appears to result from genetic recombination of human
name - pandemic influenza A (HJMJ 2009 virus. It spreads with animal or avian virus, providing a major antigenic
with travellers worldwide, resulting in the first influenza change. This can cause a major epidemic or pandemic
pandemic of this country. In between pandemics, epidemics involving most or all age groups. Antigenic drift involves
tend to occur at intervals of 2-3 years in case of influenza A “point mutation” in the gene owing to selection pressure by
and 3-6 years in the case of influenza B - but the periodicity immunity in the host population. Antigenic changes occur to
is not regular as in the case of measles or whooping cough a lesser degree in the B group influenza viruses. Influenza C
because several strains of the virus may be in simultaneous appears to be antigenically stable.
circulation, which means that there may be outbreaks of Since the isolation of the virus A in 1933, major antigenic
influenza practically every year, and sometimes even twice a changes have occurred twice - once in 1957 (H2N2) and
year (2). again in 1968 (H3N2). Strains occurring between 1946 and
Once an epidemic begins, the picture is quite 1957 have been called (H1N1) strains. The shift in 1968
characteristic. Preceded by a few early cases, there is a involved only the H antigen.
sudden outburst of the disease. This may be indicated by (b) RESERVOIR OF INFECTION : It has become
reports of increased febrile respiratory illness in children, increasingly evident that a major reservoir of influenza virus
followed by the same in adults. The next event is increased exists in animals and birds. Many influenza viruses have
hospitalization of cases and sickness-absenteeism in schools been isolated from a wide variety of animals and birds (e.g.,
and places of work. Attack rates tend to be high, varying swine, horses, dogs, cats, domestic poultry, wild birds, etc).
from 5 to 10 per cent in adults and 20-30 per cent in Some of these include the major H and N antigens related to
children. The peak of the epidemic is reached in 3-4 weeks, human strains. It is hypothesized. There is an increasing
before tending to decline. The time scale is compressed for evidence that the animal reservoirs provide new strains of
smaller geographic areas (1). The unique features of influenza virus by recombination between the influenza
influenza epidemics are the suddenness with which they viruses of man, animals and birds.
arise, and the speed and ease with which they spread. The
(c) SOURCE OF INFECTION : Usually a case or
short incubation period, large number of subclinical cases,
subclinical case. During epidemics, a large number of mild
high proportion of susceptible population, short duration of
and asymptomatic infections occur, which play an important
immunity, and absence of cross-immunity, all contribute to
role in the spread of infection. The secretions of the
its rapid spread. Worldwide, the annual epidemics are
respiratory tract are infective.
estimated to result in about 3-5 million cases of severe
illness and about 290,000 to 650,000 deaths (3). The fate of (d) PERIOD OF INFECTIVITY : Virus is present in the
the virus during inter-epidemic periods is not known. nasopharynx from 1 to 2 days before and 1 to 2 days after
Possible explanations include transmission of virus to extra­ onset of symptoms.
human reservoirs (pigs, horses, birds), latent infection in
humans or continuous transfer from one human to another. Host factors
This explains the occurrence of sporadic cases. (a) AGE AND SEX : Influenza affects all ages and both
by R△J
 BIRD FLU

sexes. In general, the attack rate is lower among adults. Reye syndrome (fatty liver with encephalopathy) is a rare
Children constitute an important link in the transmission and severe complication of influenza, usually A and B type,
chain. The highest mortality rate during an epidemic occurs particularly in young children between 2 and 16 years of
among certain high-risk groups in the population such as old age. It consists of rapidly progressive hepatic failure and
people (generally over 65 years of age), children under encephalopathy, and there is about 10-40 per cent mortality
18 months, and persons with diabetes or chronic heart rate. The pathogenesis is unknown, but the syndrome is
disease, kidney and respiratory ailments (5). (b) HUMAN associated with aspirin use in a variety of viral infections (7).
MOBILITY : This is an important factor in the spread of
infection, (c) IMMUNITY : Immunity to influenza is subtype­ AVIAN INFLUENZA (8)
specific. Antibodies against HA and NA are important in (BIRD FLU)
immunity to influenza. Resistance to initiation of infection is
related to antibody against HA, which neutralizes the virus, Avian influenza refers to a large group of different
whereas decreased severity of disease and decreased ability to influenza viruses that primarily affect birds. On rare
transmit virus to contacts are related to antibody directed occasions, these bird viruses can infect other species,
against the NA. Antibodies against ribonucleoprotein are including pigs and humans. The vast majority of avian
type-specific and are useful in typing viral isolates as in influenza viruses do not infect humans. However, avian
influenza A and B. Protection correlates with both serum H5Nx is a strain with pandemic potential, since it might
antibodies and secretory IgA antibodies in nasal secretions. ultimately adapt into a strain that is contagious among
The local secretory antibody is probably important in humans. Once this adaptation occurs, it will no longer be a
preventing infection. Serum antibodies persist for many bird virus - it will be a human influenza virus. Influenza
months, whereas secretory antibodies are shorter-lived pandemics are caused by new influenza viruses that have
(usually only few months). Antibody also modifies the course adapted to humans. Health experts have been monitoring a
of illness. A person with low titres of antibody may be infected new and extremely severe influenza virus - the H5N2 strain -
but will experience a mild form of illness. Immunity can be for almost 15 years. Fortunately, the virus does not jump
incomplete as reinfection with the same virus can occur. The easily from birds to humans or spread readily and
three types of influenza viruses are antigenically unrelated and sustainably among humans. Once a fully contagious virus
therefore induce no cross-protection. When a viral type emerges, its global spread is considered inevitable.
undergoes antigenic drift, a person with pre-existing antibody
to the original strain may suffer only mild infection with the Transmission

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new strain (6). Antibodies appear in about 7 days after the Human infections with avian influenza viruses, though
attack and reach a maximum level in about 2 weeks. After rare, have been reported sporadically. Human infections are
8 to 12 months, the antibody level drops to pre-infection level. primarily acquired through direct contact with infected live
or dead poultry birds or contaminated environments, such
Environmental factors as live bird markets.
(a) Season : The seasonal incidence is striking, epidemics
usually occurring in winter months in the Northern Incubation period
Hemisphere and in the winter or rainy season in the 2-5 days.
Southern Hemisphere (4). In tropical countries, influenza
virus circulates throughout the year with one or two peaks Diagnosis
during rainy season, (b) Overcrowding : Enhances Diagnosis is confirmed by RT-PCR. Rapid influenza
transmission. The attack rates are high in close population diagnostic tests (RDTs) are available, but they have lower
groups, e.g., schools, institutions, ships, etc. sensitivity compared to RT-PCR.
Mode of transmission Treatment
Influenza is spread mainly from person to person by Some antiviral drugs, notably oseltamivir and zanamivir
droplet infection or droplet nuclei created by sneezing, can reduce the duration of viral replication and improve
coughing or talking. The portal of entry of the virus is the prospects of survival.
respiratory tract.
Prevention
Incubation period Public health management includes personal protective
1-4 days. measures like regular hand washing and proper drying; good
respiratory hygiene (covering mouth and nose when
Pathogenesis and clinical features coughing or sneezing); early self-isolation; avoid close
The virus enters the respiratory tract and causes contact with sick people; and avoid touching eyes, mouth
inflammation and necrosis of superficial epithelium of the and nose.
tracheal and bronchial mucosa, followed by secondary Vaccine
bacterial invasion. There is no viraemia. Both the viruses
cause much the same symptoms - fever, chills, aches and In the year 2007, a vaccine for bird flu was licensed, this
pains, coughing and generalized weakness. Fever lasts from vaccine is for people 18 years through 64 years of age. It is
1-5 days, averaging 3 days in adults. Frequent an inactivated influenza vaccine given in two doses, 28 days
complications are acute sinusitis, otitis media, purulent apart. The recipient can have pain and tenderness at the
bronchitis and pneumonia. The most dreaded complication injection site, headache, muscle pain and general ill feeling.
is pneumonia, which should be suspected if fever Some other vaccines were approved, but at the time of
persists beyond 4 or 5 days or recurs abruptly after pandemic, (as the H5NX continually mutates), the current
convalescence (1). sample of H5Nj cannot be depended upon to work.

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

PANDEMIC INFLUENZA A (HjN,) 2009 Clinical features (14)

(SWINE FLU) A wide clinical spectrum of disease ranging from non-
febrile mild upper respiratory illness, febrile influenza like
The pandemic influenza A (HjNJ 2009 virus differs in its illness (ILI), to severe or even fatal complications including
pathogenicity from seasonal influenza in two key aspects. rapidly progressive pneumonia has been described. The
First, as the majority of human population has little or no case fatality rate is smilar to seasonal influenza i.e. about 0.5
pre-existing immunity to the virus, the impact of the per cent; however this could change (15). The clinical
infection has been in a wider age range, in particular among features are as described below :
children and young adults. Secondly, the virus can infect the (a) Uncomplicated influenza
lower respiratory tract and can cause rapidly progressive
pneumonia, especially in children and young to middle-aged (1) ILI symptoms include : fever, cough, sore throat,
rhinorrhoea, headache, muscle pain, and malaise,
adults.
but no shortness of breath and no dyspnoea. Patients
Following its emergence in March 2009, pandemic may present with some or all of these symptoms.
A (HjNJ 2009 virus spread rapidly throughout the world, (2) Gastrointestinal illness may also be present, such as
leading to the declaration of an inlfuenza pandemic by diarrhoea and/or vomiting, especially in children,
WHO on 11th June 2009 (9). The world is now in but without evidence of dehydration.
post-pandemic period. In India it causes local outbreaks.
(b) Complicated or severe influenza
During 2020, India reported 2,752 cases and 44 deaths, a
case fatality rate of 1.6 per cent (10). (1) Presenting clinical (e.g. shortness of breath/
dyspnoea, tachypnea, hypoxia) and/or radiological
Based on knowledge about past pandemics, the (HXNX) signs of lower respiratory tract disease (e.g.
2009 virus is expected to continue to circulate as a seasonal pneumonia), central nervous system (CNS)
virus for some years to come. While level of concern is now involvement (e.g. encephalopathy, encephalitis),
greatly diminished, vigilance on the part of national health severe dehydration, or presenting secondary
authorities remains important, when the behaviour of HjNj complications, such as renal failure, multiorgan
virus as a seasonal virus cannot be reliably predicted (11). failure, and septic shock. Other complications can
On 26th September 2011 WHO has adapted a new nomen­ include rhabdomyolysis and myocarditis.
clature as Influenza A (HjNJ pdm09 (12). (2) Exacerbation of underlying chronic disease,

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including asthma, COPD, chronic hepatic or renal
Incubation period failure, diabetes, or other cardiovascular conditions.
The incubation period appears to be approximately 1-4 (3) Any other condition or clinical presentation requiring
days, but could range upto 7 days. hospital admission for clinical management.
(4) Any of the signs of progressive disease.
Case definitions (13)
As COVID-19 and influenza, both are respiratory
Suspected case : A suspected case of influenza A (HjNJ illnesses, they share many similarities. It is very important to
2009 is defined as a person with acute febrile respiratory differentiate these both diseases so as to take timely
illness (fever > 38°C) with onset (a) within 7 days of close appropriate action to manage the disease. The
contact with a person who is a confirmed case of influenza differentiating points are as follows (16) :
A (HjNJ 2009 virus infection, or; (b) within 7 days of travel
to areas where there are one or more confirmed cases, or COVID-19 INFLUENZA
(c) resides in a community where there are one or more Incubation period 2-14 days 1-4 days
confirmed influenza A (HjNJ 2009 cases.
Common - Fever - Fever
Probable case : A probable case of influenza A (HJMJ symptoms - Cough - Chills
2009 virus infection is defined as a person with an acute - Fatigue - Cough
febrile respiratory illness who : (1) is positive for influenza A, - Shortness of - Fatigue
but unsubtypable for Hx and H3 by influenza RT-PCR or breath - Body aches
reagents used to detect seasonal influenza virus infection, or; - Loss of smell and pains
(2) is positive for influenza A by an influenza rapid test or an - Loss of taste - Headache
influenza immunofluoresence assay (IFA) and meets criteria - Runny or stuffy nose
for a suspected case, or; (3) individual with a clinically - Sore throat
compatible illness who died of an unexplained acute Less common - Body aches
respiratory illness who is considered to be epidemiollogically symptoms and pains
linked to a probable or confirmed case. - Headache - Nausea or
Confirmed case : A confirmed case of pandemic influenza - Runny or diarrhoea
A (HjNJ 2009 virus infection is defined as a person with an stuffy nose
acute febrile respiratory illness with laboratory confirmed - Sore throat
influenza A (HjNJ 2009 virus infection at WHO approved - Nausea or
laboratory by one or more of the following tests : diarrhoea
Symptom onset - Gradual - Rapid
a. Real Time PCR
Vaccine and - Vaccines are - Seasonal and swine
b. Viral culture medications available flu vaccine and
c. Four-fold rise in influenza A (HjNj) virus specific antiviral medication
neutralizing antibodies. available.

by R△J
 INFLUENZA -175
Signs and symptoms of progressive disease (RT-PCR) will provide the most timely and sensitive
detection of the infection.
Patients who present initially with uncomplicated
influenza may progress to more severe disease. Progression Clinical specimens to be collected for laboratory
can be rapid (i.e. within 24 hours). The following are some diagnosis are respiratory samples. Samples from the upper
of the indicators of progression, which would necessitate an respiratory tract, including a combination of nasal or
urgent review of patient management. nasopharyngeal samples, and a throat swab are advised.
Recent evidence supports viral replication and recovery of
(a) Symptoms and signs suggesting oxygen impairment or
pandemic A (HjNJ 2009 virus from lower respiratory tract
cardiopulmonary insufficiency :
samples (tracheal and bronchial aspirates) in patients
- Shortness of breath (with activity or at rest), difficulty presenting lower respiratory tract symptoms and in these
in breathing, turning blue, bloody or coloured sputum, patients, such samples have higher diagnostic yields than
chest pain, and low blood pressure; samples from the upper respiratory tract.
- In children, fast or laboured breathing; and
When influenza viruses are known to be circulating in a
- Hypoxia, as indicated by pulse oximetry. community, patients presenting with features of
(b) Symptoms and signs suggesting CNS complications: uncomplicated influenza can be diagnosed on clinical and
- Altered mental status, unconsciousness, drowsiness, or epidemiological grounds. All patients should be instructed to
difficult to awaken and recurring or persistent return for follow-up, should they develop any signs or
convulsions (seizures), confusion, severe weakness, or symptoms of progressive disease or fail to improve within
paralysis. 72 hours of the onset of symptoms.
(c) Evidence of sustained virus replication or invasive Diagnostic testing, when available, should be prioritized
secondary bacterial infection based on laboratory testing for patients in whom confirmation of influenza virus infection
or clinical signs (e.g. persistent high fever and other may affect clinical management, including patients
symptoms beyond 3 days). considered at-risk and/or those with complicated, severe, or
(d) Severe dehydration, manifested as decreased activity, progressive respiratory illness. In addition, results of
dizziness, decreased urine output, and lethargy. diagnostic testing may also be valuable in guiding infection
control practices and management of a patient’s close
Risk factors for severe disease (14) contacts. Under no circumstances should influenza diagnostic
testing delay initiation of infection control practices or

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Risk factors for severe disease from pandemic influenza antiviral treatment, if pandemic influenza A (H.Nj) 2009
A (H^J 2009 virus infection reported to date are disease is suspected clinically and epidemiologically (14).
considered similar to those risk factors identified for
complications from seasonal influenza. These include the Several rapid influenza diagnostic tests including (so-
following groups : called point-of-care diagnostic tests) are commercially
available. However, studies indicate that rapid diagnostic
(1) Infants and young children, in particular <2 years tests miss many infections with pandemic (HjNJ 2009 virus
(2) Pregnant women and, therefore, negative results cannot rule out disease, and
(3) Persons of any age with chronic pulmonary disease (e.g. should not be used as grounds to withhold therapy or lift
asthma, COPD) infection control measures.
(4) Persons of any age with chronic cardiac disease (e.g. Infection control
congestive cardiac failure)
Evidence to date suggests that pandemic (HjNJ 2009
(5) Persons with metabolic disorders (e.g. diabetes) virus is transmitted similarly as seasonal influenza A and B
(6) Persons with chronic renal disease, chronic hepatic viruses. Appropriate infection control measures (standard
disease, certain neurological conditions (including plus droplet precautions) should be adhered to at all times,
neuromuscular, neurocognitive, and seizure disorders), which includes strict adherence to hand hygiene with soap
haemoglobinopathies, or immunosuppression, whether and water or an alcohol based hand sanitizer, and to cover
due to primary immunosuppressive conditions, such as mouth and nose with tissue or handkerchief when coughing
HIV infection, or secondary conditions, such as or sneezing. If ill persons must go into the community e.g. to
immunosuppressive medication or malignancy seek medical care, they should wear a face mask to reduce
(7) Children receiving chronic aspirin therapy the risk of spreading the virus in the community.
(8) Persons aged 65 years and older. Whenever performing high-risk aerosol-generating
A higher risk of severe complications from pandemic procedures (for example, bronchoscopy or any procedure
influenza A (HjNJ 2009 virus infection has also been involving aspiration of the respiratory tract) use a particulate
reported in individuals who are obese particularly in those respirator (N95, FFP2 or equivalent), eye protection, gown,
who are morbidly obese. and gloves, and carry out the procedure in an adequately
ventilated room, either naturally or mechanically.
Laboratory diagnosis (14) The duration of isolation precautions for hospitalized
Laboratory diagnosis of pandemic influenza A (HjNJ patients with influenza symptoms should be continued for
2009 virus, especially at the beginning of a new community 7 days after onset of illness or 24 hours after the resolution
outbreak or for unusual cases, has important implications for of fever and respiratory symptoms, whichever is longer,
case managment, such as infection control procedures, while a patient is in a health-care facility. For prolonged
consideration of antiviral treatment options and avoiding illness with complications (i.e. pneumonia), control
the inappropriate use of antibiotics. Currently, the diagnostic measures should be used during the duration of acute illness
tests can be done by specialized laboratories in many (i.e. until the patient has improved clinically). Special
countries. Reverse transcriptase polymerase chain reaction attention is needed in caring for immunosuppressed patients

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

who may shed virus for a longer time period and are also at influenza infection in this patient population. When
increased risk for development of antiviral resistant virus. compared with patients who received standard-dose trivalent
influenza vaccines, HD-IIV was shown to be 24% more
Influenza vaccine effective in preventing laboratory confirmed influenza (17).
Currently, there are three different influenza technologies
in use, to produce influenza vaccines. These include SIDE EFFECTS
egg-based, cell-cultured, and recombinant technologies. Inactivated vaccines, administered by injection,
Egg-based inactivated influenza vaccines (IIVs) are prepared commonly cause local reactions such as soreness, swelling
from inactivated and detergent-solubilized virion particles and redness at the injection site, and less often can cause
containing HA and NA proteins prepared in embryonated fever, muscle or joint-aches or headache. These symptoms
chicken eggs. The live attenuated vaccine (LAIV) is prepared are generally mild and do not need medical attention, and
from attenuated, less virulent virus strains. Cell-cultured last for 1-2 days. Fever, aches and headaches can occur
vaccines are produced by growing the influenza virus in more frequently in children compared to elderly people.
animal cells, allowing for a faster manufacturing process. Rarely, these inlfuenza vaccines can cause allergic reactions
Although hen’s eggs are not used, trace amounts of egg such as hives, rapid swelling of deeper skin layers and
protein may be found in these vaccines. The recombinant flu tissues, asthma or a severe multisystem allergic reaction due
vaccine is an alternative method that isolates the HA gene and to hypersensitivity to certain components.
proteins in order to obtain an immunogenic response without
the use of chicken eggs. This vaccine is produced in insect cell CONTRAINDICATIONS
cultures and contains three times the amount of HA compared As a general rulej inactivated vaccines should not be
with the standard-dose preparation. It is currently the only administered to (19) :
available influenza vaccine that is completely egg-free (17). (1) People who have a severe allergy to chicken eggs;
Two types of influenza viruses are included in the (2) People with a history of anaphylactic reactions or other
influenza vaccine: human influenza A virus and influenza B life-threatening allergic reactions to any of the
virus. Vaccine composition is reviewed annually and constituents or trace residue of the vaccine;
updated as needed based on the circulating viruses, extent
(3) People with history of a severe reaction to influenza
to which those viruses are spreading, and how good the
vaccination;
response was to the previous year’s vaccine. The World
(4) People who developed Guillain-Barre syndrome (GBS)

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Health Organization makes recommendations about the
specific viruses to be included. within 6 weeks of getting an influenza vaccine;
(5) Children less than 6 months of age (inactivated influenza
Inactivated influenza vaccine (IIVs) vaccine is not approved for this age group); and
IIVs are available since 1940. Trivalent IIVs contain three (6) People who have a moderate-to-severe illness with a
inactivated viruses: type A (HjNJ, type A (H3N2), and fever (they should wait till they recover to get vaccinated).
type B. Quadrivalent influenza vaccines were introduced in the
year 2013-2014 season. They contain the same antigens as Live attenuated influenza vaccine
trivalent vaccines, with addition of another B strain virus, Live attenuated influenza vaccine (LAIV) was approved
increasing the likelihood for adequate protection. IIV is for use in 2003. It contains the same influenza viruses as IIV.
administered by intramuscular or intradermal route. The The viruses are cold-adapted, and replicate effectively in the
vaccine is available in both paediatric (0.25 ml) and adult mucosa of the nasopharynx. The vaccine viruses are grown
(0.5 ml) dose formulation. One dose of IIV may be administered in chicken eggs, and the final product contains residual egg
annually for persons 9 years of age and older. Children protein. The vaccine is provided in a single-dose sprayer
6 months through 8 years of age receiving influenza vaccine for unit; half of the dose is sprayed into each nostril. LAIV dose
the first time should receive two doses administered at least not contain thimerosal or any other preservative. LAIV is
28 days apart. Annual immunization is recommended (18). approved for use only in healthy, non-pregnant persons
The vaccine is about 60 per cent effective among healthy 2 to 49 years of age. Vaccinated children can shed vaccine
persons younger than 65 years of age. On vaccination, the virus in nasopharyngeal secretions for up to 3 weeks.
vaccine becomes effective after 14 days. Those infected LAIV is 87 per cent effective against culture confirmed
shortly before (1-3 days) or shortly after immunization can influenza in children 60-84 months old; results in 27 per
still get the disease (18). Vaccinated individuals can also get cent reduction in febrile otitis media; 28 per cent reduction
infected with other strain of influenza virus for which the
in otitis media with accompanying antibiotic use.
vaccine dose not provide protection (18). The immunity
lasts from 6-12 months. The vaccine is 50-60 per cent SIDE EFFECTS
effective in preventing hospitalization and 80 per cent
effective in preventing death among elderly persons (18). Live attenuated vaccines are given via a nasal spray, and
can commonly cause runny nose, nasal congestion, cough
The vaccine should be stored at temperature of 2-8°C. It and can less frequently cause sore throat, low grade fever,
should not be frozen. irritability and muscle-aches and headache. Wheezing and
For those persons aged 65 years and older, there are vomiting episodes have been described in children receiving
currently two influenza vaccines designed to overcome the live influenza vaccines (19).
waning immune response found in this patient population
high-dose IIV (HD-IIV) and adjuvanted IIV (allV). Both CONTRAINDICATIONS
formulations are available only as a trivalent vaccine. The Persons who should not receive LAIV include children
HD-IIV contains four times the HA-antigen compared with younger than 2 years of age; persons 50 years of age and
standard influenza vaccines, providing a better immune older; persons with chronic medical conditions, including
response and reducing clinical outcomes associated with asthma, a recent wheezing episode, reactive airways disease

by R△J
 INFLUENZA

or other chronic pulmonary or cardiovascular conditions, treatment may be appropriate. In adults, a dose of
metabolic disease such as diabetes, renal disease, or 150 mg twice daily is being used in some situations.
hemoglobinopathy, such as sickle cell disease; and children (c) Where oseltamivir is not available or not possible to
or adolescents receiving long-term therapy with aspirin or use, or if the virus is resistant to oseltamivir, patients
aspirin-containing therapy, because of the association of who have severe or progressive clinical illness should
Reye syndrome with wild-type influenza infection. Persons be treated with zanamivir.
in these groups should receive inactivated influenza vaccine.
(2) Patients at higher risk of developing severe or
As with other live-virus vaccines, LAIV should not be complicated illness, but presenting with uncomplicated
given to persons who are immuno-suppressed because of illness due to influenza virus infection, should be treated
disease, including HIV, or who are receiving immuno­ with oseltamivir or zanamvir. Treatment should be
suppressive therapy. Pregnant women should not receive initiated as soon as possible following onset of illness.
LAIV. Immuno-suppressed persons and pregnant women
(3) Patients not considered to be at higher risk of developing
should receive inactivated influenza vaccine. Since LAIV
severe or complicated illness and who have
contains residual egg protein, it should not be administered
uncomplicated illness due to confirmed or strongly
to persons with a history of severe allergy to egg or any
suspected influenza virus infection need not be treated
other vaccine component. A history of Guillain-Barre
with antivirals.
syndrome (GBS) within 6 weeks following a previous dose
of influenza vaccine is a precaution for LAIV. If used, antiviral treatment should ideally be started early
following the onset of symptoms, but it may also be used at
Since the spread of the epidemics of influenza virus is
any stage of active disease when ongoing viral replication is
unstoppable and there is limitation of vaccine availability,
anticipated or documented. Recent experience strongly
WHO recommends that all the countries should immunize
indicates that earlier treatment is associated with better
their health care workers as the first priority to protect the
outcomes. Therefore, antiviral treatment should be initiated
essential health infrastructure, and to prevent initiation of
immediately and without waiting for laboratory confirmation
nosocomial spread of disease to vulnerable patients. WHO
of diagnosis.
recommends the following groups of persons be vaccinated
according to their order of priority : (a) pregnant women; In patients who have persistent severe illness despite
(b) individuals aged more than 6 months with one of the oseltamivir treatment, there are few licensed alternative
several chronic medical conditions; (c) healthy young adults antiviral treatments. In these situations, clinicians have

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between age 15-49 years, (d) healthy children; (e) healthy considered intravenous administration of alternative
adults between age 49-65 years; and (f) healthy adults aged antiviral drugs such as zanamivir, peramivir, and ribavirin.
more than 65 years. The use of such treatments should be done only in the
context of prospective clinical and virological data collection
The time difference between a dose of COVID-19 vaccine
and with regard to the following cautions:
and influenza vaccine should be atleast 7 days.
- ribavirin should not be administered as monotherapy;
Treatment - ribavirin should not be administered to pregnant
Key principles for clinical management include basic women; and
symptomatic care, early use of antiviral drugs if available, - zanamivir formulated as a powder for inhalation should
for high risk populations, antimicrobials for co-infections, not be delivered via nebulization due to the presence of
and proactive observation for progression of illness. lactose, which may compromise ventilator function.
Hospital care requires early supplemental oxygen therapy
to correct hypoxaemia, with saturation monitoring at triage Standard antiviral treatment regimens (14)
and during hospitalization, if possible, careful fluid Oseltamivir
replacement, antimicrobials, and other supportive care. It is
important to provide appropriate antimicrobials for other Oseltamivir is indicated for treatment of influenza. For
infections which also present with severe respiratory distress. adults the recommended oral dose is 75 mg oseltamivir
A number of severely ill patients with pandemic (HjNJ 2009 twice daily for 5 days.
disease develop respiratory distress requiring mechanical For infants less than 1 year of age recommended oral
ventilation and intensive care support. doses are as follows:
Antiviral therapy (14) >3 months to 12 months 3 mg/kg, twice daily for 5 days
Pandemic influenza A (HjNj) 2009 virus is currently >1 month to 3 months 2.5 mg/kg, twice daily for 5 days
susceptible to the neuraminidase inhibitors (NAIs)
oseltamivir and zanamivir, but resistant to the M2 inhibitors 0 to 1 month * 2 mg/kg, twice daily for 5 days
amantadine or rimantadine. * There are no data available regarding the adminstration
The following is a summary of treatment recommendations. of oseltamivir to infants less than one month of age.
(1) Patients who have severe or progressive clinical illness For children older than 1 year up to 12 years of age, the
should be treated with oseltamivir. Treatment should be recommended oral doses according to body weight are as
initiated as soon as possible. follows:
(a) This recommendation applies to all patient groups,
including pregnant women, and young children 15 kg or less 30 mg twice a day for 5 days
<2 years, including neonates. 15-23 kg 45 mg twice a day for 5 days
(b) In patients with severe or progressive illness not 24-40 kg 60 mg twice a day for 5 days
responding to normal treatment regimens, higher
doses of oseltamivir and longer duration of >40 kg 75 mg twice a day for 5 days

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Zanamivir faucial and laryngeal; however, the skin, conjunctiva, vulva

Zanamivir is indicated for treatment of influenza in adults and other parts of the body may be affected. The bacilli
and children (>5 years). The recommended dose for multiply locally, usually in the throat, and elaborate a
treatment of adults and children from the age of 5 years is powerful exotoxin which is responsible for :
two inhalations (2x5 mg) twice daily for 5 days. (a) the formation of a greyish or yellowish membrane
(“false membrane”) commonly over the tonsils,
Chemoprophylaxis (13) pharynx or larynx (or at the site of implantation), with
Oseltamivir is the drug of choice for chemoprophylaxis to well-defined edges and the membrane cannot be
health care personnels and close contacts of suspected, wiped away;
probable or confirmed case of pandemic influenza A (HjNJ (b) marked congestion, oedema or local tissue destruction;
2009. It should be given till 10 days after last exposure. The (c) enlargement of the regional lymph nodes; and
dose by body weight is a follows : (d) signs and symptoms of toxaemia.
Weight less than 15 kg - 30 mg OD Fatality rate on the average is about 5-10 per cent which
15-23 kg - 45 mg OD has changed little in the past decades in untreated cases, and
24-40 kg - 60 mg OD in children under 5 years of age, and adults over 40 years of
> 40 kg - 75 mg OD age, one out of 5 persons who get diphtheria dies (1).
For infants Problem statement
< 3 months - not recommended unless WORLD : Diphtheria is a rare disease in most developed
situation is critical
countries owing to routine children vaccination. In countries
3-5 months - 20 mg OD where satisfactory vaccination schemes have been instituted
6-11 months - 25 mg OD the disease has so declined that it is no longer regarded as a
public health problem. However the disease is seen
Influenza surveillance occasionally among non-immunized children in developed
Influenza surveillance is intended to monitor the prevalence countries.
of the circulating strains and to detect new strains necessary for Improved socio-economic conditions are changing the
vaccine information; to estimate influenza related impact on epidemiology of diphtheria. Changes in lifestyle allow far
morbidity, mortality and economic loss; rapidly detect

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less opportunity to maintain natural immunity, such as
outbreaks; and disease control through rapid action. through frequent skin infection with C.diphtheriae (2).
References These epidemics are largely due to decreasing immunization
coverage among infants and children, waning immunity to
1. WHO (2012), Weekly Epidemiological Record No. 47, 23 Nov. 2012.
diphtheria in adults, movement of large groups of
2. Maxine A. Papadakis, Stephen J. McPhee, Current Medical Diagnosis
and Treatment, 53rd Ed. 2014, Lange Publication. population in the last few years, and an irregular supply of
3. WHO 2018, Fact Sheet, March 14, 2018. vaccine (3). These outbreaks highlight the need for booster
4. WHO (1980). Techn.Rep.Ser., No.642. vaccinations. Recent diphtheria outbreaks in a number of
5. WHO (1985) Bull. WHO 63 (1) 51. countries have demonstrated a shift in the age distribution
6. Jawetz, et al (2001) Medical Microbiology, 22nd ed., A Lange Med. of cases to older children and adults (4). In developing
Publication. countries, the disease continues to be endemic due to lack of
7. Jawetz, et.al. (2019), Medical Microbiology, 28th ed, A Lange Medical adequate widespread immunization. The true numbers of
Publication. diphtheria cases and deaths are unknown because of
8. WHO (2005). Weekly Epidemiological Record, No.49/50, Oct 14, incomplete reporting from most countries where the disease
. 2005.
occurs. During the year 2021, about 8,639 diphtheria cases
9. WHO (2009), Weekly Epidemiological Record, No. 41, 9th Oct, 2009.
were reported globally (5),
10. Govt, of India (2021), National Health Profile 2021, Central Bureau of
Health Intelligence, Ministry of Health and Family Welfare, New Delhi. INDIA : Diphtheria is an endemic disease. The available
11. WHO (2010), WHO Recommendations for the post-pandemic, retrospective data indicate a declining trend of diphtheria in
Pandemic (HjNJ 2009 briefing note 23. the country. It is due to increasing coverage of child
12. WHO (2011), Weekly Epidemiological Record, No. 43,21st Oct, 2011. population by immunization. During the year 2020, about
13. Govt, of India (2010), Guidelines for Swineflu (Influenza A HjNj), 1,991 cases of diptheria were reported in India with about
Ministry of Health and Family Welfare, New Delhi.
14. WHO (2009), Clinical Management of human infection with 28 deaths. Most of the cases reported were from West Bengal
pandemic, (HjNj) 2009 : revised guidance, November, 2009. (950 cases, 1 death), Telangana (254 cases and no deaths),
15. Stephen J. Mcphee et al (2010), Current Medical Diagnosis and Andhra Pradesh (202 cases no deaths), Rajasthan (148 cases
Treatment, 49th Ed., A Lange & Med. Publication. and 8 deaths) and Delhi (136 cases and 15 deaths) (6).
16. Flu Vaccine Medically reviewed by Alan Carter, 8th Sept. 2020.
17. Austin D. Yung etc. (2019), U.S. Pharmacist, The pharmacist resource Epidemiological determinants
for clinical excellence, 12th Nov. 2019 US pharm. 2019 : 44 (11)
18-22. Agent factors
18. CDC (2019), Epidemiology and Prevention of Vaccine Preventable (a) AGENT : The causative agent, C.diphtheriae is a gram­
Diseases, 15th April 2019. positive, non-motile organism. It has no invasive power, but
19. WHO (2010), Safety of pandemic (H.N) 2009 vaccines, 30th Oct, produces a powerful exotoxin. Four types of diphtheria bacilli
2009.
are differentiated - gravis, mitis, belfanti and intermedius, all
DIPHTHERIA pathogenic to man. In general, gravis infections tend to be
more severe than mitis infections. Not all the strains of the
Diphtheria is an acute bacterial infectious disease caused organism are toxigenic. There is evidence that a non-
by toxigenic strains of Corynebacterium diphtheriae. Three toxigenic strain may become toxigenic when exposed to a
major clinical types have been described : anterior nasal, particular bacteriophage - the beta phage - carrying the gene

by R△J
 DIPHTHERIA 179
for toxin production (7). The toxin can affect the heart leading Portal of entry
to myocarditis or the nerves leading to paralysis. Diphtheria (a) RESPIRATORY ROUTE : Commonly the portal of
bacilli are sensitive to penicillin and are readily killed by heat entry is the respiratory tract, (b) NON -RESPIRATORY
and chemical agents. They may survive for short periods in ROUTES : The portal of entry sometimes may be the skin
dust and fomites. (b) SOURCE OF INFECTION : The source where cuts, wounds and ulcers not properly attended to, may
of infection may be a case or carrier: (ij CASE : Cases range get infected with diphtheria bacilli, and so is the umbilicus in
from subclinical to frank clinical cases. Mild or silent infections the newborn. Occasionally, the site of implantation may be
may exhibit no more than a mere running nose or sore throat; the eye, genitalia or middle ear. The non-respiratory routes
these cases play a more important role than frank cases in of infection are less common in developed countries where
spreading the infection, (ii) CARRIER : Carriers are common spread by droplet infection is more common.
sources of infection (8). Carriers may be temporary or
chronic; nasal or throat carriers. The nasal carriers are Incubation period
particularly dangerous as source of infection because of
frequent shedding of the organism into the environment, than 2 to 6 days, occasionally longer.
do throat carriers. The temporary carrier state may last for
about a month, but the chronic carrier state may persist for a Clinical features
year or so, unless the patient is treated. Immunization does not Respiratory tract forms of diphtheria consist of
prevent the carrier state, (c) INFECTIVE MATERIAL : pharyngotonsillar, laryngotracheal, nasal, and combinations
Nasopharyngeal secretions, discharges from skin lesions, thereof. Patients with pharyngotonsillar diphtheria usually
contaminated fomites and possibly infected dust, (d) PERIOD have a sore throat, difficulty in swallowing, and low grade
OF INFECTIVITY : Unless treated, the period of infectivity fever at presentation. Examination of the throat may show
may vary from 14 to 28 days from the onset of the disease, but only mild erythema, localized exudate, or a pseudo­
carriers may remain infective for much longer periods. A case membrane. The membrane may be localized or a patch of
or carrier may be considered non-communicable, when at the posterior pharynx or tonsil, may cover the entire tonsil,
least two cultures properly obtained from nose and throat, or, less frequently, may spread to cover the soft and hard
24 hours apart, are negative for diphtheria bacilli. palates and the posterior portion of the pharynx. In the early
stage the pseudo-membrane may be whitish and may wipe
Host factors off easily. The membrane may extend to become thick,
blue-white to grey-black, and adherent. Attempts to remove

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(a) AGE : Diphtheria particularly affects children aged
1 to 5. In countries where widespread immunization is the membrane result in bleeding. A minimal area of mucosal
practised, a shift in age incidence has been observed from erythema surrounds the membrane. Patients with severe
preschool to school age. (b) SEX : Both sexes are affected, disease may have marked oedema of the submandibular
(c) IMMUNITY : Infants born of immune mothers are area and the anterior portion of the neck, along with
relatively immune during the first few weeks or months of lymphadenopathy, giving a characteristic “bull-necked”
life. Before artificial immunization, large proportion of appearance (1).
population in developing countries were acquiring active Laryngotracheal diphtheria most often is preceded by
immunity through inapparent infection which resulted in pharyngotonsillar disease, usually is associated with fever,
widespread production of antitoxin in the population. Thus hoarseness and croupy cough at presentation, and, if the
most members of the population except children were infection extends into bronchial tree, it is the most severe
immune. By age 6-8 years, approximately 75 per cent of form of disease. Initially it may be clinically indistinguishable
children in developing countries where skin infection with from viral croup or epiglottitis. Prostration and dyspnoea
C. diphtheriae are common have protective serum antitoxin soon follow because of the obstruction caused by the
levels (9). membrane. This obstruction may even cause suffocation if
not promptly relieved by intubation or tracheostomy.
Since diphtheria is principally the result of action of the
toxin formed by the organism rather than invasion by the The diphtheria bacilli within the membrane continue to
organism, resistance to the disease depends largely on the produce toxin actively. This is absorbed and results in distant
availability of specific neutralizing antitoxin in the toxic damage, particularly parenchymatous degeneration,
bloodstream and tissues. It is generally true that diphtheria fatty infiltration and necrosis in heart muscle, liver, kidneys,
occurs only in persons who possess no antitoxin (or less than and adrenals, sometimes accompanied by gross
0.01 Lf unit/ml.). Assessment of immunity to diphtheria haemorrhage. Irregularities of cardiac rhythm indicate
toxin for individual patients can best be made by review of damage to the heart. Later, there may be difficulties with
documented diphtheria toxoid immunizations and primary vision, speech, swallowing, or movement of the arms or legs.
or booster immunization if needed (9). The toxin also produces nerve damage, resulting often in
paralysis of the soft palate, eye muscles, or extremities (9).
Environmental factors Patients who survive complications recover completely.
Cases of diphtheria occur in all seasons, although winter Nasal diphtheria, the mildest form of respiratory
months favour its spread. diphtheria, usually is localized to the septum or turbinates of
one side of the nose. Occasionally a membrane may extend
Mode of transmission into the pharynx.
The disease is spread mainly by droplet infection. It can Non-respiratory mucosal surface i.e., the conjunctiva and
also be transmitted directly to susceptible persons from genitals may also be sites of infection.
infected cutaneous lesions. Transmission by objects (e.g., Cutaneous diphtheria is common in tropical areas. It
cups, thermometers, toys, pencils), contaminated by the often appears as a secondary infection of a previous skin
nasopharyngeal secretions of the patient is possible, but for abrasion or infection. The presenting lesion, often an ulcer,
only short periods. may be surrounded by erythema and covered with a

by R△J
180 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

membrane. Patients generally seek treatment because of the DIPHTHERIA IMMUNIZATION

chronicity of the skin lesion.
Current prophylactics
CONTROL OF DIPHTHERIA These may be grouped as below :
a. Combined or mixed vaccines
1. CASES AND CARRIERS - DPT (diphtheria-pertussis-tetanus vaccine)
(a) Early detection : An active search for cases and - DTPw (diphtheria, tetanus, whole-cell pertussis)
carriers should start immediately amongst family and school - DTPa (diphtheria, tetanus, acellular pertussis)
contacts. Carriers can be detected only by culture method. - DT (diphtheria-tetanus toxoid)
Swabs should be taken from both the nose and throat and - dT (diphtheria-tetanus, adult type)
examined by culture methods for diphtheria bacilli. Tests
- Pentavalent (diphtheria, tetanus, pertussis,
should be made for the virulence of the organism.
hepatitis B and Hib).
(b) Isolation : All cases, suspected cases and carriers
should be promptly isolated, preferably in a hospital, for b. Single vaccines
at least 14 days or until proved free of infection. At least - FT (formal-toxoid)
2 consecutive nose and throat swabs, taken 24 hours - APT (alum-precipitated toxoid)
apart, should be negative before terminating isolation. - PTAP (purified toxoid aluminium phosphate)
(c) Treatment : (i) CASES : When diphtheria is suspected, - PTAH (purified toxoid aluminium hydroxide)
diphtheria antitoxin should be given without delay, IM or IV, - TAF (toxoid-antitoxin flocculus)
in doses ranging from 20,000 to 100,000 units or more,
depending upon the severity of the case, after a preliminary c. Antisera
test dose of 0.2 ml subcutaneously to detect sensitization to - Diphtheria antitoxin.
horse serum. For mild early pharyngeal or laryngeal disease
the dose is 20,000-40,000 units; for moderate a. COMBINED VACCINES
nasopharyngeal disease, 40,000-60,000 units; for severe,
extensive or late (3 days or more) disease, 80,000-100,000 1. DPT vaccine
units (10). In addition to antitoxin, every case should be For immunizing infants, the preparation of choice is DPT.
treated with penicillin or erythromycin for 5 to 6 days to Firstly because, the infant can be immunized simultaneously

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clear the throat of C.diptheriae and thereby decrease toxin against three diseases, viz., diphtheria, pertussis and tetanus
production, (ii) CARRIERS : The carriers should be treated which is a great gain administratively. Secondly the pertussis
with 10 days course of oral erythromycin, which is the most component in DPT vaccine enhances the potency of the
effective drug for the treatment of carriers. The immunity diphtheria toxoid.
status should be upgraded as discussed below. There are two types of DPT vaccines - plain and adsorbed.
Adsorption is usually carried out on a mineral carrier like
2. CONTACTS aluminium phosphate or hydroxide. Studies have shown that
Contacts merit special attention. They should be throat adsorption increases the immunological effectiveness of the
swabbed and their immunity status determined. Different vaccine. The WHO recommends that only adjuvant DPT
situations pose different options : (a) where primary preparations be utilized in immunization programmes (12).
immunization or booster dose was received within the STORAGE : DPT/DT vaccines should not be frozen. They
previous 5 years, no further action would be needed should be stored in a refrigerator between 2 to 8 deg. C.
(b) where primary course or booster dose of diphtheria
toxoid was received more than 5 years before, only a (a) Optimum age : It has been found that young infants
respond well to immunization with potent vaccines and
booster dose of diphtheria toxoid need be given (c) non­
toxoids even in the presence of low to moderate levels of
immunized close contact should receive prophylactic
maternal antibodies. Accordingly, the Global Advisory
penicillin or erythromycin. They should be given
Group of the Expanded Programme on Immunization (EPI),
1000-2000 units of diphtheria antitoxin and actively
has recommended that DPT vaccine can be safely and
immunized against diphtheria. Contacts should be placed
effectively administered as early as 6 weeks after birth.
under medical surveillance and examined daily for evidence
of diphtheria for at least a week after exposure. The (b) Number of doses : Three doses of DPT each of which
bacteriological surveillance of close contacts should be is usually 0.5 ml, should be considered optimal for primary
continued for several weeks by repeated swabbing. immunization. It is associated with higher and more
sustained levels of diphtheria and tetanus antitoxin and
3. COMMUNITY acceptable level of pertussis protection i.e., vaccine
efficiency 95 per cent (13).
The only effective control is by active immunization with
diphtheria toxoid of all infants as early in life as possible, as (c) Interval between doses : The current recommendation
scheduled, with subsequent booster doses every 10 years is to allow an interval of 4 weeks between the 3 doses, with a
thereafter. The aim should be to immunize before the infant booster injection at 16-24 months, followed by another
loses his maternally derived immunity so that there will be booster at the age of 5 to 6 years.
continuous protection from birth without any gap in (d) Mode of administration : DPT should be administered
immunity to natural disease. The vaccine being a toxoid is intramuscularly in antero (lateral aspect) of the thigh.
not directed against organisms. Therefore immunization (e) Reactions : Fever and mild local reactions following
does not prevent the carrier state; consequently, the non- DPT immunization are common. It is estimated that 2 to 6
immune individuals are not protected by a high level of per cent of vaccinees develop fever of 39 deg. C or higher,
population immunity (11). This implies that immunization and that 5 to 10 per cent experience swelling and induration
rate must be maintained at a high level. or pain lasting more than 48 hours.

by R△J
 DIPHTHERIA

The most severe complications following DPT reactions. Each dose of these antigens generally contains
immunization are neurological (encephalitis/ 25 Loeffler (Lf) units of diphtheria toxoid.
encephalopathy, prolonged convulsions, infantile spasms
and Reye’s syndrome) and are thought to be due primarily c. ANTISERA
to the pertussis component of the vaccine - the estimated Diphtheria antitoxin prepared in horse serum is still the
risk is 1:170,000 doses administered. mainstay of passive prophylaxis and also for treatment of
(f) Contraindications : Minor illnesses such as cough, diphtheria.
cold, mild fever are not considered contraindications to It has been shown, protection against diphtheria toxin is a
vaccination, only such children who are seriously ill or need quantitative phenomenon, so that a serum antitoxin titre
hospitalization are not vaccinated. DPT should not be that protects against a small dose of toxin may not protect
repeated if a severe reaction occurred after a previous dose. against a large dose: for this reason, failures of diphtheria
Such reactions include collapse or shock-like state, immunization may take place (14).
persistent screaming episodes, temperature above 40 deg.C,
convulsions, other neurological symptoms and anaphylactic References
reactions. In the case of DPT, subsequent immunization with 1. WHO (2017), Weekly Epidemiological Record, No. 31,4th Aug. 2017.
DT only is recommended, without the pertussis component. 2. WHO (1999), Health Situation in the South East Asia Region 1994-
Local reactions at the site of injection or mild fever do not by 1997, Regional office for SEAR, New Delhi.
themselves preclude the further use of DPT. 3. WHO (1996), World Health Report, Fighting disease Fostering
development.
Since the severity of pertussis infection decreases with 4. WHO (1995), World Health Report, Bridging the gaps.
age, the pertussis component in DPT vaccine is not usually 5. WHO (2021), Diphtheria - Reported cases by WHO region.
recommended after the age of 6 years (1). Therefore, 6. Govt, of India (2021), National Health Profile 2021, DGHS, Ministry
children over the age of 5 years who have not received DPT, of Health and Family Welfare, New Delhi.
need only 2 doses of DT vaccine, 4 weeks apart, with a 7. Youmans, G.P. et al (1980). The Biological and Clinical Basis of
booster dose 6 months to 1 year later. Those children who Infectious Diseases, 2nd ed., Saunders.
received the primary course of DPT earlier, should receive 8. CDC Pact sheet for parents, reviewed in Feb. 2013.
only DT as booster at 5-6 years or at school entry. 9. Jawetz, et al, Medical Microbiology, 2013, 26th ed., A Lange Medical
Book.

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For immunizing children over 12 years of age and adults, 10. Lawrence, M. et al, Current Medical Diagnosis and Treatment, 2008,
the preparation of choice is dT, which is an adult-type of 47th ed., A Lange Medical Book.
diphtheria tetanus vaccine (13). This preparation contains 11. Downham, M.A.PS. (1976). Brit.Med.J., 1 : 1063.
no more than 2 Lf of diphtheria toxoid per dose, compared 12. WHO (1985), Bull WHO 63 (6) 1151-1169.
with 25 Lf in the ordinary (paediatric) DPT/DT vaccines. 13. CDC (2019), Epidemiology and Prevention of Vaccine Preventable
Administration of dT vaccine to adults is carried out in Diseases.
2 doses at an interval of 4 to 6 weeks, followed by a booster 14. Edsall, G (1975) Clinical Aspect of Immunology (Eds) P.G.H. Gelletal
6 to 12 months after the second dose (13). This vaccine (DT) Blackwell, Oxford.
is not followed by the high incidence of reactions associated
with the use of DPT or DT. Alternatively, for primary WHOOPING COUGH
immunization of adults, FT or TAF may be used and they (PERTUSSIS)
cause fewer reactions than APT or PTAP
An acute infectious disease, usually of young children,
2. Pentavalent vaccine caused by B. pertussis. It is clinically characterized by an
insidious onset with mild fever and an irritating cough,
Pentavalent vaccine provides protection to a child from gradually becoming paroxysmal with the characteristic
5 life threatening diseases - diphtheria, pertussis, tetanus, “whoop” (loud crowing inspiration) often with cyanosis and
hepatitis B and haemophilus influenzae type b (Hib). Giving vomiting. The spectrum of disease varies from severe illness
pentavalent vaccine reduces the number of pricks to a child. to atypical and mild illness without whoop. The Chinese call
When used, it replaces Hepatitis B and DPT primary it a “Hundred Day Cough” (1).
vaccination schedule at 6, 10 and 14 weeks in the
immunization programme, except that the birth dose of Problem statement
hepatitis B and booster doses of DPT are continued. Pertussis is an important cause of death in infants
The UIP pentavalent vaccine comes in liquid form in a worldwide, and continues to be a public health concern even
vial. Each dose (0.5 ml) is given by intramuscular injection in countries with high vaccination coverage. During 2020,
in anterolateral aspect of the mid-thigh, using auto-disabled about 69,414 cases were reported to WHO globally (2) and
syringe. Pentavalent vaccine is a freeze sensitive vaccine and the DPT3 immunization rate was 83 per cent.
should be stored and transported at 2-8°C temperature. It is one of the most lethal diseases of the infants and young
Pentavalent vaccine is very safe. As with all medicines, a children who have not been immunized, particularly those with
few side effects are possible. Pain, redness and swelling at the underlying malnutrition and other respiratory infections (3).
site of injection, fever, vomiting, loss of appetite, abnormal Pertussis is increasingly reported in older children, adolescents
crying, irritability are the common side effects. The rare side and adults. A serological study from the United States showed
effects are high fever (more than 39.5°C) and fits or seizures, that 21 per cent of adults with prolonged cough (lasting more
and very rarely severe allergic reaction can occur. than 2 weeks) had pertussis (4).
In India, there is marked decline of the disease after launch
b. SINGLE VACCINES of universal immunization programme. During the year 1987;
Single vaccines (e.g., FT, PTAR APT, PTAH) are less the reported incidence was about 1.63 lakh cases, whereas
frequently used. They are all good immunizing agents. APT during 2020 only 11,985 cases with 50 deaths were reported
is hardly used because it is prone to give rise to serious showing a decline of about 92.648 per cent (5).
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Epidemiological determinants Mode of transmission

Agent factors Whooping cough is spread mainly by droplet infection
and direct contact. Each time the patient coughs, sneezes or
(a) AGENT : The causative agent in a large proportion of talks, the bacilli are sprayed into the air. Most children
cases is B. pertussis. In a small percentage of cases (less than contract infection from their playmates who are in the early
5 per cent), B. parapertussis is probably responsible. Certain stages of the disease. The role of fomites in the spread of
viruses (e.g., adenoviruses, parainfluenza viruses) are also infection appears to be very small, unless they are freshly
implicated in the whooping cough syndrome, but their contaminated.
presence in cases of whooping cough is probably
coincidental and not causal (6). B. pertussis occurs in Incubation period
smooth and rough phases, capsulated and non-capsulated
forms, and elaborates an exotoxin and endotoxin. Clinical Usually 7 to 14 days, but not more than 3 weeks.
disease is associated with encapsulated, phase 1 strains.
B. pertussis is antigenically highly complex. It carries 3 Clinical course
major agglutinogens - 1, 2 and 3 and several minor ones. B. pertussis produces a local infection; the organism is
The nature of the protective antigen is not known (6). The not invasive. It multiplies on the surface epithelium of the
bacterium survives only for very short periods outside the respiratory tract and causes inflammation and necrosis of
human body, (b) SOURCE OF INFECTION : B.pertussis the mucosa leading to secondary bacterial invasion. Three
infects only man. The source of infection is a case of stages are described in the clinical course of the disease:
pertussis. More often, the source may be mild, missed and (a) catarrhal stage, lasting for about 10 days. It is
unrecognized cases. There is no evidence that infection is characterized by its insidious onset, lacrimation, sneezing
ever subclinical (6). A chronic carrier state does not exist, and coryza, anorexia and malaise, and a hacking night
(c) INFECTIVE MATERIAL : The bacilli occurs abundantly in cough that becomes diurnal, (b) paroxysmal stage, lasting
the nasopharyngeal and bronchial secretions, which are for 2-4 weeks. It is characterized by bursts of rapid,
infective. Objects freshly contaminated by such discharges consecutive coughs followed by a deep, high-pitched
are also infective, (d) INFECTIVE PERIOD : Whooping inspiration (whoop). It is usually followed by vomiting. In
cough is most infectious during catarrhal stage. The infective young infants it may cause cyanosis and apnoea. In adults

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period may be considered to extend from a week after and adolescents, uncharacteristic, persistent cough may be
exposure to about 3 weeks after the onset of the paroxysmal the only manifestation of the disease, and (c) convalescent
stage although communicability diminishes rapidly after the stage, lasting for 1-2 weeks. The illness generally lasts 6 to 8
catarrhal stage. Asymptomatic chronic carriers of weeks.
B. pertussis are uncommon (7). (e) SECOND ATTACK Complications occur in 5-6 per cent of cases, most
RATE : Averages 90 per cent in unimmunized household frequently in infants aged less than 6 months. The chief
contacts (7).
complications of pertussis are bronchitis;
Host factors bronchopneumonia and bronchiectasis. The violence of the
paroxysms may precipitate subconjunctival haemorrhages,
(a) AGE : Whooping cough is primarily a disease of epistaxis, haemoptysis and punctate cerebral haemorrhages
infants and pre-school children. The highest incidence is which may cause convulsions and coma.
found below the age of 5 years. The median age of infection,
i.e., the age when half the children are likely to develop Bronchopneumonia occurs in about 5.2 per cent of cases.
whooping cough is between 20-30 months in developing It is the most prominent problem, with relatively high
countries as compared to 50 months in developed countries mortality. The incidence of pertussis-associated
(1). Infants below 6 months have the highest mortality. In encephalopathy is 0.9 per cent 100,000. In industrialized
older children, adolescents and adults, pertussis is often countries, lethality of pertussis is very low (< 1/1000),
unrecognized because of its atypical course. However, older whereas in developing countries the average mortality is
age groups represent an important source of infection for estimated at 3.9 per cent in infants and 1 per cent in children
susceptible infants (7). (b) SEX : Incidence and fatality are aged 1-4 years (7).
observed to be more among female than male children (6).
(c) IMMUNITY : Recovery from whooping cough or Control of Whooping Cough
adequate immunization is followed by immunity. Second
attacks may occur in persons with declining immunity, but 1. CASES AND CONTACTS
these are usually mild. It is possible that the first defence (i) Cases : Early diagnosis, isolation and treatment of
against pertussis infection is the antibody that prevents cases, and disinfection of discharges from nose and throat are
attachment of the bacteria to the cilia of the respiratory the general principles of control of whooping cough. Early
epithelium (8). Infants are susceptible to infection from birth diagnosis is possible only by bacteriological examination of
because maternal antibody does not appear to give them nose and throat secretions which may be obtained by
protection. There is no cross immunity with B. parapertussis. naso-pharyngeal swabs. The chances of isolating the
Environmental factors organism are < 60 per cent if the material is obtained within
10-14 days from the onset of illness. The value of fluorescent
Pertussis occurs throughout the year, but the disease antibody technique has been emphasized in facilitating the
shows a seasonal trend with more cases occurring during rapid diagnosis of pertussis. The patient should be isolated
winter and spring months, due to overcrowding. Socio­ until considered to be non-infectious. Although several
economic conditions and ways of life also play a role in the antibiotics are effective against B. pertussis, erythromycin is
epidemiology of the disease. Thus, the risk of exposure is probably the drug of choice. A dose of 30-50 mg/kg of body
greater in the lower social classes living in overcrowded weight in 4 divided doses for 10 days has been
conditions than in well-to-do groups. recommended. Possible alternatives are Azithromycin,
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 MENINGOCOCCAL MENINGITIS 183
Clarithromycin. Antibiotics may prevent or moderate clinical CONTRAINDICATIONS : The contraindications to
pertussis when given during incubation period or in early pertussis vaccination are anaphylactic reaction,
catarrhal stage. During paroxysmal phase of disease, encephalopathy, a personal or strong family history of
antimicrobial drugs will not change the clinical course but epilepsy, convulsions or similar CNS disorders: any febrile
may eliminate the bacterium from the nasopharynx and thus upset until fully recovered: or a reaction to one of the
reduce transmission of disease (7). They are useful in previously given triple vaccine injections (10).
controlling secondary bacterial infections.
3. PASSIVE IMMUNIZATION
(ii) Contacts : Infants and young children should be kept
away from cases. Those known to have been in contact with The merit of hyperimmune globulin in pertussis
whooping cough may be given prophylactic antibiotic prophylaxis has yet to be established. So far, there is no
(erythromycin or azithromycin) treatment for 10 days to evidence of its efficacy in well-controlled trials (9).
prevent the infecting bacteria to become established. The control of pertussis by immunization is still an
The best protection that can be given to an infant is to unsolved problem. Even if the level of immunization reaches
administer a booster dose of DPT/DT to his siblings before 100 per cent, it is possible that the disease would not be
he is born (6). entirely eliminated because whooping cough vaccines have
never been claimed to be more than 90 per cent effective.
2. ACTIVE IMMUNIZATION
The vaccine is usually administered in the national References
childhood immunization programme as combined DPT, 1. Morley, David (1973). Paediatric Priorities in the Developing World,
DTWP or DTaP vaccine. In India, the national policy is to Butterworths.
immunize against diphtheria, whooping cough and tetanus 2. WHO (2022), Global Health Observatory Data.
3. WHO (1996), The World Health Report 1996, Fighting disease
simultaneously, by administering 3 doses (each dose about Fostering development.
0.5 ml) of DPT vaccine intramuscularly, at one month 4. WHO (2010), Weekly Epidemiological Record, No. 40,1st Oct, 2010.
interval, starting at the age of 6 weeks. A booster dose is 5. Govt, of India (2021), National Health Profile 2021, DGHS, Ministry
given at 18-24 months. Children whose vaccination series of Health and Family Welfare, New Delhi.
has been interrupted should have their series resumed, 6. Christie, A.B. (1980). Infectious Diseases: Epidemiology and Clinical

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without repeating previous doses. In some countries, an Practice, 3rd ed., Churchill Livingstone.
additional vaccine dose is now offered to health-care 7. WHO (2005), Weekly Epidemiological Record, No. 4, Jan. 28, 2005.
workers and young parents. Only acellular pertussis vaccines 8. Jawetz, et al, Medical Microbiology, 24th ed. 2007, A Lange Medical
Book.
are used for vaccination of older children and adults (7).
9. Manclark, C.R. (1981). Bull WHO, 59: 9-15.
Despite major differences in the content, mode of 10. Gray, James A (1981). Medicine International, 3, 112.
preparation and efficacy among both whole-cell pertussis
vaccines and acellular pertussis vaccines; comprehensive MENINGOCOCCAL MENINGITIS
clinical trials have demonstrated that the most efficacious
vaccines of either category will protect 85 per cent of the Meningococcal meningitis or cerebrospinal fever is an
recipients from clinical disease. The duration of protection acute communicable disease caused by N. meningitidis. It
following the primary 3-dose course in infants and 1 booster usually begins with intense headache, vomiting and stiff
dose atleast 1 year later is believed to be on an average neck and progresses to coma within a few hours. The
6-12 years for both whole-cell and acellular pertussis meningitis is part of a septicaemic process. The fatality of
vaccines. This is similar to, or somewhat shorter than, typical untreated cases is about 50 per cent. With early
immunity following natural infection (7). Some studies diagnosis and treatment, case fatality rates have declined to
suggest that pertussis vaccination affects pharyngeal less than 8-15 per cent.
colonization of B. pertussis, resulting in some reduction of
bacterial transmission in the community (7). All infants, Problem statement
including HIV-positive individuals should be immunized
against pertussis. Distribution worldwide, occurring sporadically and in
small outbreaks in most parts of the world. In some regions
In principle, the same type of acellular vaccine should be this endemic situation may alternate with devastating,
given throughout the primary course of vaccination. unpredictable epidemics. This is the case in the African
However, if the previous type of vaccine is unknown, any meningitis belt, which is the region in sub-Saharan Africa
type of acellular vaccine may be used (7). stretching from Senegal in the west to Ethiopia in the east.
Commercially available vaccines containing acelluar This region is inhabited by around 400 million people. In the
pertussis include combination with some or all of the African meningitis belt, the WHO definition of a
following components : diphtheria toxoid, tetanus toxoid, meningococcal epidemic is >100 cases per 100,000
Hib, HepB and IPV. population per year. In the endemic countries, the incidence
UNTOWARD REACTIONS : With some vaccines of >10 cases, 2-10 cases and <2 cases per 100,000
available in the early 1960s, persistent screaming and population per year characterize high, moderate and low
collapse were reported, but these reactions are rarely endemicity respectivety. An outbreak outside the meningitis
observed with the vaccines now available. Pertussis vaccines belt may be defined as a substantial increase in invasive
may give rise to local reactions at the site of injection, mild meningococcal disease in a defined population above that
fever and irritability. The rare vaccine reactions are which is expected by place and time (1).
persistent (more than 3 hours) inconsolable screaming, During recent years, several serious outbreaks affecting
seizures, hypotonic hypo-responsive episodes, anaphylactic numerous countries have occurred in tropical and temperate
reaction and very rarely encephalopathy. For details kindly zones of other continents, viz, Americas, Asia and Europe. In
refer to Table 36 of chapter 3 page 125. Europe, the incidence of disease ranges from 0.2 to 14 cases
by R△J
184 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

per 100,000 population and majority cases are caused by of the year from December to June. Overcrowding, as occurs
serogroup B strains. In Americas, the incidence of disease is in schools, barracks, refugee and other camps, is an
in the range of 0.3 to 4 cases per 100,000 population. In important predisposing factor. The incidence is also greater in
United States, the majority cases are caused by serogroups the low socio-economic groups living under poor housing
B, C and Y. In Asia, most meningococcal disease is caused conditions, with exposure to tobacco smoke, asplenia, HIV
by meningococci belonging to serogroup A or C (1). infection and travel to endemic areas.
Meingococcal disesase is endemic in India. Cases of Mode of transmission
meningococcal meningitis are reported sporadically or in
small clusters. During 2020, about 2,266 cases of The disease spreads mainly by droplet infection. The
meningococcal meningitis were reported in India with about portal of entry is the nasopharynx.
27 deaths. Majority of the cases were reported from only few Incubation period
states as shown in Table 1.
Usually 3 to 4 days, but may vary from 2 to 10 days.
TABLE 1
Reported cases and deaths due to Clinical course
meningococcal meningitis in some states in India - 2020 Most infections do not cause clinical disease. Many
infected people become asymptomatic carriers of the
bacteria and serve as a reservoir and source of infection for
others. In general, susceptibility to meningococcal disease
decreases with age. Meningococcal meningitis has a sudden
onset of intense headache, fever, nausea, vomiting,
photophobia, stiff neck and various neurological signs. The
disease is fatal within 24-48 hours in 5-10 per cent of cases
even with prompt antimicrobial treatment in good health
care facility. Among individuals who survive, upto 15-20 per
cent have permanent neurological sequelae. Meningococcal
septicaemia, in which there is rapid dissemination of bacteria
in the bloodstream, is a less common form of meningococcal

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disease, characterized by circulatory collapse, haemorrhagic
skin rash and high fatality rate (4).
Prevention and control
Source : (2) (a) CASES : Treatment with antibiotics can save the lives
of 95 per cent of patients provided that it is started during
Epidemiological features the first 2 days of illness. Penicillin is the drug of choice. In
(a) AGENT : The causative agent, N. meningitidis is a penicillin-allergic patients, ceftriaxone and other third-
gram-negative diplococci. 12 serotypes have been identified, generation cephalosporin should be substituted. A single
viz. Groups A, B, C, 29E, H, I, K, L, W135, X, Y, Z based on dose of long-acting chloramphenicol or cetriaxone is used
the structure of the polysaccharide capsule. The majority of for treatment of epidemic meningococcal meningitis in sub-
invasive meningococcal infections are caused by organisms Saharan Africa. Septicaemic shock and raised intracranial
of serogroups A, B, C, X, W135 and Y. Meningococci of these pressure in meningitis are particular problems in the
serogroups have the potential to cause both endemic disease management of meningococcal disease. Treatment of cases
and outbreaks. In African meningitis belt, subgroup A has has practically no effect on the epidemiological pattern of
been the most important cause of disease (1). N. meningitidis the disease because it only reduces the fatality rate of the
is a delicate organism; it dies rapidly on exposure to heat and disease according to the treatment efficiency (3). Isolation of
cold, (b) SOURCE OF INFECTION : The organism is found in cases is of limited usefulness in controlling epidemics
the nasopharynx of cases and carriers. Clinical cases present because the carriers outnumber cases.
only a negligible source of infection. More often the infection (b) CARRIERS : Treatment with penicillin does not
causes mild or even unnoticeable symptoms of naso­ eradicate the carrier state; more powerful antibiotics such as
pharyngitis. 4 to 35 per cent of the normal population may rifampicin are needed to eradicate the carrier state (5).
harbour the organism in the nasopharynx during inter­
epidemic periods. Carriers are the most important source of (c) CONTACTS : Close contacts of persons with confirmed
infection. The mean duration of temporary carriers is about meningococcal disease are at an increased risk of developing
10 months (3). During epidemics, the carrier rate may go up meningococcal illness. Antibiotics are effective in preventing
to 70-80 per cent, (c) PERIOD OF COMMUNICABILITY : additional cases through eradicating carriage of the invasive
Until meningococci are no longer present in discharges from strain. Most secondary case occur within the first 72 hours
nose and throat. Cases rapidly lose their infectiousness within after presentation of the index case; risk of secondary disease
24 hours of specific treatment, (d) AGE AND SEX : This is decreases to near baseline by 10-14 days. Close contacts
predominantly a disease of children and young adults of both include household, child care, and preschool contacts. In
sexes with highest attack rate in infants aged 3-12 months, outbreaks involving limited populations, those with direct,
(e) IMMUNITY : All ages are susceptible. Younger age groups prolonged contact with a case of meningococcal disease may
are more susceptible than older groups as their antibodies are also be offered clearance treatment. Ideally, where indicated,
lower. Immunity is acquired by subclinical infection (mostly), treatment should be started within 24 hours of identification of
clinical disease or vaccination. Infants derive passive the index case. Antibiotics effective for this purpose include
immunity from the mother, (f) ENVIRONMENTAL FACTORS rifampicin, ciprofloxacin, ceftriaxone or azithromycin.
: The seasonal variation of the disease is well established; (d) MASS CHEMOPROPHYLAXIS : This is in fact mass
outbreaks occur more frequently in the dry and cold months medication of the total population some of which are not
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 ACUTE RESPIRATORY INFECTIONS
185
infected. It is recommended that mass chemoprophylaxis be discomfort, disability and loss of time for most adults, they
restricted to closed and medically supervised communities. are a substantial cause of morbidity and mortality in young
Mass treatment causes an immediate drop in the incidence children and the elderly. Many of these infections run their
rate of meningitis and in the proportion of carriers. The natural course in older children and in adults without
efficacy of this preventive measure depends to a large extent specific treatment and without complications. However, in
on the population coverage (3). The drugs of choice are young infants, small children and in the elderly, or in
ciprofloxacin, minocycline, spiramycin and ceftriaxone. persons with impaired respiratory tract reserves, it increases
(e) VACCINE (1, 4) ; Currently available meningococcal the morbidity and mortality rates.
vaccines include polysaccharide vaccines and Acute respiratory infections (ARI) may cause
polysaccharide-protein conjugate vaccines. The conjugate inflammation of the respiratory tract anywhere from nose to
vaccines are more immunogenic and also induce alveoli, with a wide range of combination of symptoms and
immunogenic memory. Both vaccines are available against signs. ARI is often classified by clinical syndromes
meningococci of serogroup A, C, W135 and Y. depending on the site of infection and is referred to as ARI
Polysaccharide vaccines : Internationally marketed of upper (AURI) or lower (ALRI) respiratory tract. The upper
meningococcal polysaccharide vaccines are available in respiratory tract infections include common cold,
bivalent (A, C), trivalent (A,C, W 135), and quadrivalent (A, C, pharyngitis and otitis media. The lower respiratory tract
W135, Y) formulations. The vaccines contain 50 pg of each of infections include epiglottitis, laryngitis, laryngotracheitis,
the individual polysaccharides. Meningococcal polysaccharide bronchitis, bronchiolitis and pneumonia.
vaccines are administered as a single dose to persons >2 years The clinical features include running nose, cough, sore
old; most of these vaccines are given subcutaneously. throat, difficult breathing and ear problem. Fever is also
Adverse reactions to polysaccharide meningococcal common in acute respiratory infections. Most children with
vaccines are usually mild; the most frequent reaction is 1-2 these infections have only mild infection, such as cold or
days of pain and redness at the site of injection, which occur cough. However, some children may have pneumonia which
in 4%-56% of vaccine recipients. Transient fever is reported is a major cause of death. In less developed countries,
in <5% of recipients. measles and whooping cough are important causes of severe
respiratory tract infection.
Conjugate vaccines : Licensed meningococcal conjugate
vaccines are monovalent (A or C) or quadrivalent (A, C, Problem statement

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W135, Y), and also include a combination vaccine based on Pneumonia continues to kill more children under five
Haemophilus influenzae type b and Neisseria meningitidis worldwide than any other single infectious disease, claiming
serogroup C vaccines (Hib/MenC). an estimated 0.80 million children’s life in 2018. Young
Conjugate vaccine should be given as intramuscular children are at particularly high risk of developing severe
injection, preferably in the deltoid muscle (or in the pneumonia disease and death. More than 80 per cent of
anterolateral aspect of the upper thigh in children deaths associated with pneumonia occur in children during
<12 months of age). the first 2 years of life. It is more prevalent in the developing
Monovalent Men A conjugate vaccine should be given as a countries in South Asia and sub-Saharan Africa (1). Before
single dose to individuals 1-29 years of age. For monovalent widespread introduction of PCV into national immunization
Men C conjugate vaccine, one single intramuscular dose is programmes since 2006, the reported mean annual
recommended for children aged >12 months, teenagers and incidence of invasive pneumococcal disease (IPD) in
adults. Children 2-11 months of age require 2 dose children less than 2 years of age was 44.4 per lakh
administration at an interval of at least 2 months and a population per year in Europe and United States of
booster about 1 year thereafter. Quadrivalent vaccines are America, 60 per 100,000 population in South Africa and
administered as a single dose to individuals aged > 2 years. somewhere in between in Asia and Latin America (2).
Meningococcal vaccines should be stored at 2-8°C. It is difficult to determine the proportion of Straptococcus
Conjugate vaccines are preferred over polysaccharide vaccines pneumoniae to pneumonia cases. In a compilation data, it was
due to their potential for herd protection and their increased found to be responsible for 78 per cent of the lobar pneumonia
immunogenicity, particularly in children < 2 years of age. Both cases and 13 per cent of bronchopneumonia cases.
vaccines are safe when used during pregnancy (1). WHO The other common causes of pneumonia are
recommends that countries with high or medium endemic rates Haemophilus influenzae type b (the second most common
of invasive meningococcal disease and countries with frequent cause of pneumonia), respiratory syncytial virus is the most
epidemics should introduce appropriate large-scale common viral cause of pneumonia, and in HIV infected
meningococcal vaccination programmes (1). infants pneumocystis jirovecii is the most common cause of
References pneumonia responsible for at least one quarter of all
pneumonia deaths in HIV-infected infants (3).
1. WHO (2011), Weekly Epidemiological Record, No. 47,18th Nov. 2011.
2. Govt, of India (2021), National Health Profile 2021, DGHS, Ministry of Continuous spread of infection from nasopharynx can
Health and Family Welfare, New Delhi. cause otitis media or sinusitis. Pneumonia is often caused by
3. Cvjetanovic, B. et al (1978). Bull WHO, 56 (Supplement No.l): 81. aspiration of pneumococci from nanopharynx and may also
4. WHO (2012), International travel and Health, 2012. be caused by blood-borne spread. When associated with
5. Jawetz, etal, (2007), Medical Microbiology, 24th ed., A Lange Medical bacteraemia, pneumonia is classified as IPD. Case fatality
Book. rates from IPD in children can be high, ranging up-to
20 per cent for septicaemia and 50 per cent for meningitis in
ACUTE RESPIRATORY INFECTIONS low middle income countries. Long-term neurological
sequelae such as hearing loss, mental retardation,
Infections of the respiratory tract are perhaps the most motor abnormalities and seizures have been observed in
common human ailment. While they are a source of 24.7 per cent of survivors of pneumococcal meningitis.

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The risk of pneumococcal disease decreases after early show that upto 13% of inpatient deaths in paediatric wards
childhood and increases again in old age, suggesting are due to ARI. The proportion of death due to ARI in the
acquisition of natural immunity and loss of immunity in community is much higher as many children die at home.
older adults due to immunosenescence and increased The reason for high case fatality may be that children are
susceptibility due to other diseases. The mechanism of either not brought to the hospitals or brought too late.
natural immunity are not fully understood (2). In India during 2020, about 2,36,71,178 cases of ARI
H. influenzae colonizes the upper respiratory tract of were reported with 5,160 deaths. Same year 4,22,250 cases
humans and is transmitted person-to-person by inhalation of pneumonia were reported with 4,624 deaths (5)
of respiratory droplets or by direct contact with respiratory
tract secretions. Neonates can acquire infection by aspiration Epidemiological determinants
of amniotic fluid or contact with genital tract secretions Agent factors
during delivery. The contagious potential of invasive hib
disease is considered to be limited. However, certain The microbial agents that cause acute respiratory infections
circumstances particularly close contact with a case (patient are numerous and include bacteria and viruses. Even within
e.g. household, child care, institutional settings) can lead to species they can show a wide diversity of antigenic type. The
outbreaks of direct secondary transmission of the disease (4). agents are those most frequently encountered in a normal
population. The bacteria involved can all be isolated with
The exposure factors include household crowding, small varying frequency from carriers, and cause illness in only
household size, child care attendance, low socio-economic minority of infected persons. The viruses that have been found
status, low parental educational levels and school-age in association with acute respiratory disease are numerous.
siblings, chronic diseases, HIV infection, immunoglobulin They are the primary cause of the great majority of respiratory
deficiency, chemotherapy or stem cell transplant (4). illnesses. However, the severity of the illness is often
In India, in the states and districts with high infant and determined by whether or not secondary bacterial infection
child mortality rates, ARI is one of the major causes of occurs, particularly in the case of lower respiratory tract
death. ARI is also one of the major reasons for which infections. The agents considered to be capable of acute
children are brought to the hospitals and health facilities. respiratory diseases, the age group most frequently affected,
Hospital records from states with high infant mortality rates and the characteristic clinical features are as shown in Table 1.

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TABLE 1
The agents causing ARI, age group affected and clinical features

Agent Age group (s) most frequently affected Characteristic clinical features

Bacteria
Bordetella pertussis Infants and young children Paroxysmal cough
Corynebacterium diphtheriae Children Nasal/tonsillar/pharyngeal membranous exudate ±
severe toxaemia
Haemophilus influenzae Adults Acute exacerbations of chronic bronchitis pneumonia
Children Acute epiglottitis (H influenzae type B)
Klebsiella pneumoniae Adults Lobar pneumonia ± lung abscess
Legionella pneumophila Adults Pneumonia
Staphylococcus pyogenes All ages Lobar and broncho-pneumonia (esp. secondary to
influenza) ± lung abscess
Streptococcus pneumoniae All ages Pneumonia (lobar or multilobular) Acute exacerbations
of chronic bronchitis
Streptococcus pyogenes All ages Acute pharyngitis and tonsillitis
Virus
Adenoviruses - endemic types (1,2,5) Young children Lower respiratory
- epidemic types (3,4,7) Older children and young adults Febrile pharyngitis and influenza-like illness
Enteroviruses (ECHO and Coxsackie) All ages Variable respiratory
Influenza A Ail ages Fever, aching, malaise, variable respiratory
B School childrenj Occasional primary pneumonia
_ Secondary bacterial pneumonia in elderly
C Rare Mild upper respiratory
Measles Young children Variable respiratory with characteristic rash
Parainfluenza 1 re-infection in later life :
~l Young children
2 Croup Upper respiratory
3 Infants Bronchiolitis and pneumonia
Respiratory syncytial virus Infants and young children Severe bronchiolitis and pneumonia
Rhinoviruses (multiple serotypes) |
Coronavirus All ages Common cold
Other agents
Chlamydia type B (Psittacosis) Adults exposed to infected birds Influenza-like illness and atypical pneumonia
Coxiella burnetii (Q fever) Adults exposed to sheep and cattle Atypical pneumonia
Mycoplasma pneumoniae School children and young adults Febrile bronchitis and atypical pneumonia
Source : (6)

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 ACUTE RESPIRATORY INFECTIONS

Host factors the management of the acute respiratory infections. Note the
age of the child, for how long the child is coughing, whether
Small children can succumb to the disease within a matter
the child is able to drink (if the child is aged
of days. Case fatality rates are higher in young infants and
2 months upto 5 years), has the young infant stopped
malnourished children. Age-specific mortality rates show
feeding well (child less than 2 months), has there been any
wide differences between countries. In general, rates tend to
antecedent illness such as measles, does the child have fever,
be high in infants and young children, and in the elderly in all
is the child excessively drowsy or difficult to wake (if yes, for
countries, although the age group with the highest rates can
how long), did the child have convulsions, is there irregular
differ. In developing countries where malnutrition and low
breathing, short periods of not breathing or the child turning
birth weight is often a major problem, the rates in children
blue, any history of treatment during the illness.
tend to be the highest. By contrast, in developed countries
respiratory infections are only exceptionally fatal in infants Physical examination
but are commonly terminal in the elderly.
Upper respiratory tract infections, e.g., common cold and Look and listen for the following :
pharyngitis are several times higher in children than in adults. (1) COUNT THE BREATHS IN ONE MINUTE : As the
Rates for pharyngitis and otitis media increase from infancy to children get older, their breathing rate slows down.
a peak at the age of 5 years. Illness rates are highest in young Therefore, the cut-off point used to determine if a child has
children and decrease with the increasing age, except in the fast breathing will depend on the age of the child. Count the
third decade of life when young adults are exposed to infection respiratory rate for full one minute using the second’s hand
by their own young children. Adult women experience more of the watch looking at the abdominal movement or lower
illness than men. The greater exposure of women to small chest when the child is calm. The chest and abdomen must
children may be responsible for this. Under 3 years of age boys be exposed for counting. Increased respiratory rate is of
are affected more often and more severely. significance only if it persists.
Risk factors Fast breathing is present when the respiratory rate is
Many risk factors for respiratory tract infections have - 60 breaths per minute or more in a child less than
been identified. They include not only the climatic 2 months of age
conditions but also the housing, level of industrialization - 50 breaths per minute or more in a child aged
2 months upto 12 months

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and socio-economic development. In developing countries,
overcrowded dwellings, poor nutrition, low birth weight and - 40 breaths per minute or more in a child aged
intense indoor smoke pollution underline the high rates. 12 months upto 5 years.
Local mortality rates are particularly affected by the extent However, repeat the count for a young infant (age less
of influenza epidemics. Studies in developed countries have than 2 months) if the count is 60 breaths per minute or
shown that higher rate of infection is common in younger more. This is important because the breathing rate of young
sibling of school going children who introduce infection into infant is often erratic. Occasionally young infants stop
the household. Maternal cigarette smoking has also been breathing for a few seconds, and then breath very rapidly for
linked to increased occurrence of respiratory tract infections a short period.
during the first year of life. Children from low socio­
economic status tend to have more respiratory infections. (2) LOOK FOR CHEST INDRAWING : Look for chest
The infection is more common in preschool children indrawing when the child breaths IN. The child has
attending day-care centres. The infections tend to be more indrawing if the lower chest wall goes in when the child
common in urban communities than in rural communities. breaths in. Chest indrawing occurs when the effort required
to breath in, is much greater than normal.
Mode of transmission (3) LOOK AND LISTEN FOR STRIDOR : A child with
All the causative organisms are normally transmitted by stridor makes a harsh noise when breathing IN. Stridor
the airborne route. As most viruses do not survive for long occurs when there is narrowing of the larynx, trachea or
outside the respiratory tract, the chain of transmission is epiglottis which interferes with air entering the lungs. These
maintained by direct person-to-person contact. conditions are often called croup.
(4) LOOK FOR WHEEZE : A child with wheezing makes a
CONTROL OF ACUTE RESPIRATORY INFECTIONS soft whistling noise or shows signs that breathing OUT is
difficult, wheezing is caused by narrowing of the air passage
Improving the primary medical care services and in the lungs. The breathing-out phase takes longer than
developing better methods for early detection, treatment
normal and requires effort.
and where possible, prevention of acute respiratory
infections is the best strategy to control ARI. Effective If the child is wheezing, ask the mother if her child has
reduction of mortality due to pneumonia is possible if had a previous episode of wheezing within the past year. If
children suffering from pneumonia are treated correctly. so, the child should be classified as having recurrent wheeze.
Education of mother is also crucial since compliance with (5) See if the child is abnormally sleepy or difficult to
treatment and seeking care promptly when signs of wake. An abnormally sleepy child is drowsy most of the time
pneumonia are observed, are among the key factors which when he or she should be awake and alert.
determine the outcome of the disease. The
(6) Feel for fever or low body temperature.
recommendations by WHO for the management of acute
respiratory infections in children and the practical guidelines (7) CHECK FOR SEVERE MALNUTRITION : Malnutrition
for out-patient care are discussed below (7). The same when present is a high risk factor and case fatality rates are
guidelines are followed in India. higher in such children. In severely malnourished children
with pneumonia, fast breathing and chest indrawing may not
Clinical assessment be as evident as in other children. A severely malnourished
History taking and clinical assessment is very important in child may have an impaired or absent response to hypoxia and
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

a weak or absent cough reflex. These children need careful A. Child aged 2 months upto 5 years
evaluation for pneumonia as well as careful management.
The revised recommendations for children aged 2 months
(8) Cyanosis is a sign of hypoxia. Cyanosis must be to 59 months are as follows (7) :
checked in good light.
1. Children with fast breathing pneumonia with no chest
indrawing or general danger sign should be treated with
CLASSIFICATION OF ILLNESS AND TREATMENT
oral amoxicillin : at least 40 mg/kg/dose twice daily
In the early 1980s, the global burden of childhood (80 mg/kg/day) for five days. In areas with low HIV
mortality due to pneumonia led the World Health prevalence, give amoxicillin for three days.
Organization to develop a pneumonia control strategy Children with fast-breathing pneumonia who fail on first-
suitable for countries with limited resources and constrained line treatment with amoxicillin should have the option of
health systems. Management of pneumonia cases formed referral to a facility where there is appropriate second-
the cornerstone of this strategy. Simple signs were identified line treatment.
to classify varying severities of pneumonia in settings with 2. Children age 2-59 months with chest indrawing
little or no access to diagnostic technology; the pneumonia should be treated with oral amoxicillin : at
classifications determined the appropriate case management least 40 mg/kg/dose twice daily for five days.
actions. These pneumonia classification and management 3. Children aged 2-59 months with severe pneumonia
guidelines were based on evidence generated in the 1970s should be treated with parenteral ampicillin (or
and early 1980s, and were incorporated into the original
penicillin) and gentamicin as a first-line treatment.
version of Integrated Management of Childhood Illness
(IMCI). In the intervening time, new evidence has emerged - Ampicillin : 50 mg/kg, or benzyl penicillin: 50,000
which prompted the development of revised guidelines (7). units per kg IM/IV every 6 hours for at least five days
- Gentamicin : 7.5 mg/kg IM/IV once a day for at least
The revisions include changing the recommendation for five days
the first-line antibiotic and re-defining the classification of
Ceftriaxone should be used as a second-line treatment in
pneumonia severity. The data shows that oral amoxicillin is
preferable to oral cotrimoxazole for the treatment of “fast children with severe pneumonia having failed on the
breathing pneumonia” and is equivalent to injectable first-line treatment.
4. Ampicillin (or penicillin when ampicillin is not available)

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penicillin/ampicillin in cases of “chest indrawing
pneumonia”. Hence, in a programmatic context, the plus gentamicin or ceftriaxone are recommended as a
distinction between previously defined “pneumonia” (fast first-line antibiotic regimen for HIV-infected and
breathing) and “severe pneumonia” (chest indrawing) loses HIV-exposed infants and for children under 5 years of age
its significance. The new classification is therefore simplified with chest indrawing pneumonia or severe pneumonia.
to include only two categories of pneumonia; “pneumonia” For HIV-infected and HIV-exposed infants and for
with fast breathing and/or chest indrawing, which requires children with chest indrawing pneumonia or severe
home therapy with oral amoxicillin, and “severe pneumonia, who do not respond to treatment with
pneumonia”, pneumonia with any general danger sign, ampicillin or penicillin plus gentamicin, ceftriaxone
which requires referral and injectable therapy. Fig. 1 shows alone is recommended for use as second-line treatment.
the difference between previous and revised classification 5. Empiric cotrimoxazole treatment for suspected
and the treatment recommended. Pneumocystis jirovecii (previously Pneumocystis carinii)

Revised classification and treatment for

childhood pneumonia at health facility

->Cough and cold,

no pneumonia
Home care
advice

Fast breathing Oral

Child age Child age and/or chest amoxicillin
2-59 2-59 ►
indrawing: and home
months months pneumonia care advice
with cough with cough
and/or and/or
difficult difficult
breathing breathing First dose
antibiotic and
General danger referral to
signs:* severe facility for
M► pneumonia or > injectable
very severe antibiotic/
disease supportive
therapy

* Not able to drink, persistent vomiting, convulsions, lethargic or

unconscious, stridor in a calm child or severe malnutrition.
FIG. 1
Comparison of previous and revised classification and treatment of childhood pneumonia at health facility
Source : (7)
by R△J
 ACUTE RESPIRATORY INFECTIONS
189
pneumonia (PCP) is recommended as an additional kept warm and dry. Breast-feeding must be promoted
treatment for HIV-infected and HIV-exposed infants aged strongly as the child who is not breast-fed is at a much
from 2 months up to 1 year with chest indrawing or higher risk of diarrhoea.
severe pneumonia.
MANAGEMENT OF AURI (NO PNEUMONIA)
Empirical cotrimoxazole treatment for Pneumocystis
jirovecii pneumonia (PCP) is not recommended for HIV- Many children with presenting symptoms of cough, cold
infected and HIV-exposed children over 1 year of age and fever do not have pneumonia (no fast breathing or chest
with chest indrawing or severe pneumonia. indrawing) and DO NOT require treatment with antibiotics.
Dosages of amoxicillin for pneumonia treatment at health Antibiotics are not recommended for coughs and colds
facilities have been revised to reflect three age bands as shown in because majority of cases are caused by viruses and
Table 2 :2 months up to 12 months (4-< 10 kg); 12 months up to antibiotics are not effective, they increase resistant strains and
3 years (10—< 14 kg); 3 years up to 5 years (14-19 kg). Dosages cause side-effects while providing no clinical benefit, and are
and age bands for treatment of fast breathing pneumonia by wasteful expenditure. Symptomatic treatment and care at
community health workers (CHWs) have not changed. home is generally enough for such cases. The mothers must
be advised on how to take care of the child at home.
The revised recommendations present a number of
advantages such as : Prevention of Acute Respiratory Infections
Oral amoxicillin can be used to treat both fast breathing Present understanding of risk factors of respiratory tract
pneumonia and chest indrawing pneumonia; infection in childhood indicates several approaches for
- Pneumonia classification and management are simplified primary prevention. In developing countries, improved living
to two categories instead of three; conditions, better nutrition and reduction of smoke pollution
- Access to antibiotic treatment closer to home is increased; indoors will reduce the burden of mortality and morbidity
- The need for referrals to higher level facilities is decreased; associated with ARI. Other preventive measures include
- The probability of hospitalization and thus the risk of better MCH care. Immunization is an important measure to
nosocomial and injection borne diseases is reduced; reduce cases of pneumonia which occur as a complication of
vaccine preventable disease, especially measles. It is obvious
- The probability of antimicrobial resistance is diminished,
that community support is essential to reduce the disease
due to better adherence to the simplified treatment; and
burden. Families with young children must be helped to

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- Training of health workers is simplified. recognize pneumonia. Health promotional activities are
B. Pneumonia in Young Infants under specially important in vulnerable areas (8).
2 Months of Age Immunization
The treatment in these conditions is, basically the same. Vaccines hold promise of saving millions of children from
The child must be hospitalized. Treatment may be started by dying of pneumonia. Three vaccines have potential of
the health worker before referring the child. If pneumonia is reducing deaths from pneumonia. These vaccines work to
suspected the child should be treated with intramuscular reduce the incidence of bacterial pneumonia.
injections of benzyl penicillin or injection ampicillin, along
with injection gentamycin. Chloramphenicol is not 1. MEASLES VACCINE
recommended as the first line of treatment in young infants. Pneumonia is a serious complication of measles and the most
The treatment plan is as shown in Table 3. common cause of death associated with measles worldwide.
TABLE 3 Thus, reducing the incidence of measles in young children
Treatment of pneumonia in children aged less than 2 months through vaccination would also help to reduce deaths from
FREQUENCY
pneumonia. A safe and effective vaccine against measles is
available for past 40 years. Please refer to page 166 for details.
ANTIBIOTIC DOSE Age Age 7 days
< 7 days to 2 months 2. HIB VACCINE
Inj. Benzyl Penicillin 50,000 IU/kg/dose 12 hourly 6 hourly Haemophilus influenzae type B (Hib), is an important
OR cause of pneumonia and meningitis among children in
inj Ampicillin 50 mg/kg/dose 12 hourly 8 hourly
AND developing countries. Hib vaccine has been available for more
inj. Gentamycin 2.5 mg/kg/dose 12 hourly 8 hourly than a decade. It reduces dramatically the incidence of Hib
meningitis and pneumonia in infants and nasopharyngeal
Besides antibiotics, therapy for the associated conditions, colonization by Hib bacteria. It’s high cost has posed obstacle
if any, must be instituted immediately. The child should be to its introduction in developing countries.
TABLE 2
Doses of amoxicillin for children 2-59 months of age with pneumonia
Tools Category of Age/weight of child Dosage of Amoxicillin dispersible tablets
pneumonia (250 mg)
ICCM tool for Fast breathing 2 months up to 12 months (4-<10 kg) 1 tab twice a day x 5 days (10 tabs)
community health pneumonia
workers ; no change 12 months up to 5 years (10-19 kg) 2 tabs twice a day x 5 days (20 tabs)
iMCI tool for Fast breathing 2 months up to 12 months (4—< 10 kg) 1 tab twice a day x 5 days (10 tabs)
professional health and chest
workers at health 12 months up to 3 years (10—< 14 kg) 2 tabs twice a day x 5 days (20 tabs)
indrawing
facilities revised pneumonia 3 years up to 5 years (14-19 kg) 3 tabs twice a day x 5 days (30 tabs)

by R△J
190 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The vaccine is often given as a combined preparation with >7 months of age. One booster dose should be given
DPT and poliomyelitis vaccine. Three or four doses are given between 9-15 months of age (2).
depending on the manufacturers and type of vaccine used, The National Immunization Schedule of India
and is given intramuscularly. The vaccine schedule is at recommends PCV for infants up to 1 year of age in three
6, 10, and 14 weeks of age or according to national doses (2 primary doses and 1 booster dose) at 6 weeks, 14
immunization schedule. In many industrialized countries a weeks and 9 months. 0.5 ml is given using auto-disable
booster dose is given between 12-18 months which provides syringe as intramuscular injection in the anterolateral aspect
additional benefit to limit burden of Hib disease among of the right mid thigh (1).
children (9). For children more than 12 months of age, who
PCV efficacy is more than 80 per cent for serotypes present
have not received their primary immunization series a single
in the vaccine. It can be co-administered with other UIP
dose is sufficient for protection. The vaccine is not generally
vaccines. If two injections are being given in the same limb,
offered to children aged more than 24 months (9). then they should be administered at least one inch apart (1).
No serious side-effects have been recorded, and no PCV is a safe vaccine. Severe reactions are extremely rare.
contraindications are known, except for hyper-sensitivity to The most common side effects are irritability, crying, swelling
previous dose of vaccine. All conjugate vaccine have an and tenderness at injection site, and transient fever >39°C
excellent safety record, and where tested, do not interfere (102°F). PCV should not be administered to children with
substantially with immunogenecity of other vaccines given severe allergic reaction to a prior dose, or to vaccines
simultaneously (10). containing diphtheria toxoid, such as pentavalent vaccine (1).
3. PNEUMOCOCCAL PNEUMONIA VACCINE It should not be given to a child with severe illness. It is not
intended to be used for treatment of active infection.
a. PPV23 : For years, the polysaccharide non-conjugate
HIV positive and preterm babies who have received their
vaccine containing capsular antigens of 23 serotypes against 3 primary doses of vaccine before reaching 12 months of
this infection have been available for adults and children over age may benefit from a booster dose in the second year of
2 years of age. Children under 2 years of age and life. Interrupted schedules should be resumed without
immunocompromised individuals do not respond well to the repeating the previous doses (2).
vaccine. It is recommended for selected groups, e.g., those
who have undergone splenectomy or have sickle-cell disease, When primary immunization is initiated with one of these
chronic diseases of heart, lung, liver or kidney; diabetes vaccines, it is recommended that remaining doses are

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mellitus, alcoholism, generalized malignancies, organ administered with the same product. Interchangeability
transplants etc. In some industrialized countries like USA it is between PCV10 and PCV.3 has yet not been documented.
routinely advised for everyone aged above 65 years (10). WHO recommends inclusion of PCVs in childhood
immunization programme worldwide, particularly in
A dose of 0.5 ml of PPV23 contains 25 micrograms of countries with high under-five mortalities (2).
purified capsular polysaccharide from each 23 serotypes.
For primary immunization, PPV23 is administered as a The Integrated Global Action Plan for the
single intra-muscular dose preferably in the deltoid muscle Prevention and Control of Pneumonia and
or as subcutaneous dose. The vaccine should not be mixed Diarrhoea (12)
in the same syringe with other vaccines, for e.g. with
The Integrated Global Action Plan for the Prevention and
influenza vaccine, but may be administered at the same time
Control of Pneumonia and Diarrhoea (GAPPD) proposes a
by separate injection in the other arm. Simultaneous
cohesive approach to ending preventable pneumonia and
administration does not increase adverse events or decrease
diarrhoea deaths. It brings together critical services and
the antibody response to either vaccine. Protective capsular interventions to create healthy environments, promotes
type-specific antibody levels generally develop by the third practices known to protect children from disease, and
week following vaccination (11). ensures that every child has access to proven and
Minor adverse reactions, such as transient redness and appropriate preventive and treatment measures.
pain at the site of injection occur in 30-50 per cent of those The specific goals for 2025 are to:
who have been vaccinated, more commonly following
subcutaneous administration. Local reactions are more - reduce mortality from pneumonia in children less than
frequent in recipients of the 2nd dose of the vaccine (11). 5 years of age to fewer than 3 per 1000 live births;
- reduce mortality from diarrhoea in children less than
b. PCV : Two conjugate vaccines are available since 5 years of age to fewer than 1 per 1000 live births;
2009, PCV1Cj and PCV13. The PCV7 conjugate vaccine is - reduce the incidence of severe pneumonia by 75% in
gradually being removed from the market (1). Both PCV10 children less than 5 years of age as compared to 2010 levels;
and PCV13 are preservative free and their recommended - reduce the incidence of severe diarrhoea by 75% in
storage temperature is 2-8°C. The vaccine must not be children less than 5 years of age as compared to 2010 levels;
frozen. The shake test is applicable to PCV vaccine.
- reduce by 40% the global number of children less than
For PCV administration to infants, WHO recommends 5 years of age who are stunted as compared to 2010 levels.
3 primary doses (the 3p + 0 schedule) or, as an alternative, Theses goals are ambitious and will require significant
2 primary doses plus one booster (the 2p+l schedule). In political will and mobilization of additional resources if they
3p+0 schedule, vaccination can be initiated as early as are to be reached.
6 weeks of age with an interval betweeen doses of
4-8 weeks, with doses given at 6, 10 and 14 weeks or 2, 4, Coverage targets to be maintained or reached have also
and 6 months, depending on programme convenience (2). been set to define efforts needed to attain the above goals.
These are:
If 2p+l schedule is selected, the 2 primary doses are
given during infancy as early as 6 weeks of age at an interval - By the end of 2025:
preferably of 8 weeks or more for young infant, and - 90% full-dose coverage of each relevant vaccine
4-8 weeks or more between primary doses for infants (with 80% coverage in every district);
by R△J
 SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

- 90% access to appropriate pneumonia and Incubation period

diarrhoea case management (with 80% coverage The incubation period has been estimated to be 2 to
in every district); 7 days, commonly 3 to 5 days (1).
- at least 50% coverage of exclusive breast-feeding
during the first 6 months of life; Mode of transmission
- virtual elimination of paediatric HIV. The primary mode of transmission appears to be through
- By the end of 2030: direct or indirect contact of mucous membranes of eyes,
- universal access to basic drinking-water in health nose, or mouth with respiratory droplets or fomites. The use
care facilities and homes; of aerosol-generating procedures (endotracheal intubation,
bronchoscopy, nebulization treatments) in hospitals may
- universal access to adequate sanitation in health amplify the transmission of the SARS coronavirus. The virus
care facilities by 2030 and in homes by 2040; is shed in stools but the role of faecal-oral transmission is
- universal access to handwashing facilities (water unknown. The natural reservoir appears to be the horseshoe
and soap) in health care facilities and homes; bat (which eats and drops fruits ingested by civets, the
- universal access to clean and safe energy earlier presumed reservoir and a likely amplifying host).
technologies in health care facilities and homes. The SARS virus can survive for hours on common
surfaces outside the human body, and up to four days in
References human waste. The virus can survive at least for 24 hours on
1. Govt, of India (2021), National operational guidelines, Introduction of a plastic surface at room temperature, and can live for
Pneumococcal Conjugate Vaccine (PCV), Immunization Division, extended periods in the cold.
Ministry of Health and Family Welfare, New Delhi, January 2021.
2. WHO (2019), Weekly Epidemiological Record, No. 8,22nd Feb. 2019. Case definition (4)
3. WHO (2019), Fact Sheet Pneumonia, 2019.
4. CDC (2020), Pink Book, Epidemiology and Prevention of Vaccine The case definition is based on current understanding of
Preventable Diseases. the clinical features of SARS, and available epidemiological
5. Govt, of India (2021), National Health Profile 2021, DGHS, Ministry of data. It may be revised as new information accumulates.
Health and Family Welfare, New Delhi.
6. Epidemiology of Diseases, Edited by Miller, D.L. and Farmer, R.D., Case definition for notification of SARS under the
Blackwell Scientific Publications. International Health Regulation (2005)

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7. WHO (2014), Revised WHO classification and treatment of childhood
pneumonia at health facilities, Evidence summaries. In the period following an outbreak of SARS, a notifiable
8. Govt of India (1994), National Child Survival and Safe Motherhood case of SARS is defined as an individual with laboratory
Programme, Programme Interventions, MCH Division, Ministry of confirmation of infection with SARS coronavirus (SARS-
Health and Family Welfare, New Delhi. CoV) who either fulfils the clinical case definition of SARS or
9. WHO (2006), Weekly Epidemiological Record, No. 47, 24th Nov. has worked in a laboratory handling live SARS-CoV or
2006. storing clinical specimens infected with SARS-CoV.
10. WHO (2006), International Travel and Health.
11. WHO (2008), Weekly Epidemiological Record, No. 42, 17th Oct, Clinical case definition of SARS
2008.
1. A history of fever, or documented fever
12. WHO, UNICEF (2013), Ending Preventable Child Deaths from
Pneumonia and Diarrhoea by 2025. The Integrated Global Action Plan AND
for Pneumonia and Diarrhoea. 2. One or more symptoms of lower respiratory tract illness
(cough, difficulty in breathing, shortness of breath)
SEVERE ACUTE RESPIRATORY SYNDROME AND
I (SARS) 3. Radiographic evidence of lung infiltrates consistent with
pneumonia or acute respiratory distress syndrome
Severe acute respiratory syndrome (SARS) is a (ARDS) or autopsy findings consistent with the pathology
communicable viral disease, caused by a new strain of of pneumonia or ARDS without an identifiable cause
coronavirus, which differs considerably in genetic structure AND
from previously recognized coronavirus. 4. No alternative diagnosis fully explaining the illness.
The most common symptoms in patient progressing to
SARS include fever, malaise, chills, headache myalgia, Diagnostic tests required for laboratory confirmation of
dizziness, cough, sore throat and running nose. In some cases SARS
there is rapid deterioration with low oxygen saturation and (a) Conventional reverse transcriptase PCR (RT-PCR) and
acute respiratory distress requiring ventilatory support. It is real-time reverse transcriptase PCR (real-time RT-PCR)
capable of causing death in as many as 10 per cent cases (1). assay detecting viral RNA present in:
Chest X-ray findings typically begin with a small, 1. At least 2 different clinical specimens (e.g.
unilateral patchy shadowing, and progress over 1-2 days to nasopharyngeal and stool specimens)
become bilateral and generalized, with interstitial/confluent OR
infiltration. Adult respiratory distress syndrome has been 2. The same clinical specimen collected on 2 or more
observed in a number of patients in the end stages. occasions during the course of the illness (e.g.
sequential nasopharyngeal aspirates)
Problem statement OR
The earliest case was traced to a health care worker in 3. A new extract from the original clinical sample tested
China, in late 2002, with rapid spread to Hong Kong, positive by 2 different assays or repeat RT-PCR or
Singapore, Vietnam, Taiwan and Toranto. As of early August real-time RT-PCR on each occasion of testing
2003, about 8,422 cases were reported to the WHO from OR
30 countries with 916 fatalities (2). 4. Virus culture from any clinical specimen.

by R△J
192 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(b) Enzyme-linked immunosorbent assay (ELISA) and Mortality is age-related, ranging from less than 1% in persons
immunofluorescent assay (IFA) under 24 years of age to greater than 50% in persons over 65
1. Negative antibody test on serum collected during the years of age. Poor prognostic factors include advanced age,
acute phase of illness, followed by positive antibody test chronic hepatitis B infection treated with lamivudine, high
on convalescent-phase serum, tested simultaneously initial or high peak lactate dehydrogenase concentration, high
neutrophil count on presentation, diabetes mellitus, acute
OR
kidney disease, and low counts of CD4 and CD8 on
2. A 4-fold or greater rise in antibody titre against presentation. Many subclinical cases probably go undiagnosed.
SARS-CoV between an acute-phase serum specimen Seasonality, as with influenza, is not established (5).
and a convalescent-phase serum specimen (paired
sera), tested simultaneously. Prevention
In the absence of known SARS-CoV transmission to As there is no vaccine against SARS, the preventive
humans, the positive predictive value of a SARS-CoV measures for SARS control are appropriate detection and
diagnostic test is extremely low; therefore, the diagnosis should protective measures which include :
be independently verified in one or more WHO international
1. Prompt identification of persons with SARS, their
SARS reference and verification network laboratories. Every
movements and contacts;
single case of SARS must be reported to WHO.
2. Effective isolation of SARS patients in hospitals;
Epidemiological aspect 3. Appropriate protection of medical staff treating these
Health care workers, especially those involved in patients;
procedures generating aerosols, accounted for 21 per cent of 4. Comprehensive identification and isolation of suspected
all cases. Maximum virus excretion from the respiratory tract SARS cases;
occurs on about day 10 of illness and then declines. The 5. Simple hygienic measures such as hand-washing after
efficiency of transmission appears to be greatest following touching patients, use of appropriate and well-fitted
exposure to severely ill patients or those experiencing rapid masks, and introduction of infection control measures;
clinical deterioration, usually during the second week of 6. Exit screening of international travellers;
illness. When symptomatic cases were isolated within 5 days 7. Timely and accurate reporting and sharing of
of the onset of illness, few cases of secondary transmission information with other authorities and/or governments.
occurred. There was no evidence that patient transmits

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infection 10 days after fever has resolved. References
Children are rarely affected by SARS. To date, there have 1. WHO (2003), Weekly Epidemiological Record No. 12, 21 March 2003.
been two reported cases of transmission from children to 2. WHO (2003), World Health Report 2003, Shaping the future.
adults and no report of transmission from child to child. 3. WHO (2003), Weekly Epidemiological Record No. 43, 24th Oct. 2003.
Three separate epidemiological investigations have not 4. WHO (2009), Weekly Epidemiological Record No. 7, 13th Feb. 2009.
found any evidence of SARS transmission in schools. 5. Stephen J. Mcphee et al, (2010), Current Medical Diagnosis and
Furthermore, no evidence of SARS has been found in Treatment, 49th Ed. A Lange Medical Publication.
infants of mothers who were infected during pregnancy.
International flights have been associated with the CORONAVIRUS DISEASE-19
transmission of SARS from symptomatic probable cases to
passengers or crew. WHO recommends exit screening and Coronavirus disease-2019 (COVID-19) is caused by
other measures to reduce opportunities for further SARS-CoV-2, a newly emergent coronavirus, that was first
international spread associated with air travel during the recognized in Wuhan, China, in December 2019. Genetic
epidemic period. sequencing of the virus suggests that it is a betacoronavirus
Complications closely linked to SARS virus. It is from the family of single­
stranded RNA virus (+ss RNA) with a crown like appearance
As with any viral pneumonia, pulmonary under an electronic microscope, of approximately
decompensation is the most feared problem. ARDS occurs in 60-140 nm diameter, contains large widely spread club or
about 16% patients, and about 20-30% of patients require petal shaped spikes. Although high temperature decreases
intubation and mechanical ventilation. Sequelae of intensive the replication of the virus, it can resist the cold temperature.
care include infection with nosocomial pathogens, tension It is sensitive to ultraviolet rays, and is effectively inactivated
pneumothorax from ventilation at high peak pressures, and by lipid solvents including ether (75 per cent), ethnol,
non-cardiogenic pulmonary edema. chlorine-containing disinfectants, peroxyacetic acid and
Treatment chloroform except for chlorhexidine (1).
Severe cases require intensive support. Although a number The dynamics of SARS-CoV-2 are currently unknown,
of different agents including ribavirin (400-600 mg/d and but it is speculated that it has an animal origin.
4 g/d), lopinavir/ritonavir (400 mg/100 mg), interferon type 1,
intravenous immunoglobulin, and systemic cortiocosteroids Global scenario
were used to treat SARS patients during the 2003 epidemic, the In late December 2019, investigation of a cluster of
treatment efficacy of these therapeutic agents remains pneumonia cases of unknown origin in Wuhan, China,
inconclusive and further research is needed. Subsequent resulted in identification of a novel coronavirus. The virus is
studies with ribavirin show no activity against the virus in vitro, distinct from both Severe Acute Respiratory Syndrome
and a retrospective analysis of the epidemic in Toronto (SARS) coronavirus and Middle East Respiratory Syndrome
suggests worse outcomes in patients who receive the drug (5). (MERS) coronavirus, although closely related. Early
epidemiological findings suggest that the virus is more
Prognosis contagious than its predecessors. Severe Acute Respiratory
The overall mortality rate of identified cases is about 14%. Syndrome Coronavirus-2 (SARS-CoV-2) is a newly
by R△J
 COVID-19
193
identified pathogen and it is assumed that there is no Variants of concern
existing human immunity to the virus. Every one is Following is the variant of concern :
susceptible, although there may be risk factors that increase
an individuals illness severity. Omicron - B.1.1.529, BA.l, BA.1.1, BA.2, BA.3, BA.4
and BA.5.
The disease since its first detection in China, has now
spread to over 220 countries/territories. COVID-19 was First identified in South Africa. Spreads more easily than
declared a Pandemic by WHO on 11th March 2020, other variants. Data suggest that Omicron is less severe in
resulting in shift of focus from China to Europe and North general. However, a surge in cases may lead to significant
America and later on to the world. As such WHO advised increase in hospitalization and death. Breakthrough
countries to take a whole-of-government, whole-of-society infection in people who are vaccinated are expected but
approach, built around a comprehensive strategy to prevent being up to date on recommended vaccine, is effective at
disease, save lives and minimize the effect. Countries closed preventing severe illness, hospitalization and death.
their borders against travel related activities (by air, road,
railway or sea), and lockdown was imposed to minimize the Variants being monitored (VBM)
public movements. Variants designated as VBM include those where data
The pandemic has taught the world that “global problem indicates there is a potential or clear impact on approved or
requires global solution”. International co-operation is-the authorized medical countermeasures, or that have been
requirement of the day. Whether in detection of virus or associated with more severe disease or increased
development of vaccines or action on economic and social transmission but are no longer detected, or are circulating at
fronts. COVID-19 has imposed many restrictions on our daily very low levels. These variants do not pose a significant and
behaviour whether it is social distancing or wearing masks. imminent risk to public health.
We have also discovered that work-from-home-study-from- The variants being monitored are as follows (5) :
home, and shop-from-home, no visit to malls and markets are
workable concepts. E commerce portals witnessed record WHO Label Pango Lineage
traffic, which may become a permanent feature (2). Alpha B.l.1.7 and Q lineages
Beta B. 1.351 and descendent lineages
The global scenario of COVID-19 and the trend of disease
Gamma P.land descendent lineages
in top 5 countries affected are as shown in Table 1.
Delta B. 1.617.2 and AY lineages

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When compared globally, India’s cases per million Epsilon B.1.427 B.1.429
population were amongst the lowest in the world. Like-wise Eta B.1.525
the number of deaths per million was also one of the lowest. Iota B.1.526
USA reported the highest number of cases and deaths. Kappa B.1.617.1
N/A B.1.617.3
SARS-CoV-2 variants Zeta P.2
Viruses constantly change through mutation and INDIA
sometimes these mutations result in a new variant of the virus.
Some variants emerge and disappear while others persist. In India, the first case of COVID-19 was reported on
Most changes have little or no impact on the virus properties. 30th January 2020 in Kerala. India currently has the largest
However, some changes may affect the virus’s properties, number of confirmed cases in Asia. The outbreak of the disease
such as how easily it spreads, the associated disease severity, was declared an epidemic and Epidemic Disease Act, 1897 was
or the performance of vaccines, therapeutic medicines, invoked leading to temporary closure of educational, religious,
diagnostic tools or public health and social measures (4). entertainment and commercial establishments. It was followed
by gradual un-lockdown spread in 6 phases (one month each)
Scientists monitor all variants but may classify certain upto 30th November 2020.
ones as variants being monitored, variants of interest,
variants of concern and variants of high consequence. Some A three-tier arrangement of health facilities was created
variants spread more easily and quickly than other variants, for appropriate management of COVID-19 cases, [(i) COVID
which may lead to more cases of COVID-19. Even if a Care Centre with isolation beds for mild or pre-symptomatic
variant causes less severe disease in general, an increase in cases; (ii) Dedicated COVID Health Centre (DCHC) with
the overall number of cases could cause an increase in oxygen supported isolation beds for moderate cases; and
hospitalizations, put more strain on healthcare resources and (iii) Dedicated COVID Hospital (DCH) with ICU beds for
potentially lead to more deaths. severe cases] has been implemented. Tertiary care hospitals
TABLE 1
The global scenario and the trend of disease in top 5 countries affected by COVID-19 (20.09.2022)
Trend Global USA India France Brazil Germany
Total cases 61,81,41,427 9,75,94,686 4,45,47,599 3,49,73,419 3,46,44,407 3,27,97,308
Total deaths 65,33,467 10,79,206 5,28,403 1,54,824 6,85,569 1,49,169
Total recovered cases 59,80.84,372 9,41,52,770 4,39,72,980 3,43,74,410 3,37,50,459 3,20.38,000
Active cases 1,35,23,588 23,62,710 46,216 4,44,218 2,08,379 6,10,139
Serious critical cases 40,191 3,260 698 869 8,318 1,406
Total cases/million population 79,302 2,91,311 31,593 5,33,186 1,60,461 3,88,699
Deaths/million population 838.2 3,221 375 2,360 2,360 1,768
Tests/million population - 33,17,878 6,32,877 41,38,995 2,95,390 14,49,830
Population 7,97,58,74,244 33,50,19,427 1,41,07,41,415 6,55,93,263 21,59,05,241 8,43,77,058

Source : (3)
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

under ESIC, Defence, Railways, paramilitary forces, Steel surfaces and objects, creating fomites. Viable SARS-CoV-2
Ministry etc. have been leveraged for case management. virus and or RNA detected by RT-PCR can be found on
The top five states contributing to over 80 per cent active those surfaces for periods ranging from hours to days,
cases are Kerala, Maharashtra, Tamil Nadu, West Bengal depending on the ambient environment (including
and Karnataka. In India, about 92 per cent of the reported temperature and humidity) and the type of surface.
cases were having mild disease, 5.8 per cent cases required Therefore, transmission may also occur indirectly through
oxygen therapy and about 1.7 per cent cases required touching surfaces in the immediate environment or objects
intensive care (6). contaminated with virus from an infected person, followed
by touching mouth, eyes or nose.
Aarogya Setu App : Aarogya Setu App was launched by
the Government of India on the 2nd April 2020, and is SARS-CoV-2 has also been detected in other biological
available in 11 languages including Hindi and English. It is samples, including urine and faeces of some patients.
one of the many location-based surveillance app. to let the However, there have been no published reports of
users check whether they have been in contact with infected transmission of SARS-CoV-2 through faeces or urine.
people by using location and bluetooth data from
smartphones. The app. is available on both Android and Period of communicability
iOS devices. It asks a set of questions to the user to identify Knowing when an infected person can spread COVID-19
whether they are at the risk of the coronavirus infection. is important. Evidence suggests that COVID-19 can be
detected in people 1-3 days before their symptoms appear,
Mode of transmission (7) with the highest viral loads as measured by RT-PCR,
Transmission of SARS-CoV-2 can occur through direct, observed around the day of symptom onset, followed by a
indirect or close contact with infected people through gradual decline over time. The duration of RT-PCR positivity
secretions such as saliva and respiratory secretions or their generally appears to be 1-2 weeks for asymptomatic
respiratory droplets, which are expelled when infected person persons, and up to 3 weeks or more for patients with mild to
coughs, sneezes or talks. Respiratory droplets are >5-10 p.m moderate disease. In patients with severe COVID-19
in diameter whereas droplets <5 pm in diameter are droplet disease, it can be longer (8).
nuclei or aerosols. Respiratory droplet transmission can occur A study of the first patients in the Republic of Korea
when person is in close contact (within 1 metre) with an showed that 9-13 secondary cases occurred among

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infected person who has respiratory symptoms or who is household contacts.
talking. In these circumstances, respiratory droplets that
include virus can reach the mouth, nose or eyes of a Incubation period
susceptible person and can result in infection. 2-14 days.
Airborne transmission is defined as spread of an
infectious agent caused by transmission of droplet nuclei Clinical spectrum of SARS-CoV-2 infection
(aerosols) that remain infectious when suspended in air over Most patients with COVID-19 predominantly have a
long distances and time. Airborne transmission of SARS- respiratory tract infection. However, in a small proportion of
CoV-2 can occur during medical procedures that generate cases, they can progress to a more severe and systemic
aerosols or it may also spread in indoor settings with poor disease characterized by the Acute Respiratory Distress
ventilation. High variability is suggested between individuals Syndrome (ARDS), sepsis and septic shock, multiorgan
in terms of particle emission rate speech, with increased failure, including acute kidney injury and cardiac injury (8,
rates correlate with increased amplitude of vocalization (7). 9). The definition of a case, a contact, and clinical
Fomite transmission is possible. Respiratory secretions or presentation and risk factors are as shown in Table 2. Table 3
droplets expelled by infected persons can contaminate shows the progress of mild disease to a severe disease.

TABLE 2
Symptoms and risk factors associated with COVID-19
Clinical presentation Presenting signs and symptoms of COVID-19 vary
Most persons experience fever (83-99%), cough (59-82%), fatigue (44-70%), anorexia (40-84%), shortness of
breath (31-40%), myalgias (11-35%). Other non-specific symptoms, such as sore throat, nasal congestion,
headache, diarrhoea, nausea and vomiting, have also been reported Loss of smell (anosmia) or loss of taste
(ageusia) preceding the onset of respiratory symptoms has also been reported.
Older people and immunosuppressed patients in particular may present with atypical symptoms such as fatigue,
reduced alertness, reduced mobility, diarrhoea, loss of appetite, delirium, and absence of fever.
Symptoms such as dyspnoea, fever, gastrointestinal (GI) symptoms or fatigue due to physiologic adaptations in
pregnant women, adverse pregnancy events, or other diseases such as malaria, may overlap with symptoms of
COVID-19.
Children might not have reported fever or cough as frequently as adults.
Risk factors for Age more than 60 years (increasing with age).
severe disease Underlying non-communicable diseases (NCDs); diabetes, hypertension, cardiac disease, chronic lung disease,
cerebrovascular disease, chronic kidney disease, immunosuppression and cancer have been associated with
higher mortality.
Smoking.

Source : (8, 9)

by R△J
 COVID-19 195
TABLE 3
COVID-19 disease severity
Mild Symptomatic patients (Table 1) meeting the case definition for COVID-19 without evidence of viral
disease pneumonia or hypoxia.
Moderate Pneumonia Adolescent or adult with clinical signs of pneumonia (fever, cough, dyspnoea, fast breathing) but no signs
disease of severe pneumonia, including SpO2> 90% on room air.
Child with clinical signs of non-severe pneumonia (cough or difficulty breathing 4- fast breathing and/or
chest indrawing) and no signs of severe pneumonia.
Fast breathing (in breaths/min) : < 2 months : > 60; 2-11 months ; > 50; 1-5 years : > 40.
While the diagnosis can be made on clinical grounds; chest imaging (radiograph, CT scan, ultrasound)
may assist in diagnosis and identify or exclude pulmonary complications.
Severe Severe Adolescent or adult with clinical signs of pneumonia (fever, cough, dyspnoea, fast breathing) plus one of
disease pneumonia the following: respiratory rate > 30 breaths/min; severe respiratory distress; or SpO2 < 90% on room air
Child with clinical signs of pneumonia (cough or difficulty in breathing) + at least one of the following
- Central cyanosis or SpO„ < 90%; severe respiratory distress (e.g. fast breathing, grunting, very severe
chest indrawing); general danger sign, inability to breastfeed or drink, lethargy or unconsciousness, or
convulsions.
- Fast breathing (in breaths/min) : < 2 months ; > 60; 2-11 months : > 50; 1-5 years : > 40.
While the diagnosis can be made on clinical grounds; chest imaging (radiograph, CT scan, ultrasound)
may assist in diagnosis and identify or exclude pulmonary complications.
Critical Acute respiratory Onset. within 1 week of a known clinical insult (i.e. pneumonia) or new or worsening respiratory
disease distress syndrome symptoms.
(ARDS) Chest imaging : (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by
volume overload, lobar or lung collapse, or nodules.
Origin of pulmonary infiltrates : respiratory failure not fully explained by cardiac failure or fluid overload.
Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of infiltrates/oedema if
no risk factor present.
Oxygenation impairment in adults •
- Mild ARDS . 200 mmHg < PaOg/FiO^^ 300 mmHg (with PEEP or CPAP > 5 cmH20).b

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- Moderate ARDS : 100 mmHg < PaO^/FiO2< 200 mmHg (with PEEP > 5 cmH20).b
- Severe ARDS : PaO2/FiO2< 100 mmHg (with PEEP > 5 cmH20) b
Oxygenation impairment in children note OI and OSI.C Use OI when available If PaO2not available,
wean FiO2 to maintain SpO2< 97% to calculate OSI or SpOg/FiOg ratio :
- Bilevel (NIV or CPAP) > 5 cmH20 via full face mask : PaOg/FiOg < 300 mmHg or SpO^FiO^ 264.
- Mild ARDS (invasively ventilated) . 4 < OI < 8 or 5 < OSI < 7.5
- Moderate ARDS (invasively ventilated): 8 < OI < 16 or 7.5 < OSI < 12.3.
- Severe ARDS (invasively ventilated) OI > 16 or OSI > 12 3.
Critical Sepsis Adults : acute life-threatening organ dysfunction caused by a dysregulated host response to suspected or
disease proven infection. Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low
oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure,
skin mottling, laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate, or
hyperbilirubinaemia.
Children . suspected or proven infection and > 2 age-based systemic inflammatory response syndrome
(SIRS) criteria,® of which one must be abnormal temperature or white blood cell count
Septic shock Adults : persistent hypotension despite volume resuscitation, requiring vasopressors to maintain
MAP > 65mmHg and serum lactate level > 2 mmol/L
Children : any hypotension (SBP < 5th centile or > 2 SD below normal for age) or two or three of the
following: altered mental status; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and
heart rate < 70 bpm or > 150 bpm in children): prolonged capillary refill (> 2 sec) or weak pulse; fast
breathing, mottled or cool skin or petechial or purpuric rash; high lactate; reduced urine output;
hyperthermia or hypothermia.
Other complications that have been described in COVID-19 patients include acute, life-threatening conditions such as : acute pulmonary
embolism, acute coronary syndrome, acute stroke and delirium. Clinical suspicion for these complications should be heightened when caring
for COVID-19 patients, and appropriate diagnostic and treatment protocols available.
a If altitude is higher than 1000 m, then the correction factor should be calculated as follows: PaOg/FiOg x barometric pressure/760.
b When PaO2 is not available, SpO2/FiO2< 315 suggests ARDS (including in non-ventilated patients).
c Oxygenation Index (OI) is an invasive measurement of the severity of hypoxaemic respiratory failure and may be used to predict outcomes
in paediatric patients. It is calculated as follows: percentage of fraction of inhaled oxygen multiplied by the mean airway pressure (in mmHg),
divided by the partial pressure of arterial oxygen (in mmHg). Oxygen saturation index (OSI) is a non-invasive measurement and has been
shown to be a reliable surrogate marker of OI in children and adults with respiratory failure. OSI replaces PaO2 with oxygen saturation as
measured by pulse oximetry (SpO2) in the OI equation.
d The SOFA score ranges from 0 to 24 and includes points related to six organ systems: respiratory (hypoxaemia defined by low PaO«/FiO2);
coagulation (low platelets); liver (high bilirubin); cardiovascular (hypotension); central nervous system (low level of consciousness defined
by Glasgow Coma Scale); and renal (low urine output or high creatinine). Sepsis is defined by an increase in the sepsis-related SOFA score
of > 2 points. Assume the baseline score is 0 if data are not available.
e SIRS criteria : abnormal temperature (> 38.5°C or < 36°C); tachycardia for age or bradycardia for age if < 1 year; tachypnoea for age or
need for mechanical ventilation; abnormal white blood cell count for age or > 10% bands.
ABBREVIATIONS : BP blood pressure; bpm beats per minute; CPAP continuous positive airway pressure; CT computed tomography;
FiO2 fraction of inspired oxygen; MAP mean arterial pressure; NIV non-invasive ventilation; OI Oxygenation Index; OSI Oxygenation Index
using SpO2; PaO, partial pressure arterial oxygen; PEEP positive end-expiratory pressure; SBP systolic blood pressure; SD standard deviation;
SIRS systemic inflammatory response syndrome; SOFA sequential organ failure assessment; SpO2 oxygen saturation.
Source : (8, 9)

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Case definitions experience after first being infected with the virus that
causes COVID-19. Most people with COVID-19 get better
1. Suspect case (10) within a few days to a few weeks after infection, so at least
A patient with acute respiratory illness (fever and at least four weeks after infection is the start of time when post-
one sign/symptom of respiratory disease (e.g., cough, COVID conditions could first be identified.
shortness of breath), AND a history of travel to or residence Post-COVID conditions can include a wide range of
in a country/area or territory reporting local transmission of ongoing health problems; these conditions can last weeks,
COVID-19 disease during the 14 days prior to symptom months, or years. The conditions are found more often in
onset; people who had severe COVID-19 illness, but anyone can
OR experience post-COVID conditions, even people who had
A patient/health care worker with any acute respiratory mild illness or no symptoms from COVID-19. People who
illness AND having been in contact with a confirmed are not vaccinated against COVID-19 and become infected
COVID-19 case in the last 14 days prior to onset of are at higher risk of developing post-COVID conditions
symptoms; compared to people who were vaccinated and had
OR breakthrough infections. There is no single test for post-
COVID conditions. While most people with post-COVID
A patient with severe acute respiratory infection (fever
conditions have evidence of infection or COVID-19 illness,
and at least one sign/symptom of respiratory disease (e.g.,
in some cases, a person with post-COVID conditions may
cough, shortness of breath) and requiring hospitalization
not have tested positive for the virus or known they were
and with no other etiology that fully explains the clinical
infected.
presentation;
OR Symptoms of post-COVID conditions (11)
A case for whom testing for COVID-19 is inconclusive. People with post-COVID conditions may experience
2. Laboratory confirmed case (10) many symptoms. The most common symptoms are as
follows :
A. person with laboratory confirmation of COVID-19
infection, irrespective of clinical signs and symptoms. 1. General symptoms : (a) Tiredness or fatigue that
interferes with daily life; (b) Symptoms that get worse

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Definition of contact after physical or mental effort (also known as “post-
exertional malaise”); and (c) Fever.
A contact is a person that is involved in any of the
following: 2. Respiratory and heart symptoms : (a) Difficulty in
breathing or shortness of breath; (b) Cough; (c) Chest
• Providing direct care without proper personal protective pain; and (d) Fast-beating or pounding heart (also
equipment (PPE) for COVID-19 patients known as heart palpitations).
• Staying in the same close environment of a COVID-19 3. Neurological symptoms : (a) Difficulty in thinking or
patient (including workplace, classroom, household, concentrating (sometimes referred to as “brain fog”);
gatherings). (b) Headache; (c) Sleep problems; (d) Dizziness when
• Travelling together in close proximity (1 m) with a you stand up (lightheadedness); (e) Pins-and-needles
symptomatic person who later tested positive for feelings; (f) Change in smell or taste; and (g) Depression
COVID-19. or anxiety.
High risk contact 4. Digestive symptoms : Diarrhoea and stomach pain.
5. Other symptoms : Joint or muscle pain, rash, and
• Touched body fluids of the patient (Respiratory tract
changes in menstrual cycles.
secretions, blood, vomit, saliva, urine, faeces)
• Had direct physical contact with the body of the patient Some people, especially those who had severe COVID-
including physical examination without PPE. 19, experience multiorgan effects or autoimmune conditions
• Touched or cleaned the linens, clothes, or dishes of the with symptoms lasting weeks or months after COVID-19
patient. illness. Multiorgan effects can involve many body systems,
including the heart, lung, kidney, skin, and brain. As a result
• Lives in the same household as the patient. of these effects, people who have had COVID-19 may be
• Anyone in close proximity (within 3 ft) of the confirmed more likely to develop new health conditions such as
case without precautions. diabetes, heart conditions, or neurological conditions
• Passenger in close proximity (within 3 ft) of a compared with people who have not had COVID-19 (11).
conveyance with a symptomatic person who later tested Living with post-COVID conditions can be hard,
positive for COVID-19 for more than 6 hours. especially when there are no immediate answers or
Lou) risk contact solutions. The best way to prevent post-COVID conditions is
to protect yourself from becoming infected. Getting
• Shared the same space (Same class for school/worked in vaccinated is the best way to avoid the disease or getting
same room/similar and not having a high risk exposure serious illness. However, people experiencing post-COVID
to confirmed or suspect case of COVID-19). conditions can seek personal medical management plan that
• Travelled in same environment (bus/train/flight/any can help improve their symptoms and quality of life.
mode of transit) but not having a high-risk exposure.
Black Fungus Infection
Long COVID or Post-COVID conditions (11) Mucormycosis or Black Fungus is a rare fungal infection
Post-COVID conditions are a wide range of new, caused by a group of fungi called ‘mucormycetes’. They
returning, or ongoing health problems that people commonly exist in the environment, especially in animal

by R△J
 COVID-19

dung, compost, soil, leaves, and rotting produce. These fungi MOLECULAR TEST
can enter the body through exposed wounds in the skin,
inhaling, and breathing. Once they enter the body, these fungi Respiratory sample collection method (8)
have the potential to affect the brain, skin, lungs, and sinuses. A. Lower respiratory tract
The risk factors are uncontrolled pre-existing diabetes; - Bronchoalveolar lavage, tracheal aspirate, sputum
rampant overuse of steroids in management of COVID-19; - Collect 2-3 mL into a sterile, leak-proof, screw-cap
new onset of diabetes due to steroid overuse or severe cases sputum collection cup or sterile dry container.
of COVID-19; prolonged ICU stay and irrational use of broad
spectrum antibiotics; pre-existing co-morbidities such as B. Upper respiratory tract
haematological malignancies, use of immunosuppressants, - Nasopharyngeal swab and oropharyngeal swab
solid organ transplant etc.; and contamination through the
pipes and prongs used for the mechanical supply of oxygen to Oropharyngeal swab (e.g. throat swab) : Tilt patient’s
patients. head back 70 degrees. Rub swab over both tonsillar pillars
and posterior oropharynx and avoid touching the tongue,
Signs and symptoms : 1. Facial pain, pain over sinuses, teeth, and gums. Use only synthetic fiber swabs with plastic
pain in teeth and gums; 2. Decreased sensation over half of shafts. Do not use calcium alginate swabs or swabs with
face; 3. Blackish discoloration of skin over nasolabial wooden shafts. Place swabs immediately into sterile tubes
groove/alae nasi; 4. Nasal crusting and nasal discharge containing 2-3 ml of viral transport media.
.which could be blackish or blood tinged; 5. Conjunctival
redness; 6. Periorbital swelling; 7. Blurring of vision or Combined nasal & throat swab : Tilt patient’s head back
diplopia; 8. Loosening of teeth/discoloration of palate/ 70 degrees. While gently rotating the swab, insert swab less
gangrenous inferior turbinates; and 9. Worsening of than one inch into nostril (until resistance is met at
respiratory symptoms, haemoptysis, chest pain, alteration of turbinates). Rotate the swab several times against nasal wall
consciousness, headache (12). and repeat in other nostril using the same swab. Place tip of
the swab into sterile viral transport media tube and cut off
Diagnosis the applicator stick. For throat swab, take a second dry
1. KOH staining and microscopy, histopathology of polyester swab, insert into mouth, and swab the posterior
debrided tissue and culture. pharynx and tonsillar areas (avoid the tongue). Place tip of

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swab into the same tube and cut off the applicator tip.
2. Imaging techniques : CT scan of paranasal sinuses brain
and lungs. Nasopharyngeal swab : Tilt patient’s head back 70
degrees. Insert flexible swab through the nares parallel to the
3. Molecular assays. palate (not upwards) until resistance is encountered or the
distance is equivalent to that from the ear to the nostril of
Treatment the patient. Gently, rub and roll the swab. Leave the swab in
Liposomal Amphotericin B in initial dose of 5mg/kg body place for several seconds to absorb secretions before
weight (10 mg/kg body wt in case of CNS involvement) is removing.
the treatment of choice. Each vial contains 50 mg. It should
Clinicians may also collect lower respiratory tract samples
be diluted in 5% or 10% dextrose, it is incompatible with
when these are readily available (for example, in
normal saline/Ringer Lactate. It has to be continued till a
mechanically ventilated patients). In hospitalized patients in
favourable response is achieved and disease is stabilized
which may take several weeks following which step down to Dedicated Covid Hospitals (severe cases with confirmed
oral Posaconazole (300 mg delayed release tablets twice a COVID-19 infection), repeat upper respiratory tract samples
day for 1 day followed by 300 mg daily) or Isavuconazole should be collected to demonstrate viral clearance.
(200 mg 1 tablet 3 times daily for 2 days followed by 200 mg
daily). Conventional Amphotericin B (deoxy cholate) in the Nucleic acid amplification testing (NAAT) for
dose 1-1.5 mg/kg may be used if liposomal form is not SARS-CoV-2
available and renal functions and serum electrolytes are Reverse transcriptase polymerase chain reaction (RT-
within normal limits. PCR)-based diagnostic tests (which detect viral nucleic
In severe cases, surgery is required to remove dead or acids) are considered the gold standard for detecting current
infected tissues. Surgery can lead to permanent damage, SARS-CoV-2 infection.
both mentally and physically, as it involves removing parts The CT score or value in the RT-PCR report is an
of the nose or eyes. India reported more than 11,000 cases important part of the result and stands for ‘Cycle Threshold’.
of black fungus in COVID cases (6). The RT-PCR test involves converting the RNA collected from
the patient’s sample into DNA and then amplifying it. The
Diagnosis of COVID-19 CT value or score in the RT-PCR test refers to the number of
Testing strategies for Covid-19 diagnosis : There are two cycles it took for the fluorescence to be detected over the
types of testings for SARS-CoV-2. (1) Diagnostic testing : It is background signal. In simpler words, the CT score in RT-
intended to identify current infection at the individual level PCR is the number of cycles it took to detect the viral load. If
and is performed when a person has signs and symptoms the virus is not detected in a few cycles, the CT score of the
consistent with COVID-19, or when a person is RT-PCR test will keep increasing. A higher number of cycles
asymptomatic but has recent known or suspected exposure, means that the virus was undetectable in lower cycles. So,
and (2) Screening testing : It is intended to identify infected the CT value in RT-PCR report helps determine the viral
persons who are asymptomatic and without known or load and transmission potential of the virus. If the CT value
suspected exposure to SARS-CoV-2. Screening testing is is low, it means it took a lesser number of cycles to detect the
performed to identify persons who may be contagious so virus, implying a higher viral load and higher
that measures can be taken to prevent further transmission transmissibility. A higher CT value on the other hand means
of the disease. a lower viral load as well as transmissibility.
by R△J
198 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The CT Range in RT-PCR SARS-CoV-2 infection. Because it may take 21 days or

The ICMR has defined a basic CT range for RT-PCR tests longer after symptom onset for seroconversion or detection
to help diagnose the COVID-19 infection: of immunoglobulin IgM and/or IgG antibodies to
SARS-CoV-2. The use of serologic testing as the sole basis
- More than 35 : If the CT value in the report is 35 or for diagnosing acute SARS-CoV-2 infection is not
more, it is considered to be a negative report. recommended. Given that NAATs and antigen tests for
Additionally, it could also mean that the virus is in its SARS-CoV-2 occasionally yield false negative results,
initial stages and replication in the body has just started. serologic tests have been used in some settings as an
It can also indicate later phases of the infection when the additional diagnostic test for patients who are strongly
person is recovering. Clinical interpretation is necessary suspected to have SARS-CoV-2 infection. Using serology in
here. combination with a NAAT to detect IgG or total antibodies
- 25-35 : Moderate viral load and transmissibility. 3 to 4 weeks after onset of symptoms maximizes the
Whether the person is having symptoms or is sensitivity and specificity to detect past infection (10).
asymptomatic, there is need for isolation and to begin
treatment as soon as possible. CHEST IMAGING
- Less than 25 : High viral load and transmissibility.
Immediate isolation and medical consultation. Chest X-ray examination
Since the disease manifests itself as pneumonia,
More recently, NAATs have included a variety of radiological imaging has a fundamental role in the
additional platforms (e.g., real-time loop mediated
diagnostic process, management, and follow-up. Standard
isothermal amplification). Clinically, there may be a window
radiographic examination (X-ray) of the chest has a low
period of up to 5 days after exposure before viral nucleic
sensitivity in identifying early lung changes in the initial
acids can be detected. However, false negative NAAT results
can also occur outside of this 5-day window. Therefore, a stages of the disease. At this stage, it can be completely
single negative test result does not completely exclude negative. In the more advanced stages of infection, the chest
SARS-CoV-2 infection in people with a high likelihood of X-ray examination generally shows bilateral multifocal
infection based on their exposure history and/or their clinical alveolar opacities, which tend to confluence up to the
complete opacity of the lung. Pleural effusion can be

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presentation, and repeat testing using a NAAT should be
considered. associated.
SARS-CoV-2 poses several diagnostic challenges, Chest computed tomography
including potentially discordant shedding of virus from the
upper versus the lower respiratory tract. Due to the high Given the high sensitivity of the method, chest computed
specificity of NAAT, there is no need to obtain a lower tomography (CT), in particular high-resolution CT (HRCT),
respiratory tract sample to diagnose COVID-19 when a is the method of choice in the study of COVID-19
patient with recent onset of COVID-19-compatible pneumonia, even in the initial stages. Several non-specific
symptoms has a positive NAAT on an upper respiratory HRCT findings and patterns can be found. The most
sample. common findings are multifocal bilateral “ground glass”
(GG) areas associated with consolidation areas with patchy
Antigen testing for SARS-CoV-2 distribution, mainly peripheral/subpleural and with greater
involvement of the posterior regions and lower lobes. Other
When compared with RT-PCR-based tests, antigen-based
findings are the “reversed halo sign” which is a focal area of
diagnostic tests (which detect viral antigens in nasal or
nasopharyngeal swabs, also called RDT) are less sensitive GG delimited by a peripheral ring with consolidation, and
but have a similarly high specificity. Antigen tests perform the findings of cavitations, calcifications, lymphadenopathies
best early in the course of symptomatic SARS-CoV-2 and pleural effusion (10).
infection, when the viral load is thought to be highest. When
a person who is strongly suspected of having SARS-CoV-2 Lung ultrasound
infection receives a negative result on an initial antigen test, Ultrasound can allow evaluating the evolution of the
repeat testing using a NAAT should be considered. disease, from a focal interstitial pattern up to “white lung”
Advantages of antigen-based tests are their low cost and with evidence often of subpleural consolidations. It should
rapid turnaround. The availability of immediate results be performed within the first 24 hours in the suspect and
makes antigen-based tests an attractive option for point-of- every 24/48 hours and can be useful for patient follow-up,
care testing in high-risk congregate settings where choice of the setting of mechanical ventilation, and for the
preventing transmission is critical. Antigen-based tests also indication of prone positioning.
allow for repeat testing to quickly identify persons with
SARS-CoV-2 infection. Currently, there are limited data to Laboratory examinations (10)
guide the use of rapid antigen tests to detect or exclude
- In the early stage of the disease, a normal or decreased
SARS-CoV-2 infection in asymptomatic persons or to
total white blood cell count (WBC) and a decreased
determine whether a person who was previously confirmed
lymphocyte count can be demonstrated. Interestingly,
to have SARS-CoV-2 infection is still infectious.
lymphopenia appears to be a negative prognostic factor.
Serologic or antibody testing for diagnosis of - Increased values of liver enzymes, lactate dehydrogenase
SARS-CoV-2 (LDH), muscle enzymes, and C-reactive protein can be
detected.
Unlike NAATs and antigen tests for SARS-CoV-2 that
detect the presence of the virus, serologic or antibody tests - Unless a bacterial overlap, a normal procalcitonin value
are intended to identify persons with recent or prior is found.
by R△J
 COVID-19 199
- The elevated neutrophil-to-lymphocyte ratio (NLR), complications that should prompt urgent referral. Patients
derived NLR ratio (d-NLR) (neutrophil count divided by with risk factors for severe illness should be monitored
the result of WBC count minus neutrophil count), and closely, given the possible risk of deterioration. If they
platelet-to-lymphocyte ratio, can be the expression of the develop any worsening symptoms (such as mental
inflammatory storm. The correction of these indices is an confusion, difficulty breathing, persistent pain or pressure in
expression of a favourable trend. the chest, bluish coloration of face/lips, dehydration,
- Increased D-dimer. decreased urine output etc.), they should be immediately
admitted to a Dedicated Covid Health Centre or Dedicated
- In critical patients, D-dimer value is increased, blood Covid Hospital. Children with mild COVID-19 should be
lymphocytes decrease persistently, and laboratory monitored for signs and symptoms of clinical deterioration
alterations of multiorgan imbalance (high amylase, requiring urgent re-evaluation. These include difficulty in
coagulation disorders etc.) are found. breathing/fast or shallow breathing (for infants: grunting,
For COVID-19 patients with severe disease, collect blood inability to breast-feed), blue lips or face, chest pain
for blood culture, ideally prior to initiation of antimicrobial or pressure, new confusion, inability to awaken/not
therapy. Dual infection with other respiratory infections interacting when awake, inability to drink or keep down any
(viral, bacterial and fungal) have been found in COVID-19 liquids.
patients. Depending on local epidemiology and clinical An algorithm for clinical guidance for management
symptoms, test for other potential aetiologies, e.g., of COVID-19 suspect/confirmed case is as shown in Fig. 1
influenza, other respiratory viruses, malaria, dengue fever, and 2.
typhoid fever as appropriate (8). The mainstay of treatment is supplemental oxygen and
other supporting therapy. No specific antivirals have been
Management of COVID-19 proven effective. However, drugs like Ivermectin,
In the containment phase, to break the chain of Hydroxychloroquine, inhalational Budesonide,
transmission of COVID-19, patients with suspected or Dexamethasone, Methylprednisolne and Low Molecular
confirmed disease are isolated. Cases can be managed at Weight Heparin have been recommended. In addition,
Covid Care Centre, First Referral Units, Community Health provisions for Investigational Therapies have also been

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Centres (CHC), Sub-district Hospitals, District Hospitals, made using Remdesivir, and Tocilizumab for defined sub­
and Medical Colleges. group of patients under medical supervision (6).
Detailed clinical history is taken including that of
Prevention of complications
co-morbidities. The patient is followed up daily for
temperature, vitals and oxygen saturation (SpO2). Patients Implementation of the following interventions can
should be monitored for signs and symptoms of prevent complications associated with critical illness.

Prevention of complications
Anticipated outcome Interventions
Reduce days of invasive • Use weaning protocols that include daily assessment for readiness to breathe spontaneously
mechanical ventilation • Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless
contraindicated) or with daily interruption of continuous sedative infusions
• Early mobilization
• Implementation of the above as a bundle of care (may also reduce delirium); such as the Awakening and
Breathing Coordination, Delirium assessment/management, and Early mobility (ABCDE)
Reduce incidence of • Oral intubation is preferable to nasal intubation in adolescents and adults
ventilator-associated • Keep patient in semi-recumbent position (head of bed elevation 30-45°)
pneumonia • Use a closed suctioning system, periodically drain and discard condensate in tubing
• Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or
damaged, but not routinely
• Change heat moisture exchanger when it malfunctions, when soiled, or every 5-7 days
Reduce incidence of • Use a checklist with completion verified by a real-time observer as a reminder of each step needed
catheter-related for sterile insertion and as a daily reminder to remove catheter if no longer needed
bloodstream infection
Reduce incidence of • Turn patient every 2 hours
pressure ulcers
Reduce incidence of • Give early enteral nutrition (within 24-48 hours of admission)
stress ulcers and • Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for
GI bleeding GI bleeding. Risk factors for GI bleeding include mechanical ventilation for > 48 hours, coagulopathy,
renal replacement therapy, liver disease, multiple comorbidities, and higher organ failure score
Reduce the development • Utilize de-escalation protocols as soon as patient is clinically stable and there is no evidence of
of antimicrobial resistance bacterial infection
Reduce the development • Expose patient to empiric antimicrobial therapy for the shortest time possible, to prevent nephrotoxicity,
of adverse drug effects cardiac and other side-effects from unnecessary antimicrobial use
Promote appropriate • Do not prescribe antibiotics to suspected or confirmed COVID-19 patients with low suspicion of a
antimicrobial prescribing bacterial infection, to avoid more short-term side-effects of antibiotics in patients and negative
and use during the long-term consequences of increased antimicrobial resistance
COVID-19 pandemic

Source : (8)
by R△J
200 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Adult patient diagnosed with COVID-19

±
Mild disease Moderate disease

Upper respiratory tract symptoms Any one of Any one of:

and/or fever WITHOUT shortness 1. Respiratory rate > 24/min, breathlessness 1. Respiratory rate > 30/min, breathlessness
of breath or hypoxia 2. SpO2 : 90% to < 93% on room air 2. SpO2 < 90% on room air

Home Isolation & Care ADMIT IN WARD ADMIT IN HDU/ICU

(Refer to relevant guideline)

MUST DOs Oxygen Support: Respiratory support.

• Target SpO2.92-96% (88-92% in patients • Consider use of NIV (Helmet or face mask
• Physical distancing, indoor mask use, with COPD)
strict hand hygiene interface depending on availability) in
• Preferred devices for oxygenation : non- patients with increasing oxygen
• Symptomatic management (hydration, rebreathing face mask requirement, if work of breathing is LOW
anti-pyretics, anti-tussive) • Awake proning encouraged in all patients • Consider use of HFNC in patients with
• Stay in contact with treating physician requiring supplemental oxygen therapy increasing oxygen requirement
. Monitor temperature and oxygen (sequential position changes every 2 • Intubation should be prioritized in patients
saturation (by applying a SpO2 probe to hours) with high work of breathing/if NIV is not
fingers) Anti-inflammatory or immunomodulatory tolerated
therapy : • Use institutional protocol for ventilator
Seek immediate medical attention if: • Inj. Methylprednisolone 0.5 to 1 mg/kg in management when required
• Difficulty in breathing or SpO2 <93% 2 divided doses (or an equivalent dose of
• High grade fever/severe cough, dexamethasone) usually for a duration of Anti-inflammatory or immunomodulatory
particularly if lasting for >5 days 5 to 10 days therapy :
• A low threshold to be kept for those with • Patients may be initiated or switched to . Inj Methylprednisolone 1 to 2 mg/kg IV in
any of the high-risk features* * oral route if stable and/or improving 2 divided doses (or an equivalent dose of
• There is no evidence for benefit for dexamethasone) usually for a duration
injectable steroids in those NOT requiring 5 to 10 days

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MAY DOs oxygen supplementation, or on • Anti-inflammatory or immunomodulatory
Therapies based on low certainty of continuation after discharge therapy (such as steroids) can have risk of
evidence especially for those with high-risk . Anti-inflammatory or immunomodulatory secondary infection such as invasive
of progression* therapy (such as steroids) can have risk of mucormycosis when used too early, at
Inhalational Budesonide (given via secondary infection such as invasive higher dose or for longer than required
Metered dose inhaler/Dry powder inhaler) mucormycosis when used too early, at
higher dose or for longer than required Supportive measures
at a dose of 800 mcg BD for 5 days) to be
given if symptoms (fever and/or cough) are Anticoagulation • • Maintain euvolemia (if available, use
persistent beyond 5 days of disease onset • Conventional dose prophylactic dynamic measures for assessing fluid
unfractionated heparin or Low Molecular responsiveness)
*High-risk for severe disease or mortality Weight Heparin (weight based e.g., • If sepsis/septic shock : manage as per
enoxaparm 0.5mg/kg per day SC). There existing protocol and local antibiogram
• Age > 60 years should be no contraindication or high risk
• Cardiovascular disease, hypertension, Monitoring :
of bleeding
and CAD Monitoring : • Clinical Monitoring ; work of breathing,
• Diabetes mellitus and other • Clinical Monitoring : breathing rate, Hemodynamic instability, Change in
immunocompromised states Hemodynamic instability, Change in oxygen requirement
(such as HIV) oxygen requirement • Serial CXR; HRCT chest to be done
• Active tuberculosis • Serial CXR; HRCT chest to be done ONLY ONLY if there is worsening
• Chronic lung/kidney/liver disease if there is worsening • Lab monitoring : CRP, D-dimer,
. Lab monitoring . CRP, D-dimer, blood blood sugar 48 to 72 hrly; CBC, KFT,
• Cerebrovascular disease sugar 48 to 72 hrly; CBC, KFT, LET 24 to LFT 24 to 48 hrly
• Obesity 48 hrly

If cough persists for more than 2-3 weeks, investigate After clinical improvement, discharge
► as per revised discharge criteria
for tuberculosis and other conditions

EUA/Off label use (based on limited available evidence and only in specific circumstances) :
Remdesivir (EUA) may be considered ONLY in patients with
• 10 days of onset of symptoms, in those having moderate to severe disease (requiring supplemental oxygen), but who are NOT on IMV or ECMO
• Consider remdesivir for 5 days to treat hospitalized patients with COVID-19 (No evidence of benefit for treatment more than 5 days)
• NOT to be used in patients who are NOT on oxygen support or in home setting
• Monitor for RFT and LFT (remdesivir not recommended if eGFR <30 ml/min/m2; AST/ALT >5 times UNL) (not an absolute contraindication)
• Recommended dose : 200 mg IV on day 1 followed by 100 mg IV OD for next 4 days
Tocilizumab may be considered when ALL OF THE BELOW CRITERIA ARE MET
• Rapidly progressing COVID-19 needing oxygen supplementation or IMV and not responding adequately to steroids (preferably with in 24-48 hours
of onset of severe disease/ICU admission)
• Preferably to be given with steroids
• No active TB, fungal, systemic bacterial infection
• Long term follow up for secondary infections (such as reactivation of TB, flaring of Herpes etc.)
• Significantly raised inflammatory markers (CRP and/or IL-6)
• Recommended single dose : 4 to 6 mg/kg (400 mg in 60 kg adult) in 100 ml NS over 1 hour

FIG. 1
Clinical guidance for management of adult COVID-19 patients (Revised on 14.01.2022)
Source : (13)
by R△J
 COVID-19 J 20 X
Asymptomatic Mild Moderate

« Suspected contact • Sore throat, rhinorrhoea • In addition to symptoms in SpO2<90% on room air
[RAT or RTPCR negative or • Cough without breathing mild cases, check for Any of the following - signs
not available] difficulty pneumonia which may not of severe pneumonia, acute
• Incidentally detected be apparent respiratory distress
• SpO2> 94% on room air • Rapid respiration (age­
[RAT or RTPCR positive] syndrome, septic shock,
based) : <2 months RR > multi-organ dysfunction
60/min; 2-12 months, syndrome, or pneumonia
RR > 50/min; 1-5 years, with cyanosis, grunting,
RR > 40/min; >5 years, severe retraction of chest,
RR > 30/min; AND/OR lethargy, somnolence,
SpO2 90-93% on room air seizure

Home isolation
Home isolation —► Admit in DCHC or Admit in HDU/ICU of
(tele consultation SOS) or
(tele consultation SOS) «----- COVID-19 Hospital ◄ COVID-19 Hospital
COVID Care Centre

Mainstay of Treatment Mainstay of Treatment Mainstay of Treatment Mainstay of Treatment

• Infants and younger • For fever, give paracetamol Initiate oxygen if SpO2 is • Initiate immediate oxygen
children to stay under 10-15mg/kg/dose; may <94% and maintain therapy and maintain target
immediate care of parents/ repeat every 4-6 hours between 94-96% SPO2 94-96%
guardians • For cough, give throat Maintain fluid and • Maintain fluid and
• No specific medication soothing agents and warm electrolyte balance electrolyte balance
required for COVID-19 saline gargles in older
children and adolescents - Encourage oral fluids • Corticosteroids therapy to
infection • Fluids and feeds* ensure (breast feeds in infants) be initiated
• Continue medications for oral fluids to maintain
hydration and give a - Initiate intravenous fluid • Anticoagulants may also be
other conditions, if any
nutritious diet therapy if oral intake is indicated; see

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• Promote COVID • No other COVID-19 specific poor anticoagulants guide
appropriate behaviour medication needed Corticosteroids are not • Exercise caution - see use
(mask, strict hand hygiene, • Antimicrobials are not required in all children with of corticosteroids and
physical distancing; please indicated moderate illness; they may anticoagulants guide
see guide for using mask) • Maintain monitoring chart be administered in rapidly • In case Acute Respiratory
• Fluids and feeds : ensure including counting of
respiratory rate 2-3 times a progressive disease Distress Syndrome (ARDS)
oral fluids to maintain day, look for chest Fever with temperature or shock develops, initiate
hydration and give a indrawing, cold extremities, >38°C (or 100.4°F) . necessary management
nutritious diet urine output, oxygen Paracetamol 10-15mg/kg/ • Antimicrobials to be
- Advise older children and saturation, fluid intake, dose; may repeat every
activity level, especially for administered if there is
family to stay connected 4—6 hours
young children evidence/strong suspicion
and engage in positive talks
• Promote COVID Anti-microbials to be of superadded bacterial
through phone, video-calls, appropriate behaviour administered if there is infection
etc. (mask, strict hand hygiene, evidence/strong suspicion • May need organ support in
• Parent/caregivers to contact physical distancing) of superadded bacterial
• Advise older children and case of organ dysfunction
the doctor in case of infection
family to stay connected e g. renal replacement
appearance of symptoms
and engage in positive talks Supportive care for therapy
through phone, video-calls, comorbid conditions,
etc. if any
• Parent/caregivers to contact
the doctor in case of
deterioration of symptoms

Investigations Investigations Investigations Investigations

• No investigations needed • No investigations needed Baseline : CBC including Baseline : CBC including
ESR, blood glucose ESR, blood glucose, CRP,
Chest X-Ray LFT, KFT, serum ferritin.
D-Dimer
Chest X-Ray

As of now, in absence of safety and efficacy data, the use of antivirals such CT chest is not indicated in diagnosis or management of
as Remdesivir, Favipiravir, Molnupiravir, Fluvoxamine, and monoclonal COVID-19 infection in children
antibodies such as Sotrovimab, Casirivimab + Imdevimab, are NOT
recommended for children less than 18 years of age irrespective of Consider CT chest only if no improvement in respiratory status
severity of illness
Children with comorbidities should continue to receive appropriate
management for their underlying disease

FIG. 2
Comprehensive guidelines for management of COVID-19 in children and adolescents (below 18 years)
(Revised on 17.01.2022)
Source : (14)

by R△J
202 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Home care for COVID-19 patients 7. Respiratory hygiene should be practiced by all,
To ensure both safety and quality of health care of the especially ill person.
patient, isolation and monitoring is preferable in a hospital 8. Discard the material used to cover the mouth and nose
setting. However, for several reasons, in situations when or clean them appropriately.
inpatient care is not available or in case of informed refusal 9. Avoid direct contact with body fluid, particularly oral
for hospitalization, patients with mild symptoms and without and nasal secretions.
chronic lung, heart or renal diseases may be cared for in the 10. Clean and disinfect frequently touched surfaces such as
home environment. The same principle of care applies to bedside tables, bedframes, and other bedroom furniture
symptomatic patients no longer requiring hospitalization. daily with household disinfectant containing diluted
The patient and family should be provided with ongoing bleach.
support, education and monitoring. They should adhere to 11. Clean bathroom and toilet surfaces once daily.
the following recommendations (15) :
12. Clean clothes and bed clothes, bath and hand towels etc.
1. Place the patient in a well-ventilated single room. 13. Persons with symptoms should remain at home until
2. Limit the number of caretakers of the patient, ideally their symptoms are resolved based on either clinical
assign one person who is in a good health without risk and/or laboratory findings (two negative RT-PCR tests at
conditions. No visitors. least 24 hours apart).
3. Household members should stay in a different room or, if 14. All household members should be considered contacts
that is not possible, maintain a distance of at least 1 m and their health should be monitored for respiratory
from the ill person (e.g. sleep in a separate bed). infection, fever, cough, sore throat, difficult breathing.
4. Limit the movement of the patient and minimize shared 15. Use of pulse oximeter to monitor oxygen saturation.
space. Ensure that shared spaces (e.g. kitchen, Pulse oximeter: It is a compact portable device, measures
bathroom) are well ventilated (e.g. keep windows open). arterial blood oxygen saturation (SpO2), heart rate and signal
5. The caregiver should wear a medical mask fitted tightly strength. Measuring range : SpO2 30 to 100 per cent
to the face when in the same room with the ill person. (minimum graduation 1 per cent), heart rate - 20 to 250 beats
Masks should not be touched or handled during use. If per minute (minimum graduation 1 beat per minute).
the mask gets wet or dirty with secretions, it must be

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changed immediately. Discard the mask after use and Revised discharge policy for hospitalized patients
perform hand hygiene after removal of the mask. The recommendation of Government of India on the
6. Perform hand hygiene following all contacts with the ill discharge policy is summarized and is as shown in the
persons. Refer to page 145 for details. Dry hands with towel. algorithm in Fig. 3.

Confirmed COVID-19 case

Very Mild/ Mild/ Moderate**

Pre symptomatic* ——p—--------------------------------- -----

Discharge after 10 days Fever resolved within Symptoms not

of symptom onset and 3 days resolved and demand
no fever for 3 days and oxygen saturation of oxygen therapy
maintained without support continues

Discharge after 10 days of Discharge only after

symptom onset
• Resolution of
• Absence of fever without clinical symptoms
antipyretics • Ability to maintain
• Resolution of breathlessness oxygen saturation
• No oxygen requirement for 3 consecutive days

NO RT-PCR test required before discharge

* At the time of discharge, the patient will be advised to isolate himself at home
and self-monitor their health for further 7 days ** Including
immunocompromised
(HIV patients, transplant
** Clinical categorization of patients as per guidelines recipients, malignancy)

FIG. 3
Revised discharge policy for COVID-19
Source : (16)

by R△J
 COVID-19 203
Post COVID-19 management protocol (17) 3. In health-care facility setting
After acute COVID-19 illness, recovered patients may • The first follow-up visit (physical/telephonic) should be
continue to report wide variety of signs and symptoms within 7 days after discharge, preferably at the hospital
including fatigue, body ache, cough, sore throat, difficulty in where he/she underwent treatment.
breathing etc. For details please refer to page 196. A holistic • Subsequent treatment/follow-up visits may be with the
approach is required for follow-up care and well-being of all nearest qualified allopathic/AYUSH practitioner/medical
post-COVID-19 recovering patients. The recovery period is facility of other systems of medicine. Poly-therapy is to
likely to be longer for patients who suffered more severe be avoided due to potential for unknown drug-drug
form of the disease and those with pre-existing illness. interaction, which may lead to Serious Adverse Events
(SAE) or Adverse Effects (AE).
POST-COVID FOLLOW-UP PROTOCOL • The patients who had undergone home isolation, if they
1. At individual level complain of persisting symptoms, will visit the nearest
• Continue C0V1D appropriate behaviour (use of mask, health facility.
hand and respiratory hygiene, physical distancing). • Severe cases requiring critical care support will require
• Drink adequate amount of warm water (if not contra­ more stringent follow-up.
indicated). Public health surveillance for COVID-19 (18)
• Take immunity promoting AYUSH medicine, to be
The aim of national surveillance for COVID-19 is to
practiced and prescribed by a qualified practitioner of
enable public health authorities to reduce transmission of
AYUSH.
SARS-CoV-2, thereby limiting associated morbidity and
• If health permits, regular household work to be done. mortality.
Professional work to be resumed in graded manner.
• Mild/ moderate exercise The objectives of COVID-19 surveillance are to :
- Daily practice of yogasana, pranayama and - Enable rapid detection, isolation, testing, and
meditation, as much as health permits or as prescribed. management of cases
- Breathing exercises as prescribed by treating - Detect and contain clusters and outbreaks, especially
physician. among vulnerable populations

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- Daily morning or evening walk at a comfortable pace - Identify, follow-up and quarantine contacts
as tolerated. - Guide the implementation and adjustment of targetted
• Balanced nutritious diet, preferably easy to digest freshly control measures, while enabling safe resumption of
cooked soft diet. economic and social activities
• Have adequate sleep and rest. - Evaluate the impact of the pandemic on health care
• Avoid smoking and consumption of alcohol. systems and society
• Take regular medications as advised for C0V1D and also - Monitor longer term epidemiologic trends and evolution
for managing comorbidities, if any. Doctor to be always of SARS-CoV-2 virus and monitor trends in COVID-19
informed about all medicines that the individual is taking deaths
(allopathic/AYUSH) so as to avoid prescription - Contribute to the understanding of the co-circulation of
interaction. SARS-CoV-2 virus, influenza and other respiratory
• Self-health monitoring at home-temperature, blood viruses, and other pathogens.
pressure, blood sugar (especially, if diabetic), pulse Surveillance approaches
oximetry etc. (if medically advised)
• If there is persistent dry cough / sore throat, do saline Most countries need significantly strengthened surveillance
gargles and take steam inhalation. The addition of herbs/ capacities to rapidly identify and care for cases of COVID-19,
spices for gargling/steam inhalation can help. Cough trace and quarantine their contacts and monitor disease trends
medications, should be taken on advice of medical over time. Comprehensive national surveillance for COVID-19
doctor or qualified practitioner of Ayush. will require the adaptation and reinforcement of existing
national systems, where appropriate, and the scale-up of
• Look for early warning signs like high grade fever,
additional surveillance capacities, as needed. Digital
breathlessness, SpO2<95%, unexplained chest pain,
technologies for rapid reporting, contact tracing and data
new onset of confusion, focal weakness.
management and analysis may support these capacities.
2. At the level of community Robust comprehensive surveillance, once in place, should
• Recovered individuals to share their positive experiences be maintained even in areas where transmission has been
with their friends and relatives using social media, suppressed or controlled, even if there are few or no cases. It is
community leaders, opinion leaders, religious leaders for critical that new cases and clusters of SARS-CoV-2 infection be
creating awareness, dispelling myths and stigma. detected rapidly before outbreaks or widespread transmission
• Take support of community based self-help groups, civil occurs. Ongoing surveillance for COVID-19 is also important
society organizations, and qualified professionals for to understand longer-term epidemiological trends, such as
recovery and rehabilitation process (medical, social, incidence and mortality among different age groups, which
occupational, livelihood). population groups are at higher risk for severe disease and
death, and potential epidemiological changes over time.
• Seek psycho-social support from peers, community
health workers, counsellor. If required seek mental health Key actions for comprehensive COVID-19 surveillance
support service. include:
• Participate in group sessions of Yoga, Meditation etc. - Use, adaptation and strengthening of existing
while taking all due precautions like physical distancing. surveillance systems

by R△J
204 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

- Strengthen laboratory and testing capacities - Number of confirmed deaths

- Use, adaptation and enhancement of public health work­ - Number of probable deaths
force to carry out case finding, contact tracing and - Number of individuals hospitalized (confirmed and
testing probable)
- Include COVID-19 as a mandatory notifiable disease - Number discharged (confirmed and probable)
- Implement immediate reporting - Number of health care workers infected (confirmed +
- Establish systems to monitor contact tracing activity. probable) as a subset of total cases count
It is important to maintain routine syndromic surveillance - Number of health care workers who died due to
COVID-19 (confirmed + probable) as a subset of total
for other infectious diseases, especially those caused by
respiratory pathogens, such as influenza and respiratory death count
syncytial virus, through surveillance for influenza-like-illness - Number of persons tested
(ILI), severe acute respiratory infection (SARI), atypical - Number of persons tested by PCR
pneumonia and unexplained fever, with sampling and - Confirmed + probable cases by age group and sex
laboratory testing of all or a subset of cases. This is critical - Confirmed + probable deaths by age group and sex
for understanding trends in other diseases with similar
presentations to guide appropriate public health Categories for transmission pattern (19)
preparedness and clinical management. WHO. recommends using the following categories to
describe transmission patterns at national and sub-national
Essential surveillance for COVID-19 levels to guide decisions for preparedness, readiness and
Surveillance systems should be geographically response activities. The definitions of categories are as
comprehensive, and surveillance for vulnerable or high-risk shown in Table 5.
populations should be enhanced. This will require a
combination of surveillance systems including contact
Prevention of the disease
tracing for all levels of the health care system, at the “Do gaj ki doori, mask hai jaroori” is the slogan of the
community level, in closed residential settings and in other day. Although the vaccine is now available in India, it is
vulnerable groups. Table 4 shows how surveillance systems critical that people should continue to follow all the “COVID
can be combined across different sites. Appropriate Behaviour”. They should use mask, maintain a

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physical distance of at least 6 feet when in public place, not
Global surveillance touch nose, eyes and mouth, cover mouth and nose while
The objectives of the global surveillance are as follows: coughing and sneezing and avoid spitting in open, prompt
testing on observing symptoms, and isolation if having the
- Monitor trends in COVID-19 at national and global levels disease or for contacts quarantine for 14 days.
- Monitor mortality caused by, and indirectly associated
with, COVID-19 While UK and USA have emerged as the first two
countries in the world to launch the COVID vaccine, India
- Estimate morbidity and mortality for health care workers has also launched one of the world’s largest COVID
- Assess the impact of control measures. vaccination drive. This is the first time that a vaccine for
COVID-19 has been developed and launched in the country.
Weekly aggregated reporting
Dry run for the vaccine : The dry run is a mock drill to test
The aim of ongoing weekly aggregate reporting is to
the laid out mechanisms for COVID-19 vaccination roll out
obtain further information on global COVID-19 trends for
in the health system and to assess the operational feasibility
enhanced analysis. The variables are as follows (19)
of using Co-Win application in field environment for
- Number of confirmed cases planning, implementation and reporting at the block, district
- Number of probable cases and state levels (20, 21).
TABLE 4
Surveillance systems across different sites/contexts
System Immediate Contact Virologic Cluster Mortality Serologic
Site/ case notification tracing surveillance investigations surveillance surveillance
Context
Community X X X X X

Primary Care Sites X X X

(non-sentinel ILI/ARI)
Hospitals X X X X X
(non-sentmel ILI/SARI)
Sentinel ILI/ARI/ X X
SARI sites
Closed settings* X X X X X

Health care-associated X X X X X
SARS-CoV-2 infection
Travellers at points X X X
of entry
*Including but not limited to long-term living facilities, prisons and dormitories.
Source : (19)

by R△J
 COVID-19
205
TABLE 5
Definition of the categories for transmission pattern
Category name Definition
No (active) cases No new cases detected for at least 28 days (two times the maximum incubation period),
in the presence of a robust surveillance system. This implies a near-zero risk of infection
for the general population.
Imported / Sporadic cases Cases detected in the past 14 days are all imported, sporadic (e.g laboratory acquired or
zoonotic) or are all linked to imported/sporadic cases, and there are no clear signals of further
locally acquired transmission. This implies minimal risk of infection for the general population.
Clusters of cases Cases detected in the past 14 days are predominantly limited to well-defined clusters that are not
directly linked to imported cases, but which are all linked by time, geographic location and
common exposures. It is assumed that there are a number of unidentified cases in the area
This implies a low risk of infection to others in the wider community if exposure to these
clusters is avoided.
Community transmission - level 1 Low incidence of locally acquired widely dispersed cases detected in the past 14 days not linked
(CT1) to specific clusters; transmission may be focussed in certain population sub-groups. Low risk of
infection for the general population.
Community transmission - level 2 Moderate incidence of locally acquired widely dispersed cases detected in the past 14 days;
(CT2) transmission less focussed in certain population sub-groups Moderate risk of infection for the
general population.
Community transmission - level 3 High incidence of locally acquired widely dispersed cases in the past 14 days; transmission not
(CT3) focussed in certain population sub-groups High risk of infection for the general population.
Community transmission - level 4 Very high incidence of locally acquired widely dispersed cases in the past 14 days. Very high risk
(CT4) of infection for the general population.

Source : (19)

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Vaccination for COVID-19 is voluntary. However, it is verification of beneficiary at session site to ensure that the
advisable to receive the complete schedule of COVID-19 intended person is vaccinated.
vaccine for protecting one-self against this disease and also to Any of the following mentioned ID with Photo may be
limit the spread of this disease to the close contacts. It is produced at the time of registration : Aadhar Card, Driving
advisable to receive complete schedule of COVID vaccine License, Health Insurance Smart Card issued under the scheme
irrespective of past history of infection with COVID-19. This of Ministry of Labour, MGNREGA Job Card, official identity
will help in developing a strong immune response against the cards issued to MPs/MLAs/MLCs, PAN Card, passbooks issued
disease. Person with confirmed or suspected COVID-19 by bank/post Office, passport, pension document, service
infection may increase the risk of spreading the same to others identity card with photograph issued to employees by Central/
at vaccination site. For this reason, infected individuals should State Govt./PSUs/Public Limited Companies, Voter ID and
defer vaccination for 14 days after symptoms resolution. Smart card issued by RGI under NPR.
Based on the potential availability of vaccines the Following online registration, beneficiary will receive
Government of India selected the priority groups which are SMS on their registered mobile number for the due date,
at higher risk. The first group includes healthcare workers place, and time of vaccination. On getting due dose of
because they are at high risk of contracting the infection and COVID-19 vaccine, the beneficiary will receive SMS on their
protecting them helps to sustain essential health services. registered mobile number. After all doses of vaccine are
The vaccination of frontline workers (police, home-guard, administered, a QR code based certificate will also be sent to
municipal worker, armed forces etc.) will help in reducing the the registered mobile number of the beneficiary.
societal and economic impact by reducing COVID-19
It must be ensured that the entire schedule of vaccination
mortalities. The next group to receive COVID-19 vaccine
is completed by only one type of vaccine, as different
was persons over 50 years of age and persons under 50 years
COVID-19 vaccines are not interchangeable.
with comorbid conditions because there is high mortality in
this category. The reason for including more than 50 years of COVID-19 Vaccines
age group for vaccination was that it will be able to cover
78% of persons having co-morbidities and thereby reduce In the light of urgent need due to COVID pandemic in the
mortality on account of COVID-19. More than 50 years of country, Central Drugs Standard Control Organization
age group was divided into two sub-groups. One sub-group (CDSCO) has granted permissions to following six COVID-
was 60 years and above, they were vaccinated first. Second 19 vaccines for restricted use in emergency situation :
sub-group was between 50 to 60 years age group, they were 1. ChAdOxl nCoV-19 Corona Virus Vaccine
vaccinated after the first sub group is covered. In subsequent (Recombinant) (Covishield) manufactured by M/s Serum
phases the vaccine was given to the remaining persons Institute of India Pvt., Ltd., Pune.
above 18 years of age. COVID-19 vaccination for children in 2. Whole Virion Inactivated Corona Virus Vaccine
the age group 15-18 years started from 3rd January 2022. (Covaxin) manufactured by M/s Bharat Biotech
Covaxin is the only option for them (22). Only 100 persons International Limited, Hyderabad.
were vaccinated at each designated vaccination site per day. 3. Gam-COVID-Vac Combined vector vaccine (SPUTNIK-
The vaccination may not be sequential. It can go in V) imported by M/s Dr. Reddy’s Laboratories Ltd,
parallel for all beneficiaries depending on the availability of Hyderabad OR manufactured by M/s Ra (biologicals)
the vaccine. Photo ID is a must for both registration and Panacea Biotec Ltd., New Delhi.

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

4. mRNA-1273 COVID-19 vaccine (Moderna) imported by Covaxin vaccine (23)

M/s Cipla Limited, Mumbai The Bharat Biotech’s vaccine, developed in collaboration
5. Janssen/Ad 26. CoV2-S - Adenovirus vector platform with ICMR and NIV Pune, is a whole virion inactivated
based Vaccine manufactured by M/s Johnson & coronavirus vaccine. It is given intramuscularly in deltoid
Johnson. muscle in two doses 28 days apart, to persons above
6. ZyCoV-D, a DNA based COVID-19 vaccine 18 years of age and recently approved for 15-18 year age
manufactured by M/s Zydus Cadilla Ltd. group (22). The vaccine should be stored at 2-8°C.
Currently, three COVID-19 vaccines are being used Side effects
under the vaccination program namely Covishield
manufactured by M/s Serum Institute of India, Covaxin The common side effects following Covaxin are : injection
manufactured by M/s Bharat Biotech International Limited site pain, fatigue, fever, headache, bodyache, nausea,
and Sputnik V vaccine developed by Gamaleya Research abdominal pain, dizziness, sweating, and cold and cough.
Institute, Russia (imported by Dr Reddy’s Lab and is being
administered in few private hospitals, presently). Contraindications
Persons who are temporarily not eligible to get the 1. Those below 18 years of age;
vaccine are (23) : 2. Those with allergic reaction to any componant of
Covaxin vaccine, plasma centrical products and notable
(a) Persons showing active symptoms of SARS-CoV-2
food allergies;
infection;
3. Anyone who has had adverse reaction to COVID-19
(b) COVID-19 patients who have been given anti-SARS-CoV-2
vaccine earlier; and
monoclonal antibodies or convalescent plasma;
4. Currently having an acute infection or fever.
(c) The vaccine should be given with caution to persons
with a history of any bleeding or coagulation disorder Individuals with HIV infection or other
platelet disorder, clotting factor deficiency or immunocompromising conditions, or who take
coagulopathy; and immunosuppressive medications might be at increased risk
(d) Actually unwell and hospitalized patients (with or of severe COVID-19. However, data is not currently
without intensive care) due to any illness. available to establish vaccine safety and efficacy in these
groups. Individuals may not generate a full immune

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Persons with a past history of COVID-19 infection can be response to COVID-19. As Covaxin is not a live virus
administered the vaccine. Persons with a history of chronic vaccine, it is not likely to pose a safety risk.
disease and comorbidities (cardiac, neurological,
pulmonary, and metabolic) are eligible for the vaccine Sputnik V Vaccine
although efficiency of the vaccine may be less in these Sputnik V Vaccine (Gam-COVID-Vac) is manufactured by
patients. Administration of vaccine to pregnant women Gamaleya Research Institute, Russia. It is a non-replicating
should only be considered when the potential benefits out viral vector vaccine administered by intramuscular injection
weigh any potential risks for the mother and foetus. in two doses to people 18 years and above. The second dose
According to recent guidelines a pregnant women who opts is taken 21 days after the 1st dose. For both the Jabs, two
for vaccination could be vaccinated at any time of different vectors are used (Adenovirus 26 and Adenovirus 5).
pregnancy. It is unknown whether the vaccine is secreted in The use of two varying serotypes is unique that provides
human milk. However the current guidelines of the Indian long-lasting immunity. Vaccine can be stored at 2 to 8°C.
Government recommends COVID-19 vaccination for all Some people reported mild side effects such as pain,
lactating mothers. The vaccines are not interchangeable. redness or swelling at the site of injection, Asthenia, fatigue,
body and muscle pain, cough and sore throat, runny nose,
Covishield vaccine (23) fever and chills, nausea and vomiting, diarrhoea and
Covishield vaccine is a recombinant chimpanzee headache (24).
adenovirus vector vaccine, administered intramuscularly in In India vaccination is not mandatory. But if you choose
deltoid muscle. Given in two doses, 12-16 weeks apart. The to get vaccinated, you cannot choose which vaccine you will
protective level of antibodies are generally developed two get. You will be vaccinated by the vaccine that is available at
weeks after the 2nd dose of the vaccine. The vaccine has the site. 16th January, 2021 is the historical day when India
been approved for individuals 18 years of age and above. To launched the vaccination drive.
be stored at 2-8°C.
Pfizer-BioNtech COVID-19 Vaccine (25)
Side effects It is a messenger RNA vaccine with 95 per cent efficacy.
The common side effects with Covishield vaccine are : People 16 years and older are eligible for the vaccine,
injection site pain and tenderness, headache, fatigue, myalgia, administered in two doses intramuscularly, 3 weeks apart. It
discomfort, pyrexia, chills and nausea. Very rare events of is authorized for emergency use. It is not interchangeable.
demyelination disorder have been reported following vaccine Storage is at -70°C.
“without the causal relationship establishment”. Contraindications : (a) history of severe allergic reaction
after the previous dose of this vaccine; (b) had a severe
Contraindications reaction to any ingredient of this vaccine.
1. Vaccine should not be given if there is severe allergic Before taking the vaccine the provider must know the
reaction after the previous dose of this vaccine; medical history of the person : any allergy, fever, bleeding
2. Had a severe allergic reaction to any ingredient of this disorder if any, or taking blood thinner, if the person is
vaccine. immunocompromised or on a medicine that affects immune

by R△J
 COVID-19 207
system, pregnancy and breast-feeding, and have received 11. CDC (2022), Long COVID or Post COVID conditions.
another COVID-19 vaccine. 12. Govt, of India, Guidelines for management of mucormycosis in
COVID-19 patients.
Side effects : Injection site pain, tiredness, headache, 13. AI1MS/ICMR/COVID-19TaskForce/MonitoringGroup (2022), Clinical
muscle pain, chills, joint pain, fever, injection site swelling guidance for management of adult COVID-19 patients, Ministry of
and redness, nausea, feeling unwell, swollen lymph nodes. Health and Family Welfare, New Delhi, 14th Jan. 2022.
There are remote chances of severe allergic reaction (within 14. Govt, of India (2022), Comprehensive guidelines for management of
a few minutes to one hour after getting the dose). COVID-19 in children and adolescents (below 18 years), DGHS,
Ministry of Health and Family Welfare, New Delhi.
Moderna COVID-19 Vaccine (26) 15. WHO, Home care for patients with suspected noval corona infection
presenting with mild symptoms and management of contacts, 20th Jan.
It is a messenger RNA vaccine, with efficacy of about 2021.
94.1 per cent, meant for people 18 years of age and above, 16. Govt, of India (2020), Final guidance on management of COVID cases.
two doses given intramuscularly 1 month apart. It should be 17. Govt, of India (2020), Post COVID management protocol, 13th Sept.
stored between -25°C and -15°C temperature. 2020.
18. WHO (2020), Public health guidelines for COVID-19 : Interim
The vaccine provider must know about the history of guidance, 16th Dec. 2020.
allergies, fever, bleeding disorders or history of taking blood 19. WHO (2020), Public Health Surveillance, 16th Dec. 2020.
thinner, pregnancy and breast-feeding in mothers, history of 20. Govt, of India (2020), COVID-19 vaccine strategy communication
taking another COVID-19 vaccine and if the recipient is strategy, help us help you.
immunocompromised. 21. Govt, of India (2020), Frequently asked questions on COVID-19
vaccine, target group : general public.
Side effects : Side effects reported are : (a) injection site 22. Govt, of India, Guidelines for COVID-19 vaccination of children between
reactions are pain, redness, swelling, tenderness; (b) general 15-18 years and precaution dose to health care workers, frontline
side effects are fatigue, headache, muscle pain, joint pain, workers and 60+ population with comorbidities, 3rd Jan. 2022.
vomiting, and fever. Severe side effects are difficulty in 23. Govt, of India, Press release.
breathing, swelling of face and throat, fast heart beat, bad 24. Sputnik V Vaccine, efficacy, doses, side effects and price, Pace Hospital.
rash all over the body, dizziness and weakness. 25. Pfizer-BioNtech COVID-19 Vaccine - fact sheet for recipient and
provider of the vaccine.
26. Moderna COVID-19 Vaccine - fact sheet for recipient and provider of
COVID-19 dead body management the vaccine.
All staff identified to handle dead bodies in the isolation 27. Govt, of India (2020), COVID-19 : Guidelines on dead body

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area, mortuary, ambulance and those workers in the management, 15th March 2020.
crematorium/burial ground should be trained in the infection
prevention control practices. The health worker attending to TUBERCULOSIS
the dead body should perform hand hygiene, ensure proper Tuberculosis is a specific infectious disease caused by
use of PPE. Plug oral, nasal orifices of the dead body to M. tuberculosis. The disease primarily affects lungs and
prevent leakage of body fluids. Place the body in leak-proof causes pulmonary tuberculosis. It can also affect intestine,
plastic body bag. The exterior of the body bag be meninges, bones and joints, lymph glands, skin and other
decontaminated with 1 per cent hypochlorite.The body bag tissues of the body. The disease is usually chronic with
can be wrapped with a mortuary sheet or sheet provided by varying clinical manifestations. The disease also affects
the family members. Embalming of the dead body should not animals like cattle; this is known as “bovine tuberculosis”,
be allowed. Autopsies should be avoided. The crematorium/ which may sometimes be communicated to man. Pulmonary
burial ground staff should be sensitized that COVID-19 does tuberculosis, the most important form of tuberculosis which
not pose additional risk to them. Viewing of the dead body by affects man, will be considered here.
unzipping the face, for the relatives to see the body for one last
time is allowed. Bathing, kissing, hugging, etc. of the dead Problem statement
body should not be allowed. Religious rituals such as reading
WORLD
from religious scripts, sprinkling holy water and any other last
rites that does not require touching of the body can be Tuberculosis remains a worldwide public health problem
allowed. Large gathering at the crematorium/burial ground despite the fact that the causative organism was discovered
should be avoided. The funeral staff and family members more than 100 years ago and highly effective drugs and
should perform hand hygiene after cremation/burial (27). vaccine are available making tuberculosis a preventable and
curable disease. Technologically advanced countries have
References achieved spectacular results in the control of tuberculosis.
This decline started long before the advent of BCG or
1. NCBI BookShelf (2020), Features, evaluation and treatment of corona
virus, last updated 4th Oct. 2020. chemotherapy and has been attributed to changes in the
2. WHO (2020), Weekly update of global corona virus impact and “non-specific” determinants of the disease such as
implications. improvements in the standard of living and the quality of life
3. Worldometer.info, COVID-19 Corona virus pandemic, 20th Sept. 2022. of the people coupled with the application of available
4. WHO (2022), Tracking SARS-CoV-2 variants, May 2022. technical knowledge and health resources.
5. Centers for Disease Control and Prevention, 26th April 2022. It is estimated that about one-third of the current global
6. Govt, of India (2022), Annual Report 2021 -22, Ministry of Health and population is infected asymptomatically with tuberculosis, of
Family Welfare, New Delhi.
whom 5-10 per cent will develop clinical disease during
7. WHO (2020), Transmission of SARS-CoV-2, implications of infection
prevention, precautions. their lifetime (1). Most new cases and deaths occur in
8. Govt, of India (2020), Clinical Management Protocol: COVID-19, 5th developing countries where infection is often acquired in
version, 3rd July 2020. childhood. The annual risk of tuberculosis infection in high
9. WHO (2020), Clinical Management of COVID-19, 27th May 2020. burden countries is estimated to be 0.5-2 per cent (2).
10. Govt, of India (2020), National Centre for Disease Control, updated case Patients with infectious pulmonary tuberculosis disease can
definition and contact categories, Director General of Health Services. infect 10-15 persons in a year.

by R△J
208 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Globally, the COVID-19 pandemic has reversed years of for patients of all ages, including those with smear-positive,
progress in providing essential TB services and reducing TB smear-negative, extrapulmonary tuberculosis, drug-resistant
disease burden. The most obvious impact is a large global drop tuberculosis, and tuberculosis combined with HIV infection.
in the number of people newly diagnosed with TB and reported. The basic principles of care for people with, or suspected of
The fall is from 7.1 million cases in 2019 to 5.8 million in 2020, having tuberculosis are the same worldwide. The standards are
an 18 per cent decline back to the level of 2012 and far short of intended to be complementary to local and national
the estimated 10 million people who developed TB in 2020. 16 tuberculosis control policies that are consistent with WHO
countries accounted for 93 per cent of this reduction, with India, recommendations. They are not intended to replace local
Indonesia and the Philippines the worst affected (3). guidelines. There are 6 standards for diagnosis, 9 standards for
Reduced access to TB diagnosis and treatment has resulted treatment and 2 standards for public health responsibilities.
in an increase in TB deaths. The estimates for year 2020 are 1.3 Please refer to WHO publication : Weekly Epidemiological
million TB deaths among HIV-negative people and an Record, No. 5, dated 3rd Feb. 2006 for further details.
additional 2,14,000 among HIV-positive people, with the For the past two decades, national and international efforts
combined total back to the level of 2017. People who are in TB prevention, diagnosis and treatment have been guided
infected with HIV are 18 times more likely to develop active TB. by the DOTS strategy (mid-1990 until 2005) and
In the year 2020, out of estimated 10 million cases, 5.6 subsequently the Stop TB Strategy (2006-2015). The Stop TB
million were men, 3.3 million women and 1.1 million strategy was designed to achieve global TB targets set for 2015
children. The severity of national TB epidemics, in terms of within the context of the Millennium Development Goals (7).
the number of incident TB cases per 1,00,000 population It focused on five indicators to measure the implementation
per year, varies widely among countries, from less than five and impact of TB control. They are; case detection, treatment
to more than 500 new and relapse cases per 1,00,000 success, incidence, prevalence and death. The core of the
population per year. In 2020, 57 countries had a low strategy was DOTS. The WHO End TB strategy, adopted by
incidence of TB (< 10 cases/1,00,000 population), mostly in the World Health Assembly in May 2014, is a blueprint for
the WHO region of the Americas and European region. countries to end the TB epidemic by driving down TB deaths,
There were 150-400 cases/1,00,000 population in most of incidence and eliminating catastrophic costs. It outlines global
the 30 high TB burden countries (3). impact targets to reduce TB deaths by 90 per cent and to cut
new cases by 80 per cent between 2015 and 2030, and to
Drug-resistant TB continues to be a public health threat. ensure that no family is burdened with the costs due to TB.
Resistance to isoniazid and rifampicin - the two most Ending the TB epidemic by 2030 is among the health targets

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effective first-line drugs - is of greatest concern. Globally, the of the newly adopted Sustainable Development Goals. WHO
burden of MDR-TB or RR-TB is stable. For more than 10 has gone one step further and set a 2035 target of 95 per cent
years, the best estimate of the proportion of people reduction in deaths and a 90 per cent decline in TB incidence
diagnosed with MDR/RR-TB has remained at about 3-4 per - similar to current levels in low TB incidence countries
cent and the best estimate for MDR-TB in those previously today (8). For further details, please refer to page 237.
treated for TB has remained at about 18-21 per cent (3).
In September 2018, the UN General Assembly held its
In year 2020, the success rate among patients treated for first-ever high level meeting on TB. The outcome was a
DR-TB remained at 59 per cent as large proportion of patients political declaration in which commitments to SDGs and
were lost due to discontinuation of treatment or death (4). End TB Strategy were reaffirmed and new ones added.
The preventive treatment for TB is expanding, especially Global targets for funding to be mobilized for TB prevention,
in the priority risk groups of people living with HIV and care and research, and for the number of people to be
children under 5 years of age. However, most people eligible treated for TB infection and disease, were set for the first
for TB preventive treatment are not accepting it (5). time. The targets are as follows (1) .
The actual burden of paediatric TB is not known due to 1. 40 million people treated for TB from 2018 to 2022,
diagnostic difficulties. It is assumed that about 10 per cent of including :
total TB load is found in children. Globally, about 1 million - 3.5 million children
cases of paediatric TB are estimated to occur every year, with - 1.5 million people with drug-resistant TB, including
more than 100,000 deaths (6). Childhood deaths from TB 115,000 children.
are usually caused by meningitis or disseminated disease (2).
Though MDR-TB and XDR-TB is documented among 2. At least 30 million people provided with TB preventive
paediatric age groups, there are no estimates of overall treatment from 2018 to 2022, including
burden because of diagnostic difficulties and exclusion of - 6 million people living with HIV
children in most of the drug resistant surveys (6). - 4 million children under 5 years of age and 20 million
people in other age groups, who are household
In many developing countries, acquired drug resistance
contacts of people affected by TB.
remains high, because national tuberculosis control
programmes in these countries have not been able to 3. Funding of at least US$ 13 billion per year for universal
achieve a high cure rate over a very long period of time, access to TB prevention, diagnosis, treatment and care
even after the introduction of short-course chemotherapy. by 2022.
Poverty, economic recession, malnutrition, overcrowding, 4. Funding of at least US$ 2 billion per year for TB research
indoor air pollution, tobacco, alcohol abuse and diabetes from 2018 to 2022.
make populations more vulnerable to tuberculosis. Increase
in human migration has rapidly mixed infected with INDIA
uninfected communities. To make global situation worse, India is the highest TB burden country in the world in terms
tuberculosis has formed a lethal combination with HIV. of absolute number of incident cases that occur each year. It
The WHO has set International Standards for Tuberculosis accounts for 26 per cent of the estimated global incident TB
Care. These standards are intended to facilitate the effective cases in 2020. Table 1 shows the burden of tuberculosis in
engagement of all care-providers in delivering high-quality care India, the estimated and reported cases for the year 2020.

by R△J
 TUBERCULOSIS

TABLE 1 AGE DISTRIBUTION : Overall the age distribution of TB

Burden of tuberculosis in India (2020) diagnosed incident cases shows a predominance in
(Population : 1,380 million) adolescent and young adult age groups between 15 to
30 years of age, indicating ongoing disease transmission as
(thousands) population) shown in Fig. 1. However, there is a wide variation in the
age distribution pattern among the states. In southern states
Estimates of TB burden,* 2020 of Kerala, Karnataka, Tamil Nadu, Andhra Pradesh and UTs
Total TB incidence 2590(1780-3550) 188(129-257) of Puducherry,. Lakshadweep there is a general elderly
HIV positive TB incidence 53 (36-72) 3.8 (2.6-5.2) prevalence of TB towards the age 50-1- year ranges. In other
HIV negative TB mortality 493 (453-536) 36 (33-39) states the incidence is similar to that of the country.
HIV positive TB mortality 11(9 8-12) 0.78 (0.71-0 84) THE ECONOMIC AND SOCIAL BURDEN OF DISEASE :
Universal health coverage and social protection* Besides the disease burden, TB also causes an enormous
TB treatment coverage 63% (46-92) socio-economic burden to India. TB primarily affects people
(notified/estimated incidence), 2020 in their most productive years of life. While two-thirds of the
TB case fatality ratio 20% (14-27) cases are male, TB takes disproportionately larger toll
(estimated mortality/estimated incidence), 2020 among young females, with more than 50 per cent of female
TB case notifications, 2020 cases occurring before the age of 34 years (11).
Total new and relapse 1,629,301 Tuberculosis kills more women in reproductive age group
- % tested with rapid diagnostics at time of diagnosis 18% than all causes of maternal mortality combined, and it may
- % with known HIV status 92% create more orphans than any other infectious disease.
- % pulmonary 71% Nearly one-third of female infertility in India, is caused by
- % bacteriologically confirmed 54% tuberculosis. The indirect impact of tuberculosis on children
- % children aged 0-14 years 6% is considerable, as nearly 3 lacs children of tuberculosis
- % women (aged >15 years) 36% patients, either leave the school or take up employment to
- % men (aged >15 years) 58% help support their families (8). A patient of tuberculosis
Total cases notified 1,812,643 takes an average of three to four months to recuperate,
TB/HIV care in new and relapse TB patients, 2020 losing that much income. The loss is disastrous for those

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struggling against poverty. They are most likely to be
Number (%) defaulters of treatment. The vast majority (more than 90 per
Patients with known HIV-status who are HIV-positive 30,496 2% cent) of the economic burden of TB in India is caused by the
- on antiretroviral therapy 28,931 95% loss of life rather than morbidity.
Drug-resistant TB care**, 2020 In India, tuberculosis is mainly a disease of the poor. The
% of bacteriologically confirmed TB cases tested for 98% majority of its victims are migrant labourers, slum dwellers,
rifampicin resistance - New cases' residents of backward areas and tribal pockets. Poor living
% of bacteriologically confirmed TB cases tested for 96% conditions, malnutrition, shanty housing and overcrowding
rifampicin resistance - Previously treated cases' are the main reasons for the spread of the disease (12).
Laboratory-confirmed cases : MDR/RR-TB" 49,679
Patients started on treatment. MDR/RR-TB' A' 42.505
Laboratory-confirmed cases . pre-XDR-TB or XDR-TB ' ' 8,982 0-4 15,411 Q 24,269
Patients started on treatment: pre-XDR-TB or XDR-TB 8,256 5-9 15,954 21,660
MDR/RR-TB cases tested for resistance to any fluoroquinolone 16,354
10-14 40,342 27,555
Treatment success rate and cohort size
15-19 1,09,942 99,370
Success Cohort
20-24 1,24,346 1,35,279
New and relapse cases registered in 2019 84% 2,152,563
25-29 1,06,783 1,24,225
Previously treated cases, excluding relapse, 77% 147,159
registered in 2019 30-34 72,560 1,09,335
HIV-positive TB cases registered in 2019 71% 40,031 35-39 62,120 1,12,487
MDR/RR-TB cases started on second-line 56% 47,284
treatment in 2018 40-44 48,821 1,08,820

XDR-TB cases started on second-line 48% 2,661 45-49 47,327 1,15,269

treatment in 2018
50-54 42,474 1,09,065
TB preventive treatment, 2020
55-59 31,924 89,481
% of HIV-positive people (newly enrolled in care) 39%
60-64 41,628 1,11,743
on preventive treatment
% of children (aged <5) household contacts of 42% (39-46) 65-69 25,116 70,931
bacteriologically-confirmed TB cases on preventive treatment 70-74 16,286 48,572
Estimates of TB burden are produced by WHO in consultation with 75+ 12,913 37,168
countries. Ranges represent uncertainty intervals.
RR is TB resistant to rifampicin (R); MDR is TB resistant to R + i—I—I——i—r——| r-i-n—i . , i < |- f -i" | |—| | i i | | | | | i

isoniazid; pre-XDR is TB resistant to R + any fluoroquinolone. 150K 100K 50K OK 50K 100K 150K
Calculated for pulmonary cases only. Female Male
Includes cases with unknown previous TB treatment history.
Includes patients diagnosed before 2020 and patients who were not FIG. 1
laboratory-confirmed. Age distribution of TB cases, India (2019)
Source : (9) Source : (10)
by R△J
210 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

HIV increases a person’s susceptibility to tuberculosis changed, since both are registered and reported in the
infection, and tuberculosis is one of the earliest category “retreatment”. Patients reported in the “unknown
opportunistic disease to develop amongst persons infected history” category are considered incident TB episodes (new
with HIV It increases morbidity and mortality in HIV or relapse). This is a change from previous years in view of
infected persons. HIV is the most potent risk factor for past difficulties to estimate with NTPs the proportion of true
progression of TB infection to disease. new, or relapse TB episodes in this category of patients.
Since death rate is declining and the disease is showing a 6. Case detection rate ; The case detection rate is
decline in younger age groups, epidemiologists are calculated as the number of notification of new and relapse
beginning to think that perhaps we may have crossed the cases in a year divided by the estimated incidence of such
peak of the secular epidemic curve and are somewhere at cases in the same year.
the beginning of the declining limb. 7. Prevalence of drug-resistant cases : It is the
Despite a comprehensive national TB control programme prevalence of patient excreting tubercle bacilli resistant to
guiding states for implementation of TB diagnosis and anti-tuberculosis drugs. This index is directly related to
treatment, there is still a long way to go. The vision of RNTCP is chemotherapy.
that the people suffering from TB receive the highest standards (a) Prevalence of infection : It is the percentage of
of care and support from healthcare providers of their choice. individuals who show a positive reaction to the standard
It is spelt out in the National strategic plan 2012-17 to extend tuberculin test. When the test is done in defined age-groups,
the umbrella of quality TB care and control to include those it yields age-specific prevalence which is a far superior
provided by the private sector. Thus Standards of TB care indicator than the mere percentage of positive reactors in
relevant in Indian context and acceptable to medical fraternity the total population (15). Prevalence represents a
were developed. These standards represent what is expected cumulative experience of a population to recent and remote
from Indian health care system (13). infection with M. tuberculosis. It may be mentioned that the
Epidemiological indices (14) interpretation of tuberculin test has become complicated in
countries with a high coverage of BCG vaccination at birth,
Indices or parameters are needed to measure the since most of the vaccinees become positive reactors to
tuberculosis problem in a community as well as for planning tuberculin test. This presents a problem in identifying true
and evaluation of control measures. Indices are also prevalence of infection. Further, cross-sensitivity to atypical

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required for international comparison. The following mycobacteriae, where it occurred, has also caused the
epidemiological indices are generally used in tuberculosis prevalence to be over-estimated. Despite these limitations,
problem measurement and programme strategy : tuberculin-testing is widely used for estimating the
1. Incidence is defined as the number of new and recurrent prevalence of tuberculous infection in a population.
(relapse) episodes of TB (all forms) occurring in a given year. (b) Incidence of infection : (Annual Infection Rate) : It is
Recurrent episodes are defined as a new episode of TB in the percentage of population under study who will be newly
people who have had TB in the past and for whom there was infected by Mycobacterium tuberculosis among the non­
bacteriological confirmation of cure and/or documentation that infected of the preceding survey during the course of one
treatment was completed. Relapse cases are referred to as year. It reflects the annual risk of being infected (or
recurrent cases because the term is more useful when explaining reinfected) in a given community. In other words, it expresses
the estimation of TB incidence. Recurrent cases may be true the attacking force of tuberculosis in a community (16). In
relapses or a new episode of TB caused by reinfection. In developing countries, every 1% of annual risk of infection is
current case definitions, both relapse cases and patients who said to correspond to 50 new cases of smear-positive
require a change in treatment are called ‘retreatment cases’. pulmonary tuberculosis, per year for 100,000 general
However, people with a continuing episode of TB that requires population (17). Also known as “tuberculin conversion”
a treatment change are prevalent cases, not incident cases. index, this parameter is considered one of the best indicators
2. Prevalence is defined as the number of TB cases (all for evaluating the tuberculosis problem and its trend. The
forms) at a given point in time. It is the best available higher the rate, the greater the problem (16, 18). It may be
practical index to estimate the case load in a community. mentioned that a good treatment programme, lowers the risk
The age-specific prevalence of patients is considered the of tuberculosis infection in the community.
most relevant index.
Definitions of tuberculosis cases and
3. Mortality from TB is defined as the number of deaths treatment (19)
caused by TB in HIV-negative people, according to the latest
revision of the International Classification of Diseases WHO has issued updated guidance on definitions of cases
(ICD-10). TB deaths among HIV-positive people are and treatment outcomes and associated reporting framework.
classified as HIV deaths in ICD-10. For this reason, estimates These updates were necessary to accomodate diagnosis using
of deaths from TB in HIV-positive people are presented Xpert MTB/RIF and other WHO-endorsed molecular tests, as
separately from those in HIV-negative people. well as offering an opportunity to improve aspects of the existing
4. The case fatality rate is the risk of death from TB (2006) framework, such as inclusion of more comprehensive
among people with active TB disease. reporting of TB cases among children. The updated definitions
are used from 2014 in global data collection (14).
5. The case notification rate refers to new and
recurrent episodes of TB notified to WHO for a given year, Presumptive case: Presumptive TB refers to a patient who
expressed per 100,000 population. The case notification presents with symptoms or signs suggestive of TB
rate for new and recurrent TB is important in the estimation (previously known as a TB suspect).
of TB incidence. In some countries, however, information on A. CASE DEFINITIONS
treatment history may be missing for some cases. When data
on treatment history are not available, recurrent cases a. A bacteriologically confirmed TB case is one from
cannot be distinguished from cases whose treatment was whom a biological specimen is positive by smear
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 TUBERCULOSIS 211
microscopy, culture or WRD (such as Xpert MTB/RIF). All e. Patients with unknown previous TB treatment history
such cases should be notified, regardless of whether TB do not fit into any of the categories listed above. New and
treatment has started. relapse cases of TB are incident TB cases.
b. A clinically diagnosed TB case is one who does not fulfil 3. Classification based on drug resistance
the criteria for bacteriological confirmation but has been
diagnosed with active TB by a clinician or other medical Cases are classified in categories based on drug
practitioner who has decided to give the patient a full course susceptibility testing (DST) of clinical isolates confirmed to
of TB treatment. This definition includes cases diagnosed on be M. tuberculosis :
the basis of X-ray abnormalities or suggestive histology and a. Monoresistance: resistance to one first-line anti-TB
extrapulmonary cases without laboratory confirmation. drug only.
Clinically diagnosed cases subsequently found to be b. Poly drug resistance: resistance to more than one first-
bacteriologically positive (before or after starting treatment) line anti-TB drug (other than both isoniazid and rifampicin).
should be reclassified as bacteriologically confirmed.
c. Multidrug resistance: resistance to at least both
Bacteriologically confirmed or clinically diagnosed cases isoniazid and rifampicin.
of TB are also classified according to:
d. Extensive drug resistance: resistance to any
1. anatomical site of disease; fluoroquinolone and at least one of three second-line
2. history of previous treatment; injectable drugs (capreomycin, kanamycin and amikacin), in
3. drug resistance; addition to multidrug resistance.
4. HIV status. e. Rifampicin resistance: resistance to rifampicin detected
using phenotypic or genotypic methods, with or without
1. Classification based on anatomical site of disease resistance to other anti-TB drugs. It includes any resistance
a. Pulmonary tuberculosis (PTB) refers to any to rifampicin, whether monoresistance, multidrug resistance,
bacteriologically confirmed or clinically diagnosed case of TB polydrug resistance or extensive drug resistance.
involving the lung parenchyma or the tracheobronchial tree. These categories are not all mutually exclusive. When
Miliary TB is classified as PTB because there are lesions in the enumerating rifampicin-resistant TB (RR-TB), for instance,
lungs. Tuberculous intra-thoracic lymphadenopathy multidrug-resistant TB (MDR-TB) and extensively drug­
(mediastinal and/or hilar) or tuberculous pleural effusion,

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resistant TB (XDR-TB) are also included. While it has been
without radiographic abnormalities in the lungs, constitutes a the practice until now to limit the definitions of
case of extrapulmonary TB. A patient with both pulmonary monoresistance and polydrug resistance to first-line drugs
and extrapulmonary TB should be classified as a case of PTB. only, future drug regimens may make it important to classify
b. Extrapulmonary tuberculosis (EPTB) refers to any patients by their strain resistance patterns to
bacteriologically confirmed or clinically diagnosed case of TB fluoroquinolones, second-line injectable agents and any
involving organs other than the lungs, e.g. pleura, lymph nodes, other anti-TB drug for which reliable DST becomes available.
abdomen, genitourinary tract, skin, joints and bones, meninges.
4. Classification based on HIV status
2. Classification based on history of previous TB
a. HIV-positive TB patient refers to any bacteriologically
treatment (patient registration group)
confirmed or clinically diagnosed case of TB who has a
Classifications based on history of previous TB treatment positive result from HIV testing conducted at the time of TB
are slightly different from those previously defined. They focus diagnosis or other documented evidence of enrolment in
only on history of previous treatment and are independent of HIV care, such as enrolment in the pre-ART register or in the
bacteriological confirmation or site of disease. ART register once ART has been started.
Neu; patients: Patients who have never been treated for b. HIV-negative TB patient refers to any bacteriologically
TB or have taken anti-TB drugs for less than 1 month. confirmed or clinically diagnosed case of TB who has a
Previously treated patients: Patients who received negative result from HIV testing conducted at the time of TB
1 month or more of anti-TB drugs in the past. They are diagnosis. Any HIV-negative TB patient subsequently found
further classified by the outcome of their most recent course to be HIV-positive should be reclassified accordingly.
of treatment as follows: c. HIV status unknown TB patient refers to any
a. Relapse patients have previously been treated for TB, bacteriologically confirmed or clinically diagnosed case of
were declared cured or treatment completed at the end of TB who has no result of HIV testing and no other
their most recent course of treatment, and are now documented evidence of enrolment in HIV care. If the
diagnosed with a recurrent episode of TB (either a true patient's HIV status is subsequently determined, he or she
relapse or a new episode of TB caused by reinfection). should be reclassified accordingly.
b. Treatment after failure patients are those who have B. TREATMENT OUTCOME DEFINITIONS
previously been treated for TB and whose treatment failed at
the end of their most recent course of treatment. The new treatment outcome definitions make a clear
distinction between two types of patients:
c. Treatment after loss to follow-up patients have previously
been treated for TB and were declared lost to follow-up at the - patients treated for drug-susceptible TB;
end of their most recent course of treatment. (These were - patients treated for drug-resistant TB using second-
previously known as treatment after default patients.) line treatment (defined as combination chemotherapy
d. Other previously treated patients are those who have for drug-resistant tuberculosis which includes drugs
previously been treated for TB but whose outcome after other than the first-line drugs (see page 218).
their most recent course of treatment is unknown or The two groups are mutually exclusive. Any patient found
undocumented. to have drug-resistant TB and placed on second-line
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212 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

treatment is removed from the drug-suscepitble TB outcome Treatment failed Treatment terminated or need for permanent
cohort. This means that management of the standard TB regimen change of at least two anti-TB drugs
register and of the second-line TB treatment register needs because of:
- lack of conversion6 by the end of the intensive
to be coordinated to ensure proper accounting of the
phase,3 or
outcomes of treatment. - bacteriological reversion6 in the continuation
phase after conversion6 to negative, or
1. Treatment outcomes for TB patients (excluding - evidence of additional acquired resistance to
patients treated for RR-TB or MDR-TB) fluoroquinolones or second-line injectable
All bacteriologically confirmed and clinically diagnosed drugs, or
TB cases should be assigned an outcome from this list - adverse drug reactions (ADRs).
except those with RR-TB or MDR-TB, who are placed on a Died A patient who dies for any reason during the
course of treatment.
second-line drug regimen.
Lost to follow-up A patient whose treatment was interrupted for
Outcome Definition 2 consecutive months or more.
Not evaluated A patient for whom no treatment outcome is
Cured A pulmonary TB patient with bacteriologically assigned. (This includes cases “transferred out” to
confirmed TB at the beginning of treatment who another treatment unit and whose treatment
was smear or culture-negative in the last month of outcome is unknown)
treatment and on at least one previous occasion. Treatment success The sum of cured and treatment completed
Treatment A TB patient who completed treatment without Cohort A group of patients where RR-TB has been
completed evidence of failure BUT with no record to show diagnosed (including MDR-TB and XDR-TB), and
that sputum smear or culture results in the last who were started on a full course of a second-line
month of treatment and on at least one previous MDR-TB drug regimen during a specified time
occasion were negative, either because tests were period (e.g. the cohort of MDR-TB cases registered
not done or because results are unavailable. in the calendar year 2010). This group forms the
Treatment failed A TB patient whose sputum smear or culture is denominator for calculating treatment outcomes.
positive at month 5 or later during treatment. With the revised definitions, any patient found to
Died A TB patient who dies for any reason before have drug-resistant TB and placed on second-line
starting or during the course of treatment. treatment is removed from the drug-susceptible TB
outcome cohort. This means that management of

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Lost to follow-up A TB patient who did not start treatment or whose the basic management unit TB register and of the
treatment was interrupted for 2 consecutive second-line TB treatment register needs to be
months or more. coordinated to ensure proper accounting of the
Not evaluated A TB patient for whom no treatment outcome is outcomes of treatment (14).
assigned. This includes cases “transferred out” to
3 For Treatment failed, lack of conversion by the end of the intensive
another treatment unit as well as cases for whom
the treatment outcome is unknown to the reporting phase implies that the patient does not convert within the maximum
unit. duration of intensive phase applied by the programme. If no maximum
Treatment success The sum of cured and treatment completed. duration is defined, an 8-month cut-off is proposed. For regimens
without a clear distinction between intensive and continuation
Cohort A group of patients in whom TB has been phases, a cut-off 8 months after the start of treatment is suggested to
diagnosed, and who were registered for treatment determine when the criteria for Cured, Treatment completed and
during a specified time period (e.g. the cohort of Treatment failed start to apply.
new smear-positive cases registered in the calendar 6 The terms “conversion” and “reversion” of culture as used here are
year 2011). This group forms the denominator for
defined as follows:
calculating treatment outcomes. The sum of the
treatment outcomes, plus any case for which no Conversion (to negative) : culture is considered to have converted to
outcome is recorded (eg. still on treatment) should negative when two consecutive cultures, taken at least 30 days apart,
equal the number of cases registered (5). are found to be negative. In such a case, the specimen collection date
of the first negative culture is used as the date of conversion.
Patients found to have an RR-TB or MDR-TB strain at any Reversion (to positive) : culture is considered to have reverted to
positive when, after an initial conversion, two consecutive cultures,
point in time should be started on an adequate second-line taken at least 30 days apart, are found to be positive. For the purpose
drug regimen. These cases are excluded from the main TB of defining treatment failed, reversion is considered only when it
cohort when calculating treatment outcomes and included occurs in the continuation phase.
only in the second-line TB treatment cohort analysis. If
treatment with a second-line drug regimen is not possible, NATURAL HISTORY OF TUBERCULOSIS
the patient is kept in the main TB cohort and assigned an
outcome from above table. Agent factors
2. Outcomes for RR-TB/MDR-TB/XDR-TB patients (a) AGENT : M. tuberculosis is a facultative intracellular
treated using second-line treatment parasite, i.e., it is readily ingested by phagocytes and is
resistant to intracellular killing (20). Of importance to man
Outcome Definition are the human and bovine strains. The human strain is
responsible for the vast majority of cases. The bovine strain
Cured Treatment completed as recommended by the
national policy without evidence of failure AND affects mainly cattle and other animals. Regarding virulence,
three or more consecutive cultures taken at least 30 the Indian tubercle bacillus is said to be less virulent than the
days apart are negative after the intensive phase.3 * * European bacillus. In recent years, a number of “atypical”
Treatment Treatment completed as recommended by the mycobacteria have been isolated from man (21). These have
completed national policy without evidence of failure BUT no been classified into four groups - (i) photochromogens (e.g.,
record that three or more consecutive cultures M. Kansasii); (ii) scotochromogens (e.g., M. scrofulaceum);
taken at least 30 days apart are negative after the (iii) non-photochromogens (e.g., M. intercellulare)) and,
intensive phase.3 (iv) rapid growers (e.g., M. fortuitum). All these are mainly
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 TUBERCULOSIS 213
saprophytic. Diseases attributed to them have resembled The social factors include many non-medical factors such as
pulmonary tuberculosis and chronic cervical lymphadenitis. poor quality of life, poor housing, and overcrowding,
(b) SOURCE OF INFECTION : There are two sources of population explosion, undernutrition, smoking, alcohol
infection - human and bovine, (i) Human source : The most abuse, lack of education, large families, early marriages, lack
common source of infection is the human case whose sputum of awareness of causes of illness, etc. All these factors are
is positive for tubercle bacilli and who has either received no interrelated and contribute to the occurrence and spread of
treatment or has not been treated fully. An estimated annual tuberculosis. In fact, tuberculosis began to decline in the
average of 10-15 persons contract the infection from one western world long before the advent of chemotherapeutic
case of infectious pulmonary TB. Such sources can discharge drugs. This has been attributed to improvements in the
the bacilli in their sputum for years. The tubercle bacilli in a quality of life.
human case are usually a mixed group - some multiply very
rapidly and some slowly. The more rapidly a bacillary strain Mode of transmission
multiplies the more susceptible it is to the bactericidal action Tuberculosis is transmitted mainly by droplet infection
of chemotherapeutic drugs. The slow multipliers are the and droplet nuclei generated by sputum-positive patients
source of persister or dormant bacilli; they can remain alive with pulmonary tuberculosis. To transmit infection, the
for years without causing harm to the host, but when particles must be fresh enough to carry a viable organism.
conditions are favourable they may start multiplying again Coughing generates the largest number of droplets of all
and cause active disease. That is, they are the seeds of a sizes. The frequency and vigour of cough and the ventilation
future relapse (22). (ii) Bovine source: The bovine source of of the environment influence transmission of infection.
infection is usually infected milk. There is no definite Tuberculosis is not transmitted by fomites, such as dishes
evidence that bovine tuberculosis is a problem in this country and other articles used by the patients. Sterilization of these
because of the practice of boiling milk before consumption. articles is therefore of little or no value. Patients with
(c) COMMUNICABILITY : Patients are infective as long extrapulmonary tuberculosis or smear-negative tuberculosis
as they remain untreated. Effective anti-microbial treatment constitute a minimal hazard for transmission of infection.
reduces infectivity by 90 per cent within 48 hours (23).
Incubation period
Host factors The time from receipt of infection to the development of
(a) AGE : Tuberculosis affects all ages. Developing a positive tuberculin test ranges from 3 to 6 weeks, and

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countries show a sharp rise in infection rates from childhood thereafter, the development of disease depends upon the
to adolescence. In India, from an average of 2 per cent in the closeness of contact, extent of the disease and sputum
“0-14 years age group”, the infection rate climbs to about positivity of the source case (dose of infection) and host­
20 per cent at age 15-24 years age group. In the developed parasite relationship. Thus the incubation period may be
countries, the disease is now more common in the elderly. weeks, months or years.
(b) SEX : More prevalent in males than in females.
(c) HEREDITY : Tuberculosis is not a hereditary disease.
However, twin studies (24) indicate that inherited THE CONTROL OF TUBERCULOSIS
susceptibility is an important risk factor, (d) NUTRITION : Tuberculosis control means reduction in the prevalence
Malnutrition is widely believed to predispose to tuberculosis. and incidence of disease in the community.
As malnutrition is widely prevalent in developing world, it
will continue to affect the development of active disease, Since tuberculosis is an infectious disease, the basic
out- come of treatment and spread of the disease, principles of prevention and control are the same as for any
(e) IMMUNITY : Man has no inherited immunity against other infectious disease. The control measures consist of a
tuberculosis. It is acquired as a result of natural infection or curative component - namely case finding and treatment;
BCG vaccination. Past infection with atypical mycobacteria and a preventive component - namely BCG vaccination.
is also credited with certain amount of naturally acquired These are the two fundamental components of a national
immunity. It is now known that both delayed hypersensitivity tuberculosis programme. The most powerful weapon,
and acquired resistance to tuberculosis are cell-mediated however, is the combination of case-finding and treatment.
responses. In most cases, the cellular immunity proves
adequate to limit further multiplication and spread of bacilli. Case-finding in public sector (25)
The first step in a tuberculosis control programme is early
Social factors detection of sputum-positive cases. This should be an
Tuberculosis is a social disease with medical aspects. It intensive, on-going programme. The evolution of strategies
has also been described as a barometer of social welfare. for improving case findings are as shown below :

Evolution of strategies for improving case findings

Passive Case Intensified Case Active Case Population based

Finding (1962-) Finding (2001-) Finding (2017-) screening (2020-)

Based on Co-morbid Systematic screening of Vulnerability mapping

footfall in conditions - vulnerable population Periodic screening
Health HIV, DM (migrant, slums, prisons, of vulnerable
Facility contact of DR TB,
Paediatrics)

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

STRATEGIES ADOPTED FOR CASE FINDING - Economic variant of proportion sensitivity testing
(1%) using LJ medium
a. Passive case finding : An overwhelming majority of
patients of pulmonary tuberculosis have one or more of 4. Rapid molecular diagnostic tests:
the symptoms referable to chest, such as persistent - Line probe assay (LPA) for MTB complex and
cough and fever, and many of them (over 60 per cent) detection of RIF & INH resistance (FL LPA), and FQ
seek medical advice on their own initiative. The chest and SLI resistance (SL LPA)
symptoms often develop early, that is before the disease - Nucleic acid amplification test (NAAT) (CBNAAT/
has gone on to an advanced stage. This is the most truenat)
fertile group for case-finding.
Supportive tools for the clinical diagnosis of TB
b. Intensified case finding : Screening patients attending
health facilities with comorbidities, for TB (HIV care - Chest X-ray and other radiological tests.
settings, diabetes clinic, tobacco cessation clinic, - Tuberculin skin test (TST), Interferon gamma release
nutritional rehabilitation centre) and OPDs assay (IGRA) and other blood tests, histopathology and
(Gynaecology, orthopaedics etc.). This is a provider- other tissue-based tests.
initiated screening of outpatient clinic/hospital attendees Smear microscopy being the most commonly used
for symptoms of TB. method for microbiological diagnosis of TB for the last
c. Active case finding : Actively searching for TB patients several decades, has had enormous value in TB diagnosis
among vulnerable population in the community (Slum, but with limited sensitivity, more so in children and PLHIV.
tribal, prison etc.). This activity adopted by the Under the programme, two methods of microscopy are
programme enables early detection of TB patients. currently being used - ZN stain-based microscopy using
d. Vulnerability mapping is done followed by periodic conventional microscope and light emitting.
screening of vulnerable population. Leveraging outreach Diode based fluorescent microscopy (LED FM) : Culture
of other Health Programmes in Health and wellness though highly sensitive and specific method for TB
centres. diagnosis, requires 2-8 weeks to yield results and hence does
Screening strategies not help in early diagnosis. However, culture is used for
follow-up of patients on drug resistant TB treatment to detect
1. Community screening can be done by : early recurrence. In addition, it is also used for long term

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Inviting people to attend screening at a mobile facility or follow-up for DS TB patients, to ensure relapse free cure.
a fixed facility. Invitations may target specifically people Liquid culture system : Mycobacteria growth indicator
within a given vulnerable group, those tube system (MGIT-B) is an automated culture system that
- who have had recent close contact with someone who detects the growth of mycobacteria. The culture results
has TB and people with symptoms of TB. are usually available upto 42 days. DST results are available
- Going door-to-door to screen households. 14-26 days after the cultures turn positive.
2. Institutional screening Molecular assays : Polymerase-chain-reaction (PCR)
based technologies using various modifications are used for
- In health care facilities : Systematically perform active
detecting the presence of putative resistance genes (rpoB for
screening of vulnerable individuals attending hospitals rifampicin, katG and inhA for Isoniazid etc.).
and other health care institution.
- In congregate settings : Systematically perform active Sputum examination : Sputum smear examination by
screening of vulnerable individuals in shelters, old age direct microscopy is now considered the method of choice.
homes, refugee camps, correctional facilities and The reliability, cheapness and ease of direct microscopic
other specific locations such as workplaces. examination has made it number one case-finding method
all over the world. It enables us to discover the
Recommendations on at risk or vulnerable groups to epidemiologically most important cases of pulmonary
be screened tuberculosis, i.e., those excreting tubercle bacilli in their
sputum. This is the group which contributes most of the new
A vulnerable group is any group of people in which the
cases to the “pool of infection” every year.
prevalence or incidence of TB is significantly higher than in
the general population. The recommended vulnerable Collection of sputum samples
groups to be considered for intensified case finding are
discussed in detail on page 239. A pulmonary tuberculosis suspect should submit two
sputum samples for microscopy. The chances of finding
d. CASE-FINDING TOOLS TB bacilli are greater with two samples than with one
Tools for microbiological confirmation of TB are (26) sample. Secretions build up in the airways overnight. So an
early morning sputum sample is more likely to contain TB
1. Sputum Smear Microscopy (for AFB) : bacilli than one taken later in the day. It may be difficult for
- Zeihl-Neelsen staining an out-patient to provide two early morning sputum
- Fluorescence staining samples. Therefore in practice an out-patient usually
2. Culture : provides sputum samples as follows:
- Solid (Lowenstein Jensen) media
day 1 sample 1 Patient provides an “on-the-spot” sample
- Automated Liquid culture systems e.g. BACTEC MGIT under supervision when presenting to the
960, BacT Alert or Versatrek etc. health facility. Give the patient a sputum
3. Drug Sensitivity Testing: container to take home for an early morning
sample the following morning.
- Modified proportionate sensitivity testing (PST) for
MGIT 960 system day 2 sample 2 Patient brings an early morning sample.

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 TUBERCULOSIS

If the patient is coming from a long distance or there is sputum smear-positive PTB. This may arise because of the
likelihood that the patient may default to give a second following: red stain retained by scratches on the slide;
sample, 2 spot specimens are collected with a gap of one accidental transfer of AFBs from a positive slide to a
hour (27). negative one; contamination of the slide or smear by
environmental mycobacteria; presence of various particles
Ziehl-Neelsen acid-fast stain that are acid-fast (e.g. food particles, precipitates, other
This simple stain detects acid fast bacilli. The procedure is microorganisms).
as follows:
False-negative results of sputum smear
1. Fix the smear on the slide by passing the slide with the microscopy
smear up about three times slowly through a flame. It
can also be done by covering the smear with alcohol and A false-negative result means that the sputum smear
letting this evaporate. result is negative even though the patient really does have
sputum smear-positive PTB. This may arise because of
2. Cover with carbol fuchsin, steam gently for 5 minutes
problems in collecting (patient provides inadequate sample,
over direct flame (or for 20 minutes over a water bath).
inappropriate sputum container used or sputum stored too
Do not permit slide to boil or dry out.
long before smear microscopy), processing (faulty sampling
3. Wash with deionized water. of sputum for smear or faulty smear preparation and
4. Decolourize in 3.0 per cent acid-alcohol (95 per cent staining), or interpreting sputum smears (inadequate time
ethanol and 3.0 per cent hydrochloric acid) until only a spent examining smear or inadequate attention to smear
faint pink colour remains. examination), or because of administrative errors
5. Wash with water. (misidentification of patient, incorrect labelling of sample or
6. Counter stain for 1 minute with Loeffler's methylene blue. mistakes in documentation).
7. Wash with deionized water and let it dry. Fluorescence microscopy
Slide reporting (28) Fluorescence microscopy is mainly used in industralized
countries. It is performed with auramine stain. The advantage
The number of bacilli seen in a smear reflects disease of FA microscopy is from the speed of examination. The field
severity and patient infectivity. Therefore, it is important to of view is 5-10 times bigger. Scanning of one length of smear

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record the number of bacilli seen on each smear. The table will require only 1-2 minutes.
below shows the standard method of reporting using 1000 X
magnification. Light-emitting diode fluorescence microscopy (LEDs)
LEDs provide a much less expensive light source for
Number of bacilli Result reported
fluorescence microscopy. In a recent WHO evaluation, the
No AFB per 100 oil immersion fields 0 diagnostic accuracy of LED microscopy was found to be
1-9 AFB per 100 oil immersion fields scanty (or number comparable to that of conventional fluorescence microscopy
AFB seen) and superior to that of conventional Ziehl-Neelsen
10-99 AFB per 100 oil immersion fields + (1+)
microscopy. It is therefore recommended that LED
microscopy be phased in as an alternative to conventional
1-10 AFB per oil immersion field + + (2 + ) Z-N light microscopy in both high and low-volume
> 10 AFB per oil immersion field + + + (34-) laboratories (29).
Laboratory technicians should examine both the sputum Rapid diagnostic tools include
samples from each TB suspect. They must record the result
of each sputum sample with the laboratory reference The CB-NAAT system detects DNA sequences, specific
number in the laboratory register and on the sputum request for Mycobacterium tuberculosis complex and rifampicin
form. Results as indicated above are made available to the resistance by polymerase chain reaction. It concentrates
clinician who can then categorize the patient. It is advised mycobacterium tuberculosis bacilli from sputum samples,
that the smear examined by one microscopist should not isolates genomic material from the captured bacteria by
exceed 20 per day as visual fatigue leads to a deterioration sonication and subsequently amplifies the genomic DNA by
of reading quality (29). One positive specimen out of the PCR. The process identifies clinically relevant, rifampicin
two is enough to declare a patient as smear positive TB. resistance inducing mutations in the RNA polymerase beta
(rpoB) gene in the Mycobacterium tuberculosis genome in a
Sputum smear microscopy for tubercle bacilli is positive real time format using fluorescent probes called molecular
when there are at least 10,000 organisms present per ml of beacons. Results are obtained from unprocessed sputum
sputum. The sputum smear positivity rate in TB/HIV patient samples in 90 minutes.
depends on the degree of immunocompromise. If the degree
of immunocompromise is mild, the likelihood of positive Line Probe Assay (LPA) :
sputum smear is similar to HIV negative patient. If Line Probe Assays detect DNA sequences specific for
immunocompromise is severe, the likelihood of positive Mycobacterium tuberculosis complex as well as mutations
sputum smear is decreased because of decreased conferring resistance. Sputum samples are decontaminated
inflammation in lungs (28). and the concentrated deposit subjected to smear
microscopy. DNA is extracted from all smear positive
False-positive results of sputum smear samples and subjected to PCR; while all smear negative
microscopy samples are inoculated in liquid culture and LPA performed
A false-positive result means that the sputum smear result using the culture isolate obtained upon growth of
is positive even though the patient does not really have Mycobacteria. The PCR amplified products are reverse

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216 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

hybridized on nitrocellulose strips containing probes specific It has been further observed that strong reactors (i.e.,
for detection of M. tuberculosis and mutations associated those showing 20 mm or more induration) have greater
with drug resistance. First line LPA detects resistance to chances of developing tuberculosis than those showing
Rifampicin (rpoB) and Isoniazid (katG, inhA), while second 10 mm induration. Those with less than 5 mm induration
line LPA detects fluoroquinolone class resistance (gyrA, have more risk of developing tuberculosis than those with
gyrB) and second line injectable class resistance (rrs, eis). 6-9 mm induration. Studies indicate that 92 per cent of
Nucleic Acid Amplification Test (NAAT) provides accurate new cases occur in persons who are already tuberculin
and rapid diagnosis of TB by detecting Mycobacterium reactors (30). These findings illustrate the prognostic
tuberculosis (M. tuberculosis) and Rifampicin (Rif) resistance significance of the test.
conferring mutations, in sputum specimen as well as
specimen from extra-pulmonary sites. Under the Classification of positive tuberculin skin test
programme, its use is recommended for diagnosis of DR-TB, reaction (31)
in presumptive DR-TB patients and TB preferentially in key A tuberculin skin test reaction is considered positive if the
population such as children, PLHIV, Extra-pulmonary TB transverse diameter of the indurated area reaches the size
and in smear negative TB as per the diagnostic algorithm. required for the specific group. All other reactions are
Radiography considered negative. The classification is as follows :
Chest X-rays are useful for the diagnosis of smear Induration Group
negative pulmonary TB and TB in children. It is not size
routinely indicated in smear-postive cases. X-rays are
1. HIV-positive persons.
valuable tools for the diagnosis of pleural and pericardial
2. Recent contacts of individuals with active
effusion, especially in early stages of the disease when tuberculosis.
clinical signs are minimal. It is essential in the diagnosis of 3. Persons with fibrotic changes on chest films
miliary TB. The other indications are frequent or severe suggestive of prior tuberculosis.
haemoptysis to exclude bronchiectasis or aspergilloma and 4. Patients with organ transplants and other
in patients needing specific treatment for pneumothorax. immunosuppressed patients (receiving the
equivalent of > 15 mg/d of prednisone for 1 month or
more).
TUBERCULIN TEST

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> 10 mm 1. Recent immigrants (<5 years) from countries with a
The tuberculin test was discovered by Von Pirquet in high prevalence of tuberculosis (eg, Asia, Africa,
Latin America).
1907. A positive reaction to the test is generally accepted as 2. HIV-negative injection drug users.
evidence of past or present infection by M. tuberculosis. The 3. Mycobacteriology laboratory personnel
tuberculin test is the only means of estimating the 4. Residents of and employees in the following high-
prevalence of infection in a population. risk congregate settings: correctional institutions;
Tuberculin : Only two tuberculins have been accepted nursing homes and other long-term facilities for the
as standard tuberculin by WHO, i.e., purified protein elderly; hospitals and other health care facilities;
residential facilities for AIDS patients; and homeless
derivative-S (PPD-S) and PPD-RT 23. PPD is standardized shelters.
in terms of its biological reactivity as tuberculin units (TU). 5. Persons with the following medical conditions that
A standard 5 tuberculin unit (5 TU) dose of PPD-S is defined increase the risk of tuberculosis: gastrectomy, > 10%
as delayed skin activity contained in a 0.1 jig/0.1 ml dose of below ideal body weight, jejunoileal bypass, diabetes
PPD-S. 1 TU of PPD-RT 23 is equivalent to 5 TU of mellitus, silicosis, advanced chronic kidney disease,
PPD-S. In India PPD-RT 23 with Tween 80 is used. Tween some hematologic disorders, (eg. leukemias,
lymphomas) and other specific malignancies (eg,
80 is a detergent added to tuberculin to prevent their carcinoma of the head or neck and lung).
adsorption on glass or plastic surface. Use of tuberculin 6. Children <4 years of age or infants, children and
strength of 1 TU is recommended for standard Mantoux test adolescents exposed to adults at high risk.
in India.
> 15 mm 1. Persons with no risk factors for tuberculosis.
MANTOUX TEST : The Mantoux test is carried out by
injecting 1 TU of PPD in 0.1 ml intradermally on the flexor A negative tuberculin test must also be interpreted with
surface of the left forearm, mid-way between elbow and caution. For many years, it has been assumed that a
wrist. The injection should be made with a tuberculin negative test constituted strong evidence against the
syringe, with the needle bevel facing upward. When placed presence of active tuberculous disease in the majority of
correctly, injection should produce a pale wheal of the skin, cases. It has been shown that in the majority of patients with
6 to 10 mm in diameter. The result of the test is read after tuberculosis, the cellular immune response may be
48-96 hours but 72 hours (3rd day) is the ideal. depressed. It means a negative tuberculin test cannot be
Tuberculin reaction consists of erythema and induration. relied upon to exclude tuberculosis. The dermal
Since erythema is sometimes difficult to measure, induration hypersensitivity to tuberculin can also be lost in various
alone is measured (horizontal transverse diameter of states of immune suppression, e.g., malignancy, Hodgkin’s
induration in millimetres, using a transparent plastic ruler or disease, HIV infection, malnutrition, severe bacterial
callipers). Reactions exceeding 10 mm are considered infection (including TB itself), viral infections (e.g. measles,
“positive”. Those less than 6 mm are considered “negative”. chickenpox, glandular fever), recent live-virus vaccination
Those between 6 and 9 mm are considered “doubtful”, i.e., (e.g. measles), immunosuppresive drugs (e.g. steroids) and
the reaction may be due to M. tuberculosis or atypical incorrect injection of PPD. Therefore, too great a diagnostic
mycobacteria. If there is no induration, the result should be significance should not be placed on a negative tuberculin
recorded as ‘O’. test (20).

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 TUBERCULOSIS I 217
Two-step testing the blood sample must be processed fairly quickly,
laboratory facilities are required, and the test is only for
Some people who were previously infected with TB may
latent TB. It is also thought that the IGRAs may not be as
have a negative reaction when tested years after infection,
accurate in people who have HIV. In low prevalence
as the immune system response may gradually wane. This resource rich settings, IGRAs are beginning to be used in
initial skin test, though negative, may stimulate (boost) the place of the TB skin test (33).
body’s ability to react to tuberculin in future tests. Thus, a
positive reaction to a subsequent test may be misinterpreted Case-finding should not be an end in itself. It is of little
as a new infection, when in fact it is the result of the boosted value as a control measure unless followed by chemotherapy.
reaction to an old infection. Giving a second TST after an Resources and efforts should be directed towards primary
initial negative TST reaction is called a two-step testing. Use health care, rather than irrational case finding.
of two-step testing is recommended for initial skin testing of Please refer to page 220 for the flow chart for diagnosis
adults who will be retested periodically (e.g, health care of tuberculosis in adults, as followed by NTEP.
workers).
Chemotherapy
- The first test is read 48-72 hours after injection.
The development of effective treatment for tuberculosis
- If the first test is positive, consider the person infected. has been one of the most significant advances during this
- If the first test is negative, give a second test one to century. With the evolution of controlled trials (see page 92),
three weeks after the first injection. the chemotherapy of tuberculosis is now more
- The second test is read 48-72 hours after injection. rationally based, than in the treatment of other infectious
diseases.
- If the second test is positive, consider the person
previously infected. Chemotherapy is indicated in every case of active
tuberculosis. The objective of treatment is cure - that is, the
- If the second test is negative, consider the person elimination of both the fast and slowly multiplying bacilli
uninfected. (including the persisters) from the patient’s body. The effects
The validity of tuberculin test, like all medical tests, is of chemotherapy are judged not by the anatomic healing of
subject to variability. It is limited by lack of specificity. Apart lesions, but mainly by the elimination of bacilli from the
from errors associated with the mode of administration, patient’s sputum. Chemotherapy should be easily available,
free of charge to every patient detected. It should be

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reading of results and the test material used, there are other
factors such as cross-reactions due to sensitization by other adequate, appropriate and applied to the entire pool of
mycobacteria, which should be taken into account. In infectors in the community. Patient compliance is critically
countries with a high coverage of BCG, which also produces important; the patient must take the correct drugs at the
tuberculin hypersensitivity, tuberculin test has lost its correct dosage for the correct length of time. Incomplete
sensitivity as an indicator of the “true” prevalence of treatment puts the patient at risk of relapse and the
infection. The true prevalence rates of infection may be development of bacterial resistance and, importantly, the
exaggerated by infection with atypical mycobacteria as well community at risk of infection with resistant organisms.
as the “boosting effect” of a second dose of tuberculin
producing a larger reaction than the first (32). Anti-tuberculosis drugs
It is often assumed that delayed hypersensitivity as There are now twelve or thirteen drugs active against
M. tuberculosis, of which, six are considered to be essential.
measured by tuberculin testing is a correlate of the
protective immune response. But evidence indicates that An antitubercular drug should satisfy the following criteria :
this hypersensitivity is irrelevant to the ability of the host to (a) highly effective (b) free from side-effects (c) easy to
administer, and (d) reasonably cheap. The currently used
combat the disease. Despite these limitations, the tuberculin
drugs may be classified into two groups : bactericidal and
test continues to be the only tool for measuring the
bacteriostatic. The bactericidal drugs kill the bacilli in vivo.
prevalence of tuberculous infection in a community. It has
The bacteriostatic drugs inhibit the multiplication of the bacilli
been aptly said that tuberculin test “must be approached
and lead to their destruction by the immune mechanism of the
with respect, administered with care, read with deliberation host. A brief review of these drugs is given below.
and interpreted with sentient discrimination”.
THE FIRST-LINE DRUGS
TB Interferon gamma release assays (IGRAs)
BACTERICIDAL DRUGS
The Interferon Gamma Release Assays (IGRAs) are a new
type of more accurate test for TB. IGRAs are blood tests that Rifampicin (RMP)
measure a person’s immune response to the bacteria that
cause TB. The immune system produces some special RMP is a powerful bactericidal drug. It is a better
molecules called cytokines. These TB tests work by detecting sterilizing agent than INH. It permeates all tissue membranes
a cytokine called the interferon gamma cytokine. In practice including the blood-brain and placental barriers. It is equally
you carry out one of these TB tests by taking a blood sample effective against intracellular as well as extracellular bacilli. It
and mixing it with special substances to identify if the is the only bactericidal drug active against the “persisters” or
cytokine is present. Two IGRAs that have been approved dormant bacilli which are found in the solid caseous lesions,
and are commercially available, are the QuantiFERON® TB all other drugs being inactive (34). In this regard, it has a
Gold test, and the T-SPOT® TB test. The advantages of an distinct advantage over INH. Rifampicin is of special value
IGRA TB test includes the fact that it only requires a single when the bacilli resists other drugs. In combination with INH,
patient visit to carry out the TB test. Results can be available it can cure even extensive tuberculosis, in about 9 months.
within 24 hours, and prior BCG vaccination does not cause RMP is used only as oral drug. It is so well absorbed that
a false positive result. Disadvantages include the fact that there is little need for parenteral administration. The dose

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218 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

should be taken at least one hour before or 2 hours after given orally. Its major side-effect is retrobulbar neuritis; this
food because absorption is reduced by food. It is never used however does not occur at the usual dosage. Ethambutol
alone for the treatment of tuberculosis, but always used in has replaced para-aminosalicylic acid (PAS) almost entirely
combination with INH or another drug. among adults.
Many patients develop nausea at the start of treatment,
but this passes off. The toxic effects include hepatotoxicity, THE SECOND-LINE DRUGS
gastritis, influenza-like illness, purpura, thrombocytopenia
and nephrotoxicity. The patient should be told that the drug Fluoroquinolones
will turn the urine red; this can be used as test of compliance. Ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin and
PAS delays its absorption; hence concurrent gatifloxacin are active against M. tuberculosis, even those
administration with PAS should be avoided. If RMP is resistant to other drugs. They are given orally or IV. They are
stopped for some reason, it should not be restarted within useful in treating infections resistant to standard drugs and
3 weeks to avoid hypersensitivity. in cases with relapse.

INH Ethionamide
INH ranks among the most powerful drugs in the Ethionamide is structurally related to INH and acts by
treatment of tuberculosis. It can easily penetrate the cell inhibiting the mycolic acid synthesis. It is effective against
membrane, and is thus active against intracellular and bacilli resistant to other drugs and has proved effective in
extracellular bacilli. Its action is most marked on rapidly infections due to atypical mycobacteria. It is effective against
multiplying bacilli. It is less active against slow multipliers. intracellular as well as extracellular organisms.
INH gets widely distributed in the body including CSF. Its
ease of administration, freedom from toxicity and low cost Capreomycin
makes it an ideal component for any drug regimen. It is bactericidal. Its mechanism of action, pharmaco­
INH should be given as a single dose. INH reaches its kinetics and adverse reactions are similar to those of
peak level in blood 1 to 2 hours after the dose. It has been streptomycin. It should be administered with caution in
found that its peak level in serum is more important than presence of renal impairment.
sustained inhibitory level. It is for this reason, INH should Kanamycin and amikacin
not be given in divided doses (35).

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They are bactericidal and are active against bacilli
Patient may experience gastrointestinal irritation,
resistant to streptomycin, INH and cycloserine.
peripheral neuropathy, blood dyscrasias, hyperglycaemia
and liver damage. Those patients who are slow inactivators Cycloserine
experience a higher incidence of toxicity. The addition of
pyridoxine (10-20 mg daily) helps prevent the occurrence of The drug is mainly bacteriostatic. It is effective against
peripheral neuropathy. bacilli resistant to INH or streptomycin and against atypical
mycobacteria, although antitubercular activity is less than
Streptomycin that of these two drugs. It acts by inhibiting the synthesis of
Streptomycin is bactericidal. It acts entirely on rapidly the bacterial cell wall.
multiplying bacilli. It has been shown that when bacilli are
Thioacetazone
multiplying rapidly, they come out of the phagocytes and are
mostly extracellular and are, therefore, susceptible to It is a bacteriostatic drug. It rapidly diffuses into various
streptomycin. Streptomycin is less active against slow body tissues and also crosses the placenta barrier. It is also
multipliers. It has no action on persisters. It does not secreted in milk. It should never be used in HIV patients as it
permeate cell walls or normal biological membranes such as can cause severe and fatal skin reactions. Side-effects
meninges or pleura. include gastrointestinal disturbances, blurring of vision,
The daily dose of streptomycin is 0.75 g in a single haemolytic anaemia and urticaria. The incidence of these
injection. This is a disadvantage because of the organizational side-effects seem to differ in different ethnic groups.
problem involved in the long term treatment. It can cause side­ Macrolides
effects which include vestibular damage and nystagmus rather
than deafness. Renal damage may also occur. Newer macrolides azithromycin and clarithromycin also
have action against tubercular bacilli. They are used to treat
Pyrazinamide atypical mycobacterial infection and cases with relapse.
This drug is bactericidal and is particularly active against Bedaquiline (BDQ)
the slow-multiplying intracellular bacilli which are unaffected
by other drugs. It has been found to increase the sterilizing Bedaquiline (BDQ) is a new class of drug diarylquinoline,
ability of rifampicin. Therefore, pyrazinamide has been that specifically targets mycobacterial ATP synthase, an
incorporated in short-course chemotherapy regimens. enzyme essential to supply of energy to mycobacterium. It is
a bactericidal drug with high volume of tissue distribution,
Complications include hepatotoxicity and highly bound to plasma proteins and hepatically
hyperuricaemia. Pyrazinamide achieves high levels in CSF metabolized. The drug has extended half-life, which means
and is, therefore, recommended in tuberculous meningitis. that it is still present in the plasma up to 5.5 months post
BACTERIOSTATIC DRUGS stopping BDQ. The drug has shown significant benefits in
improving the time to culture convertion in MDR-TB
Ethambutol patients. The basic criteria for patient selection is : (1) age of
Ethambutol is bacteriostatic and is used in combination the patient should be > 18 years having MDR-TB;
to prevent the emergence of resistance to other drugs. It is (2) Pregnancy is a contraindication for BDQ therapy and the

by R△J
 TUBERCULOSIS ■ 219
patient should be using non-hormonal based birth control sanatoria. It is now universally accepted that with good
measure throughout the treatment period or have been post­ chemotherapy, hospital treatment has no advantage over
menopausal for past 2 years; and (3) Cardiac arrythmia is a domiciliary treatment, and domiciliary treatment is to be
contraindication for BDQ treatment (36). preferred because in the long run, it is so much cheaper than
The following group of patients are eligible for BDQ hospital treatment, and that it can be managed by the
primary health care system and the general health services
therapy :
of the country. It may be mentioned that it was this study,
1. MDR/RR TB with resistance to any/all fluoroquinolones the classical Chennai Study, that prompted a radical
(FQ) or to any/all second-line injectable agents (SLI) departure from the traditional sanatorium to ambulatory or
2. XDR-TB domiciliary treatment.
3. Mixed pattern resistant TB (XDR-TB + additional first
line / second line resistant TB) SHORT-COURSE CHEMOTHERAPY
4. Treatment failure of MDR-TB + FQ/SLI resistance or
XDR-TB For a long time, the standard duration of tuberculosis
chemotherapy was 18 months. In 1972, Wallace Fox and his
Delamanid (DLM) colleagues from the British Medical Research Council
Delamanid is a recently approved drug for the treatment showed that the addition of rifampicin or of pyrazinamide to
of TB conditional use under programmatic setting only. The regimens containing INH made it possible to reduce the
phase III clinical trial results for safety and effectiveness of duration of treatment.
the drug is yet to be published. The Drug Controller General There are a number of advantages of short-course
of India has issued permission to use Delamanid (50 mg) as chemotherapy, viz. rapid bacteriological conversion, lower
part of an appropriate combination regimen for pulmonary failure rates and a reduction in the frequency of emergence
MDR-TB in adult patients when an effective treatment of drug-resistant bacilli. Patient compliance is improved,
regimen cannot otherwise be composed for reasons of they become non-infectious earlier. The disadvantage is that
resistance or tolerability (37). the high cost of short-term chemotherapy militates against
For dosage of different second-line drugs, kindly refer to its wider use in developing countries.
page 224. There are now a number of short-course regimens of
Most TB patients complete their treatment without any 6 months duration that are highly effective, of low toxicity,

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significant drug side-effects. However, a few patients do and well-tolerated. These potent regimens are based on an
develop major reactions and it is important to monitor initial intensive phase with 4 drugs (INH, rifampicin and
clinically all the patients. A patient who develops one of the pyrazinamide, supplemented by either streptomycin or
following reactions must never receive that drug again (34) : ethambutol) for a period of 2 months, followed by 2 drugs in
the continuation phase, (INH plus rifampicin or
Reaction Drug thioacetazone) given daily or intermittently. The treatment
responsible must be fully supervised and monitored mainly by
a. Severe rash, agranulocytosis Thioacetazone bacteriological examination.
b Hearing loss or disturbed balance Streptomycin
c. Visual disturbance (poor vision and Ethambutol
DIRECTLY OBSERVED TREATMENT, SHORT
colour perception) COURSE (DOTS) CHEMOTHERAPY
d. Renal failure, shock or thrombocytopenia Rifampicin
DOTS is a strategy to ensure cure by providing the most
e. Hepatitis Pyrazinamide effective medicine and confirming that it is taken. It is the
only strategy which has been documented to be effective
Two-phase chemotherapy worldwide on a programme basis. In DOTS, during the
It is well recognized that there are two phases in the effective intensive phase of treatment a health worker or other trained
treatment of tuberculosis : (i) the first is a short, aggressive or person watches as the patient swallows the drug in his
intense phase, early in the course of treatment, lasting presence. During continuation phase, the patient is issued
1-3 months. During this intensive phase, three or more drugs medicine for one week in a multiblister combipack, of which
are combined to kill off as many bacilli as possible. The more the first dose is swallowed by the patient in the presence of
rapidly the bacilli are killed initially, the less likely are health worker or trained person. The consumption of
“persisters” to emerge. The risk of relapse is also lessened, medicine in the continuation phase is also checked by return
(ii) the second or “continuation” phase is aimed at sterilizing the of empty multiblister combipack, when the patient comes to
smaller number of dormant or persisting bacilli. In the standard collect medicine for the next week. The drugs are provided
anti-tuberculous therapy, the duration of treatment was not less in patient-wise boxes with sufficient shelf-life.
than 18 months to achieve complete sterilization of the bacilli.
With the introduction of rifampicin and pyrazinamide, this INTRODUCTION OF DAILY DOSE
period is now successfully reduced to 6-9 months.
REGIMEN IN NTEP
DOMICILIARY TREATMENT The technical and operational guidelines-2016 for TB
The self-administration of drugs (generally oral drugs) by control in India, define major groups of TB patients who are
the patients themselves without recourse to hospitalization is offered standard treatment regimen. Patient’s classification is
called domiciliary or ambulatory treatment. The classical based on drug susceptibility result as drug-sensitive TB; and
controlled clinical trials (38) carried out at the Tuberculosis mono, poly, RR, multi and extensively drug resistant TB. For
Chemotherapy Centre, Chennai showed that the incidence drug-sensitive TB patients, the thrice weekly intermittent TB
of tuberculosis was no greater in the contacts of patients regimen used since inception of the programme has been
treated at home than in the contacts of patients treated in switched to a daily fixed dose combination regimen (37).

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

1. MANAGEMENT OF DRUG SENSITIVE neurological disorder etc. It is also important to look for
TUBERCULOSIS (2019) substance abuse especially tobacco (in any form) and alcohol.
Socio-economic status of the patient may be assessed to link
Early identification of people with a high probability of
him/her with appropriate treatment support schemes. HIV
having active TB (presumptive TB) is the most important
testing should be done in all the cases of TB. This is important
activity of the case finding strategy. Screening and diagnosing
to ensure that all HIV positive cases of TB receive anti­
patients with appropriate tests and strategies will largely
retroviral therapy and co-trimoxazole preventive therapy (36).
determine the response to appropriate treatment. Passive case
finding alone can lead to missed cases or delayed diagnosis. Since the drugs used in the treatment of tuberculosis are
known to produce adverse effects, a proper pre-treatment
All presumptive TB will undergo sputum smear
evaluation is essential to identify patients who are at
examination (ZN/LEDFM). Two specimens are collected
(spot-early morning or spot-spot). If the first smear is positive increased risk of developing such adverse effects. The pre -
and the patient is not at the risk of drug resistant TB, he will treatment evaluation includes the following :
be categorized as microscopically confirmed TB (sensitivity 1. Detailed history (including mental illness, seizure, drug
status not known). If the first smear is negative, CXR may be and alcohol abuse etc).
considered and if reported as suggestive of TB, the 2nd 2. Weight and height.
sample will be subjected to smear and CBNAAT 3. Complete blood count.
simultaneously. Based on CBNAAT results, patient will be 4. Blood sugar to screen for diabetes mellitus.
categorized as microbiologically confirmed drug sensitive TB.
5. Liver function test.
For NTEP endorsed TB diagnostics, Fig. 2 shows the 6. Blood urea and creatinine to assess kidney function.
diagnostic algorithm for pulmonary tuberculosis.
7. Urine examine - routine and microscopic.
Pre-treatment counselling and evaluation 8. Chest X-ray
The patient and his/her family members should be 9. Pregnancy test (for all women in child bearing age group).
counselled about the type of disease, mode of spread, the Most TB patients on first line drugs complete their
treatment duration and dosage schedule, common drug side­ treatment without any serious drug side effects. Trivial side
effects and methods to prevent them, importance of regular effects may lead to reduced compliance with the treatment,
treatment and consequences of irregular treatment, screening hence asymptom-based approach to the management of the

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of co-morbidities like diabetes, liver or renal diseases and common adverse effect should be adopted.

PLHIV Presumptive TB patient

Smear examination

Smear positive Smear positive, Smear negative Smear negative or not available & Clinical
and CXR but CXR not but CXR CXR not suggestive of TB or suspicion
suggestive of TB suggestive of TB suggestive of TB not available high

PMDT criteria, high

MDR settings

MTB detected MTB not detected or CBNAAT Consider

result not available ► alternate Clinically
r
diagnosis diagnosed TB
and refer
to specialist
Refer to Alternate
Rif sensitive Rif indeterminate Rif resistant ----- ► management of —1► diagnosis
Rif resistance
r 5r
Repeat CBNAAT
Microbiologically on 2nd sample
confirmed TB
▼ *A1I presumptive TB cases should be offered HIV
Indeterminate on 2nd sample, collect counselling and testing, however diagnostic work
fresh sample for Liquid Culture/LPA up for TB must not be delayed.

FIG. 2
Diagnostic algorithm for pulmonary TB
Source : (39)

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 TUBERCULOSIS 221
Pharmacovigilance in TB control programme : Drug dosages for first line anti-TB drugs
Pharmacovigilance is defined by the WHO as the “science
and activities relating to the detection, assessment, Drugs Adults Children Maximum in
children
understanding and prevention of adverse effects or any other
drug-related problem”. It is fundamental activity to inform 10 mg/kg daily 5 mg/kg daily
Isoniazid 300 mg
(7-15 mg/kg) (4 to 6 mg/kg)
the management of patient safety measurement in health 15 mg/kg daily 10 mg/kg daily
care. It is a public health surveillance activity. Priority is given Rifampicin 600 mg
(10-20 mg/kg) (8-12 mg/kg)
to establish pharmacovigilance at drug resistance TB centres. 35 mg/kg daily 25 mg/kg daily
Pyrazinamide 2000 mg
(30-40 mg/kg) (20-30 mg/kg)
Recommended daily dose regimen for drug 20 mg/kg daily 15 mg/kg daily
Ethambutol** 1500 mg
sensitive TB (2019) (15-25 mg/kg) (12-15 mg/kg)
20 mg/kg daily 15 mg/kg daily
The principle of treatment for tuberculosis (other than Streptomycin* 1000 mg
(15-20 mg/kg) (15-20 mg/kg)
confirmed drug resistant forms of TB) with daily regimen is
* Streptomycin is administered only in certain situations, like TB
to administer daily fixed dose combinations of first-line meningitis or if any first line drug need to be replaced due to ADR as
anti-tuberculosis drugs in appropriate weight bands. per weight of the patient
** Ethambutol is given separately for children to monitor ophthalmic
Fixed dose combinations (FDCs) ADR.
Fixed dose combinations (FDCs) refer to products Daily dose schedule for adults
containing two or more active ingredients in fixed doses, (as per weight bands) (26)
used for a particular indication(s).
In NTEP, for Adults - 4-FDC (given in IP) consists Weight Number of tablets (FDCs)
of HRZE and 3-FDC (given in CP) consists of HRE. category Intensive phase HRZE Continuation phase HRE
For paediatric patients - dispersible 3 FDC consists of HRZ 75/150/ 400/275 75/150/275
and dispersible 2 FDC consists of HR. 25-34 kg 2 2
35-49 kg 3 3
Advantages of FDCs 50-64 kg 4 4
• Simplicity of treatment 65-75 kg 5 5

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• Increased patient acceptance >75 kg 6 6
- Fewer tablets to swallow During treatment if the weight of the patient increases by
- Prevents ‘concealed’ irregularity more than 5 kg and crosses to the next weight band category
then patient should be given the next higher weight band
• Increased health worker compliance FDC drugs.
- Fewer tablets to handle, hence quicker supervision of
DOT Treatment of paediatric TB
• Easier drug management Paediatric cases are to be treated under NTEP in daily
• Reduced use of monotherapy dosages as per 6 weight band categories. All adolescents
- Lower risk of misuse of single drugs upto 18 years of age and weighing less than 39 kg, are to be
• Lower risk of emergence of drug resistance treated using paediatric weight bands and children weighing
• Easier to adjust dosages by body weight more than 39 kg with adult weight bands.

Treatment is given in two phases (26): Key product information (for paediatric)
• Intensive phase (IP) consists of 8 weeks (56 doses) of 1. Dispersible FDC, flavoured
isoniazid (H), rifampicin (R), pyrazinamide (Z) and Rifampicin 75 mg + Isoniazid 50 mg +
ethambutol (E) given under direct observation in daily Pyrazinamide 150 mg
dosages as per weight band categories. Rifampicin 75 mg 4- Isoniazid 50 mg
• Continuation phase (CP), consists of 16 weeks (112 doses) 2. Dispersible Loose drugs
of isoniazid, rifampicin and ethambutol in daily dosages. Ethambutol 100 mg
Only pyrazinamide will be stopped in the continuation Isoniazid 100 mg
phase. The CP may be extended by 12-24 weeks in certain
forms of TB like CNS TB, skeletal TB, disseminated TB etc. Drug dosage for paediatric TB (26)
based on clinical decision of the treating physician on case Weight Number of tablets (dispersible FDCs)
to case basis. Extension beyond 12 weeks should only be category Intensive phase Continuation phase
on recommendation of specialists.
HRZ E HR E
Treatment Treatment 50/75/150 100 50/75 100
Type of TB case regimen in IP regimen in CP
4-7 kg 1 1 1 1
New and previously treated cases 2 HRZE 4 HRE 2
8-11 kg 2 2 2
(H and R sensitive / unknown)
12-15 kg 3 3 3 3
Prefix to the drugs stands for number of months. 16-24 kg 4 4 4 4
Loose drugs could be used as substitutions in case of 25-29 kg 3 + 1A* 3 3 + 1A* 3
adverse drug reaction or with comorbid conditions. 30-39 kg 2 + 2A* 2 2 + 2A* 2
Steroids as an adjunctive therapy is useful in patients * A=Adult FDC (HRZE = 75/150/400/275; HRE = 75/150/275). It is
with TB pericarditis and meningeal TB, with an initial high added in higher weight band categories i.e. > 25 kg as these children
dose tapered downwards gradually over 6-8 weeks. may be able to swallow tablets.
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222 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Change in weight bands to be effective upon crossing of - optimal models of patient support and care; and
weight bands irrespective of the quantum of weight gain/loss. - fully oral regimens should have priority and should
Pyridoxine may be given at a dosage of 10 mg per day to become option for most patients.
all children receiving INH containing therapy irrespective of It needs to be emphasized that treatment for drug resistant
age group. TB should only be provided under the supervision of an
Nikshay entry : Once the treatment regimen is finalized, experienced doctor. This includes the choice of a shorter or
all patients should be initiated on treatment after opening longer regimen, and also whether injectable drugs are used.
the treatment card and entries are done in Nikshay. MO-PHI Accordingly, India has made some changes in its
should ensure that the treatment details are entered in PMDT guidelines. The revised integrated DR-TB diagnostic
Nikshay by the PHI staff. Nikshay entry should not be a algorithm recommends testing of all TB patients for rifampicin
separate activity. All events starting from notification to and isoniazid resistance and all RR-TB patients for
treatment outcome are from Nikshay as it is integrated part fluoroquinolone and second line injectable. Fig. 3 on page 223
of documentation (26).
shows the integrated drug resistant TB algorithm.
Follow-up of the treatment The medicines recommended for longer MDR-TB regimens
There are two components of the follow-up are classified into three groups (A, B and C) based on efficacy,
experience of use and drug class and aligned with revised
a. Clinical follow up : It should be done at monthly interval.
classification as per WHO consolidated guidelines for
Improvement in chest symptoms, increase in weight etc,
treatment of drug resistant TB. The groups are as listed below :
may indicate good prognosis.
b. Laboratory investigations : Sputum smear microscopy Grouping of medicines recommended for use in
should be done at the end of intensive phase and end of longer MDR-TB regimens
treatment. A negative sputum smear at the end of IP
indicate good prognosis. However, in the presence of Groups & steps Medicine
clinical deterioration, the medical officer may consider Group A: levofloxacin OR Lfx
repeating sputum smear microscopy even during Include all three medicines moxifloxacin Mfx
continuation phase. This will provide the patient an early bedaquiline Bdq
opportunity to undergo drug susceptibility testing. At

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linezolid Lzd
completion of the treatment, a sputum smear and/or culture
Group B: clofazimine Cfz
should be done for every patient, as culture is more specific
and sensitive compared to smear microscopy to detect the Add one or both medicines cycloserine OR Cs
terizidone Trd
presence of M. tuberculosis in biological specimens.
Group C: ethambutol E
Long term follow-up at the end of 6, 12, 18, and Add to complete the delamanid Dim
24 months should be done. In presence of any clinical regimen and when pyrazinamide Z
symptoms and /or cough, sputum microscopy and/or culture medicines from Groups A imipenem-cilastatin Ipm-Cln
should be considered (36). and B cannot be used OR meropenem Mpm
2. MANAGEMENT OF DRUG-RESISTANT TB amikacin Am
(OR streptomycin) (S)
Providing treatment to diagnosed DR-TB patients is ethionamide OR Eto
extremely important. To begin with, only MDR-TB patients prothionamide Pto
were offered treatment with a standard second-line regimen. p-aminosalicylic acid PAS
Later, treatment with standard regimen was offered to
extensively drug resistant (XDR) TB patients and MDR-TB Source : (40, 26)
with additional resistance to fluoroquinolones or second-line Inclusion criteria for newer drugs (Bdq/Dlm)
injectable. Procurement and supply chain management of
second-line drugs is complex, since no standardized patient­ - Patient aged >6 years having MDR/RR TB. (Bdq/Dlm can
wise boxes are manufactured and drugs do need be provided to the patient >18 yrs) for children &
temperature regulated storage and repacking. adolescents between 6 to 17 years, Dim can be provided.
Use of Bdq for 6 to 17 yrs and Dim for 3 to
Since 2016, new drugs like Bedaquiline (Bdq) are made
6 yrs may be considered only after approval of DCGI; and
accessible to DR-TB patients through expanded access under
NTEP. In 2016, with the release of the Revised Technical and - patients with controlled stable arrhythmia can be
Operational Guidelines, regimens to treat other forms of considered after obtaining cardiac consultation.
drug resistance, such as mono and poly resistance to first Exclusion criteria for newer drugs (Bdq/Dlm)
and second-line drugs were also included.
- Pregnancy & lactating mother
The new guidelines of 2019 and later on 2020, has
- currently having uncontrolled cardiac arrhythmia that
substantially changed the approach to the treatment of requires medication;
MDR/XDR-TB. It recommends as follows (26) :
- having any of the following QTcF interval characteristics
- policy recommendations on treatment regimens for at screening:
isoniazid resistant TB and multidrug and rifampicin - QTcF >500 at baseline & normal electrolytes, ECG to be
resistant TB (MDR/RR-TB), including longer and shorter repeated after 6 hours and if both ECGs show
regimens; QTcF >500 then the patient should not be challenged
- culture monitoring of patients on treatment; with cardiotoxic drugs.
- the timing of antiretroviral therapy in MDR/RR-TB - history of additional risk factors for Torsade de Pointes,
patients infected with HIV; e.g. heart failure, hypokalaemia, family history of long
- the use of surgery for patients receiving MDR-TB treatment; QT syndrome.
by R△J
 TUBERCULOSIS

Presumptive TB All notified TB patients Non responder to treatment

J6

jr

• PLHIV NAAT* • DSTB

• EPTB • H mono/poly
• Smear-ve/NA with
X-ray suggestive of TB 1------------ --------------1
including paediatric T ±
• Vulnerable populations R resistance detected R resistance not detected
• Contact of DR TB patient
First line treatment

FL LPA
_____________________________________▼_________________
V
Presence of non DST based criteria &/or Resistance to
Lfx/Mfx(h), Km/Cm/Am &/or InhA mutation detected
1 ▼
1
No Unknown H resistance H resistance
___________▼
detected not detected
History of use for > 1 month/intolerance to
Mfx(h), Km, Eto or Cfz
No
___ ▼.-¥ In case of additional resistance,
Shorter failing regimen, drug intolerance, All oral
MDRTB return after interruption (>lm) longer MDR All oral H mono/poly Continue first-line treatment
regimen or emergence of any TB regimen DR TB regimen
exclusion criteria

telegram-@Cherry_2412
Modify regimen
* NAAT include CBNAAT & TruNAAT
LC DST will be done as per the diagnostic algorithm

FIG. 3
Integrated drug resistant TB algorithm (2019)
Source : (26)

Bedaquiline (26) Delamanid (26)

Week 0-2 : Bdq 400 mg (4 tablets of 100 mg) daily All patients >12 yrs of age will receive Tab. Delamanid
(7 days per week) + other drugs; Week 3-24 : Bdq 200 mg 100 mg (two tablets of 50 mg) orally twice a day for
(2 tablets of 100 mg) 3 times per week (with at least 24 weeks in combination with other drugs in the regimen
48 hours between doses) for a total dose of 600 mg per while patients belonging to 6 to 11 yrs of age group will
week + other drugs; and Week 25 (start of month 7) to end receive Tab. Delamanid 50 mg (one tablet of 50 mg) twice a
of treatment: Continue other second-line anti-TB drugs only day for 24 weeks. Remaining drugs in regimen will be
as per NTEP recommendations. continued beyond the 24 weeks of Dim administration for
the NTEP recommended duration of treatment. It is
If taking a light meal with Bdq and other anti-TB drugs,
important that Dim be taken daily preferably after a
patients should not consume milk-containing products at the
standard meal to improve bioavailability.
same time, as the calcium in these can decrease the
absorption of FQs. Also, large fatty meals should be Patients should not consume milk-containing products at
avoided, as these can impair absorption of some of the other the same time, as calcium can decrease the absorption of
anti-TB drugs (Cs, H, etc.). FQs. Also, large fatty meals should be avoided as these
can impair absorption of some of the other anti-TB drugs
The following medications are disallowed during the (Cs, H, etc).
24-week administration of Bdq and upto one month after
the last dose of Bdq because of potential drug-drug Dosage of DR TB drugs
interactions : The dosage for drugs used in various DR TB regimens by
~ systemic use of moderate and strong CYP3A4 inhibitors, weight bands for adults are enumerated in Table 2. These
e.g. azole antifungals: ketoconazole, voriconazole, are in accordance to the WHO recommended doses of
itraconazole, fluconazole; ketolides such as telithromycin anti-TB drugs for adults and paediatric patients.
and macrolide antibiotics other than azithromycin for
more than 2 consecutive weeks; Pretreatment evaluation for drug-resistant
- systemic use of strong CYP3A4 inducers, e.g. phenytoin, patients
carbamazepine, phenobarbital, St. John’s wort and Since the drugs used for the treatment of DR-TB have
rifamycins (rifampin, rifabutin, rifapentine); and significant adverse effects, a pretreatment evaluation is
- cholesterol lowering medications of the “statin” class. essential to identify patients at increased risk of developing
by R△J
224 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

TABLE 2
Dosage of DR TB drugs by weight bands
S.No. Drugs 16-29 kg 30-45 kg 46-70 kg >70 kg
1 Rifampicin (R)1 300 mg 450 mg 600 mg 750 mg
2 High dose H (Hh) 300 mg 600 mg 900 mg 900 mg
3 Ethambutol (E) 400 mg 800 mg 1200 mg 1600 mg
4 Pyrazinamide (Z) 750 mg 1250 mg 1750 mg 2000 mg
5 Levofloxacin (Lfx) 250 mg 750 mg 1000 mg 1000 mg
6 Moxifloxacin (Mfx) 200 mg 400 mg 400 mg 400 mg
7 High dose Mfx (Mfxh) 400 mg 600 mg 800 mg 800 mg
8 Bedaquiline (Bdq) Week 0-2: Bdq 400 mg daily
Week 3-24: Bdq 200 mg 3 times per week
9 Linezolid (Lzd) 300 mg 600 mg 600 mg 600 mg
10 Clofazimine (Cfz) 50 mg 100 mg 100 mg 200 mg
11 Cycloserine (Cs)4 250 mg 500 mg 750 mg 1000 mg
12 Delamanid (Dim) 50 mg twice daily (100 mg) for 24 weeks in 6--11 years of age
100 mg twice daily (200 mg) for 24 weeks for >11 years of age
13 Imipenem/cilastatin (Ipm/CIs)4 1000 mg imipenem/1000 mg cilastatin twice daily
14 Meropenem (Mpm)4 1000 mg three times daily (alternative dosing is 2000 mg twice daily)
15 Amikacin (Am)2 500 mg 750 mg 750 mg 1000 mg
16 Capreomycin (Am)2 - - - -
17 Kanamycin (Km)2 500 mg 750 mg 750 mg 1000 mg
18 Ethionamide (Eto)4 375 mg 500 mg 750 mg 1000 mg
19 Na-PAS (60% weight/vol)3-4 10 gm 14 gm 16 gm 22 gm
20 Amoxyclav (Amx/Clv) (In child: 875/125 mg 875/125 mg 875/125 mg 875/125 mg
WHO 80 mg/kg in 2 divided doses) BD BD (2 morning + 1 evening) (2 morning + 1 evening)

telegram-@Cherry_2412
21 Pyridoxine (Pdx) 50 mg 100 mg 100 mg 100 mg
1 For H mono/poly resistant TB;
2 For adult more than 60 years of age, dose of SLI should be reduced to lOmg/kg (max upto 750 mg)
3 In patient of PAS with 80% weight/volume the dose will be changed to 7.5gm (16—29kg); lOgm (30-45 kg); 12 gm (46-70 kg) and 16 gm (>70 kg)
4 Drugs can be given in divided doses in a day in the event of intolerance

Source : (26)

such adverse effects. This pretreatment evaluation is as Pretreatment evaluation and treatment initiation must be
follows : done at the DR-TBC (Drug-Resistant TB centre) i.e.,
DDR-TBC (District DR-TBC) and NDR-TBC (Nodal
Pretreatment evaluations DR-TBC). The concerned DR-TBC committee provides
1 Detailed history (including screening for mental counselling, initiates activities related to active drug safety
illness, seizure disorder, drug/alcohol abuse, etc.) monitoring (aDSM) like, assessing the baseline history of
2 Previous history of ATT taken especially SLI/FQ known adverse/serious adverse events, biochemical
3 Weight & height investigations, ECG etc., and initiates him/her on an
4 Thorough clinical examination appropriate treatment regimen. Care must be taken
5 Complete blood count with haemoglobin & to correct any electrolyte imbalance before treatment
platelets count
initiation.
6 Blood sugar to screen for Diabetes Mellitus
7 Blood urea and S. Creatinine to assess renal function
Newer treatment regimen
8 Urine examination - routine and microscopic
9 UPT (for all women in the child-bearing age) NTEP provides simplified regimen for various types of
10 Chest X-ray DR-TB including shorter oral Bedaquiline-containing
11 HIV counselling and testing* MDR/RR-TB regimen and longer oral M/XDR-TB regimen
12 Audiogram based on DST/DRT results with scope in difficult patients to
13 Liver function tests* extend Bdq beyond 6 months, combined use of Bdq and
14 TSH levels to assess the thyroid function Dim and Bdq use in pregnancy. As the fully oral regimens
15 Mental health evaluation get scaled up nationwide, the current shorter MDR-TB
16 Surgical evaluation regimen with injectable SLDs will be phased out. Injectable
17 ECG (if Mfxh, Dim, Bdq, Cfz used) SLDs will be available for use under PMDT to substitute oral
18 Serum electrolytes - potassium, magnesium, calcium
SLDs based on DST and ADR. Guidance is also provided for
19 Serum proteins, lipase, amylase
using Bdq for children above 5 years and Dim for children
20 Ophthalmologist opinion to rule out
chorioretinitis/uveitis above 6 years. Use of BPaL regimen consisting of Bdq,
pretomanid (Pa) & linezolid (Lzd) are ongoing in select
All DR-TB patients will be offered referral for HIV counselling and
testing at the nearest centre if the HIV status is not known or HIV test group of patients on a research mode. H mono/poly DR-TB
result is negative with results more than 6 months old. If patient is HIV treatment to be initiated at HF level. To further improve the
positive, refer to ART centre (if not on ART) quality of care offered by the DR-TB centres, difficult-to-treat
# including HBsAg at baseline
TB clinics (DT3C) are established at state and national
Source : (26) levels.
by R△J
 TUBERCULOSIS 225
1. Shorter oral Bedaquiline-containing extrapulmonary forms of disease other than
MDR/RR-TB regimen (41, 42) lymphadenopathy (peripheral nodes or isolated
mediastinal mass without compression);
Following the recommendations of WHO to implement
short oral Bedaquiline-containing MDR/RR-TB regimen, - Pregnant and lactating women; and
Govt, of India decided on transitioning from the current - Children below 5 years.
shorter injectable containing MDR/RR-TB regimen to the The regimen consists of an initial phase of 4 months that
shorter oral Bedaquiline-containing MDR/RR-TB regimen in may be extended up to 6 months and a continuation phase
patients >5 years of age weighing 15 kg or more in a phased of 5 months, giving a total duration of 9-11 months. Bdq is
manner starting with selected states to gain programmatic used for a duration of 6 months.
experience to guide future expansion within 2021. (4-6) Bdq (6m), Lfx, Cfz, Z, E, Hh, Eto (5) Lfx, Cfz, Z, E
Eligibility criteria (41) The composition or the duration of the initial or
continuation phase cannot be changed :
Shorter oral Bedaquiline-containing MDR/RR-TB regimen
is recommended for those MDR/RR-TB patients in whom 1. From start to end of 4th month - Bdq, Lfx, Cfz, Z, E, Hh, Eto;
resistance to the component drugs has been excluded or 2. From start of 5th month to end of 6 th month - (If IP not
those who have not been previously treated for more than extended) - Bdq, Lfx, Cfz, Z, E;
one month with second-line drugs used in shorter oral 3. From start of 7th month to end of 9th month - Lfx, Cfz,
Bedaquiline-containing MDR/RR-TB regimen and have no Z, E; and
other exclusion criteria. The criteria to include or exclude 4. If the IP is extended up to 6 months then all 3 drugs Bdq,
the patients from offering shorter oral Bedaquiline- Hh and Eto are stopped together.
containing MDR/RR-TB regimen are given below.
Treatment extension
Inclusion criteria - Total duration of shorter oral Bedaquiline-containing
1. DST based inclusion criteria MDR/RR-TB regimen is for 9-11 months, depending on
- Rifampicin resistance detected/inferred; IP duration.
- MDR/RR-TB with H resistance detected/inferred based - IP should be given for at least 4 months. After 4th month
on InhA mutation only or based on KatG mutation of treatment, if the result of sputum microscopy is

telegram-@Cherry_2412
only (not both); and negative then CP should be initiated with Bdq continued
- MDR/RR-TB with FQ resistance not detected. for another 2 months.
- If sputum smear microscopy does not become negative
2. Other inclusion criteria by the 4th month of treatment, subject the patient to FL-
- Children, aged 5 years to less than 18 years of age LPA and SL-LPA and culture & DST and the IP should
and weighing at least 15 kg, given their special needs, be extended. IP can be extended to 5th or 6th month
in consultation with the pediatrician; based on smear results at the end of 4th and 5th month
- No history of exposure to previous treatment with of treatment. This will be done for a maximum of 2
second-line medicines in the regimen (Bdq, Lfx, Eto months (i.e., total duration of IP is not more than 6
or Cfz) for more than 1 month (unless susceptibility to months). If any additional resistant to Z/Cfz on C&DST
these medicines is confirmed); of the baseline sample is detected or to FQ/InhA & KatG
- No extensive TB disease; mutation of the 4th month sample is detected, the
- No severe extra-pulmonary TB; and patient needs to be reassessed at N/DDR-TBC for
- Women who are not pregnant or lactating. stopping shorter oral Bedaquiline-containing MDR/RR-
TB regimen and initiation of longer oral M/XDR-TB
Exclusion criteria regimen, immediately on receiving the report.
1. DST based exclusion criteria - Duration of CP is fixed for 5 months.
- MDR/RR-TB patients with H resistance detected with Additional considerations for the use of Bdq
both KatG and InhA mutation; and
- Bdq can be provided to adults and children aged 5 years to
- MDR/RR-TB patients with FQ resistance detected.
less than 18 years of age and weighing at least 15 kg, given
2. Other exclusion criteria their special needs, in consultation with pediatrician;
- If result for FL-LPA, SL-LPA and DST to Z, BDQ & Cfz - Patients with controlled stable arrhythmia can be
is not available after pre-treatment evaluation is considered after obtaining cardiac consultation; and
completed and it is a time to initiate the first dose of - Pregnancy & lactating women.
the regimen, then, exclude those with history of
exposure for > 1 month to Bdq, Lfx, Eto or Cfz; The drug dose administration is as shown in Table 2.
- Intolerance to any drug or risk of toxicity from a drug Shorter injectable containing regimen (41)
in shorter oral Bedaquiline-containing MDR/RR-TB
Till the complete geographical coverage by shorter oral
regimen (e.g. drug-drug interactions);
Bedaquiline-containing MDR/RR-TB regimen, the states will
- Extensive TB disease found in presence of bilateral continue to use shorter injectable containing regimen for
cavitary disease or extensive parenchymal damage on MDR/RR-TB. The regimen composition and duration is as
chest radiography. In children aged under 15 years, follows :
presence of cavities or bilateral disease on chest
radiography; (4-6) Mfxh, Km/Am, Eto, Cfz, Z, Hh, E/ (5) Mfxh, Cfz, Z, E
- Severe EP-TB disease where there is a presence of - If the intensive phase is prolonged, the injectable agent
miliary TB or TB meningitis or central nervous system is only given three times a week in the extended
(CNS) TB. In children aged under 15 years, intensive phase;

by R△J
226 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

- Neither replacement of drug (except the use of Am would be no monthly extensions in this regimen. In patients
instead of Km) nor extension of treatment duration who remain sputum smear positive at the end of month 5 or
(beyond 11 months) is permitted; and later, the treatment outcome will be declared as ‘treatment
- Pyridoxine is to be given as per weight band. failed’ and the patient will be re-evaluated as per the
The drug dose administration is as shown in Table 2. diagnostic algorithm as a non-responder.

Follow-up evaluation of Shorter oral Follow-up evaluation schedule of

Bedaquiline-containing MDR/RR-TB regimen H mono/poly DR-TB patients

Duration 6 or 9 months (no separate IP/CP)

Duration 9-11 months (4-6m IP, 5m CP)
Clinical + Wt. Monthly in IP or extended IP if previous month Clinical + Wt. Monthly till the end of treatment
S+ve, quarterly in CP Smear Monthly from month 3 onwards till the
Smear Monthly from 3rd month onwards till end of IP microscopy end of treatment
Microscopy Monthly in extended IP only if previous month Conduct SM within 7 days, if the smear at
S+ve month 4 or later is positive to rapidly ascertain
Conduct SM within 7 days, if the smear at bacteriological conversion/reversion
6 months is positive to rapidly ascertain Culture At end of month 3, end of treatment
bacteriological conversion/reversion (month 6 and/or 9 if applicable)
Culture At the end of month 3, end of month 6 and/or If the culture results of month 3 are positive,
end of treatment collect one repeat specimen for culture to
If the culture results of month 6 is positive, rapidly ascertain bacteriological conversion/
collect one repeat sample immediately to reversion. If the repeat specimen is culture
rapidly ascertain the bacteriological negative, then ensure specimen collection at
conversion/reversion the end of treatment
If the repeat sample is culture negative, then do
DST NAAT, FL LPA, SL LPA (R, Eto, Lfx, Mfx) and
end of treatment specimen collection
LC DST (Mfx, Z, Lzd & Cfz) if smear/ culture
DST FL-SL LPA (Lfx, Mfx, Eto) and LC&DST +ve at month 3, end of treatment
(Z, Bdq*, Cfz*, Mfx, Lzd, Dim*) if any (month 6 and/or 9 if applicable)
- culture +ve (end of month 3 or later and

telegram-@Cherry_2412
end of treatment) or
3. Longer oral M/XDR-TB treatment regimen (41)
- smear +ve at end of IR end of extended IP
and end of treatment The longer oral M/XDR-TB regimen is as follows :
UPT As and when clinically indicated (18-20) Lfx Bdq (6 raonth or longer) Lzd*Cfz Cs
CBC As and when clinically indicated # dose of Lzd will be tapered to 300 mg after the initial 6-8 months of
TSH & LFT" At end of IP, then as and when clinically treatment
indicated Bdq will be given for 6 months & extended beyond 6 months as an
exception
CXR At end of IP, then as and when clinically
indicated, end of treatment Pyridoxine to be given to all DR-TB patients as per weight band
For Pre-XDR-TB and XDR-TB patients the duration of longer oral
ECG$ At 2 weeks, then monthly in first 6 months, then XDR-TB regimen would be for 20 months with appropriate
as and when clinically indicated modifications.
S. Electrolytes As and when indicated and in case of any
(Na, K, Mg, Ca) QTcF prolongation Once a patient is placed on a longer oral M/XDR-TB
regimen for at least 4 weeks, normally that patient can no
Specialist As and when clinically indicated
consultation longer be switched to the shorter oral Bedaquiline-containing
MDR/RR-TB regimen because this 4-weeks treatment would
Color vision test Once in two months (in children) represent an exposure to second-line medicines.
# HBsAG and other viral markers (Hepatitis A, C & E) to be done in
case of Jaundice. Treatment extension (41)
$ In case of baseline ECG abnormality or QTcF > 450ms with shorter Total duration of longer oral M/XDR-TB regimen is 18-20
oral Bedaquiline-containing MDR/RR-TB regimen that contains
Bdq & Cfz, ECG must be done on daily basis for initial 3 days or as months.
suggested by cardiologist. Repeat ECG with long II lead after an a. After month 6 of treatment, the patient must be reviewed
hour to reconfirm abnormal ECG based on month 5 culture results. If month 5 culture
* DST whenever available result is not available at the end of month 6, decision to
Source : (41) taper the dose of Lzd to 300 mg will be based on month
4 culture result. If the month 5 or 4 culture result
2. H mono/poly DR-TB regimen (41) (whichever applicable) remains positive, the dose of Lzd
H mono/poly DR-TB regimen (R resistance not detected (600 mg) and the regimen is extended by 1 month to
and H resistance detected) under NTEP is as follows : month 7 and for a maximum till month 8 based on
monthly culture results of month 6 and 7 respectively
(6 or 9) Lfx R E Z and clinical/radiographic response. If the month 8
Total duration of H mono/poly DR-TB regimen is 6 culture is also positive, subject the culture isolate to FL-
months. It can be extended directly to 9 months in certain LPA, SL-LPA and C&DST. If any additional resistant to
conditions. In patients with extensive disease; uncontrolled Group A, B or C drugs in use is detected, the patient
comorbidity; extra-pulmonary TB; if smear at the end of needs to be reassessed at N/DDR-TBC for modification
month 4 is found positive and when regimen is modified, the of longer oral M/XDR-TB regimen immediately on
treatment may be directly extended to 9 months. There receiving the report.
by R△J
 TUBERCULOSIS 227
b. The duration of Bedaquiline is limited to 6 months. The most important evidence of response to DR-TB
Extension beyond 6 months is to be considered in treatment is conversion of sputum smear and culture to
patients in whom an effective regimen cannot otherwise negative. Good quality sputum specimen is therefore
be designed if only 2 of 5 drugs are available from essential to get reliable results that form the basis of
Groups A & B and adequate number of Group C drugs monitoring bacteriological response to treatment.
are not available due to high background resistance,
non-availability or unreliability of DST. Treatment Interruptions & DRTB
c. Maximum duration of treatment is not more than Management of DR TB patients with treatment
20 months. A treatment duration of 15-17 months after interruptions and lost to follow-up
culture conversion is suggested for most patients. The All efforts must be made to ensure that DR TB patients do
duration may be modified according to the patient’s not interrupt treatment or are lost to follow-up. Action should
response to treatment. be taken to promptly retrieve patients who fail to come for
The drug dose administration is as shown in Table 2. their daily dose by the treatment supporter. The following
strategies are applicable for patients who interrupt treatment:
Follow up evaluation schedule of longer oral Patients who miss doses : In shorter MDR TB regimen, all
M/XDR-TB regimen during treatment is as follows missed doses during IP must be completed prior to switching
the patient to CP. Similarly, all missed doses during CP must
Duration 18-20 months (no separate IP/CP) be administered prior to ending treatment. In longer MDR
Clinical + Wt. Monthly up to month 6 or 7 or 8 if previous TB regimen, all missed doses during treatment must be
month S+ve administered prior to ending treatment.
Quarterly in from month 7 or 9 onwards
Patients who interrupt treatment for less than one month :
Smear With culture at C&DST lab When the patient returns to resume treatment, the treatment
microscopy Conduct SM within 7 days, if any smear at will be continued. However, the duration of treatment will
6 month or later is positive to rapidly ascertain be extended to complete the regimen. The follow-up
bacteriological conversion/reversion cultures will be done as per the schedule.
C&DST lab to update the result on Nikshay and
inform the concerned field staff of collection Patients who are “lost to follow-up” (interrupt treatment

telegram-@Cherry_2412
center on same day continuously for one month or more) and return back for
treatment: Such patients will be given an outcome of “lost to
Culture Monthly from month 3 onwards to end of
6 months or 7 or 8 if the previous month’s follow-up”. The patient would be subjected to repeat NAAT &
culture is +ve FL/SL LPA and LC DST as per the diagnostic algorithm to
Quarterly month 6 or 7 or 8 onwards based on restart with appropriate treatment. If there are signs of
previous month’s culture results impending treatment failure for any MDR/RR TB patient with
If the culture results of month 6 or any of the or without additional resistance to second line drugs, the
quarterly culture is positive, collect one repeat patient should be switched to an all oral longer DR TB
specimen immediately and send it for culture to regimen and evaluated further to modify appropriately based
rapidly ascertain bacteriological conversion/ on DST results if required. If a patient has received the shorter
reversion and if the repeat specimen is culture MDR TB regimen for more than one month and returns for
negative, then the subsequent quarterly or end
of treatment specimen collection.
treatment after an interruption of one month or more, the
patient is not restarted on a shorter MDR TB regimen.
DST FL & SL-LPA (Lfx, Mfx, Am, Eto) and LC&DST
(Mfx, Lzd, Cfz*, Bdq*, Dim*, Z) if culture +ve MDR/RR TB patients on Bdq/Dlm containing regimen who
at the end of 6 months or any time beyond interrupt treatment or are “lost to follow-up” or recurrent DR TB :
UPT As and when clinically indicated Patients who interrupt Bedaquiline treatment during the first
two weeks of Bdq course and return to resume the treatment:
CBC/platelets" Day 15, monthly in first 6 months, 6 or 7 or 8 if
previous month S+ve, then as and when - if interruption is upto 7 days, Bdq containing regimen
clinically indicated will be continued to complete the doses and the duration
of treatment will be extended to complete IP. Follow-up
TSH & LFT# LFT quarterly, then as and when clinically cultures will be done as per the revised schedule; and
indicated. TSH every 6 months
- if interruption is more than 7 consecutive days, Bdq
CXR At the end of month 6, end of treatment and as course will be reloaded (started afresh) and a fresh
and when clinically indicated specimen collected for culture. The culture isolate must
ECG$ At 2 weeks, monthly in first 6 months and till be stored for Bdq DST in future.
Bdq/Mfx/Cfz/Dlm is extended, then as and Patients who interrupt Bedaquiline treatment during
when clinically indicated. 3-24 weeks of Bdq course and return to resume treatment (26):
S. electrolytes As and when indicated and in case of any - if interruption is upto one month, Bdq containing regimen
(K, Mg, Ca) QTcF prolongation will be continued to complete the doses and duration of
treatment will be extended to complete full course of Bdq.
~ If Lzd is part of the regimen to rule out bone marrow suppression
Follow-up cultures will be done as per revised schedule; and
# HBsAG and other viral markers (Hepatitis A, C & E) to be done
in case of jaundice - if interruption is more than one month, Bdq will be
$ In case of baseline ECG abnormality or QTcF > 450ms with permanently discontinued. Such patients will be given
longer oral M/XDR-TB regimen that contains Bdq, Mfx, Cfz or an outcome of “Lost to follow-up” (LTFU), registered
Dim, ECG must be done on daily basis for initial 3 days or as afresh and initiate all oral longer MDR TB regimen with
suggested by cardiologist. Repeat ECG with long II lead after an appropriate modification. A sputum specimen will be
hour to reconfirm abnormal ECG. collected for culture. The culture isolate must be stored
* DST whenever available. for Bdq DST in future.
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Delam'anid : If the patient misses one or more doses of on : (a) the number of infectious cases; (b) closeness of
Dim during treatment upto a maximum of one month, one contact with an infectious case; (c) the age of child when
should continue the treatment and complete the Dim for rest exposed to TB; and the age structure of the population.
of the period which may prolong the Dim containing phase Children rarely have sputum smear-positive TB and it is
beyond 24 weeks from initiation of treatment to make the unlikely that they are a powerful source of transmission of TB.
adjustment of missed dosage. Tuberculosis in children is mainly due to failure of TB control
Patients who initiated on Bdq/Dlm containing regimen in adults. The risk of infection to a child depends on extent of
and return after treatment interruption of one month or exposure to infectious droplet nuclei. An infant whose mother
more will be declared as “lost to follow-up”. Such patients has sputum smear-positive PTB has a high chance of
would not be considered eligible for administration of same becoming infected. The chance of developing disease is
drug (Bdq/Dlm) anymore. greatest shortly after infection, and steadily decreases as the
time goes by. Because of less-developed immune system,
Where further treatment is concerned, if the patient has any
children under 5 years of age are more prone to develop
indication of a treatment failure or recurrence, the NDR TBC (upto 20 per cent) the disease mostly within 2 years following
Committee will be contacted to discuss whether s/he should be infection (28). The commonest age of childhood TB disease
retreated. The decision will be made on a case-to-case basis, is 1 to 4 years. Young age is a risk factor for spread of disease
using all available bacteriological and clinical data. to other parts of the body, i.e. dissemination.
Providing health education and counselling to patient In order to simplify the management of paediatric TB,
and family members (36) : RNTCP in association with Indian Academy of Paediatrics
(IAP) has described criteria for suspecting TB among children,
All MDR-TB cases are offered referral for counselling and has separate algorithms for diagnosing pulmonary TB and
HIV testing at the nearest centre. Patients should receive peripheral TB lymphadenitis and a strategy for treatment and
counselling on the nature and duration of treatment, need monitoring patients who are on treatment. In brief, TB
for regular treatment and possible side effects of these drugs diagnosis is based on clinical features, smear examination of
and the consequences of irregular treatment or pre-mature sputum where this is available, positive family history,
cessation of treatment and cough etiquette. It is advisable to tuberculin skin testing, chest radiography and histo­
involve close family members during the counselling, since pathological examination as appropriate. The treatment
family support is an essential component in the strategy comprises of components. First, as in adults, children

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management. Patients should be advised to report any side­ with TB are classified, categorized, registered and treated with
effects experienced by them. Female patients should receive daily dose short-course chemotherapy from treatment
special counselling on family planning. initiation to completion, given under direct observation of a
treatment provider (DOT provider) and the disease status is
While the MDR-TB case is undergoing pre-treatment monitored during the course of treatment. Based on their pre­
evaluation, the DTO should ensure an initial home visit to treatment weight, children are assigned to one of the pre­
verify the address and meet the family members. The treatment weight bands and are treated with good quality anti-
medical officer needs to open a treatment card for the patient TB drugs through “ready-to-use” fixed dose combination
at the time of initiating the treatment. Each patient must be tablets in patient-wise boxes containing the patients' complete
given TB Identity Card. A DOT provider (who can either be a course of anti-TB drugs, made available to every registered TB
health care worker or a community volunteer), should be patient according to programme guidelines. India is
identified in consultation with the patient. The DOT centre the first country to introduce paediatric patient-wise boxes (6).
can be either at the sub-centre of the health system or in the
community. The DOT provider should be given training for Diagnosis of Paediatric TB
drug administration, identification of adverse effects during In children with presumptive paediatric TB, every attempt
treatment and the frequency of follow-up. must be made to microbiologically prove diagnosis through
examination of appropriate respiratory/non-respiratory
Monthly patient-wise box for DR-TB patients (41) specimens with quality assured diagnostic tests. Diagnosis of
The district drug store will supply the monthly patient­ tuberculosis should not be made only on clinical features,
wise boxes as per standard regimens. The shorter oral MDR/ and further investigations are always necessary to establish
the diagnosis.
RR TB regimen will have two types of boxes - type A for
intensive phase and type B for continuation phase. The In case of suspicion of pulmonary TB, sputum
longer oral M/XDR-TB regimen and H mono/poly DR-TB examination should be carried out among children who are
regimen will standard patient-wise box as there is no able to give good quality specimens. CBNAAT is the preferred
separate intensive and continuation phase. The DR-TB investigation of choice. If CBNAAT is not readily available or
patients on longer/shorter injectable containing regimen will testing is not possible even by referral, smear microscopy
be supplied drugs continuously till the state/districts fully should be performed. If M. tuberculosis is detected, by either
transitions to all oral regimen. of methods patient is diagnosed as microbiologically
confirmed pulmonary TB. In situations where M. tubeculosis
is not detected or specimen is not available, chest X-ray and
CHILDHOOD TUBERCULOSIS Tuberculin skin test (TST) by Mantoux technique using 2 TU
Cases of tuberculosis in children usually represent of PPD RT 23 should be done. For interpretation and further
between 6-8 per cent of all reported tuberculosis in the age course of action, refer to the diagnostic algorithm for
childhood pulmonary TB (Fig. 4).
group of under 15 years, although the estimates are about
11 per cent cases are in children (43). The source of While following the flow chart, it is important to note the
infection to a child is usually an adult, often a family following points :
member with sputum smear-positive tuberculosis. The 1. This algorithm is for children who are likely to have drug
frequency of childhood TB in a given population depends sensitive disease i.e. have not received ATT previously
by R△J
 TUBERCULOSIS 229
Persistent Fever > 2 weeks, without a known cause and/or
Unremitting cough for > 2 weeks and/or
Wt loss of 5% in 3 months or no wt gain in past 3 months h/o contact

Chest X-Ray
1
L
CXR highly CXR NS shadows/NA CXR Normal
suggestive Skin test +ve/NA Skin test +ve

J.
Expectorated sputum/
▼
Give course of
'T
Evaluate for EPTB
Microbiologically
confirmed TB case GA/IS for CBNAAT Antibiotics Refer to expert

CBNAAT CBNAAT-ve CBNAAT-ve Persistent shadow

+ ve Skin test + ve Skin test - ve and symptoms

Look for
J
Expectorated sputum/
alternate cause GA/IS fo CBNAAT

No other likely alternative diagnosis CBNAAT - ve &

clinically diagnosed TB case Skin test 4- ve

CBNAAT CBNAAT - ve & Refer to expert for work-up

+ ve Skin test - ve > of persistent pneumonia

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FIG. 4
Diagnostic algorithm for paediatric pulmonary tuberculosis
Source : (39)

ever and are not presumptive drug resistant TB cases 10. Whenever Rif resistant result is reported on CBNAAT
(lost to follow-up, recurrent, treatment failure, HIV). further management should be carried out as per the
2. Proper characterization of symptoms is very important guidelines on drug resistant TB.
starting point. Weight loss or not gaining weight should
always be documented with appropriate and proper TB preventive therapy :
weighing. The dose of INH for chemoprophylaxis is 10 mg/kg
3. Where CBNAAT is doable, smear examination may not (instead of earlier recommended dosage of 5 mg/kg)
be done. Whenever smear is used for diagnosis at least administered daily for 6 months. TB preventive therapy
2 samples should be sent while a single sample is should be provided to:
subjected to CBNAAT. If a specimen is positive by any of
a. All asymptomatic contacts (under 6 years of age) of a
these methods, the disease is labelled as
smear positive case, after ruling out active disease and
microbiologically confirmed TB.
irrespective of their BCG or nutritional status.
4. Highly suggestive chest X-ray refers to skiagrams
showing either miliary or lymphadenopathy (hilar or b. Chemoprophylaxis is also recommended for all HIV
mediastinal) or chronic fibro-cavitatory shadows. If the infected children who either had a known exposure to an
radiological picture is highly suggestive of TB, then infectious TB case or are tuberculin skin test (TST) positive
proceed to do further investigations irrespective of the (>5 mm induration) but have no active TB disease.
TST result as the sensitivity of the test is not 100%. c. All TST positive children who are receiving
5. Non specific chest X-ray : Refer to patterns other than immunosuppressive therapy (e.g. children with nephrotic
highly suggestive like consolidations in homogenous syndrome, acute leukemia, etc).
shadows or bronchopneumonia, etc. d. A child born to mother, who was diagnosed to have TB
6. Whenever indicated, alternative specimens (gastric in pregnancy, should receive prophylaxis for 6 months,
aspirate/induced sputum/bronchoalveolar lavage) should provided congenital TB has been ruled out followed by
be collected by a skilled health care provider, depending BCG vaccination.
upon available infrastructure and sample should be
subjected to CBNAAT. Drug-resistant TB in children:
7. Antibiotics like linezolid or any quinolone or Amoxicillin- The principles of treatment of drug-resistant TB in
clavulanic acid should not be used as they have anti-TB children are : (1) Always treat the child in consultation with
action. an expert; (2) Include at least 4-6 bactericidal medication to
8. Children with persistent symptoms, non specific shadows which the strain is known to or likely to be susceptible;
and negative smears and negative other samples (GA/IS) (3) Do not add a single drug to a failing regimen; (4) Ensure
by CBNAAT should be referred to experts for further treatment is given for at least 12 months after M. tuberculosis
work-up of persistent pneumonia. culture has converted to negative; and extend treatment to
9. All TB cases diagnosed must be offered testing for HIV. 24 months in case of HIV infection or cavitatory lesions.

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The children are managed with regimen designs without In 2021, the number of female patients screened for
newer drugs, depending on the DST pattern. The dosage for pregnancy was 47,185, out of which 4,048 were pregnant.
drugs used in various DR-TB regimens by weight bands for Before initiating treatment for tuberculosis, women of
paediatric DR-TB patients are enumerated in Table 3 (44). childbearing age should be asked about current or planned
TABLE 3 pregnancy and counselled appropriately. A successful
WHO recommended doses of treatment of TB is important for successful outcome of
anti TB drugs for paediatric patients pregnancy. With the exception of streptomycin, the first line
anti-TB drugs are safe for use in pregnancy. Streptomycin is oto­
Drugs Daily Dose (Paediatric) toxic to the foetus and should not be used during pregnancy.
Isoniazid 1 7-15 mg/kg for patients less than 30 kg; A breast feeding woman should receive a full course of
max dose 300 mg daily TB treatment. Correct chemotherapy is the best way to
Rifampicin 10-20 mg/kg for patients less than 30 kg; prevent transmission of TB to baby. Breast feeding has to be
max dose 600 mg daily
30-40 mg/kg for patients less than 30 kg;
continued. After ruling out active TB, the baby should be
Pyrazinamide
max dose 2000 mg daily given 6 months of isoniazid preventive therapy, followed by
Ethambutol 15-25 mg/kg once daily BCG vaccination. Breast-feeding should not be discouraged.
Levofloxacm 5 years and under : 15-20 mg/kg split into The mother should be advised about cough hygiene
two doses (morning and evening) measures such as covering the nose and mouth while
Over 5 years: 10-15 mg/kg once daily coughing, sneezing or any act which can produce sputum
Moxifloxacin 7.5-10 mg/kg droplets. Mothers receiving INH and their breastfed infants
Ethionamide/ 15-20 mg/kg should be supplemented with vitamin B6 (pyridoxine).
Protionamide Recommended dose of Pyridoxine in infants is 5 mg/day.
Cycloserine 10-20 mg/kg
p-aminosalicylic 200-300 mg/kg for patients
acid less than 30 kg Pregnancy with MDR-TB
Linezolid 10 mg/kg given three times daily All MDR-TB suspects and patients of child-bearing age
(pyridoxine should also be given) should be tested for pregnancy as part of pre-treatment
Clofazimine Limited data, but 1 mg/kg once evaluation and while on treatment, if there is a history of
daily has been given amenorrhoea of any duration. They should be advised to
Amoxicillin 80 mg/kg (based on the amoxicillin
use birth control measures because of the potential risk to

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clavulanic acid 7/1 component) in two divided doses
Kanamycin 15-30 mg/kg once daily (Max 1000 mg) both mother and foetus. Oral contraceptives should be
Amikacin 15-30 mg/kg once daily (Max 1000 mg) avoided. Use of barrier methods (condoms/diaphragms),
Capreomycin 15-30 mg/kg once daily (Max 1000 mg) IUDs are recommended, based on individual preference and
Imipenem cilastatin Meropenem is preferred in children eligibility. The management of MDR-TB patients with
Meropenem 20-40 mg/kg intravenous every pregnancy is summarized in Fig. 5.
eight hours
Bedaquiline Refer to page 223
Refer to page 223 Duration of pregnancy
Delamanid
1Children at risk for peripheral neuropathy (e.g. malnutrition or
HIV co-infection) should also receive pyridoxine 5-10 mg/day as
therapeutic dose. < 20 weeks* > 20 weeks*
Source : (44)
—4
TB IN PREGNANCY AND LACTATING Advise MTP Pt unwilling for MTP
WOMEN (36) V___
While the burden of TB is higher in men in India, the MTP done > 32 weeks < 32 weeks
impact of TB in women is far-reaching, especially for women Consultative decision between
in the reproductive age group (15-49 years). Due to common . Obstetrician and Physician
non-specific symptoms in both TB and pregnancy, diagnosing 'IF V
TB disease in pregnant women is complex. TB in pregnancy
Start/continue shorter oral Start/continue longer oral
has a wide spectrum of short and long-term implications and Bedaquiline-containmg Bedaquiline-containing
could have sequential effects : repeated reproductive failure, MDR/RR-TB regimen* M/XDR-TB regimen@
foetal ill-health, preterm delivery, and TB of the new-borns
and infants, leading to high maternal and perinatal morbidity * 24 weeks will apply wherever the bill is passed.
and mortality. For example, there is a six-fold increase in # Regimen : 4-6 Bdq (6m) Lfx, Cfz, Eto, Hh, Z, E / 5 Lfx, Cfz, Z, E.
No modifications allowed.
perinatal deaths and a two-fold risk of premature birth and
@ Regimen : 18-20 Lfx, Bdq (6m or longer) Lzd#, Cfz, Cs. Lzd dose
low birth weight in mothers with active TB disease. to be tapered to half after 6-8 months based on bacteriological
The NTEP and the Maternal Health (MH) division have response. Modify regimen if one or more drug cannot be used
developed a collaborative framework for management of TB in due to reasons of resistance, tolerability, contraindication,
pregnant women to reduce morbidity and mortality due to TB availability etc.
- in the order of Z E PAS.
in pregnant women and new-borns through prevention,
- Eto may be considered after 32 weeks' gestation.
screening for early detection, and prompt management of TB in - Am may be considered in post-partum period only. Am will
pregnant women and achieve optimum maternal and perinatal not be started in the final 12 months of treatment.
outcomes. This screening for TB will be made an essential
component of ANC services. The National-level sensitization FIG. 5
workshop for all the state nodal officers of both the programmes Management of MDR-TB patients during pregnancy
has been conducted, and the training will be cascaded (43). Source : (41)

by R△J
 TUBERCULOSIS 231
Pregnant DR-TB patients need to be monitored carefully, dose (0.1 ml) in some of them might penetrate into deeper
both in relation to the treatment and progress of the tissue and give rise to local abscess formation and enlarged
pregnancy. This approach should lead to good results, since regional (axillary) lymph nodes.
the patient should be smear-negative at the time of (5) ADMINISTRATION : The standard procedure
parturition and mother and infant do not need to be recommended by WHO is to inject the vaccine intradermally
separated. Breast-feeding should be encouraged as long as using a “Tuberculin” syringe (Omega microstat syringe fitted
the patient is sputum negative. with a 1 cm steel 26 gauge intradermal needle). The syringe
In the end it may be stated that the main problem of and needle technique remains the most precise way of
chemotherapy today is not the need to introduce new administering the desired dose. All other techniques
regimens or more potent drugs, but to apply the existing (e.g., bifurcated needle, dermo-jet) are reported to be less
ones successfully. The cornerstone of successful accurate, and do not permit the desired dose to be injected
chemotherapy is adequate and regular drug intake. Patient (48). If the vaccine is injected subcutaneously an abscess is
compliance is critically important throughout the prescribed more likely to develop (49). The site of injection should be
period of treatment. All other considerations are secondary. just above the insertion of the left deltoid muscle. If it is
injected too high, too forward or too backward, the adjacent
BCG VACCINATION lymph nodes may become involved and tender. A
satisfactory injection should produce a wheal of 5 mm in
Ever since Koch discovered M. tuberculosis, attempts diameter.
have been made to prepare a prophylactic vaccine against The vaccine must not be contaminated with an antiseptic
tuberculosis using either attenuated or killed tubercle bacilli. or detergent. If alcohol is used to swab the skin, it must be
Initially BCG was given orally during 1921 to 1925. The first allowed to evaporate before the vaccine is given.
human was vaccinated by the intradermal technique in
1927. Recognition of the value of BCG came in 1948 when (6) AGE : The national vaccination policies differ from
it was accepted by tuberculosis workers from all over the country to country (47). In countries where tuberculosis is
world as a safe preventive measure. prevalent and the risk of childhood infection is high (as in
India), the national policy is to administer BCG very early in
(1) AIM : The aim of BCG vaccination is to induce a infancy either at birth (for institutional deliveries) or at
benign, artificial primary infection which will stimulate an 6 weeks of age simultaneously with other immunizing agents
acquired resistance to possible subsequent infection with

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such as DPT and polio. BCG administered early in life provides
virulent tubercle bacilli, and thus reduce the morbidity and a high level of protection, particularly against the severe forms
mortality from primary tuberculosis among those most at of childhood tuberculosis and tuberculous meningitis.
risk.
In countries with a low prevalence of tuberculosis,
(2) VACCINE : BCG is the only widely used live bacterial perhaps there is a diminishing need for widespread BCG
vaccine. It consists of living bacteria derived from an vaccination. In this situation, it would seem reasonable to
attenuated bovine strain of tubercle bacilli. The bacilli used restrict BCG vaccination to high risk groups, for example,
for vaccine production are descendants of the original hospital personnel and tuberculin-negative contacts of
Calmette strain of BCG. Due to different methods of known cases of tuberculosis particularly multi-drug resistant
maintenance in various vaccine-production laboratories, TB (MDR-TB) (46, 50).
many substrains have evolved during the past few decades.
The WHO has recommended the “Danish 1331” strain for (7) PHENOMENA AFTER VACCINATION : Two to three
the production of BCG vaccine. Since January 1967, the weeks after a correct intradermal injection of a potent vaccine,
BCG Laboratory at Guindy, Chennai, has been using the a papule develops at the site of vaccination. It increases slowly
“Danish 1331” strain for the production of BCG vaccine in size and reaches a diameter of about 4 to 8 mm in about
(45). Emphasis has been laid on regular checking of the 5 weeks. It then subsides or breaks into a shallow ulcer, rarely
quality of vaccines at the International Reference Centre for open, but usually seen covered with a crust. Healing occurs
BCG quality control at Copenhagen. spontaneously within 6 to 12 weeks leaving a permanent, tiny,
round scar, typically 4-8 mm in diameter. This is a normal
(3) TYPES OF VACCINE : There are two types of BCG reaction (51). However, with overdosage, the local lesion and
vaccine - the liquid (fresh) vaccine and the freeze-dried the later scar may be considerably larger and of irregular size.
vaccine. Freeze-dried vaccine is a more stable preparation Normally the individual becomes Mantoux-positive after a
than liquid vaccine with vastly superior keeping qualities. period of 8 weeks has elapsed, but sometimes about 14 weeks
Present-day vaccines are distributed in the freeze-dried form. are needed.
BCG vaccine is stable for several weeks at ambient (8) COMPLICATIONS : BCG has been associated with
temperature in a tropical climate, and for up to 1 year if kept adverse reactions which include : prolonged severe
away from direct light and stored in a cool environment ulceration at the site of vaccination, suppurative
preferably refrigerated at a temperature below 10 deg C (46). lymphadenitis, osteomyelitis, disseminated BCG infection
The vaccine must be protected from exposure to light and death. Ulceration and lymphadenitis occurs in
during storage (wrapped up in a double layer of red or black 1-10 per cent of vaccinations, and disseminated infection
cloth) and in the field. Normal saline is recommended as a occurs in less than one per million vaccinations. The
diluent for reconstituting the vaccine, as distilled water may disseminated infection is usually associated with severe
cause irritation. The reconstituted vaccine may be used up abnormalities of cellular immunity. The risk of adverse
within 3 hours, and the left-over vaccine should be discarded. reactions is related to the BCG strain used by different
(4) DOSAGE : For vaccination, the usual strength is manufacturers, the dose, the age of the child, the method of
0.1 mg in 0.1 ml volume (47). The dose to newborn aged immunization and the skill of the vaccinator (52).
below 4 weeks is 0.05 ml. This is because the skin of If there is a local abscess formation, it should be treated by
newborn is rather thin and an intradermal injection with full aspiration, in case it does not clear spontaneously. If this is

by R△J
232 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

not successful, it should be incised and treated with local to resort to direct BCG at a later date, when the benefits of
applications daily with PAS or INH powder. There is no need BCG are doubtful as shown by the South Indian trial (63).
for systemic treatment with INH. The patient should be (13) IMPACT : BCG vaccination is less effective in
assured of the harmless nature of the lesion (53). In order to controlling tuberculosis as compared to active case-finding
avoid these complications, the vaccination should be strictly and chemotherapy, as BCG offers only partial protection. In
intradermal and no other injection should be given for at least 1982, a WHO Expert Committee (64) concluded that
6 months into the arm which received BCG vaccine (54). although BCG vaccination of uninfected individuals (usually
(9) PROTECTIVE VALUE : The duration of protection is children) can prevent tuberculosis in them, it can have only
from 15 to 20 years. The local BCG infection generates an a relatively small epidemiological effect in that it will not
immunity response, which is associated with the development contribute significantly to the reduction in the overall risk of
of tuberculin hypersensitivity and with it, possibly, some infection in the community as a whole.
immunity. The first prospective control trial of BCG showed it to (14) BCG VACCINATION AND HIV INFECTION :
be 80 per cent effective over an observation period of 20 years Following a review of relevant data, the Global Advisory
(55). Since then several well-planned, controlled trials have Committee on Vaccine Safety (GACVS) has revised its
been conducted in various parts of the world, including the previous recommendations concerning BCG vaccination of
“Tuberculosis Prevention Trial” in South India (56, 57). children infected with HIV.
Studies have shown that the range of protection offered by WHO had previously recommended that in countries with a
BCG varied from 0 to 80 per cent in different parts of the world. high burden of TB, a single dose of BCG vaccine should be
The full explanation for the varying degrees of protection has given to all healthy infants as soon as possible after birth unless
yet to be found (58, 59). One suggestion for which there is an the child presented with symptomatic HIV infection. However,
increasing epidemiological support, is that prior exposure to evidence shows that children who were HIV-infected, when
some non-tuberculous environmental mycobacteria (e.g., vaccinated with BCG at birth, and who later developed AIDS,
M. vaccae, M. non-chromogenicum) may have conferred were at an increased risk of developing disseminated BCG
partial immunity on the population and thus masked the disease. Among these children, the benefits of potentially
potential benefit of BCG vaccination (60). There is also preventing severe TB are out weighted by the risks associated
evidence that exposure to other species (e.g., M. kansasii, with the use of BCG vaccine. GACVS, therefore, advised WHO
M. scrofulaceus) have an antagonistic action against BCG (55). to change its recommendation such that children who are
This may be one reason why BCG was not found to be known to be HIV-infected, even if asymptomatic, should no

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protective in the South Indian trial (51). However, infants and longer be immunized with BCG vaccine (65). However,
young children, BCG-vaccinated before they had contact with population with high prevalence of HIV also have the greatest
environmental mycobacteria, derived protection. burden of TB, and in such populations, uninfected children will
There is a large body of evidence which supports the benefit from the use of BCG vaccine. Furthermore, with the
conclusion that BCG gives an appreciable degree of increasing range and coverage of interventions to prevent
protection against childhood tuberculosis (61). The WHO, vertical transmission from mother to child - including early
on the basis of an extended review of BCG including the diagonsis of maternal HIV infections; management of sexually
South Indian trial (62) holds that it would seem transmitted infections; safe delivery practices; maternal and
unreasonable to stop current BCG vaccination programmes infant preventive antiretroviral medicines or maternal
(59) and recommends that the use of BCG should be antiretroviral therapy; and safe infant feeding - the majority of
continued as an antituberculosis measure (62). infants born to HIV-infected mothers are not infected and
would also be expected to benefit from BCG vaccination (65).
(10) REVACCINATION : The duration of protection
Unfortunately, accurate diagnosis of HIV infection in the
conferred by BCG is a matter of dispute. Even 90 years after
first year of life relies upon direct demonstration of the HIV
the development of the vaccine, it is not known whether virus, as maternal HIV antibody is passively transferred to
booster doses are indicated or advisable. In fact, BCG the infant in utero. Currently available assays that can be
revaccination has not been included in the official used to diagnose HIV in the first year of life are expensive
immunization schedule in India under the expanded and technically demanding in many countries with
programme on immunization. generalized HIV epidemics. WHO recommends that these
(11) CONTRAINDICATIONS : Unless specifically tests are first performed at or around 6 weeks age, yet this is
indicated, BCG should not be given to patients suffering from often after BCG vaccination has already been given (66).
generalized eczema, infective dermatosis, (15) COMBINED VACCINATION : BCG may be given at
hypogammaglobulinaemia, to those with a history of the same time as oral polio vaccine. DPT vaccine may also
deficient immunity (symptomatic HIV infection, known or be given at the same time as BCG, but in different arm
suspected congenital immunodeficiency, leukaemia, without reducing the immune responses or increasing the
lymphoma or generalized malignant diseases), patients under rate of complications (56). Mixed vaccines containing BCG
immunosuppressive treatment (corticosteroids, alkylating have not yet been introduced.
agents, antimetabolites, radiation), and in pregnancy. The
An increasing number of industrialized countries are
effect of BCG may be exaggerated in these patients.
likely to reconsider their BCG vaccination policy during the
(12) DIRECT BCG VACCINATION : Direct BCG coming years. To change from general to selective BCG
vaccination, i.e., vaccination without a prior tuberculin test, vaccination, an efficient notification system must be in place
has been adopted as a national policy in many developing in addition to the following “low endemicity” criteria : (a) an
countries, including India. It permits a more rapid and average annual notification rate of smear-positive
complete coverage of the eligible population, while reducing pulmonary TB cases below 5 per 100,000; or (b) an average
the cost. No adverse effects have been reported even if BCG annual notification rate of tubercular meningitis in children
is given to tuberculin-positive reactors (51). However, it is aged under five years, below 1 per 10 million population
sound practice to administer BCG during infancy before the during the previous five years; or (c) an average annual risk
child has had contact with environmental mycobacteria, than of tuberculosis infection below 0.1 per cent (66)

by R△J
 TUBERCULOSIS
233
To sum up, BCG vaccination is a fundamental component of Recommended regimens (68)
a national tuberculosis programme. Despite the contradictory Currently the following three regimens are recommended:
evidence of controlled trials, there is evidence that BCG plays a
valuable role in preventing severe forms of childhood - Isoniazid daily or twice weekly for nine months
tuberculosis, viz. meningitis and miliary tuberculosis. Today, - Isoniazid plus rifapentine once weekly for 12 weeks
BCG vaccination is part of WHO Expanded Programme on - Rifampicin (or rifabutin) daily for 4 months (with this
Immunization. The greatest need for BCG vaccination today is regimen dots must be used)
undoubtedly in the developing countries of the world where The WHO also recommends two other regimens of 3 or
tuberculosis is still a major health problem. 4 months of isoniazid plus rifampicin daily, and six months of
isoniazid daily. In 2019 the results were reported of
LATENT TB INFECTION 2 clinical trials looking specifically at side effects. An important
Persons with latent tuberculosis infection are infected problem limiting the treatment of latent TB infection is the
with M. tuberculosis, but do not have TB disease. The only occurrence of adverse events with isoniazid. Therefore, it was
sign of TB infection is a positive reaction to the tuberculin recommended that in patients without contraindications,
skin test or IGRA TB blood test. They are not infectious and rifampicin is likely to be the safest TB infection treatment option.
cannot spread TB infection to others. Overall, without
treatment, about 5-10 per cent of infected persons will Rehabilitation
develop TB disease at some time in their lives. About half of In recent years, there has been a good deal of fresh
those people who develop TB will do so within the first two thinking on the subject of rehabilitation, because of the
years of infection. For persons whose immune systems are success achieved in treating patients on domiciliary lines
weak, especially those with HIV infection, the risk of without interfering with their normal work and life. The
developing TB disease is considerably higher than for proportion of patients who need rehabilitation and work
persons with normal immune systems. Of special concern under sheltered conditions is becoming less and less. The
are persons infected by someone with extensively drug­ groups that need rehabilitation are those who are chronically
resistant TB (XDR TB) who later develop TB disease, these ill and are still excreting tubercle bacilli. Some of those who
persons will have XDR TB, not regular TB disease. had lung resection may require rehabilitation to suit their
A person with latent TB infection has a skin test or blood test physical and mental abilities.
result indicating TB infection; has a normal chest X-ray and a Surveillance

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negative sputum test; has TB bacteria in the body that are alive,
Surveillance is an integral part of any effective
but inactive; does not feel sick, cannot spread TB bacteria to
tuberculosis programme. It should be concerned with two
others; needs treatment for latent TB infection to prevent TB
distinct aspects : (a) surveillance of the tuberculosis situation,
disease. However, if infected by a person with MDR TB or XDR
for example, by measuring the “annual infection rates”
TB, preventive treatment may not be an option (67). which will guide the epidemiologist and health administrator
Health care interventions by indicating whether the TB problem is static, increasing or
decreasing; (b) surveillance of control measures applied such
Currently, three major categories of health care as BCG vaccination and chemotherapy.
interventions are available for TB prevention :
1. TB preventive treatment; Role of hospitals
2. prevention of transmission of TB infection through Inspite of effective domiciliary treatment services, there
infection prevention and control; and will always be some patients who will be needing
3. vaccination of children with BCG vaccine. hospitalization. The main indications for hospitalization are :
(a) emergencies such as massive haemoptysis and
Latent tuberculosis treatment (68) spontaneous pneumothorax (b) surgical treatment
It is not recommended that everyone with latent TB (c) management of serious types of tuberculosis such as
infection (LTBI) should have TB treatment. Rather it is meningeal tuberculosis, and (d) certain social indications,
recommended that certain “target” groups should receive such as when there is no one to look after the patient at home.
treatment. The main “target” groups considered to be most DRUG RESISTANCE
at risk for progressing from latent to active TB include
people in low TB burden countries : All drugs used in the treatment of tuberculosis tend to
produce resistant strains. The resistance may be of two
- who have had recent contact with an infectious patient; types : (a) PRIMARY OR PRE-TREATMENT RESISTANCE :
- with silicosis; It is the resistance shown by the bacteria in a patient, who has
- infected with both TB and HIV; not received the drug in question before. That this is not
- who have been or who are in prison; always due to infection of the individual with drug-resistant
- who are immigrants to a low burden country from a high bacilli, is well known. It is an accepted fact that when the bacilli
burden country; are rapidly multiplying, resistant mutants appear irrespective
- who are homeless; of the administration of any particular drug. According to one
hypothesis, drug resistance is induced by transference
- who are an illicit drug user;
through what are called “episomes”. Episomes are non-
- who have certain clinical conditions, or conditions which chromosomal heritable genes which can pass from one
compromise their immune system, such as people with bacterial cell to another. If there is a direct contact between the
diabetes, and people with chronic renal failure. cell containing episomes, the episomes leave the resistant cell
In high TB burden countries the populations that are and invade susceptible cells (69). (b) SECONDARY OR
most strongly recommended for the treatment of latent TB ACQUIRED RESISTANCE : Here the bacteria were sensitive
infection are people living with HIV, and children under-five, to the drug at the start of the treatment but became resistant to
who are household contacts of pulmonary TB cases. the particular drug during the course of treatment with it.

by R△J
234 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Drug resistance means that certain strains of tuberculosis necessary to prevent transmission, especially to health
bacilli are not killed by the anti-tuberculosis drugs given workers caring for MDR tuberculosis patients (71).
during the treatment. Some strains can be resistant to one or The emergence of XDR-TB and high case fatality rate in
more drugs. patients with HIV infection was the subject of an emergency
consultations held in Johannesburg on 7-8 September, 2006.
Definitions The issues included strengthening treatment adherence to
Please refer to page 210 for classification of cases based achieve high levels of completion (> 85 per cent) for all TB
on drug resistance. patients ensuring that second line drugs used to treat MDR-TB
and XDR-TB are strictly controlled and properly used
Causes of drug-resistant tuberculosis (27) according to WHO guidelines. The steps required to limit the
Drug-resistant TB has microbial, clinical and programmatic impact of MDR-TB and XDR-TB were identified and
causes. From a microbiological perspective, the resistance is incorporated into a 7-point plan of action (72).
caused by a genetic mutation that makes a drug ineffective In the short term, countries should:
against the mutant bacilli. An inadequate or poorly 1. develop national emergency response plans for MDR-
administered treatment regimen allows drug-resistant mutants TB and XDR-TB and ensure that basic TB control
to become the dominant strain in a patient infected with TB. measures meet international standards for TB care
Table 4 summarizes the common causes of inadequate and are fully implemented;
treatment. However it should be stressed that MDR-TB is man­
made phenomenon - poor treatment, poor drugs and poor 2. conduct rapid surveys of MDR-TB and XDR-TB using
adherence lead to the development of MDR-TB. a standardized protocol to assess the geographical and
temporal distribution of XDR-TB in vulnerable
In all countries and especially those where the number of populations;
cases of tuberculosis is rising rapidly because of the 3. strengthen and expand national TB laboratory
association with HIV, the development of resistant strains of capacity by addressing all aspects of laboratory
tuberculosis is a serious concern. In 2016, about 0.60 million procedures and managment;
people worldwide, are estimated to be infected with strains
4. implement infection control precautions in health-care
of drug resistant tuberculosis. An accurate picture of drug
facilities according to WHO guidelines, with special
resistance is not available because few countries have a
emphasis on those facilities providing care for people
reliable drug resistance surveillance system (5).
living with HIV/AIDS.

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It is estimated that primary MDR-TB in India is around
In the long term, countries should:
2.8 per cent. The drug resistance in re-treatment cases is
12 (10-13) per cent. Although the level of MDR-TB in the 5. establish capacity for clinical and public health
country is low in relation to percentage and proportion, it managers to respond effectively to MDR-TB and
translates into large absolute numbers (70). XDR-TB;
XDR-TB has been reported in India by isolated studies 6. promote universal access to antiretroviral therapy for
with non-representative and highly selected clinical samples. all TB patients through close collaboration with
The magnitude of the problem remains to be determined treatment and care programmes for people living with
due to the absence of laboratories capable of conducting HIV/AIDS;
quality assured second line drug susceptibility test (12). 7. support and increase funding for research into the
development of new anti-tuberculosis drugs and rapid
It has been observed that resistance to isoniazid alone diagnostic tests for MDR-TB and XDR-TB.
does not affect the results of treatment so much, if proper
regimens for treatment or retreatment are prescribed, but Prevention of Drug Resistance : Since incomplete,
simultaneous resistance to isoniazid and rifampicin limits inadequate and irregular treatment is the main cause of drug
severely the results of the treatment. resistance, this can be prevented by (a) treatment with two
or more drugs in combination (b) using drugs to which the
The most serious danger of MDR Tuberculosis is that it is bacteria are sensitive, and (c) ensuring that the treatment is
much more difficult to treat, even where second line drugs complete, adequate and regular.
are available. Treatment of MDR tuberculosis can take at
least two years and the results are poor. Second line drugs Please refer to page 222 for details of guidelines about
cost 30 times as much as drugs used in SCC treatment of management of MDR and XDR-TB.
non-resistant tuberculosis patients. Patients with MDR
tuberculosis may need to be hospitalised and isolated which Tuberculosis and comorbidities
adds to the cost of treatment, to prevent transmission of Several medical conditions are risk factors for TB and
primary resistant strains to others. Careful precautions are poor TB treatment outcomes. Similarly TB can complicate
TABLE 4
Causes of inadequate treatment
Providers/programmes : Drugs: Patients:
inadequate regimens inadequate supply/quality inadequate drug intake
- Absence of guidelines or - Non-availability of certain drugs - Poor adherence
inappropriate guidelines (stock-outs or delivery disruptions) (or poor DOT)
- Non-compliance with guidelines - Poor quality - Lack of information
- Inadequate training of health staff - Poor storage conditions - Non-availability of free drugs
No monitoring of treatment - Wrong dosages or combination - Social and economic barriers
- Poorly organized or funded TB - Malabsorption
control programmes - Substance abuse disorders

by R△J
 TUBERCULOSIS 235
course of some diseases. It is therefore important to identify identify patients with presumptive TB; strengthen
these comorbidities in people diagnosed with TB in order to intensified case finding at ART, Link ART centre and
ensure early detection and improved outcome. targeted intervention projects for high risk group
specially injection drug users; female sex workers and
TUBERCULOSIS AND HIV men having sex with men etc. and offering upfront
CBNAAT among presumptive TB cases among PLHIV.
Worldwide the number of people infected with both HIV b. Early detection and care of HIV infected drug-resistant
and tuberculosis is rising. The HIV virus damages the body’s TB patients by strengthening HIV testing in presumptive
natural defences - the immune system - and accelerates the DR-TB cases; ensure access to culture and drug
speed at which tuberculosis progresses from a harmless susceptibility test for HIV infected TB patients, prompt
infection to life-threatening condition. The estimated 10 per linkage of HIV infected DR-TB cases to ART centres, and
cent activation of dormant tuberculosis infection over the life prompt initiation of ART in HIV infected DR-TB cases.
span of an infected person, is increased to 10 per cent
c. Strengthen HIV/TB activities among children and
activation in one year, if HIV infection is superimposed.
pregnant women.
Tuberculosis is already the opportunistic infection that most
frequently kills HIV-positive people. In most people in the early stages of HIV infection,
symptoms of tuberculosis are similar as in people without
Even in HIV positive cases, tuberculosis can be cured if
HIV infection. In areas where many people have HIV
diagnosed in time and treated properly. Good TB control
infection, tuberculosis programmes should continue to focus
programme is the best thing that can be done to cure and
on identifying infectious sputum-smear-positive cases
extend the lives of HIV positive individuals. With correct TB through microscopy. However, diagnosis of tuberculosis in
treatment, the HIV positive person having tuberculosis can
individual patients using the standard diagnostic tools can be
gain, on an average two additional years of life (73). more difficult if they have advanced HIV infection because :
Epidemiological impact (a) HIV positive people with pulmonary tuberculosis may
have a higher frequency of negative sputum smears.
HIV and tuberculosis interact in several ways (71) : Confirming the diagnosis may require sputum culture.
1. Reactivation of latent infection : People who are (b) The tuberculin skin test often fails to work in people
infected with both tuberculosis and HIV, are 25-30 times who are HIV positive because it relies on measuring the
more likely to develop tuberculosis disease, than people response of a person’s immune system. If the immune

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infected only with tuberculosis. This is because HIV stops system has been damaged by HIV, it may not respond even
the immune system working effectively and tuberculosis though the person is infected with tuberculosis. HIV positive
bacilli are able to multiply rapidly. In developing countries people with tuberculosis, therefore, have a higher frequency
HIV associated tubercular disease is very common. of false negative tuberculin skin test results.
2. Primary infection : People with HIV are at risk of being (c) Chest radiography may be less useful in people with
newly infected, if they are exposed to tuberculosis because HIV because they have less cavitation. Cavities usually
their weakened immune system makes them more develop because the immune response to the tubercular
vulnerable. New tubercular infection in people with HIV can bacilli leads to some destruction of lung tissue. In people with
progress to active disease very quickly. HIV, who do not have a fully functioning immune system,
3. Recurring infection : People with HIV who have been there is less tissue destruction and hence less lung cavitation.
cured of tuberculosis infection may be more at risk of (d) Cases of extra-pulmonary tuberculosis seem to be
developing tuberculosis again. However, it is not clear more common in people who are co-infected.
whether this is because of reinfection or relapse. In short-screen for tuberculosis using sputum smear
4. In the community : There are more new cases of active microscopy, if the result is positive, start treatment; if the
tuberculosis because more people infected with tuberculosis result is negative, but it is suspected that the patient has
develop active disease, and those newly infected become ill tuberculosis, sputum culture should be carried out where
faster. This means that there are more people in the community feasible to confirm the diagnosis and give treatment to those
who are infectious to others. Larger number of people with with positive culture results.
active disease mean more people will die from tuberculosis Treatment for HIV infected TB patients
unless they are treated. The association of tuberculosis with
HIV means that people suffer additional discrimination. Based on the clinical history and investigation reports ART
Community education is needed to increase awareness that medical officer will categorize patients as rifampicin sensitive/
tuberculosis is curable and, most important, that people are no rifampicin sensitivity status not known/clinically diagnosed
longer infectious after the first few weeks of treatment. TB case, prior history of taking anti-TB drugs (Cat I/Cat II),
and initiate daily anti TB treatment in Fixed Dosage
Diagnosis of tuberculosis in people with HIV Combination as per RNTCP guidelines at ART centre itself.
The treatment of HIV positive individual with MDR-TB is
The salient features are as follows (36) : same as for HIV negative patients. However, treament is more
1. Emphasis on integrated TB and HIV services, eg., HIV difficult and adverse events more common, hence rigorous
screening at RNTCP designated microscopy centre. monitoring in this particular group of patients is required in
2. Focus on early detection and early care. order to ensure adherence to treatment, early detection and
a. Early detection of TB in PLHIV (persons living with treatment of adverse events reduce “lost to follow-up” (36).
H1V/AIDS) : Early suspicion of TB-symptoms of any ART must be offered to all patients with HIV and TB and
duration among PLHIV; use of an expanded clinical HIV and MDR-TB, irrespective of CD4 cell count. Start anti­
algorithm for TB screening that relies on presence of tuberculosis treatment first and then start ART as soon as TB
four clinical symptoms (current cough, weight loss, treatment is tolerated (between 2 weeks and 2 months). In
fever or night sweats) instead of only cough, to the absence of ART, TB treatment alone does not

by R△J
236 _ EPIDEMIOLOGY OF COMMUNICABLE DISEASES
significantly increase the CD4 cell count, nor does it It is suggested that all people with TB should be screened
significantly decrease the HIV viral load. The use of Highly for diabetes and screening for TB in diabetes should be
Active Anti-Retroviral Therapy (HAART) in patients with TB considered, particularly in setting with high TB prevalence.
can lead to a sustained reduction in the HIV viral load. It can People with diabetes and TB have a high risk of death
also facilitate immunological reconstitution, and decrease during TB treatment and of TB relapse after treatment. As
AIDS - defining illness and mortality. This benefit is seen diabetes is complicated by presence of other infectious
across different range of CD4 counts. diseases also, it is important to take proper care of diabetes
In addition to TB treatment, all HIV-infected TB patients in patients suffering from diabetes/TB (74).
must be provided access to care and support for HIV disease, National framework for joint TB-diabetes collaborative
including co-trimoxazole preventive therapy to reduce activities are as follows (36) :
mortality among PLHIV by preventing opportunistic infections. a. Activities to improve diagnosis and management of
Immune reconstitution inflammatory syndrome (IRIS) : diabetes among TB patients :
- screening of all registered TB patients for diabetes
Occasionally, patients with HIV-related TB may mellitus.
experience a temporary exacerbation of symptoms, signs of - ensuring diabetes mellitus management among TB
radiographic manifestations of TB after beginning TB patients.
treatment. This paradoxical reaction occurs in HIV-infected b. Activities to improve diagnosis and management of TB
patients with active TB and is thought to be a result of among diabetic patients :
immune restitution due to the simultaneous administration
- Intensified detection of active TB disease among
of antiretroviral and tuberculosis medication. Symptoms and
diabetic patients.
signs may include high fever, lymphadenopathy, expanding
- Ensuring TB infection control measures in health
intra-thoracic lesions and worsening of chest radiographic
care settings where diabetes mellitus is managed.
findings. The diagnosis of paradoxical reaction should be
made only after a thorough evaluation has excluded other - Ensuring TB treatment and management in comorbid
aetiologies, particularly TB treatment failure. For severe patients.
paradoxical reactions prednisone (1—2 mg/kg for 1-2 weeks, c. Joint monitoring and evaluation.
then gradually decreasing doses) may be used (36). d. TB patients diagnosed with diabetes should receive the
same duration of TB treatment with daily regimen as
Isoniazid preventive therapy for PLHIVs non-diabetic patients.

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Isoniazid preventive therapy (IPT) is one of the 3-I’s
globally recommended for prevention of incident TB among TB AND TOBACCO (36)
HIV infected individuals. It is the most effective bactericidal, Tobacco smoke contains toxic chemicals which cause
anti TB drug available currently. While it protects against disturbances in the bronchial surface of the lung. It also weakens
progression of latent TB infection to active disease the immunity of the patient to fight with TB bacteria. The
i.e reactivation, it also prevents TB reinfection in persons following evidence emerges from several studies conducted to
who are exposed to open TB cases. look at the association of TB and tobacco in India :
All children living with HIV who have completed treatment - Almost 38% of TB deaths are associated with the use of
for TB successfully should receive INH for an additional six tobacco.
months. These children who do not have poor weight gain, - Prevalence of TB is 3 times as high among ever-smokers
fever or cough currently, are unlikely to have active TB. as compared to that of among never-smokers.
Those who have above symptoms may have TB and should - Mortality from TB is 3 to 4 times as high among ever­
be evaluated for TB and other conditions. If evaluation shows smokers as compared to that among never-smokers.
no TB, such children should be offered IPT regardless of their - Smoking contributes to half the male deaths in 25-69
age. Children living with HIV who are more than 12 months age groups from TB in India.
of age and who are unlikely to have active TB on symptom­
based screening, and have no contact with a TB case should Exposure to tobacco smoke has also been found to affect
receive six months of IPT (10 mg/kg/day) as part of a TB in the following ways :
comprehensive package of HIV prevention and care services. - Increase the risk of tuberculous infection and the risk of
Providing IPT to people living with HIV does not increase developing TB.
risk of developing INH resistant TB later. Therefore, concern - Affect clinical manifestations and increase risk of relapse
regarding development on INH resistance should not be a among TB patients.
barrier to providing IPT (36). - Affect microbiological conversion (sputum smear or
culture) and outcome of treatment in TB patients.
For details regarding HIV and TB co-activities please refer
- Increase tuberculosis mortality and drug resistance to
to chapter 7 also.
anti-tubercular drugs.
TUBERCULOSIS AND DIABETES When a patient gets registered as a TB case, the status of
Diabetes has been shown to be an independent risk factor tobacco use is recorded in the TB treatment card. He/she is
for tuberculosis in community based study from south India advised to quit tobacco use with 5 R’s : Relevance of
and multiple studies globally. It is suggested that diabetes quitting; Risk of continuing; Reward of quitting; Roadblock
accounts for 20 per cent of all tuberculosis and 10 per cent of to quitting; and Repeat at each visit.
smear positive TB (36). People with weak immune system as
in diabetes are at higher risk of progressing from latent to TUBERCULOSIS AND COVID-19 (1)
active tuberculosis. The risk is 2-3 times higher than people Since the beginning of 2020, the COVID-19 pandemic has
without diabetes. A large proportion of people with diabetes caused enormous health, social and economic impacts, which
and TB are diagnosed very late. are likely to continue. Even after some of these impacts have

by R△J
 TUBERCULOSIS 237
been mitigated or contained, there will be medium- and longer- THE END TB STRATEGY
term consequences, including for the tuberculosis (TB)
epidemic and response. The pandemic threatens to reverse the Measured by the number of people who die each year due
progress made towards global TB targets. Although physical to tuberculosis, it is the deadliest infectious disease. It claims
distancing policies may help to reduce TB transmission, this 3 lives every minute. Of the 9 million people who become ill
effect could be offset by longer durations of infectiousness, with TB each year, more than 3 million are not diagnosed,
increased household exposure to TB infection, worsening treated or officially registered by national TB programmes.
treatment outcomes and higher levels of poverty. In the absence Collectively, these “missed” millions are a global public
of effective mitigation strategies, such as social protection and health failure. This is especially the case considering that TB
health insurance, severe economic contractions and loss of is airborne and that each undiagnosed and untreated person
income (particularly among the most vulnerable populations) can infect as many as 15 individuals per year. Moreover, TB
are likely to worsen some of the factors that determine TB continues to be leading cause of death among people living
epidemics, especially the prevalence of undernutrition. with HIV. Likewise drug resistant TB poses a grave challenge.
The newer scientific evidence available on TB and COVID- Many of history’s greatest successes in the fight against
19 suggests that TB is a comorbidity for COVID-19 and preventable diseases have been characterized by momentous
impacts its progression and severity and vice versa. Hence as shift in peoples belief of what is possible. A paradigm shift is
an effort to ensure early detection and timely and effective needed now - a change in the way we fight TB at every level, in
every community, in every health facility, in every country (75).
management of TB and COVID-19, the following
The global resolve for intensifying the fight against TB and
recommendations have been approved and are under process
achieving an end to the global epidemic is illustrated by
of being shared with the states in the form of a guidance
adoption of WHO’s End TB Strategy by World Health Assembly
document on “TB & COVID-19 screening and follow up.”
and the inclusion of “ending the TB epidemic” as a target within
• Screening patients with a history of TB in the past two the health related Sustainable Development Goal 3 by the
years for COVID-19 at a six-monthly interval as post­ United Nations General Assembly in September 2015.
treatment follow-up for two years. For CO VID testing,
modalities like home-based kits/ Rapid Antigen test/ RT- Evolution of End TB Strategy (76)
PCR may be utilized. The End TB Strategy, developed in the context of the UN
• Screening for TB among post COVID-19 patients at six- Sustainable Development Goals, is a logical evolution and a

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monthly intervals for two years. paradigm shift from past global TB strategies. The DOTS
- COVID-19 patients with active TB to be managed as strategy of 1994 helped revitalize national tuberculosis
per protocols programmes and equivalent entities by putting in place the
- If cough persists after 2-3 weeks, to be tested for TB essential basics to address the TB epidemic. The stop TB
strategy of 2006 broadened the response by addressing the
- Follow up COVID-19 patients post-treatment and
emerging challenges of HIV associated TB and MDR-TB. It
periodically screen for TB
aimed to improve access to quality TB care by engaging all
While the COVID-19 pandemic has had an adverse impact public and private care providers, civil society organizations
on the overall case finding of TB, it also presented us with many and communities. The stop TB strategy also encouraged
opportunities. Utilizing this opportunity in areas like lab investment in research for better tools and approaches. The
strengthening - platform technology, surveillance, End TB Strategy encompasses a package of interventions that
strengthening of currently existing treatment centres, further can be fully adopted at country level. It has ten components
expansion of the network, and airborne infection control organized under 3 pillars and four underlying principles.
measures will play an important role in ending TB by 2025 (43). Fig. 6 summarizes the evolution of WHO global TB strategies.

THE DOTS STRATEGY ◄--------

1. Government commitment
2 Case detection through predominantly
passive case finding.
3. Standardized short-course chemotherapy to at least
all confirmed sputum smear positive cases of TB
under proper case management conditions.
4. Establishment of a system for regular drug supply of > THE STOP TB STRATEGY
all essential anti-TB drugs. 1. Pursue high-quality DOTS expansion and
5. Establishment and maintenance of a monitoring enhancement.
system, for both programme supervision and 2. Address TB/HIV, MDR-TB and
evaluation. other challenges.
3. Contribute to health system strengthening.
4. Engage al! care providers.
THE END TB STRATEGY <— 5. Empower people with TB and communities.
1. Integrated, patient-centred care and prevention. 6. Enable and promote research.
2. Bold policies and supportive systems.
3. Intensified research and innovation.
FIG. 6
Evolution of WHO Global TB Strategies.
Source : (76)
by R△J
238 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Through the implementation of the DOTS strategy (1994- thriving as long as poverty persists. The End TB strategy,
2005) and the Stop TB Strategy (2006-2015), countries - whose aim is to end the TB epidemic, therefore combines a
especially those with a high burden of TB - established the holistic mix of health and social interventions.
basics required for providing high-quality TB diagnosis and The strategy envisions universal access to high-quality TB
treatment. These efforts contributed greatly to meeting the care and goes beyond it to promote TB prevention. Ending
TB-related target of the Millennium Development Goals the TB epidemic will also require new tools - a point-of-care
(MDGs) of halting and beginning to reverse the TB epidemic. test for diagnosing infection and disease; shorter and better
Between year 2000 and 2014, improvements in quality­ regimens to treat disease and infection; and ideally, a pre
assured diagnosis and treatment of TB contributed to saving and post-exposure vaccine.
43 million lives worldwide. It was apparent, however, that
while enhancing access to diagnosis and treatment The End TB Strategy identifies four barriers to achieving
remarkably improved outcomes in terms of reducing progress in the fight against TB. They are : (1) weak health
suffering and death, it had very little effect on achieving the system; (2) underlying determinants of TB such as poverty,
desired impact in terms of declining the incidence rates and undernutrition, migration and ageing population and risk
driving down the TB epidemic. This is not entirely surprising: factors such as diabetes, silicosis and smoking; (3) lack of
TB is not only a biomedical and a public health problem but effective tools; and (4) continuous unmet-funding needs.
also a disease associated with poverty; TB will continue The strategy is summarized as below :

END TB STRATEGY
VISION A world free of tuberculosis-zero deaths; disease and suffering due to tuberculosis.
GOAL End the global tuberculosis epidemic.
INDICATORS MILESTONES TARGETS
2020 2025 SDG 2030 End TB 2035
Reduction in number of
TB deaths compared 35% 75% 90% 95%
with 2015 (%)

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Reduction in TB incidence 20% 50% 80% 90%
rate compared with 2015 (%) (<85/100 000) (<55/100 000) (<20/100 000) (<10/100 000)
TB-affected families
facing catastrophic costs zero zero zero zero
due to TB (%)
PRINCIPLES 1. Government stewardship and accountability, with monitoring and evaluation.
2. Strong coalition with civil society organizations and communities.
3. Protection and promotion of human rights, ethics and equity.
4. Adaptation of the strategy and targets at country level, with global collaboration.
PILLARS AND COMPONENTS
1. Integrated, A. Early diagnosis of tuberculosis including universal drug-susceptibility testing, and systematic
patient-centred care screening of contacts and high-risk groups.
and prevention B. Treatment of all people with tuberculosis including drug-resistant tuberculosis, and patient support.
C. Collaborative tuberculosis/HIV activities, and management of co-morbidities.
D. Preventive treatment of persons at high risk and vaccination against tuberculosis.
2. Bold policies and A. Political commitment with adequate resources for tuberculosis care and prevention.
supportive systems B. Engagement of communities, civil society organizations, and public and private care providers.
C. Universal health coverage policy, and regulatory frameworks for case notification, vital registration,
quality and rational use of medicines, and infection control.
D. Social protection, poverty alleviation and actions on other determinants of tuberculosis.
3. Intensified research A. Discovery, development and rapid uptake of new tools, interventions and strategies.
and innovation B. Research to optimize implementation and impact, and promote innovations.

Source : (75)

The Global Plan’s targets are designed as 90-90-90 targets (75).

Reach at least As a part of this approach, Achieve at least

reach at least

90% 90% 90%

of all people of the key Treatment
with TB populations success
and place all of them on the most vulnerable, for all people diagnosed with TB
appropriate therapy- underserved, through affordable treatment services,
first-line, second-line and at-risk populations adherence to complete and correct
preventive therapy as required treatment, and social support.

by R△J
 TUBERCULOSIS

Key Population Groups (75) 7. WHO (2015), Health in 2015, From MDGs (Millennium Development
Goals) to SDGs (Sustainable Development Goals).
The Global Plan defines “Key populations” as people 8. WHO (2016), Fact Sheet No. 104, March 2016.
who are vulnerable, underserved or at-risk of TB infection 9. WHO (2022), Teams/Global-Tuberculosis Programme/data, 28.9.2022.
and illness. For purpose of the global plan, three key 10. Govt, of India (2020), India TB Report 2020, National Tuberculosis
Elimination Programme Annual Report, 2020.
population groups are further expanded as shown below, 11. Govt, of India (2010), TB India 2010, RNTCP Status Report, Central
along with examples of population within these groups. It is TB Division, Ministry of Health and Family Welfare, New Delhi.
important to note that people who are likely to fall into one 12. Govt, of India (2008), TB India 2008, RNTCP Status Report, I am
of these categories are also likely to be part of one or both of stopping TB, Ministry of Health and Family Welfare, New Delhi.
the other groups. 13. WHO (2014), Standards for TB care in India.
14. WHO (2016), Global Tuberculosis Report 2016.
Key Populations for TB (75) 15. WHO (1974). Techn. Rep. Ser., No.552.
16. Styblo K. (1976). Int. J. Epi. 5 : 63.
People who Prisoners, sex workers, miners, hospital visitors,
17. WHO (1981). Wkly Epi Rec., 56 (50) 393-400.
have health care workers and community health
Increased workers. 18. WHO (1967). WHO Chronicle, 21 :156.
exposure PEOPLE WHO : 19. WHO (2013), Definitions and Reporting Framework for Tuberculosis-
to TB • live in urban slums 2013 revision.
due to where • live in poorly ventilated or dusty conditions 20. Youmans, G.P. et al (1980). The Biological and Clinical Basis of
they • are contacts of TB patients, including children Infectious Diseases, 2nd ed, Saunders.
live or work • work in environments that are overcrowded 21. Gangadharan, P.R.J. (1980). Ind. J. Tuberculosis, 27 (3) 108.
• work in hospitals or are health care 22. Pamra, S.P (1976), Ind. J. Tuberculosis, 23, No.2 Supplement.
professionals. 23. American Thoracic Society (1976) Ann Rev, of Resp. Disease
People who Migrant workers, women in settings with gender 114:459.
have limited disparity, children, refugees or internally 24. Comstock. G.W. (1978). Am. Rev. Res. Dis.. 117 : 621.
access to displaced people, illegal miners, and 25. Govt, of India (2021), India TB Report, 2021, National Tuberculosis
quality TB undocumented migrants Elimination Programme Annual Report, Central TB Division.
Services PEOPLE WHO : 26. Govt, of India (2020), Training Modules for Programme Managers and
• are from tribal populations or indigenous Medical Officers, National TB Elimination Programme, Central TB
groups Division, New Delhi.

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• are homeless 27. Govt, of India (2012), Guidelines on Programmatic Management of
• live in hard-to-reach areas Drug Resistant TB in India, Ministry of Health and Family Welfare,
• live in homes for the elderly New Delhi.
• have mental or physical disabilities 28. WHO (2004), TB/HIV, A Clinical Manual, 2nd Ed.
• face legal barriers to access care 29. WHO (2010), Policy Framework for Implementing New Tuberculosis
• are lesbian, gay, bisxeual or transgender. Diagnostics, March 2010.
People at PEOPLE WHO: 30. Reichman, L.B. and Me Donald R.J. (1977). Med. Clin. N.A. Nov.
1977, p.1185.
increased risk • live with HIV
of TB because • have diabetes or silicosis 31. Maxine, A, Papadakis, Stephen J., Mcphee (2014), Current Medical
of biological or • undergo immunosuppressive therapy Diagnosis and Treatment, 2014 Ed., Lange Publication.
behavioural • are undernourished 32. CDC Fact Sheet for Parents.
factors that • use tobacco 33. TB Facts.ORG (2020), Information about tuberculosis tests for
compromise • suffer from alcohol-use disorders TB-Sputum microscopy, skin test, IGRAs.
immune function • inject drugs. 34. WHO (1980). WHO Chronicle, 34 : 101.
35. Toman, K. (1979). Tuberculosis : Case finding and Chemotherapy,
UN General Assembly Political Declaration Questions and Answers, WHO, Geneva.
36. Govt, of India (2016), Revised National TB Control Programme
Please refer to page 208 for details. Technical and Operational Guidelines for Tuberculosis Control in
India, 2016, Ministry of Health and Family Welfare, New Delhi.
Despite effective case-finding and therapeutic tools and
37. RNTCP (2018), India TB Report 2018, Annual Status Report, DGHS,
declines in mortality, and morbidity rates in some countries, Ministry of Health and Family Welfare, New Delhi.
tuberculosis appears to continue as an important 38. Govt, of India (2010), DOTS - Plus Guidelines, Jan 2010, Ministry of
communicable disease problem, worldwide, for several Health and Family Welfare, New Delhi.
decades to come. The chronic nature of the disease, the 39. Govt, of India (2020), Training modules (1-4) for Programme
ability of the tubercle bacilli to remain alive in the human Managers and Medical Officers, NTER Central TB Division, Ministry of
body for years, the concentration of the disease in the older Health and Family Welfare, New Delhi.
age-groups, the increased expectation of life, the high 40. WHO (2019). Consolidated guidelines on drug resistant TB treatment,
2019.
prevalence of infection rates in some countries, the relatively 41. Govt, of India (2021), Guidelines for Programmatic Management of
high reactivation rate, the emergence of drug-resistant Drug Resistant Tuberculosis in India, March 2021, NTEP, Ministry of
strains, association of tuberculosis and HIV infection, and Health and Family Welfare, New Delhi.
above all, the perpetuation of the “non-specific 42. WHO (2020). Operational handbook on tuberculosis, Module 4,
determinants” of the disease in the third world countries Treatment, Drug resistant tuberculosis treatment.
impede a rapid conquest of the disease. 43. Govt, of India (2022), India TB Report 2022, Coming together to End
TB altogether, Ministry of Health and Family Welfare, New Delhi.
References 44. RNTCP (2017), Guidelines on Programmatic Management of drug­
resistant tuberculosis in India, 2017.
1. WHO (2020), Global Tuberculosis Report 2020. 45. Suri, J.C. etal (1971). Ind. J. Tuberculosis, 18 : 48.
2. WHO (2004), Weekly Epidemiological Record, 23rd Jan 2004, No. 4. 46. Snell, N.J.C. (1985). P.G. Doctor Middle East April 1985, 1232.
3. WHO (2021), Global Tuberculosis Report, 2021. 47. WHO (1980). Tech.Rep Ser., No. 651.
4. WHO (2022), Weekly Epidemiological Record, No. 28,15th July 2022. 48. WHO (1976). The Work of WHO Annual Rep. of the Director General
5. WHO (2018), Global Tuberculosis Report 2018. for 1975, p. 73.
6. Govt, of India (2014), TB India 2014, RNTCP Annual Status Report, 49. Humphrey, J.H. et al (1970). Immunology for Students of Medicine,
DGHS, Ministry of Health and Family Welfare, New Delhi. Blackwell.
by R△J
240 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

50. WHO (1982). Tech. Rep. Ser. No. 652. poliomyelitis globally. Since then, implementation of the
51. Dam, H.G.T. etal (1976) Bull WHO, 54 (3) 255. eradication strategies has reduced the number of polio
52. Galazka, A.M. etai (1984). W.H. Forum 5 (3) 269. endemic countries from more than 125 in 1988 to 2 in 2021.
53. Any Questions (1981). Brit. Med.J. 282 : 1305, 18 April 1981. A total of 5 cases of wild poliovirus were reported globally in
54. Banker, D.D. (1969). Modern Practice in Immunization. Indian 2021. Afghanistan reported 4 cases and Pakistan reported 1
Journal of Medical Sciences, Mumbai.
case. All the reported cases are of typel wild poliovirus (1,2).
55. Aronson, J.D. etal (1958) Archieves of Int. Med. 101 : 881.
India was certified as polio free since 27th March 2014.
56. WHO (1979). Bull WHO, 57 (5) 819-827.
57. Tuberculosis Prevention Trial, Madras (1979). Ind. J. Med. Res., Since the 1988 World Health Assembly resolution to
70:349-363. eradicate poliomyelitis, transmission of all the 3 types of
58. Baily, G.V.J. (1981). Ind. J. Tuberculosis, 28 (3) 117. wild poliovirus (WPV) has been greately reduced. WPV type
59. WHO (1980). WHO Chronicle, 34 : 119. 2 has not been detected since 1999 and was declared
60. Gangadharan, PR. (1981) Tubercle 62 : 223. eradicated in September 2015. Given that WPV type3 has
61. Wijsmuller, G. (1971). Bull WHO 45 : 633. not been detected since November 2012, WPV type 1 is
62. Dam, H.G.T and Hitze, K.L. (1980). Bull WHO, 58 : 37. likely to be the sole WPV remaining in circulation. This
63. WHO (1980). Techn Rep Ser., No.652. marked progress has been achieved through widespread use
64. WHO (1982), Tech. Rep. Ser. No. 671. of trivalent oral polio vaccine (tOPV). The attenuated
65. WHO (2007), Weekly Epidemiological Record No. 21, May 25, 2007.
polioviruses in OPV can undergo genetic changes during
66. WHO (2004), Weekly Epidemiological Record, No. 4,23rd Jan. 2004.
replication, and in communities with low vaccination
67. CDC (2014), Centre for Disease Control and Prevention -
Tuberculosis : Fact Sheet, Oct. 2014. coverage, rarely, results in vaccine derived polioviruses
68. TB Facts.ORG (2020), Information about tuberculosis, Jan. 2020. (VDPV) that can cause paralytic polio indistinguishable from
69. Pamra, S.P (1976). Ind. J. Chest Dis and allied Sciences, 23 : 152. the disease caused by WPV (3). Eliminating the risk of polio
70. WHO, Tuberculosis Control in South-East Asia Region, Regional caused by VDPVs requires stopping of all OPV use.
Report, 2017. Recognizing the epidemiological opportunity, a new Polio
71. AIDS Action, Asia - Pacific edition, The international newsletter on HIV/ Eradication and Endgame Strategic Plan 2013-2018 was
AIDS prevention and cure, AHRTAG Issue 30, January - March 1996. developed. The plan was to eradicate all types of polio
72. WHO (2006), Weekly Epidemiological Record, No. 41,13th Oct. 2006 disease simultaneously - both due to WPV and VDPV.
73. WHO (1996) TB Groups At Risk, WHO Report on the Tuberculosis
Epidemic, Geneva. Polio Eradication and Endgame Strategic Plan

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74. WHO (2011), Tuberculosis and diabetes, The stop TB Department,
Sept 2011. The Polio Eradication and Endgame Strategic Plan
75. StopTB Partnership, UNOPS (2015), The Paradigm shift 2016-2020, 2013-2018 represents a major milestone in polio eradication
Global Plan to End TB. and describes specific steps to take to successfully achieve
76. WHO (2015), Implementing the End TB Strategy: the Essentials. eradication. The plan has four objectives as summarized
in Fig. 1.
II. INTESTINAL INFECTIONS Under this endgame plan to achieve and sustain a polio-
free world, the use of oral polio vaccine (OPV) must
POLIOMYELITIS eventually be stopped worldwide, starting with OPV that
contains type 2 poliovirus (OPV type 2). At least one dose of
inactivated polio vaccine (IPV) must be introduced as a risk
Poliomyelitis is an acute viral infection caused by an RNA mitigation measure. The steps involved are (5) :
virus. It is primarily an infection of the human alimentary
tract but the virus may infect the central nervous system in a 1. By end 2015, introduce at least 1 dose of IPV into all routine
very small percentage (about 1 per cent) of cases resulting in immunization systems, at least 6 months before the switch
varying degrees of paralysis, and possibly death. from trivalent oral polio vaccine (tOPV) to bivalent oral
polio vaccine (bOPV, containing types 1 and 3 poliovirus).
Problem statement 2. During 2016, switch from tOPV to bOPV, which does not
In the pre-vaccination era, poliomyelitis was found in all contain type 2 virus, in routine immunization and polio
countries of the world. The extensive use of polio vaccines campaigns, as before that bOPV was only licensed for
since 1954 eliminated the disease in developed countries. use in SIAs.
In 1988, the World Health Assembly resolved to eradicate 3. Plan for the eventual withdrawal of all OPV.

2013 2014 2015 2016 2017 2018

1. Virus detection Wild virus
and interruption interruption Outbreak response

2. RI strengthening Routine immunization strengthening

and OPV withdrawal IPV introduction Switch to bOPV Withdraw OPV
3. Containment and Finalize long-term Contain poliovirus and certify
certification containment plans interruption of transmission

4. Legacy planning Consultation Mainstream polio functions,

infrastructure and learnings

FIG. 1
The time-bound endgame objectives
Source : (4)

by R△J
 _______________________________ POLIOMYELITIS 241
The first stage of OPV withdrawal involved a global permanently interrupt all poliovirus transmission in the final
synchronized cessation of tOPV use between 18th April and wild polio virus endemic countries of Afghanistan and
1st May 2016, replacing tOPV with bOPV containing only Pakistan, and to stop circulating vaccine-derived poliovirus
type 1 and 3 poliovirus and withdrawing OPV type 2 from transmission and prevent outbreaks in non-endemic
all immunization activities called “the Switch”. Once countries (2).
switch is made, tOPV will no longer be used anywhere in the
world and manufacturers will no longer supply tOPV (3, 6). Fractional dose IPV
The tOPV to bOPV switch is necessary because no WPV As an alternative to the full dose intramuscular injection
type 2 has been recorded since 1999. The risk of vaccine of IPV, countries may consider using fractional dose of IPV
associated paralytic poliomyelitis and cVDPV to type 2 (FIPV) via intradermal route. Studies have demonstrated
component of OPV now out weighs its benefits. Replacing that 2 FIPV doses intradermally at 6th and 14th weeks
the tOPV with bOPV is key to ensuring the eradication of provide higher seroconversion rates than a single full dose of
type 2 poliovirus. The switch will serve as a dry run for IPV given intramuscularly at 14 weeks. Table 1 shows
withdrawal of other type of OPV It needed IPV to be comparison between IPV full dose and FIPV.
introduced on an accelerated timeline i.e. by end of 2015,
so that OPV2 can be withdrawn. Introducing atleast one TABLE 1
dose of IPV will ensure that a substantial proportion of the Comparing IPV and FIPV
population is protected against type 2 serotype. It will also
IPV Fractional IPV (flPV)
boost immunity to the remaining type 1 and 3 serotypes. It
will mitigate paralysis risks in case of outbreak by priming Volume per dose 0.5 mL 0 1 mL
the population against type 2 poliovirus and ensure better
Schedule 1 dose : 14 weeks 2 doses : 6 and 14 weeks
immune response to OPV if needed. IPV introduction sets
the stage for ending OPV use entirely in 2019-2020 (5). Administration Intramuscular (IM) Intradermal (ID)
injection injection
In the endgame, polio eradication activities and
strengthening routine immunization can be mutually Site of Thigh Upper arm
administration
beneficial as : (1) IPV will be introduced through routine
immunization delivery systems; (2) Strengthening routine Syringe 0 5 mL AD syringe 0.1 mL AD syringe

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immunization is necessary to achieve and maintain high Are two fractional Two fractional doses of IPV (ID) given at
population immunity against polioviruses, especially type 2, doses as effective 6 and 14 weeks produces better
after OPV type 2 is withdrawn. The magnitude, number and as a single immunogenicity than a single standard
length of both wild poliovirus (WPV) and cVDPV outbreaks standard dose ? dose (IM) given at 14 weeks
are closely correlated with weaknesses in routine Source : (8)
immunization systems; (3) This is an opportunity for the
global polio eradication initiative to use its infrastructure to In response to an isolation of VDPV2 from a sewage
contribute more systematically to strengthening routine sample taken in Telangana state, India conducted a massive
immunization systems; and (4) One of the goals is to compaign in June 2016, using an intradermal fractional
improve infant routine immunization coverage in a group of dose (0.1 ml) of IPV over a period of 6 days. The campaign
focus countries which have some of the lowest routine vaccinated 311,064 children aged from 6 weeks to 3 years,
immunization coverage levels in the world and the greatest reaching an estimated coverage of 94 per cent. The
proportion of the world's unvaccinated children. The third campaign was implemented using fixed site approach. The
dose of DPT-containing vaccine will be used to measure success of the campaign indicates that with appropriate
routine immunization coverage improvements. preparation, an emergency response using FIPV can be
It is recommended that the dose of IPV be added at implemented promptly and effectively (9). In April 2016,
14 weeks when the 3rd dose of DPT or pentavalent vaccine India introduced FIPV into routine immunization
is given or at the contact soon thereafter (5). programme in 8 states. In August 2016, the use of FIVP was
expanded to another 8 states (8). Presently it covers the
Containment : The eradication of WPV2 means it does
whole country.
not circulate in human population any longer and it is not
detectable in environment sample either. However, the virus Polio Surveillance (10)
is still present in a number of facilities including research
laboratories and vaccine producing sites. The identification Surveillance is the most important part of the whole polio
and destruction of any unneeded type 2 poliovirus or eradication initiative. Without surveillance, it would be
appropriate containment of needed type 2 poliovirus is now impossible to pinpoint where and how wild poliovirus is still
critical to sustain polio eradication efforts and to prevent circulating, or to verify that the virus has been eradicated.
accidental or malicious release of these viruses from facility Surveillance identifies new cases and detects importation of
and their subsequent transmission to people. Within two wild poliovirus.
weeks of national switch date, the Ministry of Health of all
countries were to submit a report confirming the withdrawal Acute flaccid paralysis surveillance
of tOPV (7). There are four steps of acute flaccid paralysis (AFP)
surveillance:
The Polio Eradication Strategy 2022-2026 1. Finding and reporting children with acute flaccid
Over the last decade, the Global Polio Eradication paralysis (AFP) : The first links in the surveillance chain are
Initiative made steady progress for the eradication of polio, staff in all health facilities - from district health centres to
to achieve a polio-free world. The Polio Eradication Strategy large hospitals. They must promptly report every case of
2022-2026 offers a comprehensive set of actions to acute flaccid paralysis (AFP) in any child under 15 years of
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

age. In addition, public health staff make regular visits to Surveillance indicators (10)
hospitals and rehabilitation centres to search for AFP cases
which may have been overlooked or misdiagnosed. The Indicator Minimum levels for certification
number of AFP cases reported each year is used as an standard surveillance
indicator of a country’s ability to detect polio - even in Completeness At least 80% of expected routine
countries where the disease no longer occurs. A country's of reporting (weekly or monthly) AFP surveillance
surveillance system needs to be sensitive enough to detect at reports should be received on time,
least one case of AFP for every 100,000 children under 15 including zero reports where no AFP
years, even in the absence of polio. cases are seen. The distribution of
2. Transporting stool samples for analysis : In the early reporting sites should be representative
stages, polio may be difficult to differentiate from other of the geography and demography of
forms of acute flaccid paralysis, such as Guillain-Barre the country.
Syndrome, transverse myelitis, or traumatic neuritis. All Sensitivity of At least one case of non-polio AFP
children with acute flaccid paralysis (AFP) should be surveillance should be detected annually per
reported and tested for wild poliovirus within 48 hours of 100,000 population aged less than 15
onset, even if doctors are confident on clinical grounds that
years. In endemic regions, to ensure
the child does not have polio. To test for polio, faecal
even higher sensitivity, this rate should
specimens are analyzed for the presence of poliovirus.
be two per 100,000.
Because shedding of the virus is variable, two specimens -
taken 24-48 hours apart are required. Speed is essential, Completeness of All AFP cases should have a full clinical
since the highest concentrations of poliovirus in the stools of case investigation and virological investigation with at
infected individuals are found during the first two weeks least 80% of AFP cases having
after onset of paralysis. ‘adequate’ stool specimens collected.
Stool specimens have to be sealed in containers and ‘Adequate’ stool specimens are two
stored immediately inside a refrigerator or packed between stool specimens of sufficient quantity
frozen ice packs at 4-8°C in a cold box, ready for shipment for laboratory analysis, collected at least
to a laboratory. Undue delays or prolonged exposure to heat 24 hours apart, within 14 days after the
onset of paralysis, and arriving in the

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on the way to the laboratory may destroy the virus.
Specimens should arrive at the laboratory within 72 hours of laboratory by reverse cold chain and
collection. with proper documentation.
3. Isolating poliovirus : In a laboratory, virologists begin Completeness At least 80% of AFP cases should have
the task of isolating poliovirus from the stool samples. If of follow-up a follow-up examination for residual
poliovirus is isolated, the next step is to distinguish between paralysis at 60 days after the onset of
wild (naturally occurring) and vaccine-related poliovirus. paralysis.
This is necessary because the oral vaccine consists of Laboratory All AFP case specimens must be
attenuated live polioviruses and resembles wild virus in the performance processed in a WHO accredited
laboratory. If wild poliovirus is isolated, the virologists laboratory within the Global Polio
identify which of the two surviving types of wild virus is Laboratory Network (GPLN).
involved. Wild poliovirus type 2 has not been recorded since
1999. VACCINE DERIVED POLIOVIRUS (VDPV) (11)
4. Mapping the virus : Once wild poliovirus has been Although OPV is a safe vaccine, on rare occasions
identified, further tests are carried out to determine where adverse events may occur. Vaccine-associated paralytic
the strain may have originated. By determining the exact poliomyelitis (VAPP) is the most important of these rare
genetic make-up of the virus, wild viruses can be compared adverse events. Cases of VAPP are clinically
to others and classified into genetic families which cluster in indistinguishable from poliomyelitis caused by WPV, but can
defined geographical areas. The newly-found poliovirus be distinguished by laboratory analysis. The incidence of
sequence is checked against a reference bank of known VAPP has been estimated at 4 cases/1000,000 birth cohort
polioviruses, allowing inferences about the geographical per year in countries using OPV VAPP occurs in both OPV
origin of the newly found virus. When polio has been recipients and their unimmunized contacts; it is most
pinpointed to a precise geographical area, it is possible to frequently associated with Sabin 3 (60% of cases), followed
identify the source of importation of poliovirus - both long- by Sabin 2 and Sabin 1.
range and cross-border. Appropriate immunization strategies
can then be determined to prevent further spread of the VDPVs resemble WPVs biologically and differ from the
poliovirus. majority of vaccine-related poliovirus (VRPV) isolates in that
they have genetic properties consistent with prolonged
Environmental surveillance replication or transmission, which is substantially longer
Environmental surveillance involves testing sewage or than the normal period of vaccine virus replication of
other environmental samples for the presence of poliovirus. 4-6 weeks in the OPV recipient (12). All poliovirus isolates
Environmental surveillance often confirms wild poliovirus are characterized by Global Polio Laboratory Network. The
infections in the absence of cases of paralysis. Systematic diagnosis is made by real-time reverse transcription-
environmental sampling (e.g. in Egypt and Mumbai, India) polymerase chain reaction (rRT-PCR) nucleic acid
provides important supplementary surveillance data. Ad- amplification targetted to nucleotide substitution that occur
hoc environmental surveillance elsewhere (especially in early in VDPV emergence.
polio-free regions) provides insights into the international VDPVs are divided into three categories as (1) cVDPVs,
spread of poliovirus. when evidence of person-to-person transmission in the
by R△J
 POLIOMYELITIS

community exists; (2) immunodeficiency-associated VDPVs Host factors

(iVDPVs), which are isolates from persons with primary (a) AGE : The disease occurs in all age groups, but
immunodeficiencies, who have prolonged VDPV infections; children are usually more susceptible than adults because of
and (3) ambiguous VDPVs (aVDPVs), which are either the acquired immunity of the adult population. In developed
clinical isolates from person with no known countries, before the advent of vaccination, the age
immunodeficiency or sewage isolates whose source is distribution shifted so that most patients were over the age
unknown (12). of 5 years, and 25 per cent were over age 15 years (16). In
The prolonged large outbreak of cVDPV2 in Nigeria and India, polio is essentially a disease of infancy and childhood.
D.R. of Congo, the increased detection of iVDPV infection in About 50 per cent of cases are reported in infancy. The most
developing countries and continued detection of aVDPVs vulnerable age is between 6 months and 3 years, (b) SEX :
that resemble cVDPV and iVDPV reaffirm the following Sex differences have been noted in the ratio of 3 males to
points (12): one female, (c) RISK FACTORS : Several provocative or risk
1. The clinical signs and severity of paralysis associated factors have been found to precipitate an attack of paralytic
with VDPV and WPV infections are indistinguishable. polio in individuals already infected with polio viruses. They
include fatigue, trauma, intramuscular injections, operative
2. cVDPVs pose the same public health threat as WPVs and . procedures such as tonsillectomy undertaken especially
require the same control measures. during epidemics of polio and administration of immunizing
3. Surveillance for WPVs and VDPVs should continue to be agents particularly alum-containing DPT. (d) IMMUNITY :
strengthened. The maternal antibodies gradually disappear during the first
6 months of life. Immunity following infection is fairly solid
4. Environmental surveillance to detect VDPVs and WPV although reinfection can occur since infection with one type
infection can serve as an important, sensitive does not protect completely against the other two types of
supplement to AFP surveillance in many settings. viruses. Type-2 virus appears to be the most effective
5. Persons with prolonged iVDPV infection may transmit antigen. Neutralizing antibody is widely recognized as an
poliovirus to others, raising the risk of VDPV circulation important index of immunity to polio after infection (17).
in settings of low population immunity to the
corresponding poliovirus serotype. Environmental factors

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6. Prolonged iVDPV excretion is uncommon among Polio is more likely to occur during the rainy season.
persons with primary immunodeficiencies exposed to Approximately 60 per cent of cases recorded in India were
OPV. during June to September (18). The environmental sources
of infection are contaminated water, food and flies. Polio
7. The prevalence of long-term iVDPV excretors may be virus survives for a long time in a cold environment.
higher than suggested. Overcrowding and poor sanitation provide opportunities for
Because of these risks of emergence of vaccine-derived exposure to infection.
polioviruses, OPV use will be discontinued worldwide once
Mode of transmission
all WPV transmission has been interrupted (i.e. inactivated
polio vaccine (IPV) will replace OPV) and strategies to (a) FAECAL-ORAL ROUTE : This is the main route of
strengthen global polio immunization and surveillance are spread in developing countries. The infection may spread
needed to limit the emergence of VDPVs. directly through contaminated fingers where hygiene is poor,
or indirectly through contaminated water, milk, foods, flies
Epidemiological determinants and articles of daily use. (b) DROPLET INFECTION : This
may occur in the acute phase of disease when the virus
Agent factors occurs in the throat. Close personal contact with an infected
(a) AGENT : The causative agent is the poliovirus which person facilitates droplet spread. This mode of transmission
has three serotypes 1,2 and 3. Most outbreaks of paralytic may be relatively more important in developed countries
polio are due to type-1 virus. Poliovirus can survive for where faecal transmission is remote.
long periods in the external environment. In a cold
environment, it can live in water for 4 months and in faeces Incubation period
for 6 months (13). It is, therefore, well-adapted for the Usually 7 to 14 days (range 3 to 35 days).
faecal-oral route of transmission (14). However, the virus
may be rapidly inactivated by pasteurization, and a variety Clinical spectrum
of physical and chemical agents, (b) RESERVOIR OF When an individual susceptible to polio is exposed to
INFECTION : Man is the only known reservoir of infection. infection, one of the following responses may occur (Fig. 2)
Most infections are subclinical. It is the mild and subclinical (a) INAPPARENT (SUBCLINICAL) INFECTION : This
infections that play a dominant role in the spread of occurs approximately in 91-96 per cent of poliovirus
infection; they constitute the submerged portion of the infections (19). There are no presenting symptoms.
iceberg. It is estimated that for every clinical case, there may Recognition only by virus isolation or rising antibody titres.
be 1000 subclinical cases in children and 75 in adults (15). (b) ABORTIVE POLIO OR MINOR ILLNESS : Occurs in
There are no chronic carriers. No animal source has yet approximately 4 to 8 per cent of the infections (20). It causes
been demonstrated, (c) INFECTIOUS MATERIAL : The virus only a mild or self-limiting illness due to viraemia. The
is found in the faeces and oropharyngeal secretions of an patient recovers quickly. The diagnosis cannot be made
infected person, (d) PERIOD OF COMMUNICABILITY : The clinically. Recognition only by virus isolation or rising
cases are most infectious 7 to 10 days before and after onset antibody titre, (c) NON-PARALYTIC POLIO : Occurs in
of symptoms. In the faeces, the virus is excreted commonly approximately 1 per cent of all infections (21). The
for 2 to 3 weeks, sometimes as long as 3 to 4 months. presenting features are stiffness and pain in the neck and

by R△J
244 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

PREVENTION
Immunization is the sole effective means of preventing
poliomyelitis. Both killed and live attenuated vaccines are
available and both are safe and effective when used
correctly. It is essential to immunize all infants by 6 months
of age to protect them against polio. Two types of vaccines
are used throughout the world; they are :
1. Inactivated (Salk) polio vaccine (IPV).
2. Oral (Sabin) polio vaccine (OPV).

1. Inactivated (Salk) polio vaccine

The vaccine mixture is formulated to contain at least
40 units of type-1, 8 units of type-2 and 32 units of type-3
D-antigen (D-antigen, which is expressed only on intact
poliovirus particles, is used to adjust the concentration of
the individual viruses included in the trivalent IPV). All
versions of IPV have higher antigenicity than the first-
generation vaccines, and they are sometimes referred to as
IPVs of enhanced potency. IPV may contain trace amounts
of formaldehyde, streptomycin, neomycin or polymyxin B;
some versions of IPV contain the preservative phenoxy­
FIG. 2 ethanol (0.5%), but neither thiomersal (incompatible with
Time course of events in infection with poliovirus. IPV antigenicity) nor adjuvants are used (11).
Source : (23) IPV is administered by intramuscular injection or
fractional dose by intradermal injection. The vaccine is
back. The disease lasts 2 to 10 days. Recovery is rapid. The stable at ambient temperature, but should be refrigerated to

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disease is synonymous with aseptic meningitis, ensure no loss of potency. Freezing should be avoided as it
(d) PARALYTIC POLIO : Occurs in less than one per cent of could diminish potency. IPV is available either as a stand­
infections. The virus invades CNS and causes varying alone product or in combination with >1 other vaccine
degrees of paralysis. The predominant sign is asymmetrical antigens including diphtheria, tetanus, whole-cell or
flaccid paralysis. A history of fever at the time of onset of acellular pertussis, hepatitis B, or Haemophilus influenzae
paralysis is suggestive of polio. The other associated type b. In the combination vaccines, the alum or the
symptoms are malaise, anorexia, nausea, vomiting, pertussis vaccine, or both, have an adjuvant effect.
headache, sore throat, constipation and abdominal pain.
The primary or initial course of immunization consists
There might be signs of meningeal irritation, i.e., stiffness of
of 4 inoculations. The first 3 doses are given at intervals of
neck and back muscles. Tripod sign may be present, i.e. the
1-2 months and 4th dose 6-12 months after the third dose.
child finds difficulty in sitting and sits by supporting hands at
First dose is usually given when the infant is 6 weeks old.
the back and by partially flexing the hips and knees.
Additional doses are recommended prior to school entry and
Progression of the paralysis to reach its maximum in the
then every 5 years until the age of 18. Alternatively, one or
majority of cases occurs in less than 4 days (may take 4-7
two doses of live vaccine (OPV) can be given safely as
days). The paralysis is characterized as descending, i.e.
boosters after an initial course of immunization with
starting at the hip and then moving down to the distal parts
inactivated vaccine.
of the extremity. As it is asymmetrical patchy paralysis,
muscle strength varies in different muscle groups of different IPV induces, humoral antibodies (IgM, IgG and IgA
limbs. However, proximal muscle groups are more involved serum antibodies) but does not induce intestinal or local
as compared to distal ones. Deep tendon reflexes (DTRs) are immunity. The circulating antibodies protect the individual
diminished before the onset of paralysis. There is no sensory against paralytic polio, but do not prevent reinfection of the
loss. Cranial nerve involvement is seen in bulbar and gut by wild viruses. For the individual, it gives protection
bulbospinal forms of paralytic poliomyelitis. There might be from paralysis and nothing more; for the community, it
facial asymmetry, difficulty in swallowing, weakness or loss offers nothing because the wild viruses can still multiply in
of voice. Respiratory insufficiency can be life-threatening the gut and be a source of infection to others. This is a major
and is usually the cause of death. After the acute phase, drawback of IPV. Further, in the case of an epidemic, IPV is
atrophy of the affected muscles lead to a life with residual unsuitable because : (i) immunity is not rapidly achieved, as
paralysis which is typical and relatively easy to identify as more than one dose is required to induce immunity, and
poliomyelitis (22). (ii) injections are to be avoided during epidemic times as
they are likely to precipitate paralysis (24). Therefore, IPV is
Progressive paralysis, coma or convulsions usually
not efficacious in combating epidemics of polio.
indicate a cause other than polio, as does a very high case
fatality rate (21). Advantages : Inactivated polio vaccine, because it does
not contain living virus, is safe to administer (i) to persons
There is no specific treatment for polio. Good nursing
with immune deficiency diseases (ii) to persons undergoing
care from the beginning of illness can minimize or even
corticosteroid and radiation therapy (iii) to those over 50
prevent crippling. Physiotherapy is of vital importance. It
years who are receiving vaccine for the first time, and
can be initiated in the affected limb immediately. It helps the
(iv) during pregnancy.
weakened muscles to regain strength. Very probably, the
child may have to put on metal callipers. Associated risks : No serious adverse reactions to IPV

by R△J
 POLIOMYELITIS ^B5
vaccines currently in use have been reported except minor to all susceptibles in a community. This procedure virtually
local erythema (0.5-1 per cent), induration (3-11 per cent) eliminates the wild polio strains in the community and
and tenderness (14-29 per cent). replaces them by attenuated strains (26). The duration of
immunity produced by the OPV is not known, it may
2. Oral (Sabin) polio vaccine (OPV) possibly even be lifelong (27).
Oral polio vaccine (OPV) was described by Sabin in
1957. It contains live attenuated virus (types 1, 2 and 3) Advantages
grown in primary monkey kidney or human diploid cell The advantages of OPV are : (i) since given orally, it is
cultures. Ideally each virus type should be given separately easy to administer and does not require the use of highly
as monovalent vaccine, but for administrative convenience, trained personnel (ii) induces both humoral and intestinal
rather than efficacy, it is given as bivalent (bOPV) vaccine. immunity, (iii) antibody is quickly produced in a large
The vaccine contains not less than 106 0 CCID50 of type 1 proportion of vaccinees, even a single dose elicits (except in
poliomyelitis virus Sabin strain and not less than 1058 tropical countries) substantial immunity (iv) the vaccinee
CCID50 of type 3 poliomyelitis virus Sabin strain. excretes the virus and so infects others who are also
immunized thereby (v) useful in controlling epidemics, and
National Immunization Schedule (vi) relatively inexpensive.
The WHO Programme on Immunization (EPI) and the
National Immunization Programme in India recommends a Complications
primary course of 3 doses of OPV at one-month intervals, OPV is remarkably free from complications. However,
commencing the first dose when infant is 6 weeks old being living viruses, the vaccine viruses, particularly type 3
(see page 135). It is recommended that a dose of OPV (zero­ do mutate in the course of their multiplication in vaccinated
dose) is required to be given to all children delivered in children, and rare cases of vaccine-associated paralytic
health institutions before their discharge from the hospital. polio have occurred in (a) recipients of the vaccine, and
The vaccine should be given in maternity wards, the (b) their contacts. For details please refer to page 242.
newborn should not be taken to regular immunization
sessions to avoid infection. OPV is given concurrently with Contraindications
DPT or pentavalent vaccine. BCG can be given Diarrhoea should not be considered a contraindication to
simultaneously with the first dose of OPV It is very

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OPV. However, to ensure full protection, a dose of OPV
important to complete vaccination of all infants before given to a child with diarrhoea should not be counted as
6 months of age. This is because most polio cases occur part of the series and the child should receive another dose
between the ages of 6 months and 3 years. One booster at the first available opportunity. Live vaccines are not
dose of OPV is recommended 12 to 18 months later. usually given to immunocompromised individuals (23).
Patients suffering from leukaemias and malignancy and
Dose and mode of administration those receiving corticosteroids may not be given OPV IPV is
The dose is 2 drops or as stated on the label. WHO an alternative to OPV for immunization of children with HIV
recommends that vaccinators use dropper supplied with the infection (23). There is as yet no indication that polio
vial of oral polio vaccine. This is the most direct and immunization may pose any danger to a pregnant mother or
effective way to deliver the correct drop size. Tilt the child’s developing foetus. However, OPV should be delayed until
back, and gently squeeze the cheeks or pinch the nose to after pregnancy unless immediate protection is required,
make the mouth open. Let the drops fall from the dropper when IPV is indicated (14).
onto the child’s tongue. Repeat the process if the child spits
out the vaccine. If the vaccine is spoon-fed there is a chance Storage
that it will not all be licked up by the child (25). (a) Stabilized vaccine : Recent oral polio vaccines are
heat stabilized by adding magnesium chloride. They can be
Development of immunity kept without losing potency for a year at 4 deg. C, and for a
On administration, the live vaccine strains infect intestinal month at 25 deg. C temperature (16). (b) Non-stabilized
epithelial cells. After replication, the virus is transported to vaccine : The vaccine should be stored at -20 deg C in a
the Peyer’s patches where a secondary multiplication with deep freeze until used. In case a deep freeze is not available,
subsequent viraemia occurs. The virus spreads to other it might be stored temporarily in the freezing chamber of the
areas of the body, resulting in the production of circulating refrigerator. During transport, the vaccine must be kept
antibodies which prevent dissemination of the virus to the either on dry ice (solid carbon dioxide) or a freezing mixture
nervous system and prevent paralytic polio. Intestinal (equal quantities of wet ice and ammonium chloride) (28).
infection stimulates the production of IgA secretory At the vaccination clinic, the bottle containing the OPV
antibodies which prevent subsequent infection of the should not be frozen and thawed repeatedly, since repeated
alimentary tract with wild strains of poliovirus, and thus is freezing and thawing has a deleterious effect on the potency
effective in limiting virus transmission in the community. of live polio vaccine. It would be preferable to keep the
Thus OPV induces both local and systemic immunity. vials of the vaccine in ice during its administration to
The vaccine progeny is excreted in the faeces and children (28).
secondary spread occurs to household contacts and Studies indicate that breast-feeding does not impede the
susceptible contacts in the community. Non-immunized effectiveness of oral poliovirus vaccine (29). Breast milk can
persons may therefore, be immunized. Thus widespread be given whenever the child is hungry. However, hot water,
“herd immunity” results, even if only approximately 66 per hot milk or hot fluids should be withheld for about half an
cent of the community is immunized (14). This property of hour after the administration of the vaccine. The vaccine
OPV has been exploited in controlling epidemics of polio by should be administered preferably in a cool room, rather
administering the vaccine simultaneously in a short period than in a hot, humid and crowded room.

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2 46 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The problems with OPV may be summarized as follows epidemiological investigation, including an active search for
(a) A primary problem is the instability of the vaccine at high other cases. Samples of faeces from all cases or suspected
ambient temperatures. The vaccine has to be kept frozen cases of polio should be collected and forwarded to the
during storage, and kept cold during transportation, right up laboratory for virus isolation. In addition, where possible,
to the point of administration, (b) A second problem is the paired sera should be collected, the first specimen at the
frequent vaccine failures even with fully potent vaccines, clinical suspicion of paralytic polio and the second at the
(c) A third problem is the very small residual neurovirulence period of convalescence. A rising titre of poliovirus
in OPV. neutralizing antibody provides useful confirmatory evidence.
The Indian Council of Medical Research has set up National
Sequential administration of IPV and OPV Enterovirus Units at Mumbai, Coonoor, Chennai, Delhi and
Over the past decade, a number of countries in central Kasauli where samples may be sent for examination.
and eastern Europe, the Middle East, the Far East, and The following check-list indicates the essential data to be
southern Africa have adopted sequential schedules of 1-2 collected when investigating an outbreak (30, 31).
doses of IPV followed by > 2 doses of OPV. Combined 1. Name of the administrative area and locality
schedules of IPV and OPV appear to reduce or prevent 2. Date first case reported from locality
VAPP while maintaining the high levels of intestinal mucosal
immunity conferred by OPV. In addition, such schedules 3. Period of field investigation
economize on limited resources by reducing the number of From................. to..................(dates)
doses of IPV, and may optimize both the humoral and 4. No.of paralytic polio cases detected
mucosal immunogenicity of polio vaccination. The 4.1 Clinical diagnosis only
effectiveness of this approach in preventing polio caused by 4.2 Laboratory confirmed
WPV as well as VAPP has been documented by 2 large 4.3 Type(s) of virus isolated
studies (11). 5. No. of deaths from paralytic polio
The difference between IPV and OPV are given in 6. No.of paralytic cases of polio by age
Table 2. -1 year 10-14 years
1-4 years 15-19 years
TABLE 2 5-9 years 20+ years
Differences between IPV and OPV 7. No.of contacts of paralytic polio examined

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IPV OPV Household contacts
(Salk type) (Sabin type) Other, (specify)
8. Brief description of field investigation
1 Killed formolized virus Live attenuated virus
2 Given subcutaneously or IM Given orally 9. History of previous vaccination practice in the locality
including the dates of the last community vaccination
3 Induces circulating antibody, Immunity is both humoral programme, and the type of vaccine used.
but no local (intestinal) and intestinal Induces
immunity antibody quickly 10. Name of the principal investigator and laboratory.
4 Prevents paralysis, but does Prevents not only Within an epidemic area, OPV should be provided for all
not prevent reinfection by paralysis, but also
wild polio viruses intestinal reinfection persons over 6 weeks of age who have not been completely
immunized or whose immune status is unknown.
5 Not useful in controlling Can be effectively used in
epidemics controlling epidemics. Under the International Health Regulations, polio is
Even a single dose elicits subject to international surveillance. The WHO should be
substantial immunity notified as soon as possible of the occurrence of paralytic
(except in tropical countries)
polio and to supplement reports on such outbreaks with
6 More difficult to manufacture Easy to manufacture additional epidemiological information such as the type of
7 The virus content is 10,000 Cheaper virus, and the number of cases and deaths reported. In
times more than OPV
Hence costlier addition a quarterly report (on prescribed form) should be
sent to WHO, Geneva. The WHO has prepared guidelines to
8 Does not require stringent Requires to be stored and
conditions during storage transported at sub-zero poliovirus isolation and serological techniques for polio
and transportation. temperatures, unless surveillance.
Has a longer shelf-life stabilized
Strategies for polio eradication in India
Human Normal Ig
(a) Conduct Pulse Polio Immunization days every year
The current widespread practice of immunization has until poliomyelitis is eradicated.
virtually eliminated the need for passive immunization.
(b) Sustain high levels of routine immunization coverage.
Normal human Ig in a dose of 0.25-0.3 ml per kg of body
weight has been found to be protective for a few weeks (c) Monitor OPV coverage at district level and below.
against paralytic disease but does not prevent sub-clinical (d) Improve surveillance capable of detecting all cases of
infections. Immunoglobulin is effective only if given shortly AFP due to polio and non-polio aetiology.
before infection, it is of no value after clinical symptoms
develop (17). The subject shall be actively immunized (e) Ensure rapid case investigation, including the
collection of stool samples for virus isolation.
against polio after a few weeks.
(f) Arrange follow-up of all cases of AFP at 60 days to
Epidemiological Investigations check for residual paralysis.
The occurrence of a single case of polio is now considered (g) Conduct outbreak control for cases confirmed or
as an epidemic, and should prompt an immediate suspected to be poliomyelitis to stop transmission.

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 POLIOMYELITIS
247
Even a single case is treated as an outbreak and An important improvement in PPI during 1998 has been
preventive measures are initiated, usually within 48 hours of the use of vaccine vial monitor. Colour monitors or labels
notification of the case. The complete and timely reporting are put on vaccine bottles. Each label has a circle of deep
of cases of poliomyelitis is an important element for the blue colour. Inside it is a white square which changes colour
eradication of poliomyelitis. Reporting of all cases of acute and gradually becomes blue, if vaccine bottle is exposed to
flaccid paralysis in children under 15 years of age is higher temperature. When the colour of the white square
mandatory, and line lists of all reported cases of becomes blue like that of surrounding circle, the vaccine
poliomyelitis are maintained. Since 1992, the active should be considered ineffective. Thereby, the health worker
surveillance has been extended to all cases of acute flaccid can easily ascertain that the vaccine being given is effective
paralysis, including causes other than poliomyelitis. or not. This mechanism has been made mandatory in all
vaccine procurements since 1998. This quality assurance
Line listing of cases will ensure that the children will have better protection
Line listing of reported cases was started in the year 1989 against polio in 1999 and thereafter.
to check for duplication (same case reported more than once Following recommendations from the India Expert
if the child visited more than one health facility), year of Advisory Group on Polio Eradication (1EAG), several
onset of illness (to screen children with residual paralysis strategies were utilized during 2005 and early 2006 to
who developed poliomyelitis prior to the year of reporting), improve the impact of SIAs : (i) development and licensure of
identification of high risk pockets (by analysis of residential monovalent OPV1 (mOPVl) and mOPV3 for targeted use
status) and documentation of high-risk age groups. during SIAs based on surveillance data; (ii) deployment of
Line listing of cases made it possible to take appropriate additional peronnel to assist with intensified SIAs in the States
follow-up action in areas from where the cases had been of Bihar and UP and in Mumbai City; (iii) social mobilization
reported. The line lists have also provided useful targeted at reaching population groups missed during
epidemiological data for programme purposes. For example, previous SIAs; (iv) use of mobile teams to vaccinate children
it provided information on the age at onset of illness and to at transit points (e.g. railway and bus stations) and on moving
understand the urgency for the early completion of the OPV trains; and (v) increased engagement and accountability of
immunization schedule. political leaders and of health staff at all levels. To further
improve population immunity in the most critical age group,
All cases of acute flaccid paralysis must be reported the IEAG added a specific recommendation at its May 2006

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immediately to the chief medical officer/district meeting to identify and target all neonates in high-risk areas of
immunization officer with the following details : UP with a “birth dose” of mOPVl (33).
- Name, age and sex of the patient The last case of polio in the country was reported from
- Father’s name and complete address Howrah of West Bengal with date of onset of disease on
- Vaccination status 13th January 2011. Thereafter no polio case has been
- Date of onset of paralysis and date of reporting reported in the country. On 27th March 2014, India was
- Clinical diagnosis declared as non-endemic country for polio.
- Doctor’s name, address and phone number The steps taken by the Government to achieve the target
Mopping Up of polio eradication and maintain the polio-free state are as
follows (34) :
Mopping up activities are usually the last stage in polio 1. All states and union territories in the country have
eradication. The strategy of “mopping up” involves door- developed a Rapid Response Team (RRT) to respond to
to-door immunization in high-risk districts, where wild polio
any polio outbreak in the country. An Emergency
virus is known or suspected to be still circulating. This
Preparedness and Response Plan (EPRP) has also been
strategy is being implemented in India.
developed by all states indicating steps to be undertaken
Pulse Polio Immunization in case of detection of a polio case.
2. In the states of UP and Bihar every new born child is being
In India NIDs have become the largest public health
identified and vaccinated during the polio immunization
campaigns ever conducted in a single country. Government of
campaigns and is being tracked for 8 subsequent rounds.
India conducted the first round of PPI consisting of two
immunization days 6 weeks apart on 9th December 1995 and 3. In order to reach every eligible child during the pulse
20th January 1996. The first PPI conducted targeted all polio round, apart from the strategy of vaccinating
children under 3 years of age irrespective of their immunization children at fixed booths and house to house visit, efforts
status. Later on, as recommended by WHO, it was decided to in vaccinating children in transit at railway stations,
increase the age group from under 3 to under 5 years. inside long distance trains, major bus stops, marker
places, religious congregations, major road crossings etc.
The term “pulse” has been used to describe this sudden,
throughout the country have been intensified. Special
simultaneous, mass administration of OPV on a single day to
booths are established in areas bordering neighbouring
all children 0-5 years of age, regardless to previous
countries like Wagah border and Attari train station in
immunization. PPIs occur as two rounds about 4 to 6 weeks
Punjab and Munabao train station in Barmer district of
apart during low transmission season of polio, i.e. between
Rajasthan, to ensure that all children under 5 years of age
November to February. In India, the peak transmission is
coming from across the border are given polio drops.
from June to September. The dose of OPV during PPIs are
extra doses which supplement, and do not replace the doses 4. An extremely high level of vigilance through surveillance
received during routine immunization services. The children across the country for any importation or circulation of
including 0-1 year old infants should receive all their poliovirus and Vaccine Derived Polio Virus (VDPV) is being
scheduled doses and PPI doses. There is no minimum maintained. Environmental surveillance is continuing at
interval between PPI and scheduled OPV doses (32). four sites with establishment of two new sites in 2012.

by R△J
248 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

5. Government of India has identified 107 high risk blocks 21. WHO (1981). Wkly Epi.Rec., 56 (17) 131-132.
for polio where a multi-pronged strategy is being 22. Govt, of India CSSM review, A Newsletter on the Child Survival and
implemented to ensure sanitation, hygiene and clean Safe Motherhood Programme, No.32, August 1995.
drinking water in addition to vaccinating each and every 23. WHO (1993), The Immunological Basis of Immunization Series,
Module 6 : Poliomyelitis Global Programme for Vaccines and
child oral polio vaccine (OPV). Immunization EPI, WHO.
6. Migratory population from UP and Bihar are being 24. Galazka, A.M. et al (1984) Bull WHO, 62 : 357.
identified in the states of Punjab, Haryana, Gujarat and 25. AHRTAG (1988) Dialogue on diarrhoea No. 33 June P.7.
West Bengal and these migratory children are being 26. Nightingale, E. (1977). N.Eng.J.Med., 297 : 249.
covered during the Sub National Immunization Day 27. WHO (2016), Weekly Epidemiological Record Ho. 12, 2016.
(SNID) in UP and Bihar. 28. Ministry of Health, Govt, of India (1977). Manual on Immunization,
Dept, of Family Welfare.
7. Social mobilization activities are being intensified by 29. Sabin, A.B. (1980). Bull WHO 58 (1) 141.
involving the local influencers, community and religious 30. WHO (1975). Wkly Epi Rec., 50 : 205-209.
leaders to improve community participation and 31. WHO (1976). WHO Chronicle, 30 : 72-75.
acceptance of polio vaccine. 32. Govt, of India (1996), Pulse Polio Immunization in India, Operational
Guide, MCH Division, Department of Family Welfare, New Delhi.
8. A rolling emergency stock of oral polio vaccine (OPV) is
33. WHO (2006), Weekly Epidemiological Record, No. 29,21st July, 2006.
being maintained to respond to any wild polio vaccine 34. Govt, of India (2013), Annual Report 2012-2013, Ministry of Health
(WPV) or circulating vaccine derived polio virus and Family Welfare, New Delhi
(cVDPV) detection. 35. Govt, of India (2016), Annual Report 2015-2016, Ministry of Health
As part of the polio endgame strategic plan, India has and Family Welfare, New Delhi.
introduced IVP in the national immunization programme 36. WHO (2020), Weekly Epidemiological Record Ho. 38, 2020.
from 30th November 2015 and tOPV - bOPV switch was
carried out in April 2016 (35). VIRAL HEPATITIS
AFP SURVEILLANCE : PPI is supported by AFP Viral hepatitis is a term commonly used for several
surveillance system since 1997. It is being conducted through clinically similar yet aetiologically and epidemiologically
a network of surveillance medical officers (SMOs), who are distinct diseases. It is caused by five different viruses with
specially trained and are responsible for a defined area. transmission either through contaminated food or water
A national surveillance team is positioned in Delhi. The SMOs

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(hepatitis A and E) or through exposure to blood or body
are located at the state headquarters and at regional places fluids (hepatitis B, C and D). Hepatitis A and hepatitis B
in case of larger states. A regular weekly reporting system has have been recognized as separate entities since early 1940s
been established. As a result of more meticulous search/ and can be diagnosed with specific serological tests. Delta
reporting, the number of reported cases of AFP increased hepatitis is an infection dependent on the hepatitis B virus. It
from 1,005 in 1996 to 11,675 and the completeness of stool may occur as a coinfection with acute HBV infection or as
specimen collection improved markedly from 59 per cent in superinfection of an HBV carrier.
1998 to 82 per cent at the end of September 2020 (36).
HEPATITIS A
References
1. WHO (2022), Weekly Epidemiological Record No. 23, 2022. Hepatitis A (formerly known as “infectious” hepatitis or
2. WHO (2021), Polio Global Eradication Initiative, Polio Eradication epidemic jaundice) is an acute infectious disease caused by
Strategy 2022-2026, Delivering on a promise. hepatitis A virus (HAV). The disease is heralded by non­
3. WHO (2016), Weekly Epidemiological Record No. 36/37, 9th Sept. specific symptoms such as fever, chills, headache, fatigue,
2016. generalized weakness and aches and pains, followed by
4. WHO, Immunization, Vaccines and Biologicals, About the Polio anorexia, nausea, vomiting, dark urine and jaundice. The
Endgame Strategic Plan. disease spectrum is characterized by the occurrence of
5. EPI (2014), The Polio Eradication Endgame, Brief on IPV introduction, numerous subclinical or asymptomatic cases. The disease is
OPV withdrawal and routine immunization strengthening, March
2014. benign with complete recovery in several weeks. The case
6. EPI (2015), Polio-Global Eradication Initiative - Preparing for fatality rate of icteric cases is less than 0.1 per cent, usually
withdrawal of all oral polio vaccine (OPV) : Replacing trivalent OPV from acute liver failure and mainly affects older adults.
with bivalent OPV frequently asked questions, Feb. 2015. Although the disease has, in general, a low mortality,
7. EPI, Polio-Global Eradication Initiative - Polio Today, Key Points about patients may be incapacitated for many weeks.
containment.
8. WHO (2016), Immunization, Vaccine and Biologicals, Fractional dose Problem statement
IPV.
9. WHO (2016), Weekly Epidemiological Record No. 34,26th Aug. 2016. Being an enterovirus infection like poliomyelitis, hepatitis
10. Global Polio Eradication Initiative, Data and Monitoring, Surveillance. A is endemic in most developing countries, with frequent
11. WHO (2010), Weekly Epidemiological Record, No. 23,4th June, 2010. outbursts of minor or major outbreaks. The exact incidence
12. WHO (2012), Weekly Epidemiological Record No. 38,21st Sept. 2012. of the disease is difficult to estimate because of the high
13. Provoost, P. (1985). Children in the Tropics No. 156-157 P.58. proportion of asymptomatic cases. However, based on an
14. Ichout, B.D. (1988). Med. Int. 53 : 2189-2191. ongoing reassessment of the global burden of hepatitis A,
15. Christie, A.B. (1980). Infectious Diseases : Epidemiology and Clinical WHO estimates suggest that about 1.4 million cases occur
Practice, 3rd ed, Churchill Livingstone. every year world-wide (1).
16. Jewetz, Melnick and Adelberg’s. Medical Microbiology, 26th Ed, 2013, Geographical areas can be characterized as having high,
A Lange Medical Book.
17. WHO (1983). Tech.Rep.Ser. No.693. intermediate or low levels of hepatitis A infection (2).
18. ICMR (1975). ICMRBulletin, Jan. 1975. Areas with high levels of infection
19. Krishnan, R.et al (1983). Bull WHO, 61 (4) 689-692.
20. Young, N.A. (1979) in Principles and Practice of Infectious Diseases, In developing countries with very poor sanitary conditions
Mandell, G.L. et al (eds), John Wiley, New York. and hygienic practices, most children (90%) have been

by R△J
 HEPATITIS A 9
infected with the hepatitis A virus before the age of 10 years. Host factors
Those infected in childhood do not experience any noticeable (a) AGE : Infection with HAV is more frequent among
symptoms. Epidemics are uncommon because older children children than in adults. However, people from all ages may
and adults are generally immune. Symptomatic disease rates be infected if susceptible. In young children, infections tend
in these areas are low and outbreaks are rare. to be mild or subclinical; the clinical severity increases with
Areas with intermediate levels of infection age. The ratio of anicteric to icteric cases in adults is about
1:3; in children, it may be as high as 12:1. However, faecal
In developing countries, countries with transitional
excretion of HAV antigen and RNA persists longer in the
economies, and regions where sanitary conditions are
variable, children often escape infection in early childhood. young than in adults (5). (b) SEX : Both sexes are equally
Ironically, these improved economic and sanitary conditions susceptible, (c) IMMUNITY : Immunity after attack probably
may lead to a higher susceptibility in older age groups and lasts for life; second attacks have been reported in about
higher disease rates, as infections occur in adolescents and 5 per cent of patients. Most people in endemic areas acquire
adults, and large outbreaks can occur. Thus, paradoxically, immunity through subclinical infection. The IgM antibody
with the transition from high to intermediate endemicity, the appears early in the illness and persists for over 90 days. IgG
incidence of clinically significant hepatitis A increases (2). appears more slowly, and persists for many years.

Areas with low levels of infection Environmental factors

In developed countries with good sanitary and hygienic Cases may occur throughout the year. In India the disease
conditions, infection rates are low. Disease may occur tends to be associated with periods of heavy rainfall (9). Poor
among adolescents and adults in high-risk groups, such as sanitation and overcrowding favour the spread of infection,
injecting-drug users, homosexual men, people travelling to giving rise to water-borne and food-borne epidemics.
areas of high endemicity, and in isolated populations such as Paradoxically, when standards of hygiene and sanitation are
closed religious communities (2). improved, morbidity from infection with enteric viruses may
The exact incidence of HAV in India is not known. The increase. This is what happened with hepatitis A (6).
Indian literature is replete with numerous reports of sporadic Modes of transmission
and epidemic occurrence of this disease in various cities,
residential colonies and campuses. Epidemics of hepatitis A (a) FAECAL-ORAL ROUTE : This is the major route of
often evolve slowly, involve wide geographic areas and last transmission. It may occur by direct (person-to-person)

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many months, but, common source epidemics (e.g., faecal contact or indirectly by way of contaminated water, food or
contamination of drinking water) may evolve explosively. milk. Water-borne transmission, is not a major factor in
developed countries, where food-borne outbreaks are
Epidemiological determinants becoming more frequent. For example, consumption of salads
and vegetables, and of raw or inadequately cooked shellfish
Agent factors and oyesters cultivated in sewage polluted water is associated
(a) AGENT : The causative agent, the hepatitis A virus, is with epidemic outbreaks of hepatitis A (5). Direct transmission
an enterovirus (type 72) of the Picornaviridae family (3). It comprises an array of routes such as contaminated hands or
multiplies only in hepatocytes. Faecal shedding of the virus objects such as eating utensils. Direct infection occurs readily
is at its highest during the later part of the incubation period under conditions of poor sanitation and overcrowding.
and early acute phase of illness. Only one serotype is
(b) PARENTERAL ROUTE : Hepatitis A is rarely, if ever,
known, (b) RESISTANCE : The virus is fairly resistant to low
transmitted by the parenteral route (i.e., by blood and blood
pH, heat and chemicals. It has been shown to survive more
products or by skin penetration through contaminated
than 10 weeks in well water (4). It withstands heating to
needles). This may occur during the stage of viraemia. This
60 deg C for one hour, and is not affected by chlorine in
doses usually employed for chlorination. Formalin is stated mode of transmission is of minor importance as viraemic
to be an effective disinfectant. The virus is inactivated by stage of infection occurs during prodromal phase and there
ultraviolet rays and by boiling for 5 minutes or autoclaving. is no carrier state (5).
In short the virus survives for long periods under variable (c) SEXUAL TRANSMISSION : As a sexually transmitted
conditions and resists many procedures that eliminate or infection hepatitis A may occur mainly among homosexual
inactivate most bacterial agents, (c) RESERVOIR OF men because of oral-anal contact (7).
INFECTION : The human cases are the only reservoir of Food handlers are not at increased risk for hepatitis A,
infection. The cases range from asymptomatic infections to because of their occupation, but are noteworthy because of
severe ones. Asymptomatic (anicteric) infections are their critical role in common-source food-borne HAV
especially common in children. These cases play an transmission. Health care personnel do not have an increased
important role in maintaining the chain of transmission in prevalence of HAV infection and nosocomial HAV transmission
the community. There is no evidence of a chronic carrier is rare. Children play an important role in HAV transmission as
state, (d) PERIOD OF INFECTIVITY : The risk of they generally have asymptomatic or unrecognized illness (8).
transmitting HAV is greatest from 2 weeks before to 1 week
after the onset of jaundice. Infectivity falls rapidly with the Incubation period
onset of jaundice (2). (e) INFECTIVE MATERIAL : Mainly
10 to 50 days (usually 14-28 days). The length of the
man’s faeces. Blood, serum and other fluids are infective
incubation period is proportional to the dose of the virus
during the brief stage of viraemia, (f) VIRUS EXCRETION :
HAV is excreted in the faeces for about 2 weeks before the ingested (4).
onset of jaundice and for up to 2 weeks thereafter. There is Clinical spectrum
little evidence for HAV transmission by exposure to urine or
naso-pharyngeal secretions of infected patients. The onset of jaundice is often preceded by gastrointestinal
Haemodialysis plays no role in the spread of hepatitis A symptoms such as nausea, vomiting, anorexia, and mild
infections to either patients or the staff (5). fever. Jaundice may appear within a few days of the

7 by R△J
?5 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

prodromal period, but anicteric hepatitis is more common. the incubation period and early phase of illness (b) the
Hepatitis A resolves completely in 98 per cent of cases but occurrence of large number of subclinical cases (c) absence of
relapse of symptoms are noted in 3-20 per cent cases (10). specific treatment, and (d) low socio-economic profile of the
The outcome of infection with HAV is as shown in Table 1. population usually involved. Strict isolation of cases is not a
TABLE 1 useful control measure because of (a) and (b). However,
Outcomes of infection with hepatitis A virus attention should be paid to the usual control measures such
as complete bed rest and disinfection of faeces and fomites.
Outcome Children Adults The use of 0.5 per cent sodium hypochlorite has been
strongly recommended as an effective disinfectant (11).
Inapparent (sub-clinical) infection 80-95% 10-25%
Icteric disease 5-20% 75-90% b. Control of transmission
Complete recovery >98% >98% The best means of reducing the spread of infection is by
Chronic disease None None promoting simple measures of personal and community
Mortality rate 0.1% 0.3-2.1% hygiene, e.g., hand washing before eating and after toilet; the
Source : (5) sanitary disposal of excreta which will prevent contamination
of water, food and milk; and purification of community water
Diagnosis supplies by flocculation, filtration and adequate chlorination.
Tests for abnormal liver function, such as serum alanine A question is often asked how much chlorine is needed to
aminotransferase (ALT) and bilirubin, supplement the inactivate the virus. Studies indicated that 1 mg/L of free
residual chlorine can cause destruction of the virus in
clinical, pathologic, and epidemiologic findings.
30 minutes at pH values of 8.5 or less (12). The water
A specific laboratory diagnosis of hepatitis A can be treatment and distribution system should be improved.
obtained by : During epidemics, boiled water should be advocated for
a. Demonstration of HAV particles or specific viral drinking purposes. Several countries of the world have
antigens in the faeces, bile and blood. HAV is achieved control of water-borne HAV infection. Other control
detected in the stool from about 2 weeks prior to measures include proper disposal of sewage within
the onset of jaundice, up to 2 weeks after. communities. If all these measures are properly implemented,
a substantial reduction of HAV infection can be expected.
b. Anti-HAV appears in the IgM fraction during the acute
phase, peaking about 2 weeks after elevation of liver

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c. Control of susceptible population
enzymes. Anti-HAV IgM usually declines to non- Targeted protection of high-risk groups should be
detectable levels within 3-6 months. Anti-HAV IgG considered in low and very low endemicity, settings. Groups
appears soon after the onset of disease and persists for at increased risk of hepatitis A include travellers to areas of
decades. Thus, detection of IgM-specific anti-HAV in intermediate or high endemicity, those requiring life-long
the blood of an acutely infected patient confirms the treatment with blood products, men having sex with men,
diagnosis of hepatitis A. ELISA is the method of workers in contact with non-human primates, and injection
choice for measuring HAV antibodies (5). drug users. In addition, patients with chronic liver disease
The clinical, virologic and serological events following are at increased risk for fulminant hepatitis A and should be
exposure to HAV are as shown in Fig. 1 vaccinated (10). Use of hepatitis A vaccine rather than
passive prophylaxis with immune globuline should be
Prevention and containment considered for pre-exposure prophylaxis (e.g. for travellers)
and post-exposure prophylaxis (e.g. for close contacts of
a. Control of reservoir acute cases of hepatitis A.
Control of reservoir is difficult because of the following 1. Vaccines : Two types of hepatitis A vaccines are
factors: (a) faecal shedding of the virus is at its height during currently used worldwide:
(a) Formaldehyde inactivated vaccines - produced in several
Virus in blood countries and which are most commonly used worldwide.
(b) Live attenuated vaccinces - which are manufactured in
China and are available in several countries.
Inactivated hepatitis A vaccine are licensed for use in
persons >12 months of age. The complete vaccination
schedule consists of 2 dose administration into the deltoid
muscle. The interval between the first (primary) dose and
second (booster) dose is commonly 6-12 months; however,
the interval between the doses is flexible and can be
extended to 18-36 months. It can be administered
simultaneously with other vaccines. Following 2 doses of
vaccine the protective efficacy is about 94 per cent.
The live attenuated vaccine is administered as a single
subcutaneous dose.
Weeks after exposure
Both inactivated and live attenuated hepatitis A vaccines
are highly immunogenic and immunization will generate
FIG. 1 long-lasting, possibly life-long, protection against the disease
Immunologic and biologic events associated with human infection in children and adults.
with hepatitis A virus. Recommendations for hepatitis A vaccination in outbreak
Source : (5) situation depend on the epidemiologic features of disease in

by R△J
 HEPATITIS B

the community and the feasibility of rapidly implementing acquired the virus. Prevalence is lower in the South-East
a widespread vaccination programme. National immunization Asia (3.0%), Eastern Mediterranean (2.5%) and European
programmes may consider inclusion of single-dose regions (1.5%), and in the Region of the Americas (0.5%).
inactivated hepatitis A vaccine in immunization schedule (10). Only 30.4 million people with chronic hepatitis B
Combination of hepatitis A and B, or hepatitis A and infection knew their hepatitis B status and 6.6 million were
typhoid vaccines have been developed, mainly intended for receiving treatment. The infection caused an estimated
use in adult travellers. 8,20,000 deaths in 2019, mostly from cirrhosis and
2. Human immunoglobulin : The protective efficacy of hepatocellular carcinoma. Globally in 2019, 36,000 people
immune globulin (Ig) against HAV infection is well died from acute hepatitis B (2), with the South-East Asia
documented. The duration of protection is, however, limited Region accounting about one third of those deaths (12,600).
to approximately 1-2 months and 3-5 months following Safe and effective vaccines exist for preventing hepatitis
administration of IgG at dose of 0.02 and 0.06 ml/kg body B infection. Their widening use has reduced the global
weight, respectively. Prophylaxis is achieved within hours of proportion of children under five years of age who are
injection and is 80 to 90 per cent effective when chronically infected with hepatitis B virus to just under
administered before or no later than 14 days after exposure. 1 per cent in 2019, down from around 5 per cent from the
The use of Ig worldwide is now declining because of 1980s to the early 2000s before vaccines were available.
insufficient concentration of anti-HAV IgG in non-specific Ig
preparations, the high cost of specific HAV IgG preparations, Most of the burden of HBV-related disease results from
the limited duration of protection following passive IgG infections acquired in infancy through perinatal or early
prophylaxis against HAV infection, and because hepatitis A childhood exposure to HBV because infection acquired at an
vaccines have been shown to induce rapid protection early age is more likely to become chronic than infection
against HAV after first dose (10). acquired later in life. The risk of chronic infection remains high
until after 5 years of age when the rate stabilizes at around 5%.
HEPATITIS B Co-infections with other viral infections occur most
Hepatitis B (formerly known as “serum” hepatitis) is an frequently in high HBV endemic areas. About 2.7 million of the
acute systemic infection with major pathology in the liver, 36.7 million people infected with HIV worldwide are co­
caused by hepatitis B virus (HBV). HBV infection can be infected with HBV. Approximately 10%-15% of patients with
either acute or chronic, and may range from asymptomatic chronic HBV infection are co-infected with HCV. HDV infection
infection or mild disease, to severe, or rarely fulminant occurs exclusively in HBV-infected individuals, as the virus is

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hepatitis. Acute hepatitis B is usually a self-limiting disease deficient, requiring HBV surface proteins to form its envelope in
marked by acute inflammation and hepatocellular necrosis HDV/HBV co-infected hepatocytes. Approximately 5% of
with case fatality rate of 0.5 to 1 per cent. Chronic hepatitis B HBV-infected persons are infected with HDV (14).
infection encompasses a spectrum of disease and is defined Major progress in the global response to viral hepatitis has
as persistent HBV infection with or without associated active been achieved through the expansion of routine hepatitis B
viral replication and evidence of hepatocellular injury and vaccination, which was facilitated by the introduction of new
inflammation. Age is a key factor in determining the risk of combination vaccines. In 2015, global coverage with 3 doses
chronic infection. Worldwide, the majority of persons with of hepatitis B vaccine during infancy reached 84 per cent
CHB were infected at birth or in early childhood (13). (14). By the year 2015, 185 countries had incorporated
Hepatitis B virus can form a dangerous alliance with delta hepatitis B vaccination in the national infant immunization
virus and produce a new form of virulent hepatitis which is schedule, and 97 countries had introduced the recommended
considered to be widespread threat for much of the world. birth dose. In the absence of the universal birth dose or other
Problem statement effective interventions, the transmission HBV infection from
mother-to-child remains a major source of chronic liver
WORLD disease when infected children become adults (14).
Hepatitis B is endemic throughout the world, especially in HBV infection also causes a significant economic burden
tropical and developing countries and also in some regions in terms of years of life lost from liver disease in high-income
of Europe (8). Its prevalence varies from country to country settings as well as in developing countries and accounts for
and depends upon a complex mix of behavioural, 5-10 per cent of liver transplants (13).
environmental and host factors. In general, it is lowest in
countries or areas with high standards of living. Epidemiological determinants
The HBV infection is a global problem, with 60 per cent Agent factors
of all the world’s population living in areas where there are (a) AGENT : Hepatitis B virus was discovered by Blumberg
high levels of infection. The endemicity of active HBV in 1963. Efforts to grow this virus have been so far
infection is reflected in the serologic prevalence of the unsuccessful (15). HBV is a complex, 42-nm, double-shelled
hepatitis B surface antigen (HBsAg) in the general DNA virus, originally known as the “Dane particle”. It
population of a defined geographical area. HBsAg replicates in the liver cells. HBV occurs in three morphological
prevalence of >8% defines highly endemic areas, prevalence forms in the serum of a patient: (a) small spherical particles
of 5%-7% defines high intermediate, 2%-4% low with an average diameter of 22-nm. These particles are
intermediate, and <2% defines low endemic areas. antigenic and stimulate production of surface antibodies;
WHO estimated that, in 2019, 296 million people were (b) tubules of varying length and diameter, and (c) the Dane
living with chronic hepatitis B infection (defined as hepatitis particle which corresponds morphologically to hepatitis B
B surface antigen positive), including about 1.5 million virus. A person who is serologically positive for the surface
people newly infected with the virus during that year. antigen is circulating all morphological forms, of which 22-nm
Hepatitis B prevalence is highest in the WHO African and particles constitute the bulk. Of the three morphological
Western Pacific regions where an estimated 7.5 per cent and forms, only the Dane particle is considered infectious, the
5.9 per cent, respectively, of the adult population have other circulating morphological forms are not infectious.

by R△J
252 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(b) RESERVOIR OF INFECTION : Man is the only perinatally, in 30-50 per cent infected in early childhood
reservoir of infection which can be spread either from (less than 6 years of age) and in <5 per cent occurring in
carriers or from cases. The continued survival of infection otherwise healthy adults (14).
is due to the large number of individuals who are carriers of (b) HIGH-RISK GROUPS: Certain groups carry higher risks.
the virus. The persistent carrier state has been defined as the The annual incidence of HBV infection in surgeons is estimated
presence of HBsAg (with or without concurrent HBeAg) for to be 50 times greater than that in the general population, and is
more than 6 months. Cases may range from inapparent to more than twice that of other physicians. Other high risk groups
symptomatic cases. comprise recipients of blood transfusions, health care and
(c) INFECTIVE MATERIAL : Contaminated blood is the laboratory personnel, homosexuals, prostitutes, percutaneous
main source of infection, although the virus has been found drug abusers, infants of HBV carrier mothers, recipients of solid
in body secretions such as saliva, vaginal secretions and organ transplants and patients who are immunocompromised.
semen of infected persons. Serological screening and vaccination of high-risk groups is
(d) RESISTANCE : The virus is quite stable and capable highly recommended.
of surviving for at least 7 days on environmental surfaces. It (c) HEPATITIS B AND HIV INFECTION : It is estimated
can be readily destroyed by sodium hypochlorite, as is by that 10 per cent of the 40 million people infected with HIV
heat sterilization in an autoclave for 30 to 60 minutes. worldwide are coinfected with HBV. Although HBV infection
(e) PERIOD OF COMMUNICABILITY : The virus is appears to have a minimal effect on the progression of HIV,
present in the blood during the incubation period (for a the presence of HIV markedly increases the risk of
month before jaundice) and acute phase of the disease. developing HBV-associated liver cirrhosis and hepatocellular
Period of communicability is usually several months carcinoma. The mortality rate increases among HIV-positive
(occasionally years in chronic carriers) or until disappearance people due to HBV coinfection both before and after
of HBsAg and appearance of surface antibody. commencement of highly active anti-retroviral therapy (15).
(d) HUMORAL AND CELLULAR RESPONSES (16):
Host factors Hepatitis B virus has three distinct antigens - a surface antigen,
(a) AGE The outcomes of HBV infection are also known as “Australia antigen” (HBsAg), a core antigen
age-dependent. Acute hepatits B occurs in approximately (HBeAg), and an “e” antigen (HBeAg). They stimulate the
1 per cent of perinatal, 10 per cent of early childhood production of corresponding antibodies e.g., surface antibody
(1-5 years of age), and 30 per cent of late (>5 years age) (anti-HBs), core antibody (anti-HBc) and “e” antibody (anti-

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HBV infections. Mortality from fulminant hepatitis B is HBe). These antibodies and their antigens constitute very
approximately 70 per cent. The development of chronic useful markers of HBV infection. Patients with HBV infection
HBV infection is inversely related to age and occurs in are expected to have one or more HBV markers. The course of
approximately 80-90 per cent of persons infected a typical acute hepatitis is outlined in Fig. 2.

Incubation Prodrome, Convalescence

period acute disease Early Late
Important HBsAg_______ | Anti-HBs_______
diagnostic tests
IjM anti-HBe i IgG anti-HBc
i jIIi x i

ALT
Symptoms

FIG. 2
Course of a typical acute hepatitis
ALT - alanine aminotransferase; anti-HBc - antibody to hepatitis B core antigen; anti-HBe - antibody to hepatitis Be antigen;
anti-HBs - antibody to hepatitis B surface antigen; HBeAg - hepatitis B e antigen; HBsAg - hepatitis B surface antigen;
HBV - hepatitis B virus; IgG - immunoglobulin G; IgM - immunoglobulin M.
Source : (5)

by R△J
 HEPATITIS B 253
Modes of transmission In short, transmission occurs in a wide variety of
epidemiological settings. It can spread either from carriers or
a. Parenteral route from people with no apparent infection, or during the
Hepatitis B is essentially a blood-borne infection. It is incubation period, illness or early convalescence.
transmitted by infected blood and blood products through
Incubation period
transfusions, dialysis, contaminated syringes and needles,
pricks of skin, handling of infected blood, accidental 30 to 180 days. Lower doses of the virus result often in
inoculation of minute quantities of blood such as may occur longer incubation period. The average incubation period is
during surgical and dental procedures, immunization, about 75 days (15).
traditional tattooing, ear piercing, nose piercing, ritual
circumcision, accupuncture, etc. Accidental percutaneous Clinical picture
inoculations by shared razors and tooth brushes have been The symptoms and manifestations of hepatitis B are
implicated as occasional causes of hepatitis B (13). similar to those of other types of viral hepatitis. The picture
is complicated by the carrier state and by chronic liver
b. Perinatal transmission disease, which may follow the infection. The spectrum of
Spread of infection from HBV carrier mothers to their disease and natural history of chronic HBV infection are
babies appears to be an important factor for the high diverse. In some people, CHB is inactive and does not lead
prevalence of HBV infection in some regions, particularly to significant liver disease. In others, it may cause
China and SE Asia. The risk of infection varies from country progressive liver fibrosis, leading to cirrhosis with end-stage
to country and unless vaccinated at birth, the majority of liver disease, and markedly increased risk of hepatocellular
children born to mothers who are HBeAg-positive become carcinoma, independent of the presence of cirrhosis -
chronically infected. The mechanism of perinatal infection is usually many years after initial infection. Longitudinal
uncertain. Although HBV can infect the foetus in utero, this studies of untreated persons with CHB show 8-20 per cent
rarely happens and most infections appear to occur at birth, cumulation risk of developing cirrhosis over 5 years. In
as a result of a leak of maternal blood into the baby’s those with cirrhosis, there is an approximately 20 per cent
circulation, or ingestion or accidental inoculation of blood annual risk of hepatic decompensation and the annual
(17). Infection of the baby is usually anicteric and is incidence of hepatic B related HCC is high, ranging from 1

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recognized by the appearance of surface antigen between to 5 per cent. Untreated patients with decompensated
60-120 days after birth (9). cirrhosis have poor prognosis, with 15-40 per cent survival
at 5 years. Several host and viral factors, especially
c. Sexual transmission coinfections with HIV, HCV and hepatitis D virus
There is ample evidence for the spread of infection by together with other cofactors such as alcohol use, may
intimate contact or by sexual route. Various body fluids increase the rate of disease progression and risk of
including saliva, vaginal, menstrual and seminal fluids have developing HCC (13).
been implicated as vehicles of human transmission. The
sexually promiscuous, particularly male homosexuals, are at Diagnosis
very high risk of infection with hepatitis B. There are three distinct antigen antibody systems that
relate to HBV infection and a variety of circulating markers
d. Other routes that are useful in diagnosis. The assays that detect the
Transmission from child-to-child, often called horizontal presence of either antigens or antibodies, typically in serum
transmission, is responsible for a majority of HBV infections or plasma but also in capillary blood and oral fluid. These
and carriers in parts of the world other than Asia. The include rapid diagnostic tests (RDTs), and laboratory-based
researchers believe that the spread occurs through physical immunoassays, e.g. enzyme immunoassays (EIAs),
contact between children with skin conditions such as cuts or chemiluminescence immunoassays (CLIAs), and electro­
grazes. Often transmission occurs when children play chemiluminescence immunoassays (ECLs). Interpretation of
together or share the same bed (18). common serological patterns is as shown in Table 2.

TABLE 2
Common serologic patterns in hepatitis B virus infection and their interpretation

1 Low levels of IgM anti-HBc may also be detected.

Source : (16)

by R△J
254 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

PREVENTION AND CONTAINMENT the primary vaccination series drops below 90 per cent; by
60 years, protective antibody levels are achieved in only
Since there is no specific treatment, prevention has been 65-75 per cent of the vaccinees. The duration of protection
the major aim in managing viral hepatitis B. The following is at least 15 years and based on current scientific evidence,
measures are available : life long (20). Some infants born prematurely with low birth
weight (< 2000 g) may not respond well to vaccination at
a. Hepatitis B vaccine birth. However, by one month of chronological age, all
The recombinant hepatitis B vaccine was introduced in premature infants, regardless of initial birth weight or
1986 and has gradually replaced the plasma-derived gestational age, are likely to respond adequately. In such
hepatitis B vaccine. The active substance in recombinant cases the vaccine dose given at birth should not be counted
hepatitis B vaccine is HBsAg. towards the primary series and 3 additional doses should be
Hepatitis B vaccine is available as monovalent given according to the national immunization schedule (15).
formulation, or in fixed combination with other vaccines, Immunosuppressive illness such as advanced HIV
including DPT, Hib, hepatitis A and inactivated polio. The infection, chronic liver disease, chronic renal failure, and
immune response and safety of these combinations of diabetes are associated with reduced immunogenicity of the
vaccines are comparable to those observed when the vaccine.
vaccines are administered separately. When immunizing Data on immunogenecity suggest that in any age group,
against HBV at birth, only monovalent hepatitis B vaccine interruption of the vaccination schedule does not require
should be used. Internationally marketed hepatitis B restarting of the vaccine series. If the primary series is
vaccines are considered immunologically comparable and interrupted after the first dose, the second dose should be
can be used interchangeably (19). administered as soon as possible and the second and the
The dose for adults is 10-20 micrograms initially third doses separated by a minimum interval of 4 weeks; if
(depending on the formulation) and again at 1 and 6 only the third dose is delayed, it should be administered as
months. Children under 10 years of age should be given half soon as possible (15).
of the adult dose at the same time intervals. For greatest Immunization in adults Routine pre-exposure
reliability of absorption, the deltoid muscle is preferred for vaccination should be considered for groups of adults who
injection as gluteal injection often results in deposition of are at increased risk of HBV infection. Adults 20 years of age

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vaccine in fat rather than muscle, with fewer serologic and older should receive 1 ml of adult formulation. The
conversion. For infants and children under 2 years, usual schedule for adults is two doses separated by no less
anterolateral aspect of thigh is used as vaccination site. than 4 weeks, and a third dose 4 to 6 months after the
Intradermal administration is not recommended because the second dose. If an accelerated schedule is needed, the
immune response is less reliable particularly in children. The minimum interval between first and second dose is 4 weeks
hepatitis B vaccine does not interfere with immune response and the minimum interval between the second and third
to any other vaccine and vice-versa. The birth dose dose is 8 weeks. However, the first and the third doses
of hepatitis B can be given safely together with BCG should be separated by no less than 16 weeks. Doses given
vaccine. However, the vaccines should be given at different at less than these minimum intervals should not be counted
sites. as part of the vaccination series. It is not necessary to restart
There are multiple options for incorporating the hepatitis the series or add doses because of an extended interval
B vaccine into national immunization programmes. The between doses (8).
choice of schedule depends on the local epidemiological The high-risk persons for whom the vaccination is
situation and programme considerations. The recommended recommended are persons with high-risk sexual behaviour,
schedule for vaccination can be divided into those that partners and household contacts of HBsAg-positive
include a birth-dose and those that do not. Schedules with a persons, injecting drug users, persons who frequently
birth-dose call for the first dose at birth, followed by a require blood or blood products, recipients of solid organ
second dose and third dose at the time of the first and third transplantation, those at occupational risk of HBV infection,
dose of DPT vaccination respectively. Alternatively, a four- including health care workers, as well as for international
dose schedule may be used (as in India) where the dose at travellers to HBV endemic countries.
birth is followed by three additional doses at 6, 10 and Hepatitis B vaccine is contraindicated for individuals with
14 weeks with DPT vaccination. These doses may be given a history of allergic reactions to any of the vaccine's
either as monovalent vaccine or as a combination (eg. with components. Neither pregnancy nor lactation is a
DPT and/or Hib) following the schedules commonly used for contraindication for use of this vaccine (20).
these vaccines. The minimum recommended interval
between the doses is four weeks. Longer dose intervals may The vaccine should be stored at 2-8°C. Freezing must be
increase the final anti-HBs titres but not the sero-conversion avoided as it dissociates antigen from the alum adjuvant.
rates. These schedules will prevent most perinatally acquired
infection. In countries where a high proportion of HBV Pentavalent Vaccine
infection is acquired perinatally, specifically in countries It is a combined vaccine giving protection against
where the prevalence in the general population of chronic diphtheria, pertussis, tetanus, hepatitis B and Hib. Kindly
HBV infection is more than 8 per cent, the first dose of refer to page 181 for details.
hepatitis B vaccine should be given within 24 hours after
birth to prevent perinatal transmission (20). b. Hepatitis B immunoglobulin (HBIG)
The complete vaccine series induces protective antibody For immediate protection, HBIG is used for those acutely
levels in more than 95 per cent of infants, children and exposed to HBsAg-positive blood, for example (a) surgeons,
young adults. After the age of 40 years, protection following nurses or laboratory workers (b) newborn infants of carrier
by R△J
 HEPATITIS B 255
mothers (c) sexual contacts of acute hepatitis B patients, and CHRONIC HEPATITIS B AND
(d) patients who need protection against HBV infection after HEPATITIS C INFECTION
liver transplantation. The HBIG should be given as soon as
possible after an accidental inoculation (ideally within Chronic HBV infection is defined as persistence of
6 hours and preferably not later than 48 hours). At the same hepatitis B surface antigen (HBsAg) for six months or more
time the victim’s blood is drawn for HBsAg testing. If the test after acute infection with HBV. Worldwide, there are an
is negative, vaccination should be started immediately and a estimated 257 million people living with chronic HBV
full course given. If the test is positive for surface antibody, infection and 110 million persons are HCV-antibody
no further action is needed (21). positive, and 80 million have chronic viraemic HCV
infection.
The recommended dose is 0.05 to 0.07 ml/kg of
body weight (22); two doses should be given 30 days Despite the high global burden of disease due to chronic
apart (22, 23). HBIG provides short-term passive protection hepatitis B and C infection, and the advances and
opportunities for treatment, most people infected with HBV
which lasts approximately 3 months. Since the median
and/or HCV remain unaware of their infection and therefore
incubation period is said to be lower than 100 days (24),
frequently present with advance disease. Early identification
two doses of HBIG given one month apart should suffice.
of the infection would enable infected persons to receive the
The general use of HBIG for long-term prophylaxis has not necessary care and treatment to prevent or delay the onset
been recommended because of its limited availability, its of liver disease and in addition, prevent transmission by
high cost and risk (although remote) of complications HBV vaccination of the non-immune household contacts
through repeated use over a long period of time (25). and sex partners (26).
c. Passive-active immunization The WHO “5Cs”
The simultaneous administration of HBIG and hepatitis B The WHO “5Cs” are principles that apply to all models of
vaccine is more efficacious than HBIG alone. HBIG does not hepatitis testing and in all settings : Consent, Confidentiality,
interfere with the antibody response to the hepatitis B Correct test results, Counselling and Connection (linkage to
vaccine. This combined procedure is ideal both for prevention, treatment and care services). This means
prophylaxis of persons accidentally exposed to blood known hepatitis testing for diagnosis must always be voluntary, and
to contain hepatitis B virus, and for prevention of the carrier consent for testing informed by pre-test information (26).

telegram-@Cherry_2412
state in the newborn babies of carrier mothers. HBIG Fig. 3 and 4 show summary algorithm for diagnosis,
(0.05-0.07 ml/kg) should be given as soon as possible treatment and monitoring of chronic HBV and HCV
and within 24 hours, if possible. Hepatitis B virus vaccine infection respectively.
1.0 ml (20 mcg/1.0 ml) should be given intramuscularly
Chronic hepatitis B infection can be treated with drugs.
within 7 days of exposure, and second and third doses
Treatment can slow the progression of cirrhosis, reduce
should be given one and six months, respectively, after the
incidence of liver cancer and improve long term survival.
first dose. WHO recommends the use of oral treatments - tenofovir or
entecavir, as these are the most potent drugs to suppress
d. Other measures
hepatitis B virus. They rarely lead to drug resistance as
All blood donors should be screened for HBV infection, compared with other drugs, are simple to take (1 pill a day),
and those positive for HBsAg also known as Australia and have few side effects so require only limited monitoring.
antigen should be rejected. Voluntary blood donation should In most people, however, the treatment only supresses the
be encouraged because purchased blood has shown a replication of the virus. Therefore, people who start hepatitis
higher risk of post-transfusion hepatitis (8). Health B treatment must continue it for life. Treatment using
personnel should be alerted to the importance of adequate interferon injections may be considered in some people in
sterilization of all instruments and to the practice of simple certain high-income settings, as this may shorten treatment
hygienic measures. Carriers should be told not to share duration. But its use is less feasible in low-resource settings
razors or tooth brushes and use barrier methods of due to high cost and significant adverse effects requiring
contraception; they should not donate blood. careful monitoring (27).
Most international guidelines recommend that several In March 2015, WHO launched its first “Guidelines for the
high-risk groups be screened for HBsAg, and that those at prevention, care and treatment of persons living with chronic
risk and not immune should be offered hepatitis B hepatitis B infection”. The recommendations are (27) :
vaccination. These include: household and sexual contacts - promote the use of simple, non-invasive diagnostic tests
of persons with CHB, HIV-infected persons, persons who to assess the stage of liver disease and eligibility for
inject drugs (PWID), men who have sex with men, sex treatment;
workers, as well as other groups such as indigenous people, - prioritize treatment for those with most advanced liver
persons who are imprisoned, and persons of transgender. disease and at greatest risk of mortality; and
Blood and organ donors should also be screened for HBsAg - recommend the preferred use of the nucleotide/
and other bloodborne pathogens in accordance with WHO nucleoside analogues with a high barrier to drug
recommendations to prevent HBV transmission (13). resistance (tenofovir and entecavir, and entecavir in
children aged between 2-11 years) for first and second-
Treatment line treatment.
There is no specific treatment for acute hepatitis B. Care These guidelines also recommend lifelong treatment in
is aimed at maintaining comfort and adequate nutritional those with cirrhosis; and regular monitoring for disease
balance, including replacement of fluids lost from vomiting progression, toxicity of drugs and early detection of liver
and diarrhoea. cancer (27)
by R△J
256 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

HEPATITIS B SURFACE ANTIGEN (HBsAg)

J Single RDT1 or laboratory-based immunoassay2
<
5z ▼ ____ r__________ 1±
O
-J H
(/) HBsAg + (reactive) HBsAg - (non-reactive)
O w Report positive Report negative
KH
U
C/> Compatible with No serological evidence
HBV infection of HBV infection

ASSESSMENT OF STAGE OF LIVER DISEASE

(using clinical criteria3 and/or non-invasive tests (NITs) for
presence of cirrhosis, i.e. APRI score4 >2 or based on TE5)

HBV DNA Nucleic Acid Test (NAT) (quantitative)

H (to further guide who to treat and not treat,
zw if no evidence of cirrhosis)
s
<c
u Presence of Cirrhosis
tx
H
X ALL AGES AGE
oU
m >30 years (in particular) <30 years
H I
ZUJ ALT6’7 ALT6 ALT6 ALT6
5
x Persistently abnormal Intermittently Persistently Persistently
6
UJ abnormal normal normal
_i_______,

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cn
< HBV DNA HBV DNA HBV DNA HBV DNA
>20,000 IU/mL 2000-20,000 IU/mL <2000 IU/mL <2000 IU/mL
i 4 ” * i'
___________ ▼___________ 3 ' ______ ▼ ,
"i
INITIATE ANTIVIRAL THERAPY8
AND MONITOR DEFER TREATMENT AND MONITOR
• Tenofevir or entecavir
• Entecavir in children aged 2-11 years

DETECTION OF HCC in persons with cirrhosis or HCC family history (every 6 months)
• Ultrasound and serum AFP

TREATMENT RESPONSE AND/OR DISEASE PROGRESSION (every 12 months)

• Adherence at each visit, if on treatment
• ALT, HBV DNA and HBeAg
• Staging of liver disease (clinical criteria and NITs (e.g. APRI in adults or TE)

TOXICITY MONITORING IN PERSONS ON TREATMENT (baseline and every 12 months)

• Renal function and risk factors for renal dysfunction

FIG. 3
Summary algorithm for diagnosis, treatment and monitoring of chronic HBV infection
Abbreviations : RDT: rapid diagnostic test; ALT: alanine aminotranferase: APRI: aspartase aminotransferase-to-platelet ratio index; TE: transient
elastography; HCC: hepatocellular carcinoma: AFP: apha fetoprotein
1 In settings or populations with a low HBsAg seroprevalence <0.4%, confirmation of HBsAg positivity on the same immunoassay with a
neutralization step or a second different RDT assay for detection of HBsAg may be considered.
2 Laboratory-based Immunoassays include enzyme immunoassay (EIA), chemoluminescence immunoassay (CLIA), and electrochemolumin­
escence assay (ECL)
3 Decompensated cirrhosis is defined by the development of portal hypertension (ascites, variceal haemorrhage and hepatic encephalopathy),
coagulopathy, or liver insufficiency (jaundice). Other clinical features of advanced liver disease/cirrhosis may include: hepatomegaly,
splenomegaly, pruritus, fatigue, arthralgia, palmar erythema, and oedema.
4 Aspartate aminotransferase (AST)-to-platelet ratio index (APRI) is a simple index for estimating hepatic fibrosis based on a formula derived
from AST and platelet concentrations.
The formula for calculating the APRI score is : APRI = (AST/AST ULN) x 100)/platelet count (109/L). Most recommend using 40 IU/L as the
value for AST upper limit of normal (ULN).
5 Transient elastography (Fibroscan): a technique to measure liver stiffness (as a surrogate for fibrosis)
6 ALT levels fluctuate in persons with chronic hepatitis B and require longitudinal monitoring to determine the trend. Upper limits for normal
ALT have been defined as below 30 U/L for men and 19 U/L for women, though local laboratory normal ranges should be applied. Persistently
normal/abnormal may be defined as three ALT determinations below or above the upper limit or normal, made at unspecified intervals during
a 6-12 month period or predefined intervals during a 12 month period.
7 Where HBV DNA testing is not available, treatment may be considered based on persistently abnormal ALT levels, such as impaired glucose
tolerance, dyslipidaemia and fatty liver should be excluded.
8 Initiate antiviral therapy with tenofovir alone only after exclusion of HIV coinfection.

Source : (26)

by R△J
 HEPATITIS B

ANTI-HCV ANTIBODY
Single RDT or laboratory-based immunoassay1

Anti-HCV + (reactive) Anti-HCV - (non-reactive)

Report positive Report negative

Compatible with current or past No serological evidence of

HCV infection HCV infection

HCV RNA NUCLEIC ACID TEST (NAT)

(qualitative or quantitative) or
HCV core antigen (cAg)

.y y__________________
HCV RNA test or cAg + Report detected HCV RNA test or cAg -
(with viral load if available) Report not detected

Compatible with viraemic No current viraemic HCV

HCV infection

y
ASSESSMENT OF STAGE OF LIVER
DISEASE (using clinical criteria2 and FACTORS TO BE CONSIDERED IN
non-invasive tests (NITs), i.e. APRI PRIORITIZING TREATMENT
score3 >2 or based on TE4) 1. Increased risk of death (e.g. advanced
fibrosis and cirrhosis, post-liver
OTHER CONSIDERATIONS FOR transplantation)
Z TREATMENT (e.g. comorbidities, 2. Risk of accelerated fibrosis (e.g. HIV
UJ

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HCV genotyping, pregnancy and or HBV coinfection, metabolic
S syndrome, high level of alcohol use)
c/> potential drug-drug interactions)
X 3. Extrahepatic manifestations and
UJ evidence of end-organ damage (e.g.
(f) debilitating fatigue, vasculitis and
in
<
SELECT DIRECT-ACTING lymphoproliferative disorders)
H ANTIVIRAL (DAA) REGIMEN5 4. Significant psychosocial morbidity
z Daclatasvir/sofosbuvir or ledipasvir/ (e.g. due to stigma, discrimination,
LU fear of transmission to others)
S sofosbuvir ± ribavirin for 12 or 24 weeks 5. Maximizing reduction in incidence
< (depending on genotype and presence (e.g. in PWID, MSM, prisoners, sex
LU of cirrhosis) workers, women of childbearing age,
X health -care workers)
H

ASSESSMENT OF CURE (sustained virological response (SVR) at 12 weeks (i.e. SVR 12) after the end of treatment)
HCV RNA NAT (qualitative and quantitative)

DETECTION OF HCC in persons with cirrhosis (every 6 months)

Ultrasound and AFP

FIG. 4
Summary algorithm for diagnosis, treatment and monitoring of chronic HCV infection

Abbreviations: RDT: rapid diagnostic test: APRI: aspartase aminotransferase-to-platelet ratio index, TE: transient elastography; PWID: people
who inject drugs; MSM: men who have sex with men; HCC: hepatocellular carcinoma; AFP: alpha fetoprotein
1 Laboratory-based immunoassays include enzyme immunoassay (EIA), chemoluminescence immunoassay (CLIA), and
electrochemoluminescence assay (ECL).
2 Decompensated cirrhosis is defined by the development of portal hypertension (ascites, variceal haemorrhage and hepatic encephalopathy),

coagulopathy , or liver insufficiency (jaundice). Other clinical features of advanced liver disease/cirrhosis may include: hepatomegaly,
splenomegaly, pruritus, fatigue, arthralgia, palmar erythema, and oedema.
3 Aspartate aminotransferase (AST)-to-platelet ratio index (APRI) is a simple index for estimating hepatic fibrosis based on a formula derived

from AST and platelet concentrations. The formula for calculating the APRI score is: APRI = (AST/AST ULN) x 100)/platelet count (109/L).
Most recommend using 40 IU/L as the value for AST upper limit of normal (ULN).
4 Transient elastography (Fibroscan) is a technique to measure liver stiffness (as a surrogate for fibrosis).

5 Caution: there is a potential but uncertain risk of HBV reactivation during or after HCV clearance. Prior to starting DAA therapy, test for HBV
infection (HBsAg, HBeAg, and HBV DNA) to assess indication for HBV treatment. Continue careful monitoring after completion of DAA
therapy, including for HCC.
Source : (26)

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Surveillance (27A) 2030. It focuses on HBV and HCV and proposes to increase
Infections with HBV or HCV evolve in three phases. New the coverage of preventions and to scale up testing and
infections (mostly asymptomatic but sometimes symptomatic treatment. The key interventions of the Global Health Sector
in the form of acute hepatitis) may evolve into chronic strategy for Viral Hepatitis are :
infections (usually asymptomatic), which may further evolve Prevention 1. Three-dose hepatitis B vaccine for
into sequelae (cirrhosis and HCC) that lead to morbidity and Interventions infants.
mortality. As there can be more than 20-30 years between 2. Prevention of HBV mother-to-child
infection and mortality, viral hepatitis surveillance needs to transmission using hepatitis B birth
capture these three phases to fully describe the dose or other approaches.
epidemiological situation. Estimations of current, prevalent 3. Blood safety and injection safety,
infections guide testing and treatment, which would prevent including use of engineered devices.
future morbidity and mortality. Current mortality from the 4. Harm reduction for persons who use
sequelae of chronic infections acquired in the past quantifies drugs.
the baseline burden and evaluates the impact of past Treatment 5. Diagnosis of HBV and HCV.
interventions. The three components of viral hepatitis Interventions 6. Treatment of HBV and HCV.
surveillance as shown in Table 3, may be implemented by WHO commissioned a mathematical model, which
different acts of the public health system. Thus, the suggests that hepatitis B and C could be eliminated as a public
programme responsible for viral hepatitis needs to health threat by 2030 if the response to viral hepatitis reaches
consolidate and triangulate sources of information from the service coverage targets for five core interventions of
these different systems to describe the epidemiological prevention, testing and treatment. The standard indicators,
situation of HBV and HCV infection. 2015 baseline and the targets are as shown in Table 4.
Global Health Sector Strategy on Viral HEPATITIS C
Hepatitis 2016-2021 (28, 29) Hepatitis C is a contagious liver disease that results from
In May 2016, The World Health Assembly adopted the infection with the hepatitis C virus. It can range in severity
first “Global Health Sector Strategy on Viral Hepatitis, from a mild illness lasting a few weeks to a serious, lifelong
2016-2021”. The strategy highlights the critical role of illness. It is among the most common virus that infect the

telegram-@Cherry_2412
Universal Health Coverage and the targets of the strategy liver and it has been shown to be a major cause of
are aligned with those of the Sustainable Development parenterally transmitted hepatitis.
Goals. The strategy has a vision of eliminating viral hepatitis Every year, 1.5 million people are infected with the
as a public health problem and this is encapsulated in the hepatitis C virus. About 110 million people are HCV
global targets of reducing new cases of chronic HBV and antibody positive and 58 million are chronically infected
HCV infections by 90% and reducing deaths due to viral and are at risk of developing liver cirrhosis and/or liver
hepatitis by 65% (from 1.4 million to less than 500,000) by cancer. More than 2,90,000 people died from hepatitis C -

TABLE 3
Activities that contribute to surveillance for viral hepatitis

1. Surveillance for acute hepatitis 2. Surveillance for chronic, 3. Surveillance for sequelae
that reflects new infections prevalent hepatitis
Activities - Syndromic surveillance in the - Regular biomarker surveys Combination of data from death
general population certificates, and testing of
- Event-based surveillance patients with cirrhosis and HCC
- Enhanced case reporting (with for HBV and HCV infection
in-vitro diagnosis and collection
of information on risk factors)
Population - Persons presenting with acute - Persons without acute symptoms - Persons diagnosed with cirrhosis
under hepatitis to health-care facilities tested during population surveys and HCC
surveillance (discrete onset of symptoms)
Usual - Communicable disease - Hepatitis programme in - Vital registration
implementer surveillance coordination with the other - Sentinel sites caring for patients
- Communicable disease actors implementing with cirrhosis and HCC
surveillance (if countrywide) biomarker surveys Cancer registries
- Hepatitis programme
(if sentinel sites)
Case - Presumptive case of acute - Chronic HBV and HCV Cases of cirrhosis or HCC
definitions hepatitis infection Chronic HBV or HCV infection
to use - Confirmed case of acute - Serological evidence of past or
hepatitis (by type) present HCV infection
Objective of - Detect outbreaks - Estimate the prevalence Estimate mortality from HBV- or
the surveillance - Describe trends in type-specific of infections HCV-associated HCC
activity acute hepatitis and identify - Model incidence trends and cirrhosis
risk factors
HBV: hepatitis B virus; HCC: hepatocellular carcinoma; HCV: hepatitis C virus
Source : (27A)

by R△J
 HEPATITIS C 259

TABLE 4
Service coverage indicators : 2015 baseline and targets
Baseline 2020 2030
Level Areas Indicators 2015 target target
Service Prevention 1. Three-dose hepatitis B vaccine for infants 82% 90% 90%
coverage (coverage %)
2. Prevention of mother-to-child transmission of HBV: 38% 50% 90%
hepatitis B birth-dose vaccination or other
approaches (coverage %)
3a Blood safety: donations screened with quality 89% 95% 100%
assurance (coverage %)
3b. Injection safety: use of engineered devices 5% 50% 90%
(coverage %)*
4. Harm reduction (sterile syringe/needle sets 20 200 300
distributed per person per year for PWID)
Testing and 5a. Diagnosis of HBV and HCV <5% 30% 90%
treatment (coverage %)
5b. Treatment of HBV and HCV <1% 5 million (HBV) 80% eligible
(coverage %) 3 million (HCV) treated

Impact leading Incidence Incidence of chronic HBV and HCV infections 6-10 million -30% -90%
to elimination Mortality Mortality from chronic HBV and HCV infections 1.46 million -10% -65%
HBV: hepatitis B virus; HCV: hepatitis C virus; PWID: persons who inject drugs
* While the service coverage target is about output (adoption of reuse-prevention injection devices), the C.5 indicator focusses on outcome
(provision of safe injections).
Source : (27A)

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related liver diseases in 2019. It is estimated that about methods of antibody detection cannot differentiate between
2.3 million people were co-infected with HCV and HIV (31). acute and chronic infection. The presence of antibodies
against the hepatitis C virus indicates that a person is or has
Transmission been infected. The hepatitis C virus recombinant
The hepatitis C virus is most commonly transmitted immunoblot assay (RIBA) and hepatitis C virus RNA testing
through exposure to infectious blood. This can occur are used to confirm the diagnosis. Diagnosis of chronic
through: (a) receipt of contaminated blood transfusions, infection is made when antibodies to the hepatitis C virus
blood products and organ transplants; (b) injections given are present in the blood for more than six months. Similar to
with contaminated syringes and needle-stick injuries in acute infections, diagnosis is confirmed with an additional
health-care settings; (c) injection drug use; and (d) being test. Specialized tests are often used to evaluate patients for
born to a hepatitis C-infected mother. liver disease, including cirrhosis and liver cancer.
Hepatitis C may be transmitted through sex with an Early diagnosis can prevent health problems that may
infected person or sharing of personal items contaminated result from infection and prevent transmission to family
with infectious blood, but these are less common. Hepatitis members and other close contacts. Some countries
C is not spread through breast milk, food or water, or by recommend screening for people who may be at risk for
casual contact such as hugging, kissing and sharing food or infection. These include: (a) people who recevied blood,
drinks with an infected person. blood products or organs before screening for hepatitis C virus
was implemented, or where screening was not yet widespread,
Incubation period (b) current or former injecting drug users (even those who
The incubation period for hepatitis C is 2 weeks to injected drugs once many years ago); (c) people on long-term
6 months. haemodialysis; (d) health-care workers; (e) people living with
HIV; (f) people with abnormal liver tests or liver disease, and
Symptoms (g) infants born to infected mothers; people having invasive
Following initial infection, approximately 80 per cent of procedures in health care facilities with inadequate infection
people do not exhibit any symptoms. Those people who are control; people who have had tattoos and piercings; and
acutely symptomatic may exhibit fever, fatigue, decreased people with sexual partners who are HCV infected (31).
appetite, nausea, vomiting, abdominal pain, dark urine, grey­
coloured faeces, joint pain and jaundice. About, Treatment (31)
15-45 per cent of infected persons spontaneously clear the Hepatitis C does not always require treatment as the immune
virus within 6 months of infection without any treatment. The response in some people will clear the infection, and some
remaining 55-85 per cent of persons will develop chronic people with chronic infection do not develop liver damage.
HCV infection. Of those with chronic HCV infection, the risk When treatment is necessary, the goal of hepatitis C treatment is
of cirrhosis of liver is 15-30 per cent within 20 years (31). cure. The cure rate depends on several factors including the
strain of the virus and the type of treatment given. The standard
Diagnosis (32) of care for hepatitis C is changing rapidly. Until recently,
Diagnosis of acute infection is often missed because a hepatitis C treatment was based on therapy with interferon and
majority of infected people have no symptoms. Common ribavirin, which required weekly injections for 48 weeks, cured

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

approximately half of treated patients, but caused frequent and Secondary and tertiary prevention
sometimes life-threatening adverse reactions. Recently, new For people infected with the hepatitis C virus, WHO
antiviral drugs have been developed. These medicines, called recommends:
direct antiviral agents (DAA) are much more effective, safer and
better-tolerated than the older therapies. Therapy with DAAs - education and counselling on options for care and
can cure most persons with HCV infection and treatment is treatment;
shorter (usually 12 weeks) and safer. Although the production - immunization with the hepatitis A and B vaccines to
cost of DAAs is low, these medicines remain very expensive in prevent coinfection from these hepatitis viruses to
many high- and middle-income countries. The cost of generic protect their liver,
version of these medicines are low. - early and appropriate medical management including
antiviral therapy if appropriate; and
Prevention - regular monitoring for early diagnosis of chronic liver
Primary prevention disease.
1. Hand hygiene: including surgical hand preparation, For a number of technical reasons, the development of a
hand washing and use of gloves; vaccine to prevent HCV infection is unlikely for many years.
2. Safe and appropriate use of health care injections; The epidemiologic and clinical features of hepatitis A,
3. Safe handling and disposal of sharps and waste; hepatitis B and hepatitis C are summarized in Table 5.
4. Provision of comprehensive harm-reduction services to HEPATITIS E
people who inject drugs including sterile injecting
equipment; The infection caused by the hepatitis E virus (HEV) which
5. Testing of donated blood for hepatitis B and C; was discovered in 1980, is essentially a water-borne disease.
Formerly termed enterically transmitted hepatitis non-A,
6. Training of health personnel; and non-B (HNANB), HEV is a 29-nm to 32-nm RNA virus with
7. Promotion of correct and consistent use of condoms. 4 genotypes (type 1, 2, 3 and 4).

TABLE 5

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Epidemiologic and clinical features of viral hepatitis types A, B and C
Viral Hepatitis Type A Viral Hepatitis Type B Viral Hepatitis Type C
Incubation period 10-50 days (avg. 25-30) 50-180 days (avg. 60-90) 2 weeks-6 months
(avg. 40-120 days)
Principal age distribution Children1, young adults 15-29 years2 Adults2
Seasonal incidence Throughout the year but tends Throughout the year Throughout the year
to peak in autumn
Route of infection Predominantly faecal-oral Predominantly parenteral Predominantly parenteral
Occurrence of virus :
Blood 2 weeks before to < 1 week Months to years Months to years
after jaundice
Stool 2 weeks before to 2 weeks Absent Probably absent
after jaundice
Urine Rare Absent Probably absent
Saliva, semen Rare (saliva) Frequently present Unknown
Clinical and laboratory features :
Onset Abrupt Insidious Insidious
Fever > 38°C (100.4°F) Common Less common Less common
Duration of aminotransferase 1-3 weeks 1-6+ months 1-6+ months
elevation
Immunoglobulins (IgM levels) Elevated Normal to slightly elevated Normal to slightly elevated
Complications Uncommon, no chronicity Chronicity in 5-10% Chronicity in 50% or more
Mortality rate (icteric cases) < 0.5% < 1-2% 0.5-1%
HBsAg Absent Present Absent
Immunity :
Homologous Yes Yes ?
Heterologous No No No
Duration Probably lifetime Probably lifetime ?
Immune globulin intramuscular Regularly prevents jaundice Prevents jaundice only if ?
(IG, gammaglobulin, ISG) immunoglobulin is of sufficient
__________________________ ______________________ potency against HBV
1 Non-icteric hepatitis is common in children.
2 Among the age group 15-29 years, hepatitis B and C are often associated with drug abuse or promiscuous sexual behaviour. Patients with
transfusion-associated HBV or HCV are generally over age 29.
Source : (5)

by R△J
 HEPATITIS E

Hepatitis E is found worldwide and different genotypes of Treatment

the hepatitis E virus determine differences in epidemiology.
Hepatitis E is usually self-limiting. Prevention is the most
For example, genotype 1 is usually seen in developing
effective approach against the disease as there is no specific
countries and causes community-level outbreaks while
treatment for altering the course of acute hepatitis.
genotype 3 is usually seen in the developed countries, and
Hospitalization is required for fulminant cases and in
does not cause outbreaks. Hepatitis E prevalence is highest
symptomatic pregnant women. Recovery from disease is always
in East and South Asia with genotype 1 most commonly
complete. No specific immunoglobulin prophylaxis is available.
found in India. Countries with limited resources, i.e., limited
access to essential water, sanitation, hygiene and health Prevention
services are frequently affected. In recent years, some of
The risk of infection and transmission can be reduced by
these outbreaks have occurred in areas of conflict and
maintaining quality standards for public water supplies and
humanitarian emergencies, such as war zones, and in camps
establishing proper disposal systems to eliminate sanitary
for refugees or internally displaced populations. An
estimated 20 million infections and 3.3 million acute cases waste. On an individual level, infection risk can be reduced
occur annually worldwide. An estimated 44,000 deaths by : (a) maintaining hygienic practices such as hand washing
with safe water, particularly before handling food;
occurred in 2015 (33). Over 60 per cent of all hepatitis E
(b) avoiding drinking water and/or ice of unknown purity;
infections and 65 per cent of hepatitis deaths occur in East
and (c) adhering to WHO safe food practices.
and South Asia, where seroprevalence rate of 25 per cent
are common in some age groups (34). In 2011, the first vaccine to prevent hepatitis E infection
was registered in China, although it is not available globally.
Transmission
The hepatitis E virus is transmitted mainly through the HEPATITIS D (35)
faecal-oral route, due to faecal contamination of drinking
Hepatitis D is caused by hepatitis D virus that requires HBV
water. Other transmission routes have been identified, which
for its replication. Hepatitis D cannot occur in the absence of
include : (a) food-borne transmission from ingestion of
HBV. The coinfection or super infection of HDV with HBV
products derived from infected animals; (b) transfusion of
causes a more severe disease than HBV monoinfection.
infected blood products; and (c) vertical transmission from a
pregnant woman to her foetus.
Geographic distribution

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Incubation period It is estimated that globally, 5% of HBsAg positive people
The incubation period following exposure to the are coinfected with HDV and the distribution is resulting in a
hepatitis E virus ranges from three to eight weeks, with a total of 15-20 million persons infected with HDV world­
mean of 40 days. The period of communicability is wide. High-prevalence areas include the Mediterranean,
unknown. Middle East, Pakistan, Central and Northern Asia, Japan,
Taiwan, Greenland and parts of Africa (mainly the horn of
Symptoms Africa and West Africa), the Amazon Basin and certain areas
Symptomatic infection is more common in young adults of the Pacific. Prevalence is low in North America and
aged 15-40 years. Although infection is frequent in children, Northern Europe, South Africa, and Eastern Asia.
the disease is mostly asymptomatic or causes a very mild
illness without jaundice that goes undiagnosed. The typical Route of transmission
symptoms are jaundice, loss of appetite, abdominal pain The route of HDV transmission are the same as for HBV:
and tenderness, nausea and vomiting, fever and enlarged percutaneously or sexually through contact with infected
and tender liver. The symptoms are largely indistinguishable blood or blood products. Vertical transmission is possible
from those experienced during any acute phase of hepatic but rare. Vaccination against HBV prevents HDV
illness and last for one or two weeks. coinfection, and hence expansion of childhood HBV
In rare cases, acute hepatitis E can result in fulminant immunization programmes has resulted in a decline in
hepatitis D incidence worldwide. However, in some settings,
hepatitis (acute liver failure) and death. Fulminant hepatitis
the increase of hepatitis D prevalence has been observed in
occurs more frequently during pregnancy. Pregnant women
people who inject drugs, or as a result of migration from
are at greater risk of obstetrical complications and mortality
areas where HDV is endemic.
from hepatitis E, which can induce a mortality rate of
20 per cent among pregnant women in their third trimester. Diagnosis
Cases of chronic hepatitis E infection have been reported HDV infection is diagnosed by high titres of
in immunosuppressed people. Reactivation of hepatitis E Immunoglobulin G (IgG) and Immunoglobulin M (IgM) anti­
infection has also been reported in immunocompromised HD V, and confirmed by detection of HDV RNA in serum.
people.
However, HDV diagnostics are not widely available and
Diagnosis there is no standardization for HDV RNA assays, which are
used for monitoring response to antiviral therapy.
Cases of hepatitis E are not clinically distinguishable from
other types of acute viral hepatitis. Diagnosis of hepatitis E Treatment
infection is, therefore, usually based on the detection of There is no specific treatment for acute or chronic HDV
specific IgM and IgG antibodies to the virus in the blood. infection. Persistent HDV replication is the most important
Additional tests include reverse transcriptase polymerase predictor of mortality and the need for antiviral therapy.
chain reaction (RT-PCR) to detect the hepatitis E virus RNA Pegylated interferon alpha is the only drug effective against
in blood and/or stool, but this assay may require specialized HDV; antiviral nucleotide analogues for HBV have no or
laboratory facilities. limited effect on HDV replication. The optimal duration of
by R△J
262 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

therapy is not well defined, nor how long patients need to be References
HDV RNA negative after the end of therapy to achieve a
1. WHO (2014), Fact Sheet Hepatitis A, No. 328, June 2014.
sustained virological response. More than 1 year of therapy
2. WHO (2022), Fact sheet, 24th June 2022.
may be necessary. 3. WHO (1989), Techn.Rep.Ser. No.784 Page 25.
The overall rate of sustained virological response remains 4. Change, S.L. Bull WHO : 38, 401-414.
low, including in children, and most patients relapse after 5. Jawetz et al (2013), Medical Microbiology, 26th ed., 2013, A Lange
discontinuation of therapy. Liver transplantation may be Medical Book.
considered for cases of fulminant hepatitis and end-stage 6. Dientardt, F. (1983). WHO Chr 37 (6) 203-207.
liver disease. New therapeutic agents and strategies are 7. Weller, lan. (1984), Brit Med. J., 288 : 47-49.
needed, and novel drugs, such as prenylation inhibitor or 8. Centre for Disease Control and Prevention (2012), Epidemiology and
Prevention of Vaccine, Preventable Diseases, 12th ed., May 2012.
HBV entry inhibitors, have shown early promise.
9. WHO (1977), Techn.Rep.Ser. No : 602.
10. WHO (2012), Weekly Epidemiological Record, No. 28-29,13th July
Prevention 2012.
Prevention and control of HDV infection requires 11. Jawetz, J.L. (2019), Review of Medical Microbiology, 28th ed, Lange
prevention of HBV transmission through hepatitis B Medical Publications, California.
immunization, blood safety, injection safety, and harm 12. JAMA, 1975:233:1316.
13. WHO (2016), Guidelines for prevention care and treatment of
reduction services. Hepatitis B immunization does not provide persons with chronic hepatitis B infection, March 2016.
protection against HDV for those already HBV infected. 14. WHO (2017), Weekly Epidemiological Record, 7th July 2017.
15. WHO (2009), Weekly Epidemiological Record, No. 40, 2nd Oct.
HEPATITIS G 2009.
16. Lawrence M. Tierney, Jr., Stephen J. McPhee, and Maxine A.
Hepatitis G virus HGV was discovered in 1996. The Papadakis, Current Medical Diagnosis and Treatment, 49th Ed.
prevalence of this infection is still not known. A few (2010), a Lange medical book.
publications provide information on the association of this 17. Dienhardt, F et al (1982). Bull WHO, 60 : 661.
infection with blood transfusion in India (16). 18. WHO (1996), The World Health Report 1996, Fighting disease
Fostering development, Report of the Director-General.
The nomenclature and definitions used in the disease are 19. WHO (2000), Weekly Epidemiological Record, No. 5, 4th June,
shown in Table 6. 2000.

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TABLE 6
Nomenclature and definitions of hepatitis viruses, antigens and antibodies
Component
Disease of system Definition

Hepatitis A HAV Hepatitis A virus Etiologic agent of infectious hepatitis. A picornavirus, the prototype of a
new genus, Hepatouirus.
Anti-HAV Antibody to HAV Detectable at onset of symptoms; lifetime persistence.
IgM Anti-HAV IgM class antibody to HAV. Indicates recent infection with hepatitis A; positive up to 4-6
months after infection.
Hepatitis B HBV Hepatitis B virus. Etiologic agent of serum hepatitis. A hepadnavirus.
HBsAg Hepatitis B surface antigen. Surface antigen(s) of HBV detectable in large quantity in
serum; several sub-types identified.
HBeAg Hepatitis Be antigen. Soluble antigen ; associated with HBV replication, with high titers of
HBV in serum, and with infectivity of serum
HBcAg Hepatitis B core antigen
Anti-HBs Antibody to HBsAg. Indicates past infection with and immunity to HBV, presence of passive
antibody from HBIG, or immune response from HBV vaccine.
Anti-HBe Antibody to HBeAg. Presence in serum of HBsAg carrier suggests lower titer of HBV
Anti-HBc Antibody to HBeAg. Indicates infection with HBV at some undefined time in the past
IgM Anti-HBc IgM class antibody to HBeAg. Indicates recent infection with HBV ; positive for 4-6 months
after infection
Hepatitis C HCV Hepatitis C virus, a common etiologic agent of post-transfusion hepatitis A flavivirus, genus
Hepacivirus.
Anti-HCV Antibody to HCV.
Hepatitis D HDV Hepatitis D virus. Etiologic agent of delta hepatitis causes infection only in presence of
HBV
HDAg Delta antigen (delta-Ag). Detectable in early acute HDV infection.
Anti-HDV Antibody to delta-Ag (anti-delta). Indicates past or present infection with HDV.
Hepatitis E HEV Hepatitis E virus. Enterically transmitted hepatitis virus. Causes large epidemics in Asia and
North Africa ; faecal-oral or waterborne transmission. Perhaps a calicivirus.
Hepatitis G HGV Hepatitis G virus, aflauivirus.
Immune globulins IG Immune globulin USP. Contains antibodies to HAV ; no antibodies to HBsAg, HCV, or HIV.
HBIG Hepatitis B immune globulin. Contains high titers of antibodies to HBV.
Source : (5)

by R△J
 ACUTE DIARRHOEAL DISEASES

20. WHO (2008), Weekly Epidemiological Record No. 48, 28th Nov. children used to die each year of the dehydration caused by
2008. diarrhoea. Diarrhoea is still a major killer of children
21. Sherlock, S. (1984) Post Graduate Doctor Middle East, 7 (1) 49-56. under 5 years of age, although its toll has dropped by a third
22. WHO (1982), Bull WHO, 60 (1) 43-47.
over the past decade. It killed more than 3,70,000 children
23. WHO (1983), Tech.Rep.Ser. No.693.
under 5 years of age in 2019. It accounts for 8 per cent of all
24. Krugman, S. et al (1979) N.Eng.J.Med., 300 : 101 : 106.
under-five deaths. Most of these deaths occur among
25. WHO (1983), World Health Forum, 4 (2) 135-141.
children less than 2 years of age (2).
26. WHO (2017), Guidelines on Hepatitis B and C Testing, Feb. 2017.
27. WHO (2020), Fact Sheet Hepatitis B, July 2020. Comparing estimates of the current global burden of
27A. WHO (2019), Consolidated Strategic Information Guidelines for diarrhoeal disease with previously published estimates,
Viral Hepatitis, Planning and tracking progress towards elimination. highlights that the incidence of diarrhoea have not changed
28. WHO (2016), Global Health Sector Strategy on Viral Hepatitis much, although overall diarrhoeal mortality has declined.
2016-2021, Towards Ending Viral Hepatitis, June 2016. For children aged under 5 years, a median of 3 episodes of
29. WHO (2016), World Health Statistics2016, Monitoring Health for the diarrhoea occurred per child-year, which is similar to that
SDGs, 2016.
30. WHO (2017), Global Hepatitis Report, 2017. reported previously. The current estimates in under-five
31. WHO (2022), Fact Sheet Hepatitis C, 24th June 2022. children suggest that there are about 2.5 billion episodes of
32. WHO (2012), Weekly Epidemiological Record, No. 41 7th Oct, diarrhoea per year with 123 million clinic visits annually and
2011. 9 million hospitalizations worldwide, with a loss of 62 million
33. WHO (2017), Hepatitis E Fact Sheet, 3rd July 2017. disability-adjusted life years (DALYs) (3).
34. WHO (2014), Fact Sheet Hepatitis E, No. 280, June 2014. In India, acute diarrhoeal disease accounts for about
35. WHO (2018), Hepatitis D Fact Sheet, 23rd July 2018. 10 per cent of deaths in under-5 years age group. During
the year 2020, about 7.20 million cases with 1,606 deaths
| ACUTE DIARRHOEAL DISEASES were reported in India (4).
Diarrhoea is defined as the passage of loose, liquid or Diarrhoea is a leading cause of death during complex
watery stools. These liquid stools are usually passed more emergencies and natural disasters. Displacement of
than three times a day. However, it is the recent change in population into temporary, overcrowded shelters is often
consistency and character of stools rather than the number associated with polluted water sources, inadequate
of stools that is more important. sanitation, poor hygiene practices, contaminated food and

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The term “diarrhoeal diseases” should be considered malnutrition - all of which affect the spread and severity of
only as a convenient expression - not as a nosological or diarrhoea. At the same time, the lack of adequate health
epidemiological entity - for a group of diseases in which the services and transport reduces the likelihood of prompt and
predominant symptom is diarrhoea. appropriate treatment of diarrhoea cases.
Diarrhoeal disease causes a heavy economic burden on the
CLINICAL TYPES OF DIARRHOEAL DISEASE (1) health services. Much attention has been given to acute
It is most practical to base treatment of diarrhoea on the diarrhoeal disease and its management over the last decade,
clinical type of illness, which can easily be determined. Four which is dominated by advances in oral rehydration technique
clinical types of diarrhoea can be recognized, each reflecting and through integrated management of childhood illness. The
the basic underlying pathology and altered physiology : treatment recommendations reflect a better understanding of
what works to reduce child death from diarrhoea, as well as
(1) Acute watery diarrhoea - which lasts several hours to
new insights into treatment feasibility. These changes in
days; the main danger is dehydration, weight loss also
treatment recommendations and preventive measures have
occurs if feeding is not continued. The pathogens that
subsequently led to monitorable treatment and diarrhoea
usually cause acute diarrhoea include V. cholerae or
prevention indicators. They are as follows (5) :
E. coli bacteria, as well as rotavirus.
(2) Acute bloody diarrhoea - which is also called dysentery (A) Diarrhoea prevention indicators
- the main dangers are damage of the intestinal mucosa,
sepsis and malnutrition; other complications including (1) Percentage of population using :
dehydration, may also occur. It is marked by visible (a) improved drinking water sources (urban, rural,
blood in the stools. (The most common cause of bloody total);
diarrhoea is shigella, a bacteria that is also a most (b) improved sanitation facilities (urban, rural, total);
common cause of severe cases). (2) Percentage of one year old immunized against
(3) Persistent diarrhoea - which lasts 14 days or longer. The measles;
main danger is malnutrition and serious non-intestinal (3) Percentage of children who are :
infection, dehydration may also occur. Persons with - under-weight (moderate and severe) - 0 to 59m
other illness, such as AIDS, are more likely to develop onths age
persistent diarrhoea.
- stunted (moderate and severe) - 0 to 59
(4) Diarrhoea with severe malnutrition (marasmus and months age
Kwashiorkor) - The main dangers are severe systemic
infection, dehydration, heart failure, and vitamin and - exclusively breast-fed - 0 to 5
mineral deficiency. months age
- breast-fed with complementary - 6 to 9
Problem statement food months age
Acute diarrhoea is rivalled in importance only by - still breast-feeding - 20 to 23
respiratory infection, as a cause of morbidity on a worldwide months age
scale. When the WHO initiated the Diarrhoeal Diseases (4) Vitamin A supplementation coverage rate (per cent
Control Programme in 1980, approximately 4.6 million full coverage) - 6 to 59 months (India—53%)

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(B) Diarrhoea treatment Indicators TABLE 2

Percentage of children under-five years with diarrhoea Pathogens frequently identified in children with acute
diarrhoea in treatment centres in developing countries
receiving :
(1) ORT with continuous feeding Pathogen % of cases

(2) ORS packet Viruses Rotavirus 15-25

Bacteria Enterotoxigenic
(3) Recommended home made fluids Escherichia coli 10-20
(4) Increased fluids Shigella 5-15
Campylobacter jejuni 10-15
(5) Continued feeding Vibrio cholerae 01 5-10
Salmonella (non-typhoid) 1-5
(C) Use of oral rehydration therapy
Enteropathogenic
Percentage of children under-five years with diarrhoea Escherichia coli 1-5
receiving oral rehydration therapy (ORS packet or Protozoans Cryptosporidium 5-15
recommended home-made fluids or increased fluids with No pathogen found - 20-30
1
continued feeding)
Source : (7)
(1) Gender - male, female
(2) Residence - Urban, rural (a) VIRUSES
(3) Wealth index quintiles - poorest, second, middle, A great many diarrhoeal diseases are caused by viruses
fourth, richest (Table 1).
ROTAVIRUSES : The rotavirus, first discovered in 1973,
Epidemiological determinants has emerged as the leading cause of severe, dehydrating
Agent factors diarrhoea in children aged <5 years globally, with an
estimated more than 25 million out-patient visits and more
In developing countries, diarrhoea is almost universally than 2 million hospitalizations attributable to rotavirus
infectious in origin. A wide assortment of organisms cause infections each year. In developing countries, three-quarters
acute diarrhoea, and many of them have been discovered of children acquire their first episode of rotavirus diarrhoea

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only in recent years such as rotaviruses and Campylobacters before the age of 12 months, whereas in developed countries
(Table 1). the first episode is frequently delayed until the age of
TABLE 1 2-5 years. Severe rotavirus gastroenteritis is largely limited to
Infections causing diarrhoea children aged 6-24 months. Fatal outcomes in children,
estimated to be approximately 420,000-494,000 in 2008 (8),
1. Viruses : 3. Others : occur predominantly in low-income countries. Rotavirus
Rotaviruses Entamoeba histolytica reinfection is common, although the primary infection is
Astroviruses Giardia intestinalis usually the most significant clinically. In temperate climates,
Adenoviruses Trichuriasis the incidence of rotavirus gastroenteritis typically peaks
Calciviruses Cryptosporidium SPP during the winter season, whereas in tropical settings
Coronaviruses Intestinal worms rotavirus occurs year round and a marked seasonality may be
Norwalk group viruses Cyclospora
Enteroviruses masked by high background levels (9).
Cytomegalovirus Rotaviruses are shed in very high concentrations
2. Bacteria : (>1012 particles/gram) and for many days in the stools and
Campylobacter jejuni vomit of infected individuals. Transmission occurs primarily
Enterotoxigenic Escherichia coli by the faecal-oral route, directly from person to person or
Shigella indirectly via contaminated fomites. The universal
Salmonella occurrence of rotavirus infections shows that clean water
Vibrio cholerae supplies and good hygiene are unlikely to have a substantial
Vibrio parahaemolyticus effect on virus transmission (9).
Bacillus cereus
Staphylococcus aureus (b) BACTERIAL CAUSES
Clostridium perfringens
Enterohaemorrhagic E. coli Besides the well-known bacterial causes of enteric
Clostridium difficile infections and diarrhoeal diseases such as V. cholerae 01,
Enteroinvasive E. coli Salmonella, Shigella, enterotoxigenic E.coli and
Aeromonas Campylobacter jejuni are the most frequent cause of
Yersinia enterocolitica
Chlamydia diarrhoea. They produce a potent enterotoxin similar to that
Neisseria gonorrhoeae produced by V. cholerae. The less-known pathogens which
cause diarrhoea are Yersinia enterocolitica, and
Source : (6) V. parahaemolyticus.
Until recent years, the identification of pathogens in the Enterotoxigenic Escherichia coli (ETEC) is an important
stool was only feasible in about 25 per cent of patients with cause of acute watery diarrhoea in adults and children in
acute diarrhoea. At present, new techniques enable developing countries causing annually 280-400 million
competent laboratories to identify these pathogens in about diarrhoeal episodes in children under 5 years of age, and an
75 per cent of cases. The infectious agents most often additional 100 million episodes in children aged 5-14 years.
connected with diarrhoea in young children, in developing In adults it causes substantial disease (about 400 million
countries, are as shown in Table 2. cases per year). It is also the most common cause of

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 ACUTE DIARRHOEAL DISEASES
265
traveller’s diarrhoea. Being responsible for one-third to one- the disease. Children with measles or who have had measles
half of all diarrhoeal episodes in travellers to Africa, Asia recently, run a high risk of developing severe or fatal
and Latin America, the illness results in 0.3 to 0.5 million diarrhoea (7).
deaths per year mostly in young children (10). ETEC does
not invade the bowel mucosa and the diarrhoea it causes is Reservoir of infection
mediated by toxins. There are two ETEC toxins, heat labile For some enteric pathogens, man is the principal
(LT) and heat stable (ST). Some strains produce only one reservoir and thus most transmission originates from human
type of toxin, some both. The LT toxin is closely related to factors ; examples are enterotoxigenic E. coli, shigella spp..
cholera toxin. ETEC is spread mostly by means of V. cholerae, Giardia lamblia and E. histolytica. For other
contaminated food and water. enteric pathogens, animals are important reservoirs and
Salmonella cause inflammation of the bowel epithelium; transmission originates from both human and animal faeces;
Vibrio cholerae 01 do not. Both are endemic diseases in examples are Campylobacter jejuni, Salmonella spp and
India. In cholera-endemic areas, cholera probably accounts Y enterocolitica. For viral agents of diarrhoea, the role of
for not more than 5 to 10 per cent of all acute diarrhoeas animal reservoirs in human disease remains uncertain.
yearly, and in more than 90 per cent of instances is clinically
indistinguishable from other acute diarrhoeas. Host factors
Campylobacters are slim, highly motile, S-shaped, gram­ Diarrhoea is most common in children especially those
negative rods, formerly classed as vibrios. They are one of the between 6 months and 2 years. Incidence is highest in the
commonest causes of enteritis. They do not seem to produce age group 6-11 months, when weaning occurs. It reflects the
any toxin. It is not clear how they cause diarrhoea (11). combined effects of declining levels of maternally acquired
Shigella accounts for a high percentage of mortality due antibodies, the lack of active immunity in the infant, the
to diarrhoeal disease. The estimates suggest that it causes introduction of contaminated food, and direct contact with
about 1 million deaths every year in children aged under-5 human or animal faeces when the infant starts to crawl. It is
years, mostly in the developing countries. In addition about also common in babies under 6 months of age fed on cow’s
164.7 million Shigella episodes are estimated worldwide, milk or infant feeding formulas (16). Diarrhoea is more
with 69 per cent of all episodes in young children (12). It is a common in persons with malnutrition. Malnutrition leads to
major cause of diarrhoea in India. infection and infection to diarrhoea which is a well known
vicious circle. Poverty, prematurity, reduced gastric acidity,

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(c) OTHERS immunodeficiency, lack of personal and domestic hygiene
Amoebiasis, giardiasis and other intestinal parasitic and incorrect feeding practices are all contributory factors.
infections are associated with diarrhoea (13). Giardiasis is a
recognized cause of diarrhoea. It flourishes in the duodenum Environmental factors
and jejunum. The organisms can be present in very large Distinct seasonal patterns of diarrhoea occur in many
numbers, the lumen of the intestine teeming with them and geographical areas. In temperature climates, bacterial
the epithelial surfaces almost smothered with them (14). diarrhoea occur more frequently during the warm season,
Cryptosporidium is a coccidian parasite that causes whereas viral diarrhoea, particularly diarrhoea caused by
diarrhoea in infants, immunodeficient patients, and a rotavirus peak during the winter. In tropical areas, rotavirus
variety of domestic animals. In developing countries most diarrhoea occurs throughout the year, increasing in
episodes of illness occur in the first year of life. Thereafter, frequency during the drier, cool months, whereas bacterial
infections are usually asymptomatic. Diarrhoea is usually diarrhoeas peak during the warmer, rainy season. The
neither severe nor prolonged, except in immunodeficient incidence of persistent diarrhoea follows the same seasonal
patients, such as those with severe malnutrition or AIDS. In patterns as that of acute watery diarrhoea (14).
such individuals cryptosporidium is an important cause of
persistent diarrhoea with wasting (14). Mode of transmission
The enumeration of the germs causing the enteric Most of the pathogenic organisms that cause diarrhoea
infections which lead to acute diarrhoea should not and all the pathogens that are known to be major causes of
overshadow the fact that diarrhoea may be caused by a diarrhoea in many countries, are transmitted primarily or
parenteral infection (non-digestive origin) and particularly exclusively by the faecal-oral route. Faecal-oral
so in younger children. These include ENT infections, transmission may be water-borne; food-borne, or direct
respiratory or urinary infections, malaria, bacterial transmission which implies an array of other faecal-oral
meningitis, or even simple teething (7). routes such as via fingers, or fomites, or dirt which may be
Besides the above causes, malnutrition may lead to ingested by young children (17).
certain nutritional diseases such as kwashiorkor, sprue,
coeliac disease and pellagra which are all associated with CONTROL OF DIARRHOEAL DISEASES
diarrhoea. In the developed countries, the causes of
diarrhoea may be slightly different. Diarrhoea in the It is now obvious that many different organisms - some
newborn is unusual and may be due to inborn errors of known, probably many unknown - cause diarrhoea. It is
metabolism such as congenital enzyme deficiencies. It may also clear that they do not act in the same way to cause
also be associated with severe infections like septicaemia or diarrhoea. But from an epidemiological point of view, they
necrotizing enterocolitis (15). are considered together because of the common symptom,
Persistent diarrhoea is one of the main clinical signs of diarrhoea. It is now firmly established that regardless of the
AIDS in the tropics (an episode of diarrhoea lasting more causative agent or the age of the patient, the sheet anchor of
than 30 days, according to the WHO definition of AIDS in treatment is oral rehydration therapy such as the one
children). This is associated with one or several other signs of advocated by WHO/LJNICEF.

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The Diarrhoeal Diseases Control (DDC) Programme of Composition of reduced osmolarity ORS
WHO has since its inception in 1980, advocated several
Reduced osmolarity ORS grams / litre
interventional measures to be implemented simultaneously
Sodium chloride 2.6
with mutually reinforcing and complementary impacts. Glucose, anhydrous 13.5
These measures centre round the widespread practice of Potassium chloride 1.5
“oral rehydration therapy”. Trisodium citrate, dihydrate 2.9
Total weight 20.5
Components of a Diarrhoeal Diseases Control Reduced osmolarity ORS mmol / litre
Programme Sodium 75
Chloride 65
The intervention measures recommended by WHO (15) Glucose, anhydrous 75
may be classified as below : Potassium 20
Citrate 10
1. Short-term
Total osmolarity 245
a. Appropriate clinical management.
Source : (19)
2. Long-term
Guidelines for assessing dehydration and oral
b. Better MCH care practices. rehydration : The guidelines for assessing dehydration and
c. Preventive strategies. oral rehydration are given in Tables 3 and 4 (20, 21).
d. Preventing diarrhoeal epidemics. TABLE 3
a. Appropriate clinical management Assessment of dehydration

(I) ORAL REHYDRATION THERAPY : With introduction DEHYDRATION

of oral rehydration by WHO it is now firmly established that Mild Severe
oral rehydration treatment can be safely and successfully
used in treating acute diarrhoeas due to all aetiologies, in all (1) Patient’s Thirsty; alert, Drowsy; limp, cold,
appearance restless sweaty; may be
age groups, and in all countries. The aim of oral fluid comatose
therapy is to prevent dehydration and reduce mortality. It (2) Radial pulse Normal rate and Rapid, feeble,
has been the experience of workers at Kolkata that as many volume

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sometimes
as 90-95 per cent of all cases of cholera and acute impalpable
diarrhoea can be treated by oral fluids alone (18). Oral fluid (3) Blood pressure Normal Less than 80 mm Hg;
therapy is based on the observation that glucose given orally may be unrecordable
enhances the intestinal absorption of salt and water, and is (4) Skin elasticity Pinch retracts Pinch retracts very
immediately slowly (more than 2
capable of correcting the electrolyte and water deficit. seconds)
At first the composition of oral rehydration salt (ORS) (5) Tongue Moist Very dry
recommended by WHO was sodium bicarbonate based. (6) Ant. fontanelle Normal Very sunken
Inclusion of trisodium citrate in place of sodium bicarbonate (7) Urine flow Normal Little or none
made the product more stable and it resulted in less stool % body weight loss 4-5% 10% or more
output especially in high-output diarrhoea as in cholera,
probably because of direct effect of trisodium citrate in Estimated fluid 40-50 ml/kg 100-110 ml/kg
deficit
increasing intestinal absorption of sodium and water.
More recently an improved ORS formulation has been When obvious signs of dehydration exist, the water
developed which is as safe and effective as the original in deficit is somewhere between 50 and 100 ml per kg of body
preventing and treating diarrhoeal dehydration but also weight. If the child’s weight is known, the amount of ORS
reduced stool output or offers additional clinical benefit or solution required for rehydration during the first four hours
may be calculated by setting the deficit at approximately
both. It is focussed on reducing the osmolarity of ORS solution
75 ml/kg. If the child’s weight is not known, the approximate
to avoid possible adverse effects of hypertonicity on net fluid
deficit may be determined on the basis of age, although this
absorption by reducing the concentration of glucose and
procedure is less accurate. The guidelines for oral
sodium chloride in the solution. Decreasing the sodium rehydration are given in Table 4.
concentration of ORS solution to 75 mOsm/1 improved the
efficacy of the ORS regimen for children with acute non­ TABLE 4
cholera diarrhoea. The need for unscheduled supplemental Guidelines for oral rehydration therapy (for all ages)
intravenous therapy in children given the new ORS fell by during the first four hours
33 per cent, the stool output decreased by 20 per cent and
Age (*) under 4 4-11 1-2 2-4 5-14 15 yrs
vomiting was reduced by 30 per cent. The reduced osmolarity months months yrs. yrs. yrs. or over
(245 mOsm/1) solution also appears to be as safe and effective
as standard ORS for use in children with cholera (19). Weight under 5 5-79 8-10.9 11-15.9 16-29.9 30 or
(kg) over
Recommended formulation : Because of the improved
effectiveness of reduced osmolarity ORS solution, WHO and ORS 200-400 400-600 600-800 800- 1200- 2200-
solution 1200 2200 4000
UNICEF are recommending that countries manufacture and (ml)
use the following formulation in place of the previously
recommended ORS solution. Since January 2004, the new (*) The patient’s age should only be used if weight is not known. The
ORS formulation is the only one procured by UNICEF. India approximate amount of ORS required in ml. may also be calculated
by multiplying the patient’s weight (expressed in kg) by 75.
was the first country in the world to launch this ORS
1
formulation since June 2004. Source : (1)

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 CONTROL OF DIARRHOEAL DISEASES

The actual amount given will depend on the patients unsalted soup, yogurt drinks, green coconut water, weak tea
desire to drink and by surveillance of signs of dehydration, etc. The mothers should be taught to add salt about
keeping in mind the fact that greater amounts should be 3 g/litre to an unsalted drink or soup during diarrhoea. A few
given to heavier patients, those with greater signs of fluids are potentially dangerous and should be avoided
dehydration and those who still have watery diarrhoea during diarrhoea. Especially important are drinks sweetened
during rehydration. The general rule is that patients should with sugar, which can cause osmotic diarrhoea and
be given as much ORS solution as they want, and that signs hypernatremia. Examples are commercial carbonated
of dehydration should be checked until they subside. beverages, commercial fruit juices and sweetened tea. Other
Older children and adults should be given as much water fluids to be avoided are those with stimulant diuretic or
as they want, in addition to the ORS solution. purgative effect, e.g. coffee and some medicinal tea or
infusions (1).
Mothers should be taught how to administer ORS
solution to their children. It is best for a demonstration to be The infant’s usual diet of cereals, vegetables and other
given by a nurse or by a health worker following which the foods should be continued during diarrhoea, and increased
mother feeds the solution to her child under their afterwards. Food should never be withheld and the child’s
usual food should never be diluted. The aim is to give as
supervision respecting the following rules :
much nutrient rich food as the child will accept. Most
- for children under age 2 years, give a teaspoon every children with watery diarrhoea regain their appetite after
1 to 2 minutes, and offer frequent sips out of a cup for dehydration is corrected, whereas those with bloody
older children. Adults may drink as much as they like. diarrhoea often eat poorly until the illness resolves. These
Try to give the estimated required amount within a children should be encouraged to resume normal feeding as
4-hour period. As a general guide, after each loose soon as possible.
stool, give - children under 2 years of age : 50-100 ml Please refer to end of Chapter 11, Annexure A for plan A,
(a quarter to half a large cup) of fluid; children aged Plan B and Plan C for the management of dehydration due
2 up to 10 years : 100-200 ml (a half to one large to diarrhoea.
cup); and older children and adults : as much fluid as
they want. (II) INTRAVENOUS REHYDRATION
- if the child vomits, wait for 10 minutes, then try again,
giving the solution slowly - a spoonful every 2 to 3 Intravenous infusion is usually required only for the initial
rehydration of severely dehydrated patients who are in

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minutes.
shock or unable to drink. Such patients are best transferred
- if the child wants to drink more ORS solution than the to the nearest hospital or treatment centre.
estimated amount, and does not vomit, there can be
no harm in feeding him/her more. If the child refuses The solutions recommended by WHO for intravenous
to drink the required amount and signs of dehydration infusion are: (a) Ringer’s lactate solution (also called
have disappeared, rehydration is completed. The Hartmann’s solution for injection) : It is the best
treatment plan for non-dehydrated diarrhoeic children commercially available solution. It supplies adequate
is then resumed. concentrations of sodium and potassium and the lactate
yields bicarbonate for correction of the acidosis. It can be
- if the child is breast-fed, nursing should be pursued used to correct dehydration due to acute diarrhoeas of all
during treatment with ORS solution. causes, (b) Diarrhoea Treatment Solution (DTS): Also
The introduction of oral rehydration fluid has not only recommended by WHO as an ideal polyelectrolyte solution
reduced the cost of treatment, but also made possible for intravenous infusion. It contains in one litre, sodium
treatment of patients in their own homes by primary health chloride 4 g sodium acetate 6.5 g potassium chloride lg and
workers or relatives of patient. The ingredients required for glucose lOg (21). It must meet purity and sterility
the preparation of oral fluid are inexpensive and readily requirements of fluid for injection.
available, and the solution can be prepared with ordinary If nothing else is available, normal saline can be given
drinking water. The development of oral rehydration because it is often readily available. Normal saline is the
therapy is a major breakthrough in the fight against cholera poorest fluid because it will not correct the acidosis and will
and other diarrhoeal diseases. not replace potassium losses. It should be replaced by the
above solutions as early as possible. Plain glucose and
Packets of “oral rehydration mixture” are now freely
dextrose solutions should not be used as they provide only
available at all primary health centres, sub-centres, hospitals
water and glucose.
and chemist shops. The contents of the packet are to be
dissolved in one litre of drinking water. The solution should The recommended dose of the IV fluid to be given is
be made fresh daily and used within 24 hours. It should not 100 ml/kg, divided as follows (Table 5) :
be boiled or otherwise sterilized. TABLE 5
If the WHO mixture of salts is not available, a simple Treatment plan for rehydration therapy
mixture consisting of table salt (one level teaspoon) and
sugar (6 level teaspoon) dissolved in one litre of drinking Age First give 30 ml/kg in Then give 70 ml/kg in
water may be safely used until the proper mixture is
obtained. The earlier the treatment is instituted the better it Infants 1 hour 5 hours
is for the patient. (under 12 months)

Many countries have designated recommended house Older 30 minutes 2V2 hours
fluids. Wherever possible these should include at least one
fluid that contains salt. Fluids that do not contain salt are The initial rehydration should be fast until an easily
water in which a cereal has been cooked e.g. rice water; palpable pulse is present. Reassess the patient every

by R△J
268 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

1-2 hours. If dehydration is not improving give the IV drip TABLE 7

more rapidly. The use of large-bore needle (No. 18) will Symptomatic differential diagnosis of shigella and cholera
permit rapid infusion. After infusing 1-2 litres of fluid,
rehydration should be carried out at a somewhat slower rate Symptoms Cholera Shigella
until pulse and blood pressure return to normal. When the Diarrhoea Acute watery Acute bloody
patient can drink the oral fluids give ORS about 5 ml/kg/hour. diarrhoea diarrhoea
The patient must be examined at intervals during Fever No Yes
rehydration. After 4-6 hours of satisfactory treatment, all Abdominal cramps Yes Yes
signs of dehydration should have disappeared except that
Vomiting Yes No
the urine flow may not have yet started. Sometimes if too
much rehydration fluid is given, the eyelids become puffy; if Rectal pain No Yes
this occurs, IV fluid should be stopped. It is most helpful to Stool > 3 loose stools per > 3 stools per day,
examine skin elasticity and pulse strength, both of which day, watery with blood
should be normal. Rehydration must continue until all signs like rice water or pus
of dehydration have disappeared.
For diarrhoea due to cholera the drug of choice is
(Ill) MAINTENANCE THERAPY doxycycline, tetracycline, TMP-SMX and erythromycin. For
diarrhoea due to shigella, the drug of choice is ciprofloxacin
After the initial fluid and electrolyte deficit has been
as shigella is usually resistant to ampicillin and TMP-SMX.
corrected (i.e., the signs of dehydration (Table 3) have gone)
oral fluid should be used for maintenance therapy. In adults The medicines that should not be used in the treatment of
and older children, thirst is an adequate guide for fluid diarrhoea are as follows (16) :
needs; they can be told to drink as much as they want to - neomycin (damages the intestinal mucosa and can
satisfy their thirst. The guidelines for maintenance therapy cause malabsorption);
are given in Table 6. The general principle is that the oral - purgatives (worsen diarrhoea and dehydration);
fluid intake should equal the rate of continuing stool - tincture of opium or atropine (dangerous for children
loss, which should be measured. Diarrhoea usually lasts for and dysentery patients because of decreased intestinal
1 or 2 days. transit time);
- cardiotonics such as Coramine; shock in diarrhoea

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TABLE 6
Maintenance therapy must be corrected by intravenous fluids and not by
drugs;
- steroids (expensive, useless, and may cause adverse
Amount of diarrhoea Amount of oral fluid
effects);
Mild diarrhoea 100 ml/kg body weight per - oxygen (expensive, unnecessary);
(not more than one stool every day until diarrhoea stops - charcoal, kaolin, pectin, bismuth (no value);
2 hours or longer, or less than
5 ml stool per kg per hour) - mexaform (no value and can be dangerous).
Severe diarrhoea Replace stool losses volume (VI) ZINC SUPPLEMENTATION : When a zinc
(more than one stool every for volume; if not measurable supplement is given during an episode of acute diarrhoea, it
2 hours, or more than 5 ml of give 10-15 ml/kg body reduces the episode’s duration and severity. In addition, zinc
stool per kg per hour) weight per hour
supplements given for 10 to 14 days lower the incidence of
diarrhoea in the following 2 to 3 months. WHO and UNICEF
(IV) APPROPRIATE FEEDING : Medical profession has therefore recommend daily 10 mg of zinc for infants under
reeled for centuries under the mistaken assumption that it is 6 months of age, and 20 mg for children older than
important to “rest the gut” during diarrhoea. The current 6 months for 10-14 days (19).
view is that during episodes of diarrhoea, normal food
intake should be promoted as soon as the child whatever its b. Better MCH care practices
age, is able to eat. This is especially relevant for the
(a) MATERNAL NUTRITION : Improving prenatal
exclusively breast-fed infants. Newborn infants with
nutrition will reduce the low birth weight problem. Prenatal
diarrhoea who show little or no signs of dehydration can be
and postnatal nutrition will improve the quality of breast milk.
treated by breast-feeding alone. Those with moderate or
severe dehydration should receive oral rehydration solution. (b) CHILD NUTRITION : (i) Promotion of breast-feeding :
Breast-feeding is continued along with oral rehydration Any measures to promote breast-feeding are likely to reduce
solution given after each liquid stool. Not only breast milk the diarrhoeal diseases in infants. The breast-fed child is at
helps the infant to recover from an attack of diarrhoea both very much less risk of severe diarrhoea and death than the
in terms of the nutrients it supplies, and its rehydrating bottlefed child. Promotion of breast-feeding should include
effect, but it helps to prevent further infection because it has strong efforts to limit the use of commercial and artificial
protective properties. formulas. Breast-feeding should be continued as long as
possible, (ii) Appropriate weaning practices : Poor weaning
(V) CHEMOTHERAPY : Unnecessary prescription of practices are a major risk factor for diarrhoea. The child
antibiotics and other drugs will do more harm than good should be weaned neither too soon, nor too late, in any case
in the treatment of diarrhoea. Antibiotics should be not earlier than the sixth month of life using nutritious and
considered where the cause of diarrhoea has been clearly locally available foods, and the foods should be hygienically
identified as shigella, typhoid or cholera. The symptomatic prepared and given, (Hi) Supplementary feeding : This is
differential diagnosis of shigella and cholera are as shown in necessary to improve the nutritional status of children aged
Table 7. 6-59 months. As soon as the supplementary food is

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 CONTROL OF DIARRHOEAL DISEASES
269
introduced, the child enters the high-risk category. major vehicles for the transmission of faecal pathogens
(iu) Vitamin A supplementation : Vitamin A supplementation during early infancy, e.g., diluted milk, cereal gruels, etc.
is a critical preventive measure, and studies have shown Delays in consumption add to the problem.
mortality reductions ranging from 19 per cent to 54 per cent (ii) HEALTH EDUCATION : Environmental sanitation
in children receiving supplements. This reduction is measures require educational support, to ensure their proper
associated in large part with decline in deaths due to use and maintenance of such facilities. An important part of
diarrhoeal diseases and measles. It also reduces the duration, health worker’s job is to help prevent diarrhoea by
severity and complications associated with diarrhoea (2). convincing and helping community members to adopt and
maintain certain preventive practices such as breast-feeding,
c. Preventive strategies improved weaning, clean drinking water, use of plenty of
(i) SANITATION : Measures to reduce transmission water for hygiene, use of latrine, proper disposal of stools of
emphasize the traditional improved water supply, improved young children etc.
excreta disposal and improved domestic and food hygiene. (iii) IMMUNIZATION : Immunization against measles is a
Without an adequate supply of clean water close to their potential intervention for diarrhoea control. When
homes, it is extremely difficult to promote personal and administered at the recommended age, the measles vaccine
domestic hygiene. Simple hygienic measures like hand can prevent upto 25 per cent of diarrhoeal deaths in
washing with soap before preparing food, before eating, children under 5 years of age.
before feeding a child, after defecation, after cleaning a child
who has defecated, and after disposing off a child’s stool The protect, prevent and treat framework of integrated
should be promoted. All families should have a clean and global action plan for prevention and control of pneumonia
functioning latrine. The latrine should be kept clean by and diarrhoea is summarized in Fig. 1.
regular washing of dirty surface. If there is no latrine, family
members should defecate at a distance from the house, Rotavirus vaccine (9)
paths or areas where children play and at least 10 metres Two live, oral, attenuated rotavirus vaccines were
away from the water supply source. It should be recognized licensed in 2006 : the monovalent human rotavirus
that in many communities, young children are often vaccine (Rotarix™) and the pentavalent bovine-human,
permitted to defecate indiscriminately. Because diarrhoea reassortant vaccine (Rota Teq™). Both vaccines have

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attack rates are higher among children, it is the defecation in demonstrated very good safety and efficacy profiles in large
this age group that deserves the most attention. clinical trials. The rotavirus vaccines are now introduced for
Contaminated foods of all sorts have been identified as routine use in a number of industrialized and developing

PROTECT \ Vaccines: Pertuss1®’

children by PREVENT Hib, PCV and rotaviru
establishing good children becoming ill
health practices from pneumonia ^ce
from birth and diarrhoea “'Polhi

REDUCE
pneumonia and
diarrhoea
morbidity
and mortality

’Vo

Improved care seeking TREAT

and referral children who are ill
from pneumonia
and diarrhoea
7^42?
Ose
FIG. 1
Integrated global action plan for the prevention and control of pneumonia and diarrhoea
Source: (2)
by R△J
270 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

countries. 5. WHO, UNICEF (2009), Diarrhoea : Why children are still dying and
what can be done.
The Rotarix™ vaccine is administered orally in a 2-dose 6. Stephen J. McPHEE, MAXINEA (2010), Current Medical Diagnosis
schedule to infants of approximately 2 and 4 months of age. and Treatment, 49th Ed., A Lange publication.
The first dose can already be administered at the age of 7. Fricker, J., Children in the Tropics 1993 - No.204.
6 weeks and should be given no later than at the age of 8. UNICEF (2012), Pneumonia and Diarrhoea, tackling the deadliest
12 weeks. The interval between the 2 doses should be at disease for the world's poorest children.
least 4 weeks. The 2-dose schedule should be completed by 9. WHO (2007), Weekly Epidemiological Record, No. 37, 10th Oct,
2007.
age 16 weeks, and no later than by 24 weeks of age.
10. WHO (2006), Weekly Epidemiological Record, No. 11, 17 March,
For RotaTeq™, the recommended schedule is 3 oral doses 2006.
at ages 2, 4 and 6 months. The first dose should be 11. Christie, A.B. (1980) Infectious Diseases : Epidemiology and Clinical
administered between ages 6-12 weeks and subsequent Practice (3rd Ed), Churchill Livingstone.
doses at intervals of 4-10 weeks. Vaccination should not be 12. WHO (2006), Weekly Epidemiological Record No. 6,10th Feb., 2006
initiated for infants aged >12 weeks. All 3 doses should be 13. WHO (1980) Bull WHO, 58 (6) 819-830.
14. WHO (1992) Readings on diarrhoea, Student Manual.
administered before the age of 32 weeks.
15. Pizzarro, D. (1985). Dialogue on Diarrhoea, Issue No.22 Sept. 1985,
There is a potentially higher risk of intussusception when AHRTAG, 85 Marylebone High Street, London.
the first dose of these vaccines is given to infants aged 16. WHO (1981). Surveillance and control of acute diarrhoeal diseases.
>12 weeks; consequently, current rotavirus vaccines EURO Reports. Ser.No.44 Copenhagen, WHO.
should not be used in catch-up vaccination campaigns, 17. R.G. Feachem (1984) Bull WHO 62 (3) 467-476.
where the exact age of the vaccinees may be difficult to 18. De, S. et al (1975), J. Com. Dis., 7:124-128.
ascertain. 19. WHO, UNICEF (2004), Clinical Management of Acute Diarrhoea,
WHO / UNICEF Joint Statement.
(iu) FLY CONTROL : Flies breeding in association with 20. Govt, of India (1998), Health Information of India 1995 and 1996,
human or animal faeces should be controlled. Ministry of Health and Family Welfare, New Delhi.
21. WHO (1980), A Manual for the treatment of Acute Diarrhoea, WHO /
d. Control and/or prevention of diarrhoeal CDD/ SER/ 80.2.
epidemics
CHOLERA
This requires strengthening of epidemiological

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surveillance systems. Cholera is an acute diarrhoeal disease caused by
V. Cholerae 01 (classical or El Tor) and 0139. It is now
c. The Integrated Global Action Plan for the commonly due to the El Tor biotype and 0139. Cases range
Prevention and Control of Pneumonia and from symptomless to severe infections. The majority of
Diarrhoea (GAPPD) infections are mild or asymptomatic. Typical cases are
Please refer to page 190 for details. characterized by the sudden onset of profuse, effortless,
watery diarrhoea followed by vomiting, rapid dehydration,
PRIMARY HEALTH CARE muscular cramps and suppression of urine. Unless there is
rapid replacement of fluid and electrolytes, the case fatality
The concept of primary health care involves the delivery may be as high as 30 to 40 per cent.
of a package of curative and preventive services at the
community level. An intersectoral approach centred upon Problem statement
primary health care involving activities in the fields of water
The number of cholera cases reported to WHO continues
supply and excreta disposal, communicable disease control,
to rise. For 2020 alone, a total of 3,23,320 cases were notified
mother and child health, nutrition and health education is
from 27 countries, including 857 deaths. Many more cases
regarded as essential for the ultimate control of diarrhoeal
were unaccounted for due to limitations in surveillance
diseases.
systems and fear of trade and travel sanctions. The true
Diarrhoeal Diseases Control Programme in India burden of the disease is estimated to be 1.3-4.0 million cases
and 21,000-143,000 deaths annually (1).
The Diarrhoeal Disease Control Programme was started
Two serogroups of V cholerae - 01 and 0139 - cause
in 1978 with the objective of reducing the mortality and
outbreaks. V. cholerae 01 causes the majority of outbreaks,
morbidity due to diarrhoeal diseases. Since 1985-86, with while 0139 - first identified in Bangladesh in 1992 - is
the inception of the National Oral Rehydration Therapy
confined to South-East Asia. Non-01 and non-0139
Programme, the focus of activities has been on V. cholerae can cause mild diarrhoea but do not generate
strengthening case management of diarrhoea for children epidemics. Recently, new El Tor variant strains have been
under the age of 5 years and improving maternal knowledge detected in several parts of Asia and Africa. Observations
related to use of home available fluids, use of ORS and suggest that these strains cause more severe cholera with
continued feeding. For details, refer to chapter 7 and 11. higher case fatality rates. Careful epidemiological
References monitoring of circulating strains is recommended (2).
1. WHO (2005), The Treatment of Diarrhoea, A manual for physicians Recent studies indicate that global warming creates a
and other senior health workers, Department of Child and Adolescent favourable environment for the bacteria.
Health and Development, WHO. Cholera transmission is closely linked to inadequate
2. WHO (2021), Fact sheet on Diarrhoea. environmental management. Typical at-risk areas include
3. WHO (2008), Health Situation in the South-East Asia Region, 2001-
2007. peri-urban slums, where basic infrastructure is not available
4. Govt, of India (2021), National Health Profile 2021, DGHS, Central and in areas, where as a consequence of a disaster,
Bureau of Health Intelligence, Ministry of Health and Family Welfare, disruption of water and sanitation system takes place, or the
New Delhi. displacement of population to inadequate and overcrowded
by R△J
 CHOLERA 271
camps. Risk of cholera transmission increases, should the In areas where cholera is endemic, it does not show a
bacteria be present or introduced. Epidemics have never stable endemicity like typhoid fever (5). It undergoes
arisen from dead bodies (2). seasonal fluctuations as well as epidemic outbreaks. The
Cholera remains a global threat to public health and a seasonal variation differs between countries and even
key indicator of lack of social development. between regions of the same country. The seasonal
incidence is also subject to change. For example, the disease
The dynamics of cholera occurrences since 2005, used to be most common in the summer in Kolkata and in
combined with the emergence of new strains that lead to a the early winter in Bangladesh; now in both places, it is most
more severe clinical presentation; increased antimicrobial frequent in the autumn (6). In some parts of India, the peak
resistance and climate change, suggest that cholera may well
incidence is in August.
return to the forefront of the global public health agenda (3).
The El Tor biotype, wherever it has spread, has become
INDIA endemic with periodic outbreaks. It appears to have greater
Since the introduction of Cholera El Tor biotype in 1964, “endemic tendency” than its classical counterpart in that it
the geographic distribution of cholera in India has causes a higher infection-to-case ratio (i.e., inapparent
considerably changed. West Bengal has lost its reputation as infections and mild cases).
the “home” of cholera. Many of the States which never had Cholera occurs at intervals even in endemic areas.
cholera or were free from it for a long time, got infected and A question that is frequently asked is about the fate of
became endemic foci of El Tor infection. In several of the V cholerae in the inter-epidemic periods. Three
recently invaded areas, the disease is seen persisting as a explanations are offered : (a) the existence of long-term
smouldering infection. The classical severe epidemics with carriers (7); (b) the existence of diminished but continuous
high mortality are now uncommon. Explosive outbreaks, transmission involving asymptomatic cases (8), and (c) the
particularly following large fairs and festivals are also now rare. persistence of the organism in a free-living, perhaps altered
The bacteriology of cholera also presents a changed form in the environment (9, 10). The existence of a
picture. For reasons that are not known, there has been no free-living cycle may explain why cholera became endemic
large scale epidemic of classical cholera since 1964. In short, for varying periods in certain areas after introduction of the
the El Tor biotype of V. Cholerae 01 has rapidly replaced current pandemic strains (9, 10). Atypical non-toxigenic
the classical biotype in all parts of the country. Most of the El V. cholerae 01 of the El Tor biotype have sometimes been

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Tor biotype isolated today belong to the serotype Ogawa. found in surface waters in endemic and non-endemic areas
without any related human infection or disease (11).
During 2018, about 651 cholera cases were reported in
A question of considerable epidemiological significance is
India with 6 deaths. Majority of the cases were reported
whether “transmission” of somatic antigen can occur in the
from Uttar Pradesh (153) followed by Delhi (134),
natural environment, i.e., can non-01 V. cholerae become
West Bengal (126) and Gujarat (106) (4).
V cholerae 01 (12). Such “transformation” has been
Epidemiological features claimed by many workers (13)
Cholera is both an epidemic and endemic disease. The Epidemiological determinants
epidemicity and endemicity of a disease will depend on the
characteristics of the agent, and those of the system Agent factors
(environment). Characteristics of the agent which influence (a) AGENT : The organism that causes cholera is labelled
its distribution include its ability to survive in a given as V cholerae O Group 1 or Vibrio cholerae 01 and 0139.
environment, its virulence, the average number of The term “epidemic strain” has also been used for these
organisms required to cause infection, etc. Characteristics of vibrios. Vibrios that are biochemically similar to the
the system which affect the distribution of the agent include epidemic strains (V cholerae 01 and 0139) but do not
the number of susceptibles, and the opportunities it provides agglutinate in V cholerae 01 and 0139 antiserum have
for transmission of the infection. Global experience has been referred to in the past as non-agglutinating (NAG)
shown that the introduction of cholera into any country vibrios or as non-cholera vibrios (NCV). These are now
cannot be prevented, but cholera can create a problem only included in the species V. cholerae and are referred to as
in areas where sanitation is defective. non-0 Group IV/ 0139 cholerae (non-epidemic strains). It
Epidemics of cholera are characteristically abrupt and is now recognized that the NCV/NAG vibrios include some
often create an acute public health problem. They have a species that are pathogenic for humans (e.g., Vibrio
high potential to spread fast and cause deaths. The epidemic parahaemolyticus) which have caused outbreaks of cholera­
reaches a peak and subsides gradually as the “force of like diarrhoea. It is, therefore, necessary to identify
infection” declines. Often-times, by the time control V. cholerae 01 and 0139 for specific diagnosis of cholera.
measures are instituted the epidemic has already reached its Within the O-Group 1, two biotypes - classical and El Tor,
peak and is waning. Thus, cholera epidemic in a community have been differentiated. It may be mentioned that the
is self-limiting. This is attributed to the acquisition of El Tor biotype was first isolated at the El Tor quarantine
temporary immunity, as well as due to the occurrence of a station in Egypt in 1905. Cholera is now caused mostly by
large number of subclinical cases. the El Tor biotype and 0139. Classical and El Tor vibrios
The “force of infection” is composed of 2 components, are further divided each into 3 serological types
namely the force of infection through water and the force of namely Inaba, Ogawa and Hikojima. Most of the El Tor
infection through contacts (5). It is well-known that the vibrios isolated in India belong to the Ogawa serotype. The
elimination of contaminated water does not immediately El Tor biotype which are known for their haemolytic
bring an outbreak to an end, but a so-called “tail” of the property, lost this property as the pandemic progressed.
epidemic is produced. This is due to the continuation of They may be distinguished from classical vibrios by the
transmission through contacts (5) following tests :
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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(1) El Tor vibrio agglutinate chicken and sheep recovered from an attack of cholera may continue to excrete
erythrocytes vibrios, during his convalescence for 2-3 weeks.
(2) they are resistant to classical phage IV Convalescent state has been found to occur in patients who
have not received effective antibiotic treatment. The
(3) they are resistant to polymyxin B-50-unit disc, and
convalescent carriers can often become chronic or long-term
(4) the VP reaction and haemolytic test do not give carriers, (c) CONTACT OR HEALTHY CARRIER : This is the
consistent results. result of subclinical infection contracted through association
with a source of infection, be it a case or infected
(b) RESISTANCE : V cholerae are killed within 30
minutes by heating at 56 deg.C or within a few seconds by environment. The duration of contact carrier state is usually
boiling. They remain in ice for 4-6 weeks or longer. Drying less than 10 days; the gall bladder is not infected, and the
and sunshine will kill them in a few hours. They are easily stool culture is frequently positive for V cholerae 01. Contact
destroyed by coal tar disinfectants such as cresol. Bleaching carriers probably play an important role in the spread of
powder is another good disinfectant which kills vibrios cholera, (d) CHRONIC CARRIER : A chronic carrier state
instantly at 6 mg/litre. The El Tor biotype tends to be more occurs infrequently. The longest carrier state was found to be
resistant than do classical vibrios, (c) TOXIN PRODUCTION over 10 years (16). Studies indicate that gall bladder is
: The vibrios multiply in the lumen of the small intestine and infected in chronic carriers. Since carriers excrete fewer
produce an exotoxin (enterotoxin). This toxin produces vibrios than cases, selective media and proper enrichment
diarrhoea through its effect on the adenylate cyclase-cyclic are important for their diagnosis. In carriers, the antibody
AMP system of mucosal cells of the small intestine. The titre against V cholerae 01 rises and remains positive as long
exotoxin has no effect on any other tissue except the as the person harbours the organism. This method may be
intestinal epithelial cells, (d) RESERVOIR OF INFECTION: used to detect long-term carriers along with bacteriological
The human being is the only known reservoir of cholera examination of stools.
infection. He may be a case or carrier, (i) Cases : Cases Host factors
range from inapparent infections to severe ones. About
75 per cent of people infected with V cholerae do not (a) AGE AND SEX : Cholera affects all ages and both
develop any symptoms, although the bacteria are present in sexes. In endemic areas, attack rate is highest in children,
their faeces for 7-14 days after infection and are shed back (b) GASTRIC ACIDITY ; An effective barrier. The vibrio is
into the environment, potentially infecting other people. destroyed in an acidity of pH 5 or lower. Conditions that

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Among people who develop symptoms, about 20 per cent reduce gastric acidity may influence individual
develop acute watery diarrhoea with severe dehydration. susceptibility (19). (c) POPULATION MOBILITY : Movement
People with low immunity, e.g., malnourished children and of population (e.g., pilgrimages, marriages, fairs and
people living with HIV are at a greater risk of death if festivals) results in increased risk of exposure to infection. In
infected (1). It is the mild and asymptomatic cases that play this jet age, cases and carriers can easily transfer infection to
a significant role in maintaining endemic reservoir. other countries, (d) ECONOMIC STATUS : The incidence of
(ii) Carriers : The carriers are usually temporary, rarely cholera tends to be the highest in the lower socio-economic
chronic. They also make an important contribution to the groups, and this is attributable mainly to poor hygiene,
reservoir of infection. Since carriers excrete fewer vibrios (e) IMMUNITY : An attack of cholera is followed by immunity
than clinical cases, carriers are best detected by to reinfection, but the duration and degree of immunity are
bacteriological examination of the purged stool induced by not known. In experimental animals specific IgA antibodies
the administration of 30-60 gram of magnesium sulphate in occur in the lumen of the intestine. Similar antibodies in
100 ml of water by mouth, (e) INFECTIVE MATERIAL : The serum develop after the infection but only last a few months.
immediate sources of infection are the stools and vomit of Vibriocidal antibodies in serum (titer > 1:20) have been
cases and carriers. Large numbers of vibrios (about 107-109 associated with protection against colonization and disease.
vibrios per ml of fluid) are present in the watery stools of The presence of antitoxin antibodies has not been associated
cholera patients; and an average patient excretes 10-20 with protection (17). Vaccination gives only temporary,
litres of fluid. Carriers excrete fewer vibrios than cases, partial immunity for 3-6 months.
102-105 vibrios per gram of stools, (f) INFECTIVE DOSE :
Cholera is dose-related. Infection occurs when the number Environmental factors
of vibrios ingested exceeds the dose that is infective for the Vibrio transmission is readily possible in a community
individual. Experimental work suggests that in the normal with poor environmental sanitation. The environmental
person a very high dose-something like 1011 organisms - is factors of importance include contaminated water and food.
required to produce the clinical disease (14). (g) PERIOD Flies may carry V cholerae but not vectors of proven
OF COMMUNICABILITY : A case of cholera is infectious for importance. Numerous social factors have also been
a period of 7-10 days. Convalescent carriers are infectious responsible for the endemicity of cholera in India. These
for 2-3 weeks. The chronic carrier state may last from a comprise certain human habits favouring water and soil
month up to 10 years or more. pollution, low standards of personal hygiene, lack of
education and poor quality of life.
Carriers in cholera (15)
A cholera carrier may be defined as an apparently Mode of transmission
healthy person who is excreting V cholerae 01 (classical or El Transmission occurs from man to man via (a) FAECALLY
Tor) in stools. Four types of cholera carriers have been CONTAMINATED WATER : Uncontrolled water sources such
described (16) : (a) PRECLINICAL OR INCUBATORY as wells, lakes, ponds, streams and rivers pose a great threat,
CARRIERS : Since the incubation period of cholera is (b) CONTAMINATED FOOD AND DRINKS : Ingestion of
short (1-5 days), incubatory carriage is of short duration. contaminated food and drinks have been associated with
The incubatory carriers are potential patients, outbreaks of cholera. Bottle feeding could be a significant
(b) CONVALESCENT CARRIER : The patient who has risk factor for infants. Fruits and vegetables washed with
by R△J
 CHOLERA 273
contaminated water can be a source of infection. After decreases and may ultimately cease. The patient becomes
preparation, cooked food may be contaminated through restless, and complains of intense thirst and cramps in legs
contaminated hands and flies. There is growing opinion that and abdomen. Death may occur at this stage, due to
El Tor cholera may in some instances be transmitted through dehydration and acidosis resulting from diarrhoea,
a complex interaction of contaminated food, water and (c) STAGE OF RECOVERY : If death does not occur, the
environment rather than through public drinking water patient begins to show signs of clinical improvement. The
supplies (18). (c) DIRECT CONTACT : In developing blood pressure begins to rise, the temperature returns to
countries, a considerable proportion of cases may result from normal, and urine secretion is re-established. If anuria
secondary transmission, i.e., person to person transmission persists, the patient may die of renal failure. The classical
through contaminated fingers while carelessly handling form of severe cholera occurs in only 5-10 per cent of cases.
excreta and vomit of patients and contaminated linen and In the rest, the disease tends to be mild characterized by
fomites. diarrhoea with or without vomiting or marked dehydration.
As a rule, mild cases recover in 1-3 days.
Incubation period Epidemiologically, cholera due to El Tor biotype differs
From a few hours upto 5 days, but commonly 1-2 days. from classical cholera in the following respects : (a) a higher
incidence of mild and asymptomatic infection. This implies
Pathogenesis that the characteristic picture of rice-water stools and other
The main symptom of cholera is diarrhoea. Diarrhoea in signs of classical cholera described above may not be seen
cholera was attributed in the past to such factors as increased often; (b) fewer secondary cases in the affected families;
permeability of the intestinal epithelial cells, increased (c) occurrence of chronic carriers, and (d) since El Tor
peristalsis, mucosal damage, an increase in mesenteric blood vibrios are more resistant than classical cholera vibrios, they
flow and failure of the “sodium pump”, i.e., interference with survive longer in the extra-intestinal environment.
the passage of sodium from the lumen to the plasma. None
of these theories stood the test of time (19). Laboratory diagnosis of cholera (21)
According to current concepts, the cholera vibrio get The diagnosis of cholera can never be made with certainty
through the mucus which overlies the intestinal epithelium. on clinical grounds. Laboratory methods of diagnosis are
It probably secretes mucinase, which helps it move rapidly required to confirm the diagnosis : (a) COLLECTION OF

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through the mucus. Then it gets attached or adhered to the STOOLS : A fresh specimen of stool should be collected for
intestinal epithelial cells, and this it probably does by an laboratory examination. Sample should be collected before
adherence factor on its surface. When the vibrio becomes the person is treated with antibiotics. Collection may be made
adherent to the mucosa, it produces its enterotoxin which generally in one of the following ways : (i) Rubber catheter :
consists of 2 parts - the light or L toxin and the heavy or Collection by the catheter is the best method but is
H toxin. The L toxin combines with substances in the complicated under field conditions. Soft rubber catheter
epithelial cell membrane called gangliosides and this binds (No.26-28) sterilized by boiling should be used. The catheter
the vibrio to the cell wall. Binding is irreversible. The mode is introduced (after lubrication with liquid paraffin) for at least
of action of H toxin is not fully clear. What we know is that 4-5 cm into the rectum. The specimen voided may be
there is a substance called “adenyl cyclase” in the intestinal collected directly into a transport (holding) media, e.g.,
epithelial cells, and H toxin activates this substance. The Venkatraman-Ramakrishnan (VR) medium, alkaline peptone
activated adenyl cyclase causes a rise in another substance, water, (ii) Rectal swab : Swabs consisting of 15-20 cm long
called 3, 5-adenosine monophosphate, better known as wooden sticks, with one end wrapped with absorbent cotton,
cyclic or cAMP (A physiologist got Noble Prize for describing sterilized by autoclaving have been found to be satisfactory.
this substance). cAMP provides energy which drives fluid Rectal swabs should be dipped into the holding medium
and ions into the lumen of the intestine. This fluid is isotonic before being introduced into the rectum, (iii) If no transport
and is secreted by all segments of small intestine. The medium is available, a cotton-tipped rectal swab should be
increase in fluid is the cause of diarrhoea, and not increased soaked in the liquid stool, placed in a sterile plastic bag,
peristalsis. There is no evidence that V. cholerae invades any tightly sealed and sent to the testing laboratory (22).
tissue, nor the enterotoxin to have any direct effect on any (b) VOMITUS : This is practically never used as the chances
organ other than the small intestine (19). of isolating vibrios are much less and there is no advantage.
(c) WATER : Samples containing 1-3 litres of suspect water
Clinical features should be collected in sterile bottles (for the filter method), or
The severity of cholera is dependent on the rapidity and 9 volumes of the sample water added to 1 volume of 10 per
duration of fluid loss. Epidemiological studies have shown cent peptone water, and despatched to the laboratory by the
that more than 90 per cent of El Tor cholera cases are mild quickest method of transport, (d) FOOD SAMPLES : Samples
and clinically indistinguishable from other acute diarrhoeas of food suspected to be contaminated with V cholerae (or
(20). However, a typical case of cholera shows 3 stages : other enteric bacteria) amounting to 1 to 3 g are collected in
(a) STAGE OF EVACUATION : The onset is abrupt with transport media and sent to the laboratory,
profuse, painless, watery diarrhoea followed by vomiting. (e) TRANSPORTATION : (i) The stools should be transported
The patient may pass as many as 40 stools in a day. The in sterilized McCartney bottles, 30 ml capacity containing
stools may have a “rice water” appearance, (b) STAGE OF alkaline peptone water or VR medium. VR medium can be
COLLAPSE : The patient soon passes into a stage of used if larger stool specimens can be collected. The specimen
collapse because of dehydration. The classical signs are : should be transported in alkaline peptone water or
sunken eyes, hollow cheeks, scaphoid abdomen, sub­ Cary-Blair medium if it is collected by a rectal swab. One
normal temperature, washerman’s hands and feet, absent gram or one ml of faeces in 10 ml of the holding medium will
pulse, unrecordable blood pressure, loss of skin elasticity, suffice. Rectal swabs should have their tops broken off so that
shallow and quick respirations. The output of urine caps of the containers can be replaced (ii) If suitable plating
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

media are available (e.g., bile salt agar) at the bed-side, the 2. Notification
stools should be streaked on to the media and forwarded to Cholera is a notifiable disease locally and nationally.
the laboratory with the transport media, (f) DIRECT Since 2005 cholera notification is no longer mandatory
EXAMINATION : If a microscope with dark field illumination internationally. Health workers at all levels (particularly
is available, it may be possible to diagnose about 80 per cent those who are closest to the community such as the
of the cases within a few minutes, and more cases after community health workers and the multi-purpose workers)
5-6 hours of incubation in alkaline peptone water. In the dark should be trained to identify and notify cases immediately to
field, the vibrios evoke the image of many shooting stars in a the local health authority. Under the International Health
dark sky. If motility ceases on mixing with polyvalent Regulations, cholera is notifiable to the WHO within
anti-cholera diagnostic serum, the organisms are presumed 24 hours of its occurrence by the National Government; the
to be cholera vibrios. A presumptive diagnosis of cholera can number of cases and deaths are also to be reported daily
thus be established, (g) CULTURE METHODS : On arrival at and weekly till the area is declared free of cholera. An area is
the laboratory, the specimen in holding fluid is well shaken, declared free of cholera when twice the incubation period
and about 0.5 to 1.0 ml of material is inoculated into Peptone (i.e., 10 days) has elapsed since the death, recovery or
Water Tellurite (PWT) medium for enrichment. After 4 to isolation of the last case (24).
6 hours incubation at 37 deg. C, a loopful of the culture from
the surface is subcultured on Bile Salt Agar medium (BSA, pH 3. Early case-finding
8.6). After overnight incubation, the plates are screened An aggressive search for cases (mild, moderate, severe)
under oblique light illumination for vibrio colonies. should be made in the community to be able to initiate
(h) CHARACTERIZATION : V cholerae usually appears on prompt treatment. Early detection of cases also permits the
bile salt agar (BSA) as translucent, moist, raised, smooth and detection of infected household contacts and helps the
easily emulsifiable colonies about 1 mm in diameter. The epidemiologist in investigating the means of spread for
typical colonies are picked up and tested as follows : deciding on specific intervention.
(i) Gram's stain and motility : Gram negative and curved rods
with characteristic scintillating type of movement in hanging 4. Establishment of treatment centres
drop preparations are very characteristic of V. cholerae
In the control of cholera, no time should be lost in
(ii) Serological test: Slide agglutination test is done by picking
providing treatment for the patients. To achieve this
up suspected colonies and making a homogeneous

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objective, it is necessary to establish easily accessible
suspension in 0.85 per cent sterile saline and adding one
treatment facilities in the community.
drop of polyvalent anti-cholera diagnostic serum. If
agglutination is positive, the test is repeated with Inaba and The mildly dehydrated patients (which account for over
Ogawa antisera, to determine the subtype, 90 per cent of cases) should be treated at home with oral
(i) BIOCHEMICAL TESTS : Serologically positive colonies rehydration fluid. Severely dehydrated patients, requiring
should be subcultured in one tube each of the sugar broths intravenous fluids, should be transferred to the nearest
(mannose, sucrose, arabinose) and a tube of peptone water treatment centre or hospital; if possible, they should receive
pH 7.2 for the cholera red reaction. Production of acid in oral rehydration on the way to the hospital or treatment
sucrose and mannose, but not arabinose is characteristic of centre. If there is no hospital or treatment centre within a
V cholerae. (j) FURTHER CHARACTERIZATION : For convenient distance, a local school or public building should
further characterization of biotypes of V cholerae organisms be taken .over and converted into a temporary treatment
are identified by slide agglutination tests using anti-01 or centre, as close to the site of epidemic as possible.
group 139 antisera and by biochemical reaction patterns. Transportation of cases over long distances is not desirable;
it has been linked with the spread of the disease.
Suspicious colonies that do not agglutinate with
anticholera sera are tested further by the oxidase and string In areas where peripheral health services are poor and
tests (19). cholera is endemic or threatening, mobile teams should be
established at the district level. When needed, these teams
should be brought promptly into the epidemic area to assist
CONTROL OF CHOLERA
the local workers.
It is now considered that the best way to control cholera
is to develop and implement a national programme for the 5. Rehydration therapy
control of ALL diarrhoeal diseases because of similarities in Cholera is now the most effectively treated disease.
the epidemiology, pathophysiology, treatment and control of Mortality rates have been brought down to less than 1 per
cholera and other acute diarrhoeal diseases (23). The cent by effective rehydration therapy. The rehydration
following account is based on the “Guidelines for Cholera may be oral or intravenous. The guidelines for ORT
Control” proposed by the WHO (11). and intravenous rehydration are discussed in detail on
page 266, 267.
1. Verification of the diagnosis
It is important to have confirmation of the outbreak as 6. Adjuncts to therapy
quickly as possible. All cases of diarrhoea should be Antibiotics should be given as soon as vomiting has
investigated even on the slightest suspicion. For the specific stopped, which is usually after 3 to 4 hours of oral
diagnosis of cholera, it is important to identify V. cholerae rehydration. Injectable antibiotics have no special
01 in the stools of the patient. Once the presence of cholera advantages. The commonly used antibiotics for the
has been proved, it is not necessary to culture stools of all treatment of cholera are flouroquinolones, tetracycline,
cases or contacts. Bacteriological diagnosis of cholera Azithromycin, ampicilline and Trimethoprim TMP-
envisages a well-organized system of laboratory services in Sulfamethoxazole (SMX). No other medication should be
the community. given to treat cholera, like antidiarrhoeals, antiemetics,

by R△J
 CHOLERA 275
antispasmodics, cardiotonics and corticosteroids. In regions The housefly plays a relatively small role in transmitting
where cholera is present, it is important to identify those cholera, but its prevalence is a general indicator of the level
antibiotics to which the vibrio cholerae 01 is resistant. If of sanitation.
diarrhoea persists after 48 hours of treatment, resistance to (d) DISINFECTION : Disinfection should be both
antibiotic should be suspected. concurrent and terminal. The most effective disinfectant for
general use is a coal tar disinfectant with a Rideal-Walker
7. Epidemiological investigations (RW) coefficient of 10 or more such as cresol. A disinfectant
General sanitation measures must be applied at the onset with a RW coefficient of less than 5 should not be used (26).
of an outbreak (see under sanitation measures). At the same Bleaching powder, if used, should be of good quality. For
time, epidemiological studies must be undertaken to define disinfection, attention should be paid to the following :
the extent of the outbreak and identify the modes of patient’s stools and vomit; clothes and other personal items
transmission so that more effective and specific control that may have been contaminated; the latrine, if any; the
measures can be applied. The epidemiologist must maintain patient’s house and neighbourhood.
contact with all health and civic units in his area to ensure
detection of new foci of disease. 9. Chemoprophylaxis
There are certain institutions which are able to assist in Studies have shown that approximately 10-12 per cent
investigating outbreaks. These include the National Institute of close household contacts of a cholera case may be
of Communicable Diseases, Delhi and the All India Institute bacteriologically positive, and some of these develop clinical
of Hygiene and Public Health, Kolkata, where illness. In contrast, a very small proportion (0.6-1 per cent)
epidemiological teams are available for investigating in the community may be excreting vibrios. Mass
epidemics. In addition, stools for phage typing may be sent chemoprophylaxis is not advised for the total community
to the National Institute of Cholera and Enteric Diseases, 3, because in order to prevent one serious case of cholera,
Dr Isaque Road, Kolkata-700016, where the WHO some 10,000 persons must be given the drug. Further, the
International Centre for Vibrios is located. drug’s effect is only short-lived for a few days. Whenever
mass chemoprophylaxis was attempted, it failed to stop the
8. Sanitation measures spread of cholera. Because of these reasons,
(a) WATER CONTROL : As water is the most important chemoprophylaxis is advised only for household contacts or

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vehicle of transmission of cholera, all steps must be taken to of a closed community in which cholera has occurred.
provide properly treated or otherwise safe water to the Tetracycline is the drug of choice for chemoprophylaxis. It
community for all purposes (drinking, washing and cooking). has to be given over a 3-day period in a twice-daily dose of
Various approaches have been described for supplying 500 mg for adults, 125 mg for children aged 4-13 years, and
safe water quickly and with limited resources (25). Facilities 50 mg for children aged 0-3 years. Alternatively, the long-
selected and installed should be appropriate and acceptable acting tetracycline (doxycycline) may be used for
to the community. The ultimate aim should be provision of chemoprophylaxis, if the prevailing strains are not resistant. A
piped water supply on a permanent basis and elimination of single oral dose of doxycycline (300 mg for adults and 6 mg/kg
alternative unsafe water sources. Because of financial for children under 15 years) has proved to be effective.
limitations and other competitive priorities, this measure
cannot be applied immediately on a large scale in 10. Vaccination
developing countries, such as India. As an emergency
ORAL VACCINE (27)
measure, in urban areas, properly treated drinking water
containing free residual chlorine should be made available Three types of oral cholera vaccines are available :
to all families; this water should be stored in the household (a) Dukoral (WC-rBS), (b) Sanchol and mORCVAX and
in narrow-mouthed, covered containers. In rural areas, (c) Euvichol. The live attenuated single-dose vaccine
water can be made safe by boiling or by chlorination. The (CVD103-HgR) is no longer produced.
emergency measures should be followed by the
development of more permanent facilities. (a) Dukoral (WC-rBS)
(b) EXCRETA DISPOSAL : Provision of simple, cheap Dukoral is a monovalent vaccine based on formalin and
and effective excreta disposal system (sanitary latrines) is a heat-killed whole cells (WC) of V cholerae 01 (classical and
basic need of all human settlements. When cholera appears El Tor, Inaba and Ogawa) plus recombinant cholera toxin B
in a community, the need for these facilities becomes vital. subunit. The vaccine is provided in 3 ml single-dose vials
With the cooperation of the community, sanitary system together with the bicarbonate buffer (effervescent granules
should be selected and constructed (25), taking into in sachets to protect the toxin B subunit from being
consideration the customs and practices of the population, destroyed by gastric acid). Vaccine and buffer are mixed in
the existing terrain and geology, and the available resources. 150 ml of water (chlorinated or not) for persons aged >5
Simultaneously, health education messages should stress the years and in 75 ml of water for children aged 2-5 years. The
proper use of such facilities, the dangers involved in vaccine has a shelf life of 3 years at 2-8°C and remains
depositing faeces on the ground, and in or near water, and stable for 1 month at 37°C.
the importance of handwashing with soap after defecation.
Vaccine schedule and administration
(c) FOOD SANITATION : Since food may be an
important vehicle of infection, steps should be taken to According to the manufacturer, primary immunization
improve food sanitation, particularly sale of foods under consists of 2 oral doses given >7 days apart (but <6 weeks
hygienic conditions. Health education must stress the apart) for adults and children aged >6 years. Children aged
importance of eating cooked hot food and of proper 2-5 years should receive 3 doses >7 days apart (but < 6 weeks
individual food handling techniques. Cooking utensils apart). Intake of food and drink should be avoided for 1 hour
should be cleaned and dried after use. before and after vaccination. If the interval between the
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

primary immunization doses is delayed for >6 weeks, primary 10. Levine, M.M. (1980). N. Eng.J.Med., 302 (6) 345.
immunization should be restarted. Protection may be 11. WHO (1980). Guidelines for Cholera Control, WHO/CDD/SER/80.4,
expected about 1 week after the last scheduled dose. Geneva.
12. Blake, Paul A (1980). in Annua/ Review of Microbiology, 34 : 351.
Provided there is continued risk of V. cholerae infection, 13. Seal, S.C. (1977). Ind. J. Pub. Health, 21 (2) 48.
1 booster dose is recommended by manufacturer, after 14. Mackay, D.M. (1979). Trans. Roy.Soc.Trop.Med & Hyg., 73 (1) 1.
2 years for adults and children aged >6 years. If the interval 15. Seal, S.C. (1977). Ind. J. Pub. Health, 21 (2) 48.
between the primary series and booster immunization is 16. Shrivastava, D.L. (1968).J.Indian M.A., 50 : 581.
>2 years, primary immunization must be repeated. For 17. Jawetz. Melnick & Adelberg's Medical Microbiology, 25th Ed. 2010,
children aged 2-5 years 1 booster dose is recommended A Lange Publications.
every 6 months, and if the interval between primary 18. Gunn, R.A. et al (1981). Bull WHO, 59 (1) 65.
immunization and the booster is >6 months, primary 19. Christie, A.B. (1980). Infectious Diseases: Epidemiology and Clinical
immunization must be repeated. Practice, 3rd ed., Churchill Livingstone.
20. WHO (2004), Weekly Epidemiological Record, No.31, July 30, 2004.
Dukoral is not licensed for children aged <2 years. 21. WHO (1974). Guidelines for the Laboratory Diagnosis of Cholera.
22. WHO (2001), Weekly Epidemiological Record, No. 31, 3 Aug. 2001.
(b) Sanchol and mORCVAX 23. WHO (1978). Development of a Programme for Diarrhoeal Diseases
The closely related bivalent oral cholera vaccines are Control, Report of an Advisory Group, WHO/DDC/78.1.
based on serogroups 01 and 0139. Unlike Dukoral, these 24. Delon, P.J. (1975). International Health Regulations, A Practical
Guide, WHO, Geneva.
vaccines do not contain the bacterial toxin B subunit 25. Rajagopalan, S. and Shiftman, M.A. (1974). Guide to Simple Sanitary
therefore it does not require buffer. According to the Measures for the Control of Enteric Diseases, Geneva, WHO.
manufacturer, vaccine should be administered orally in 26. ICMR (1959). Report of the Central Expert Committee on Smallpox
2 liquid doses 14 days apart for individuals aged >1 year. and Cholera, New Delhi.
A booster dose is recommended after 2 years (27). 27. WHO (2010), Weekly Epidemiological Record, No. 13, 26th March
2010.
(c) Euvichol 28. Govt, of India, Ministry of Health and Family Welfare (1981). Report
1980-81, Department of Health and Family Welfare, New Delhi.
It was prequalified in December 2015 and has same 29. Govt, of India, Ministry of Health & Family Welfare (1982). Annual
characteristics as Sanchol (2). Report 1981-1982.
30. Govt, of India, Annual Report 1993-94, DGHS, New Delhi.

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11. Health education
The most effective prophylactic measure is perhaps TYPHOID FEVER
health education. It should be directed mainly to (a) the
effectiveness and simplicity of oral rehydration therapy Typhoid fever is the result of systemic infection mainly by
(b) the benefits of early reporting for prompt treatment S. typhi found only in man. The disease is clinically
(c) food hygiene practices (d) hand washing after defecation characterized by a typical continuous fever for 3 to 4 weeks,
and before eating, and (e) the benefit of cooked, hot foods relative bradycardia with involvement of lymphoid tissues
and safe water. Since cholera is mainly a disease of the poor and considerable constitutional symptoms. The term
and ignorant, these groups should be tackled first. "enteric fever" includes both typhoid and paratyphoid
fevers. The disease may occur sporadically, epidemically or
Diarrhoeal Diseases Control Programme endemically.
The incidence of cholera cases and deaths has decreased Problem statement
in recent years. During the year 1980-81, strategy of the
National Cholera Control Programme has undergone WORLD
changes (28). It is now termed as Diarrhoeal Diseases Typhoid fever occurs in all parts of the world where water
Control Programme (29). Oral Rehydration Therapy supplies and sanitation are sub-standard. The disease is now
Programme was started in 1986-87 in a phased manner. uncommon in the developed countries where most of the
The main objective of the programme is to prevent cases that occur are either acquired abroad or imported by
diarrhoea-associated deaths in children due to dehydration. immigrants (1). Improved living conditions and the
The training programme and health education material introduction of antibiotics in the late 1940s resulted in
highlight the rational management of diarrhoea in children, drastic reduction of typhoid fever morbidity and mortality in
including increased intake of home available fluids and industrialized countries. In developing areas of Asia, Africa,
breast feeding. ORS is promoted as first line of treatment. Latin America, however, the disease continues to be a public
ORS is being supplied as a part of the sub-centre kits (30). health problem, albeit with incidence rate that vary
considerably between and within countries. WHO estimated
References the global typhoid fever disease burden at 11-20 million
1. WHO(2020), Weekly Epidemiological Record, No. 37, llthSep. 2020. cases annually, resulting in an estimated 128,000-161,000
2. WHO (2016), Weekly Epidemiological Record, No. 38,23rd Sep. 2016. deaths per year, predominantly in children of school age or
3. WHO (2010), Weekly Epidemiological Record, No. 31,30th July 2010. younger. Majority of this burden occurs in Asia (2).
4. Govt, of India (2021), National Health Profile 2021, Central Bureau of Since 1950, the organism’s resistance to antibiotics has
Health Intelligence, DGHS, Ministry of Health and Family Welfare, also been a growing problem; by 1989 resistance was reported
New Delhi.
5. Cvjetanovic, B. et al (1978). Bull WHO, 56 Supplement No. 1, p. 76. in a number of countries, particularly in Asia and Middle East.
6. WHO (1980) Programme for Control of Diarrhoeal Diseases, Scientific Resistant strains have caused outbreaks of the disease in India
Working Group Reports 1978-1980, CDD/80.1, WHO, Geneva. and Pakistan in recent years. In South-East Asia, 50 per cent
7. Azurin, J.C. etal (1967). Bull WHO, 37 : 745-749. or more of the strains of the bacteria may already be resistant
8. Sinha, R. et al (1967). Bull WHO, 37 : 89-100. to several antibiotics (3). Typhoid fever caused by multidrug­
9. Nalin, D.R. (1976). Lancet, 2 : 958. resistant (MDR) strains of S. typhi - that is resistant to all 3 of

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 TYPHOID FEVER

the first line of antibiotics (chloramphenicol, ampicillin and group. Prospective population-based surveillance in some
cotrimoxazole) - is associated with more severe illness and Asian urban slum areas has shown that in the age group
higher rates of complications and death, especially in children 5-15 years, the annual incidence of blood culture-confirmed
aged less than 2 years. Also, compared with typhoid fever typhoid fever may reach 180-494 per 100,000. In some of
caused by sensitive strains, a ten-fold higher rate of these areas, pre-school-age children less than 5 years, show
post-treatment symptomatic bacterial carriers has been incidence rates similar to those of school-age children (2).
reported with MDR S. typhi infection (2). Without effective After the age of 20 years, the incidence falls probably due to
treatment, typhoid fever kills almost 10 per cent of those acquisition of immunity from clinical or subclinical infection.
infected (3). (b) Sex: More cases are reported among males than females,
The socio-economic impact of the disease is huge, probably as a result of increased exposure to infection. But
because typhoid survivors may take several months to carrier rate is more in females, (c) Immunity: All ages are
recover and resume work. susceptible to infection. Antibody may be stimulated by the
infection or by immunization; however, the antibody to the
INDIA somatic antigen (O) is usually higher in the patient with the
Typhoid fever is endemic in India. Reported data for the disease, and the antibody to the flagellar antigen(H) is
year 2020 shows 1.069 million cases and 126 deaths. usually higher in immunized individuals. Serum antibodies
Maximum cases were reported from Uttar Pradesh are not the primary defences against infection; S. typhi being
(297,170 cases) West Bengal (117,842 cases and 9 deaths), an intracellular organism, cell-mediated immunity plays a
Karnataka (88,558 cases), Telangana (68,280 cases) and major role in combating the infection. Natural typhoid fever
Andhra Pradesh (65,068 cases and 9 deaths) (5) does not always confer solid immunity; second attacks may
occur when challenged with a large oral dose. Among the
Epidemiological determinants host factors that contribute to resistance to S. typhi are
gastric acidity and local intestinal immunity.
Agent factors
Environmental and social factors
(a) AGENT : S. typhi is the major cause of enteric fever.
S. para A and S. para B are relatively infrequent (6). S. typhi Enteric fevers are observed all through the year. The
has three main antigens - O, H and Vi and a number of peak incidence is reported during July-September (8). This
phage types (at least 80). Phage typing has proved a useful period coincides with the rainy season and an increase in fly

telegram-@Cherry_2412
epidemiological tool in tracing the source of epidemics. population.
S. typhi survives intracellularly in the tissues of various Outside the human body, the bacilli are found in water,
organs. It is readily killed by drying, pasteurization, and ice, food, milk and soil for varying periods of time. Typhoid
common disinfectants. The factors which influence the onset bacilli do not multiply in water; many of them perish within
of typhoid fever in man are the infecting dose and virulence 48 hours, but some may survive for about 7 days. They may
of the organism. survive for over a month in ice and icecream. They may
(b) RESERVOIR OF INFECTION : Man is the only known survive for up to 70 days in soil irrigated with sewage under
reservoir of infection, viz. cases and carriers, (i) CASES : moist winter conditions, and for half that period under drier
The case may be mild, missed or severe. A case (or carrier) summer conditions (9). Food being a bad conductor of heat,
is infectious as long as bacilli appear in stools or urine, provides shelter to the bacilli which may multiply and
(ii) CARRIERS : The carriers may be temporary (incubatory, survive for sometime in food. Typhoid bacilli grow rapidly in
convalescent) or chronic. Convalescent carriers excrete the milk without altering its taste or appearance in anyway.
bacilli for 6 to 8 weeks, after which their numbers diminish Vegetables grown in sewage farms or washed in
rapidly. By the end of three months, not more than contaminated water are a positive health hazard. These
4 per cent of cases are still excreting the organisms; and by factors are compounded by such social factors as pollution
the end of one year, the average carrier rate is around of drinking water supplies, open air defecation and
3 per cent (7). Persons who excrete the bacilli for more than urination, low standards of food and personal hygiene and
a year after a clinical attack are called chronic carriers. In health ignorance. Typhoid fever may therefore be regarded
most chronic carriers, the organisms persist in the gall as an index of general sanitation in any country.
bladder and in the biliary tract. A chronic carrier state may
be expected to develop in 2 to 5 per cent of cases. A chronic Incubation period
carrier may excrete the bacilli for several years (may be as Usually 10-14 days. But it may be as short as 3 days or
long as 50 years) either continuously or intermittently. The as long as three weeks depending upon the dose of the
famous case of “Typhoid Mary” who gave rise to more than bacilli ingested.
1300 cases in her life time is a good example of a chronic
carrier. Faecal carriers are more frequent than urinary Modes of transmission
carriers. Chronic urinary carrier state is often associated Typhoid fever is transmitted via the faecal-oral route or
with some abnormality of the urinary tract. urine-oral routes. This may take place directly through
(c) SOURCE OF INFECTION : The primary sources of soiled hands contaminated with faeces or urine of cases or
infection are faeces and urine of cases or carriers; the carriers, or indirectly by the ingestion of contaminated
secondary sources contaminated water, food, fingers and water, milk and/or food, or through flies.
flies. There is no evidence that typhoid bacilli are excreted in Fig. 1 shows the dynamics of transmission. There are
sputum or milk. numerous sources of infection and many vehicles of
transmission, each making its own contribution to the total
Host factors magnitude of the problem. The situation is rendered more
(a) Age : Typhoid fever may occur at any age. Highest complex by the web of social, cultural and economic factors
incidence of this disease occurs in the 5-19 years of age which determine the quality of life of the people.

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278 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

with the patient). The test has only moderate sensitivity and
specificity. It can be negative in upto 30 per cent of culture -
proven cases of typhoid fever. This may be because of prior
antibiotic therapy that has blunted the antibody response.
On the other hand, S. typhi shares 0 and H antigens with
other salmonella serotypes and has cross-reacting epitopes
with other Enterobacteriacae, and this can lead to false­
positive results. Such results may also occur in other clinical
conditions, e.g. malaria, typhus, bacteraemia caused by
other organisms, and cirrhosis.
(c) NEW DIAGNOSTIC TESTS : The recent advances for
quick and reliable diagnostic tests for typhoid fever as an
alternative to the Widal test include the IDL Tubex® test
FIG.l marketed by a Swedish company, which reportedly can
Dynamics of typhoid fever transmission
detect IgM09 antibodies from patient within a few minutes.
Another rapid serological test, Typhidot®, takes three hours
to perform. It was developed in Malaysia for the detection of
Clinical features specific IgM and IgG antibodies against a 50 kD antigen of
8. typhi. A newer version of the test, Typhidot-M®, was
The onset is usually insidious but in children may be
recently developed to detect specific IgM antibodies only.
abrupt, with chills and high fever. During the prodromal
The dipstick test, developed in the Netherlands, is based on
stage, there is malaise, headache, cough and sore throat,
the binding of S. typhi - specific IgM antibodies in samples
often with abdominal pain and constipation. The fever
to 8. typhi lipopolysaccharide (LPS) antigen and the staining
ascends in a step-ladder fashion. After about 7-10 days, the
of bound antibodies by an anti-human IgM antibody
fever reaches a plateau and the patient looks toxic,
conjugated to colloidal dye particles.
appearing exhausted and often prostrated. There may be
marked constipation, especially in early stage or “pea soup”
diarrhoea. There is marked abdominal distention. There is CONTROL OF TYPHOID FEVER
leukopenia and blood, urine and stool culture is positive for The control or elimination of typhoid fever is well within

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salmonella. If there are no complications the patient's the scope of modern public health. This is an accomplished
condition improves over 7-10 days. However, relapse may fact in many developed countries. There are generally three
occur for upto 2 weeks after termination of therapy. lines of defence against typhoid fever :
During the early phase, physical findings are few. Later, 1. control of reservoir
splenomegaly, abdominal distension and tenderness, relative 2. control of sanitation, and
bradycardia, dicrotic pulse, and occasionally meningismus 3. immunization.
appear. The rash (rose spots) commonly appears during the
second week of disease. The individual spot, found The weakest link in the chain of transmission is sanitation
principally on the trunk, is a pink papule 2-3 mm in diameter which is amenable to control.
that fades on pressure. It disappears in 3-4 days.
1. Control of reservoir
Serious complications occur in up to 10 per cent of
typhoid fever patients, especially in those who have been ill The usual methods of control of reservoir are their
longer than 2 weeks, and who have not received proper identification, isolation, treatment and disinfection.
treatment. Intestinal haemorrhage is manifested by a sudden
a. CASES
drop in temperature and signs of shock, followed by dark or
fresh blood in the stool. Intestinal perforation is most likely (i) Early diagnosis : This is of vital importance as the early
to occur during the third week. Less frequent complications symptoms are non-specific. Culture of blood and stools are
are urinary retention, pneumonia, thrombophlebitis, important investigations in the diagnosis of cases.
myocarditis, psychosis, cholecystitis, nephritis and (ii) Notification: This should be done where such notification
osteomyelitis. is mandatory, (in) Isolation : Since typhoid fever is infectious
and has a prolonged course, the cases are better transferred
Estimates of case-fatality rates of typhoid fever range
to a hospital for proper treatment, as well as to prevent the
from 1 per cent to 4 per cent; fatality rates in children aged
spread of infection. As a rule, cases should be isolated till
less than 4 years being 10 times higher (4.0%) than in older
three bacteriologically negative stools and urine reports, are
children (0.4%). In untreated cases, the fatality rates may
obtained on three separate days, (iv) Treatment : The
rise to 10-20 per cent (2).
fluoroquinolones are widely regarded as the drug of choice
Laboratory diagnosis of typhoid (3) for the treatment of typhoid fever. They are relatively
inexpensive, well tolerated and more rapidly and reliably
(a) MICROBIOLOGICAL PROCEDURES : The definitive effective than the former first-line drugs, viz.
diagnosis of typhoid fever depends on the isolation of chloramphenicol, ampicillin, amoxicillin and trimethoprim -
S. typhi from blood, bone marrow and stools. Blood culture sulfamethoxazole (TMP-SMX). The antibiotics used in
is the mainstay of diagnosis of this disease. uncomplicated typhoid fever are as shown in Table 1. Patients
(b) SEROLOGICAL PROCEDURE : Felix-Widal test seriously ill and profoundly toxic may be given an injection of
measures agglutinating antibody levels against O and hydrocortisone 100 mg daily for 3 to 4 days, (v) Disinfection :
H antigens. Usually, O antibodies appear on day 6-8 and Stools and urine are the sole sources of infection. They
H antibodies on day 10-12 after the onset of disease. The should be received in closed containers and disinfected with
test is usually performed on an acute serum (at first contact 5 per cent cresol for at least 2 hours. All soiled clothes and

by R△J
 TYPHOID FEVER

TABLE 1
Treatment of uncomplicated typhoid fever

Optimal therapy Alternative effective drugs

Susceptibility Antibiotic Daily dose Days Antibiotic Daily dose Days
mg/kg mg/kg
Fully sensitive Fluoroquinolone e.g. 15 5-7 8 Chloramphenicol 50-75 14-21
ofloxacin or Amoxicillin 75-100 14
ciprofloxacin TMP-SMX 8-40 14
Multidrug Fluoroquinolone 15 5-7 Azithromycin 8-10 7
resistance or cefixime 15-20 7-14 Cefixime 15-20 7-14
Quinolone Azithromycin or 8-10 7 Cefixime 20 7-14
resistance b ceftriaxone 75 10-14
a Three-day courses are also effective and are particularly so in epidemic containment.
b The optimum treatment for quinolone-resistant typhoid fever has not been determined. Azithromycin, the third-generation

cephalosporins, or a 10-14 days course of high-dose fluoroquinolones, is effective. Combinations of these are now being evaluated.
Source : (10)

linen should be soaked in a solution of 2 per cent chlorine and combined with health education, the effects tend to be
steam-sterilized. Nurses and doctors should not forget to cumulative, resulting in a steady reduction of typhoid
disinfect their hands, (vi) Follow-up : Follow-up examination morbidity (11).
of stools and urine should be done for S. typhi 3 to 4 months
after discharge of the patient, and again after 12 months to 3. Immunization
prevent the development of the carrier state. With early While ultimately, control of typhoid fever must take the
diagnosis and appropriate treatment, mortality has been form of improved sanitation and domestic and personal
reduced to about 1 per cent as compared to about 30 per cent hygiene, these are long-term objectives in many developing
in untreated cases. countries. A complementary approach to prevention is

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immunization, which is the only specific preventive measure,
(b) CARRIERS likely to yield the highest benefit for the money spent.
Since carriers are the ultimate source of typhoid fever, Immunization against typhoid does not give 100 per cent
their identification and treatment is one of the most radical protection, but it definitely lowers both the incidence and
ways of controlling typhoid fever. The measures seriousness of the infection. It can be given at any age
recommended are : (i) Identification : Carriers are identified upwards of two years. It is recommended to : (i) those living
by cultural and serological examinations. Duodenal in endemic areas (ii) household contacts (iii) groups at risk
drainage establishes the presence of salmonella in the biliary of infection such as school children and hospital staff
tract in carriers. The Vi antibodies are present in about (iv) travellers proceeding to endemic areas, and (v) those
80 per cent of chronic carriers, (ii) Treatment : The carrier attending melas and yatras.
should be given an intensive course of ampicillin or
amoxycillin (4-6 g a day) together with Probenecid ANTI-TYPHOID VACCINES (2)
(2 g/day) for 6 weeks. These drugs are concentrated in the The old parenteral killed whole-cell vaccine was effective
bile and may achieve eradication of the carrier state in but produced strong side-effects. Two safe and effective
about 70 per cent of carriers. Chloromycetin is considered vaccines are now licensed and available. One is based on
worthless for clearing the carrier state. (Hi) Surgery : defined subunit antigens, the other on whole-cell live
Cholecystectomy with concomitant ampicillin therapy has attenuated bacteria.
been regarded as the most successful approach to the
treatment of carriers. Cure rate may be as high as The Vi polysaccharide vaccine
80 per cent. Urinary carriers are easy to treat, but refractory This subunit vaccine was first licensed in the United
cases may need nephrectomy when one kidney is damaged States in 1994. It is composed of purified Vi capsular
and the other healthy, (iv) Surveillance : The carriers should polysaccharide from the Ty2 S. Typhi strain and elicits a
be kept under surveillance. They should be prevented from T-cell independent IgG response that is not boosted by
handling food, milk or water for others, (v) Health education additional doses. The vaccine is administered
: Health education regarding washing of hands with soap, subcutaneously or intramuscularly. The target value for each
after defecation or urination, and before preparing food is single human dose is about 25pg of the antigen. The vaccine
an essential element. In short, the management of carriers is stable for 6 months at 37°C, and for 2 years at 22°C. The
continues to be an unsolved problem. This is the crux of the recommended storage temperature is 2-8°C. The Vi vaccine
problem, in the elimination of typhoid fever. does not elicit adequate immune responses in children aged
less than 2 years.
2. Control of sanitation
Protection and purification of drinking water supplies, Schedule
improvement of basic sanitation, and promotion of food The vaccine is licensed for individuals aged >2 years.
hygiene are essential measures to interrupt transmission of Only 1 dose is required, and the vaccine confers protection
typhoid fever. For instance, typhoid fever is never a major 7 days after injection. To maintain protection, re-vaccination
problem where there is a clean domestic water supply. is recommended every 3 years. The Vi polysaccharide
Sanitary measures, not followed by health education may vaccine can be co-administered with other vaccines relevant
produce only temporary results. However, when sanitation is for international travellers, such as yellow fever and

by R△J
280 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

hepatitis A, and with vaccines of the routine childhood 6. Basu, S. et al (1975). Bull WHO, 52 (3) 333.
immunization programmes. 7. Christie, A.B. (1974). Infectious Diseases : Epidemiology and Clinical
Practice, 2nd ed., Churchill Livingstone.
8. Mangal, H.N. et al (1967). Indian J. Med. Res., 55 : 219.
Safety
9. WHO (1969), Public Health Papers No.38, p. 78.
No serious adverse events and a minimum of local side­ 10. WHO (2003), Background document: The diagnosis, treatment and
effects are associated with Vi vaccination. There are no prevention of typhoid fever, Communicable Disease Surveillance and
contraindications to the use of this vaccine other than Response Vaccines and Biologicals.
previous severe hypersensitivity reaction to vaccine 11. Cvjetanovic, B. etal (1978). Bull WHO, Supplement No. 1 56 : 45.
components. Although the Vi polysaccharide vaccine is safe
for HIV-infected individuals, the induction of protective FOOD POISONING
antibodies is directly correlated to the levels of CD4 positive
T-cells. Food poisoning is an acute gastroenteritis caused by
ingestion of food or drink contaminated with either living
The Ty21a vaccine bacteria or their toxins or inorganic chemical substances and
This vaccine, which was first licensed in Europe in 1983 poisons derived from plants and animals. The condition is
and in the USA in 1989, is an orally administered, characterized by: (a) history of ingestion of a common food
live-attenuated Ty2 strain of S. Typhi in which multiple (b) attack of many persons at the same time, and
genes, including the genes responsible for the production of (c) similarity of signs and symptoms in the majority of cases.
Vi, have been mutated chemically. The lyophilized vaccine is
available as enteric coated capsules. Protection is markedly High risk people
influenced by the number of doses and their spacing. There Some group of people are more likely to get sick and
are currently no field trials to document the efficacy of Ty21a have a more serious illness. These groups include :
vaccine in children aged <3 years. Ty21a requires storage at
a. Adults age 65 and older;
2-8°C; it retains potency for approximately 14 days
at 25°C. b. Children younger than age 5 years;
c. Pregnant women; and
Schedule
d. People whose immune systems are weekened by health
The capsules are licensed for use in individuals aged conditions or medicines used to treat them including

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>5 years. The vaccine is administered every other day; on people with diabetes, liver or kidney disease, HIV/AIDS
1, 3, and 5th day; a 3-dose regimen is recommended. With or cancer.
the 3-dose regimen, protective immunity is achieved 7 days
People who are more likely to get food poisoning should
after the last dose. The recommendation is to repeat this
not eat undercooked food from animals, raw or lightly
series every 3 years for people living in endemic areas, and
cooked sprouts, unpasteurized (raw) milk and juices and soft
every year for individuals travelling; from non-endemic to
cheese (such as queso freso), unless it is labled as made with
endemic countries. The Ty21a vaccine may be given
pasteurized milk (2).
simultaneously with other vaccines, including live vaccines
against polio, cholera, and yellow fever, or the measles, Types of food poisoning
mumps and rubella (MMR) combination.
Food poisoning may be of two types : non-bacterial and
Safety and precautions bacterial, (a) Non-bacterial : Caused by chemicals such as
arsenic, certain plant and sea foods. In recent years, there
Proguanil and antibacterial drugs should be stopped from
has been a growing concern about contamination of food by
3 days before until 3 days after giving Ty21a, as such drugs
chemicals, e.g., fertilizers, pesticides, cadmium, mercury etc.
may harm live bacterial vaccines. The vaccine is unlikely to
(b) Bacterial : Caused by the ingestion of foods
be efficacious if administrated at the time of ongoing contaminated by living bacteria or their toxins. The
diarrhoea. It is not known whether this live attenuated conventional classification of bacterial food poisoning into
vaccine may cause foetal harm when administered to toxic and infective types is becoming increasingly blurred
pregnant women. Ty21a can be administered to with the knowledge that in some types, both multiplication
HIV-positive, asymptomatic individuals as long as the T-cell and toxin production are involved (1). Bacterial food
count (CD4) is >200/mm3. poisoning may be of the following types : Salmonellosis,
Ty21a is remarkably well tolerated and has low rates of Staphylococcal intoxication, C. perfringens illness, Botulism,
adverse events. B. cereus food poisoning, E. coli diarrhoea, Non-cholera
The vaccine is not recommended in congenital or vibrio illness, V. parahaemolyticus infection, streptococcal
acquired immunodeficiency including treatment with infection, Shigellosis Brucellosis, (c) Viral diseases : hepatitis
immuno-suppressive and antimitotic drugs, acute febrile A and E, Norovirus Gastroenteritis, Rotavirus. Some viruses
illness and acute intestinal infection. can be transmitted by food consumption. It is characterized
by nausea, explosive vomiting, watery diarrhoea and
References abdominal pain (1). (d) Parasites : Taeniasis Hydatidosis,
Trichinosis, Ascariasis, Amoebiasis, Oxyuriasis. Some
1. Anderson, E.S. and Smith, H.P (1972). Brit. Med.J., 3 : 329-331.
parasites, such as fish-borne trematodes, are only
2. WHO (2018) Fact Sheet, 31st Jan. 2018.
transmitted through food. Others, for example tapeworms
3. WHO (1996), The World Health Report, Report of the Director
General WHO. like Echinococcus spp, or Taenia spp, may infect people
4. Ramesh Kumar, et al (1988). Ann-Nat. Aced.Med. Sc. (INDIA) 24 (4) through food or direct contact with animals. Other parasites,
255-257. such as Ascaris, Cryptosporidium, Entamoeba histolytica or
5. Govt, of India (2021), National Health Profile 2021, DGHS, Ministry of Giardia, enter the food chain via water or soil and can
Health and Family Welfare, New Delhi. contaminate fresh produce (1).

by R△J
 CONTROL OF TYPHOID FEVER 281
1. Salmonella food poisoning made cheese and similar low acid foods. In fact, botulism
derives its name from the Latin word for sausage (botulus)
An extremely common form of food poisoning. Five
(c) INCUBATION PERIOD : 18 to 36 hours.
reasons have been given for its increase in recent years : (d) MECHANISM OF FOOD POISONING : The toxin is
(a) an increase in community feeding (b) increase in preformed in food (“intradietetic”) under suitable anaerobic
international trade in human food (c) a higher incidence of conditions. It acts on the parasympathetic nervous system.
salmonelibsis in farm animals (d) widespread use of house­ Botulism differs from other forms of food poisoning in that
hold detergents interfering with sewage treatment, and the gastrointestinal symptoms are very slight. The prominent
(e) wide distribution of “prepared foods” (4). symptoms are dysphagia, diplopia, ptosis, dysarthria,
(a) AGENT(S) : The species most often incriminated in blurring of vision, muscle weakness and even quadriplegia.
human outbreaks are S. typhimurium, S. cholera-suis and Fever is generally absent, and consciousness is retained. The
S. enteritidis, besides many others, (b) SOURCE : condition is frequently fatal, death occurring 4-8 days later
Salmonellosis is primarily a disease of animals. Man gets the due to respiratory or cardiac failure. Patients who recover do
infection from farm animals and poultry - through not develop antitoxin in the blood. Since the toxin is
contaminated meat, milk and milk products, sausages, thermolabile, the heating of food which may be subjected to
custards, egg and egg products. Rats and mice are another 100 deg. C for a few minutes before use will make it quite
source; they are often heavily infected and contaminate safe for consumption (6).
foodstuffs by their urine and faeces. Temporary human Botulism occurring in infants is called “infant botulism”. It
carriers can also contribute to the problem. is due to infection of the gut by C. botulinum with
(c) INCUBATION PERIOD : 12 to 24 hours commonly. subsequent in vivo production of toxin (7).
(d) MECHANISM OF FOOD POISONING : The causative
organisms, on ingestion, multiply in the intestine and give Antitoxin is of considerable value in the prophylaxis of
rise to acute enteritis and colitis. The onset is generally botulism. When a case of botulism has occurred, antitoxin
sudden with chills, fever, nausea, vomiting, and a profuse should be given to all individuals partaking of the food. The
watery diarrhoea which usually lasts 2-3 days. Mortality is dose varies from 50,000 to 100,000 units IV (8). The
about 1 per cent. A convalescent carrier state lasting for antitoxin will be of no avail if the toxin is already fixed to the
several weeks may occur (3). nervous tissue. Guanidine hydrochloride given orally in
doses of 15 to 40 mg/kg of body weight has been shown to

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Salmonellosis is described in detail separately, reverse the neuromuscular block of botulism. When
(Page 280). combined with good medical and nursing care, the drug can
be a useful adjunct in the treatment of botulism (9). Active
2. Staphylococcal food poisoning immunization with botulinum toxoid to prevent botulism is
It is about as common as salmonella food poisoning, also available (10).
(a) AGENT : Enterotoxins of certain strains of coagulase­
positive Staphylococcus aureus. At least 5 different C. perfringens food poisoning
Enterotoxins have been identified, and a sixth may exist (5).
(a) AGENT : Clostridium (C.) perfringens (welchii).
Toxins can be formed at optimum temperatures of 35 deg. to
(b) SOURCE : The organism has been found in faeces of
37 deg. C. These toxins are relatively heat stable and resist humans and animals, and in soil, water and air. The
boiling for 30 minutes or more, (b) SOURCE : Staphylococci majority of outbreaks have been associated with the
are ubiquitous in nature, and are found on the skin and in the ingestion of meat, meat dishes and poultry. The usual story
nose and throat of men and animals. They are a common is that the food has been prepared and cooked 24 hours or
agent of boils and pyogenic infections of man and animals. more before consumption, and allowed to cool slowly at
Cows suffering from mastitis have been responsible for room temperature and then heated immediately prior to
outbreaks of food poisoning involving milk and milk products. serving, (c) INCUBATION PERIOD : 6 to 24 hours, with a
The foods involved are salads, custards, milk and milk peak from 10 to 14 hours (d) MECHANISM OF FOOD
products which get contaminated by staphylococci, POISONING : The spores are able to survive cooking, and if
(c) INCUBATION PERIOD : 1-8 hours. The incubation period the cooked meat and poultry are not cooled enough, they
is short because of “preformed” toxin, (d) MECHANISM OF will germinate. The organisms multiply between 30 deg. and
FOOD POISONING : Food poisoning results from ingestion of 50 deg. C and produce a variety of toxins, e.g., alpha toxin,
toxins preformed in the food in which bacteria have grown theta toxin, etc. Prevention consists either by cooking food
^“intradietetic” toxins). Since the toxin is heat-resistant, it can just prior to its consumption or, if it has to be stored, by
< in food after the organisms have died. The toxins act rapid and adequate cooling (11). (e) CLINICAL
directly on the intestine and CNS. The illness becomes SYMPTOMS : The most common symptoms are diarrhoea,
manifest by the sudden onset of vomiting, abdominal cramps abdominal cramps and little or no fever, occurring 8 to 24
and diarrhoea. In severe cases, blood and mucus may appear. hours after consumption of the food. Nausea and vomiting
Unlike salmonella food poisoning, staphylococcal food are rare. Illness is usually of short duration, usually 1 day or
poisoning rarely causes fever. Death is uncommon. less. Recovery is rapid and no deaths have been reported.
Botulism B. cereus food poisoning
Most serious but rare. It kills two-thirds of its victims, Bacillus cereus is an aerobic, spore-bearing, motile, gram
(a) AGENT : Exotoxin of Clostridium botulinum generally positive rod. It is ubiquitous in soil, and in raw, dried and
Type A, B or E. (b) SOURCE : The organism is widely processed foods. The spores can survive cooking and
distributed in soil, dust and the intestinal tract of animals germinate and multiply rapidly when the food is held at
and enters food as spores. The foods most frequently favourable temperatures. B. cereus has been recognized as a
responsible for botulism are home preserved foods such as cause of food poisoning, with increasing frequency in recent
home-canned vegetables, smoked or pickled fish, home­ years.
by R△J
282 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Recent work has shown that B. cereus produces at least and food handlers should also be investigated. The samples
2 distinct enterotoxins, causing 2 distinct forms of food should be examined aerobically and anaerobically. Phage
poisoning. One, the emetic form with a short incubation typing of the organisms should be done to complete the
period (1-6 hours) characterized by predominantly upper laboratory investigation, (c) Animal experiments : It may be
gastro-intestinal tract symptoms, rather like staphylococcal necessary to feed rhesus monkeys with the remnants of food.
food poisoning. The other, the diarrhoeal form, with a Protection tests are useful in the case of botulism;, in this, a
longer incubation period (12-24 hours) characterized by saline filtrate of food-stuff is injected subcutaneously into
predominantly lower intestinal tract symptoms like mice protected with antitoxic sera, keeping suitable controls,
C. perfringens food poisoning (diarrhoea, abdominal pain, fd} Blood for antibodies : This is useful for retrospective
nausea with little or no vomiting and no fever. Recovery diagnosis, (e) Environmental study : This includes inspection
within 24 hours is usual). The toxins are preformed and of the eating place(s), kitchen(s), and questioning, of food
stable. handlers regarding food preparation, (f) Data analysis : The
Diagnosis can be confirmed by isolation of 105 or more data should be analyzed according to the descriptive methods
B. cereus organisms per gram of epidemiologically of time, place and person distribution. Food-specific attack
incriminated food. Treatment is symptomatic. rates should be calculated. A case control study may be
undertaken to establish the epidemiologic association
Differential diagnosis between, illness and the intake of a particular food.
Food poisoning may be mistaken for cholera, acute
bacillary dysentery and chemical (arsenic) poisoning. The PREVENTION AND CONTROL
differentiating points between cholera and food poisoning
are given in Table 1. (a) FOOD SANITATION : (i) Meat inspection : The food
animals must be free from infection. This can be ensured by
INVESTIGATION OF FOOD POISONING their examination by veterinary staff, both before and after
slaughter, (ii) Personal hygiene : A high standard of personal
(a) Secure complete list of people involved and their hygiene among individuals engaged in the handling,
history : All the people who have shared part of the food preparation and cooking of food is needed, (lit) Food
should be interviewed. They may be supplied questionnaires handlers : Those suffering from infected wounds, boils,

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concerning the foods eaten during the previous 2 days, and diarrhoea, dysentery, throat infection, etc should be
place of consumption; time of onset of symptoms; symptoms excluded from food handling. The medical inspection of food
of illness (e.g., nausea, vomiting, diarrhoea, abdominal pain, handlers is required in many countries; this is of limited value
headache, fever, prostration, etc.) in order of occurrence; in the detection of carriers, although it will remove some
personal data such as age, sex, residence, occupation, and sources of infection (12). (iv) Food handling techniques : The
any other helpful information. Questionnaires may be handling of ready-to-eat foods with bare hands should be
administered to kitchen employees and those working in the reduced to a minimum. Time between preparation and
dining halls, (b) Laboratory investigations : An important part consumption of food should be kept short. The importance
of the investigation. The object is not only to incriminate the of rapid cooling and cold storage must be stressed. Milk, milk
causative agent from stool, vomit or remnants of food by products and egg products should be pasteurized. Food must
inoculating into appropriate media, but also to determine the be thoroughly cooked. The heat must penetrate the centre of
total number of bacteria and the relative numbers of each the food leaving thereby no cool spots. Most food poisoning
kind involved. This will give a better indication of the organisms are killed at temperatures over 60 deg. C.
organism involved. Stool samples of the kitchen employees Separate raw meat, poultry, seafood and eggs from ready to

TABLE 1
Differential diagnosis of cholera and food poisoning

Cholera Food poisoning

1. Epidemiology Occurs often in epidemic form associated Often a single group of persons who shared a common
with other cases in the neighbourhood meal
Secondary cases occur No secondary cases
2. Incubation From a few hours upto 5 days 1 to 24 hours •. lOlera
3. Onset With purging With vomiting
4. Nausea and retching None Present
5. Vomiting Projectile, effortless, watery and continuous Often single, severe vomit, mucus and blood streaked
6. Stools Copious rice watery, inoffensive Frequent, may contain mucus and blood, offensive
7. Tenesmus None Yes
8. Abdominal tenderness None Yes
9. Dehydration Very marked Distinct
10. Muscular cramps Constant and severe Less constant
11. Surface temperature Subnormal Often upto 100-102 deg.F
12. Headache None Often
13. Urine Suppressed Seldom suppressed
14. Blood Leucocytosis Normal

by R△J
 AMOEBIASIS 283
eat foods. Use separate cutting boards and keep raw meat especially Mexico. Globally it is estimated that 50 million
away from other foods in shopping cart and refrigerator (2). people carry E. histolytica in their intestinal tract and
(v) Sanitary improvements : Sanitization of all work surfaces, approximately one-tenth of infected people suffer from
utensils and equipments must be ensured. Food premises invasive amoebiasis. It is probable that invasive amoebiasis,
should be kept free from rats, mice, flies and dust, (vi) Health accounted for about 50,000 deaths in the world (3).
educationFood handlers should be educated in matters of Prevalence rates vary from as low as 2 per cent to 60 per
clean habits and personal hygiene, such as frequent and cent or more in areas devoid of sanitation (4). In areas of
thorough hand washing. high prevalence, amoebiasis occurs in endemic forms as a
result of high levels of transmission and constant reinfection.
(b) REFRIGERATION : In the prevention of bacterial food
Epidemic water-borne infections can occur if there is heavy
poisoning, emphasis must be placed on proper temperature contamination of drinking water supply.
control. Food should not be left in warm pantries; a few
germs can multiply to millions by the next morning. Foods INDIA : It is generally agreed that amoebiasis affects
not eaten immediately should be kept in cold storage to about 15 per cent of the Indian population (5). Amoebiasis
prevent bacterial multiplication and toxin production. “Cook has been reported throughout India : the prevalence rate is
and eat the same day” is a golden rule. When foods are held about 15% ranging from 3.6 to 47.4 per cent in different
between 10 deg. C (50 deg. F) and 49 deg. C (120 deg.F) areas (4). The reported variations in prevalence are
they are in the danger zone for bacterial growth. Cold is attributed to variations in clinical diagnostic criteria (6) and
bacteripstatic at temperature below 4 deg. C (40 deg.F), and to technical difficulties in establishing a correct diagnosis
refrigeration temperature should not exceed this level. and lack of sampling criteria (7).
SURVEILLANCE: Food samples must be obtained from the Epidemiological determinants
food establishments periodically and subjected to laboratory
analysis if they were unsatisfactory. Continuing surveillance is Agent factors
necessary to avoid outbreaks of food-borne diseases.
(a) AGENT : Amoebiasis is caused by potentially
pathogenic strains of E. histolytica. Studies have shown that
References E. histolytica can be differentiated into at least 18
1. WHO (2022), Fact sheet on food safety, 19th May 2022. zymodemes (a zymodeme is a population of organisms

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2. CDC (2022), Food facts, Feb. 2022. differing from similar population in the electrophoretic
3. Mandal, B.K. (1981). Medicine International, 2 : 56. mobilities of one or more enzymes). It has furthermore been
4. Beveridge, W.I.B. (1967). in Health of Mankind, 100th Symposium, shown that pathogenic strains are all from particular
Ciba Foundation, Churchill, London.
5. Werner, S.B. (1980). in Maxcy-Rosenau : Public Health and
zymodemes; that non-invasive strains are from quite distinct
Preventive Medicine, 11th ed, John M. Last (ed), Appleton-Century zymodemes; that invasive strains can give rise to faecal
Crofts, New York. cysts, and the organisms breed true (8). The iso-enzyme
6 Jawetz, Melnick and Adelberg’s Medical Microbiology, 26th ed., A characteristics do not, however, determine why a particular
Lange Publication. zymodeme is able to invade. Isoenzyme electrophoretic
7. Amon, S.S. et al (1977). JAMA, 237 : 1946-1951. mobility analysis have so far identified 7 potentially
8. Christie, A.B. (1980). Infectious Diseases: Epidemiology and Clinical pathogenic and 11 non-pathogenic zymodems (9).
Practice, 3rd ed., Churchill Livingstone.
9. Ryan, D.W. et al (1971). JAMA, 216 : 513. E. histolytica exists in two forms - vegetative
10. Stuart, PF. et al (1970). Cand. J. Pub. Health, 61 (6) 509. (trophozoite) and cystic forms. Trophozoites dwell in the
11. Bailey, J. (1977). Guide to Hygiene and Sanitation in Aviation, WHO, colon where they multiply and encyst. The cysts are excreted
Geneva. in stool. Ingested cysts release trophozoites which colonize
12. WHO (1980). WHO Chronicle, 34 (2) 83. the large intestine. Some trophozoites invade the bowel and
cause ulceration, mainly in the caecum and ascending
AMOEBIASIS colon; then in the rectum and sigmoid. Some may enter a
vein and reach the liver and other organs.
The term “amoebiasis” has been defined by WHO as the The trophozoites are short-lived outside the human body;
condition of harbouring the protozoan parasite Entamoeba they are not important in the transmission of the disease. In
histolytica with or without clinical manifestations. The contrast the cysts are infective to man and remain viable and
symptomatic disease occurs in less than 10 per cent of infective for several days in faeces, water, sewage and soil in
TLfected individuals (2). The symptomatic group has been the presence of moisture and low temperature. The cysts are
further subdivided into intestinal and extraintestinal not affected by chlorine in the amounts normally used in
amoebiasis. Only a small percentage of those having water purification, but they are readily killed if dried, heated
intestinal infection will develop invasive amoebiasis. The (to about 55 deg C) or frozen.
intestinal disease varies from mild abdominal discomfort
and diarrhoea to acute fulminating dysentery. Extraintestinal (b) RESERVOIR OF INFECTION : Man is the only
amoebiasis includes involvement of liver (liver abscess), reservoir of infection. The immediate source of infection is
lungs, brain, spleen, skin, etc. Amoebiasis is a the faeces containing the cysts. Most individuals infected
potentially lethal disease. It carries substantial morbidity and with E. Histolytica remain symptom free and are healthy
mortality. carriers of the parasite (12). The carriers can discharge upto
1.5 x 107 cysts daily (6). The greatest risk is associated with
Problem statement carriers engaged in the preparation and handling of
WORLD : Amoebiasis is a common infection of the food (6).
human gastro-intestinal tract. It has a worldwide (c) PERIOD OF COMMUNICABILITY : As long as cysts
distribution. It is a major health problem in the whole of are excreted; the period may be several years, if cases are
China, South East and West Asia and Latin America, unrecognized and untreated.
by R△J
 EPIDEMIOLOGY OF COMMUNICABLEDISEASES

Host factors fruits and vegetables. Since food handlers are major
transmitters of amoebiasis, they should be periodically
Amoebiasis may occur at any age. There is no sex or
racial difference in the occurrence of the disease. Amoebiasis examined, treated and educated in food hygiene practices
is frequently a household infection. When an individual in a such as hand washing, (d) Health education : In the
family is infected, others in the family may also be affected. long-term, a great deal can be accomplished through health
Specific antiamoebic antibodies are produced when tissue education of the public.
invasion takes place. There is strong evidence that cell- 2. Secondary prevention
mediated immunity plays an important part in controlling the
recurrence of invasive amoebiasis (10). (a) Early diagnosis : Demonstration of trophozoites
containing red cells is diagnostic. They are most readily seen
Environmental factors in fresh mucus passed per rectum. Microscopy should be
performed immediately before its cooling results. The
Amoebiasis is more closely related to poor sanitation and
absence of pus cells in the stool may be helpful in the
socio-economic status than to climate. The use of nightsoil
differential diagnosis with shigellosis. Serological tests are
for agricultural purposes favours the spread of the disease. often negative in intestinal amoebiasis, but if positive, they
In countries with marked wet-dry seasons, infection rates provide a clue to extraintestinal amoebiasis. Indirect
are higher during rains, presumably since cysts may survive haemagglutination test (IHA) is regarded as the most
longer and the potential for transmission is thereby sensitive serological test. Newer techniques include counter
increased. Epidemic outbreaks are usually associated with immuno-electrophoresis (CIE) and ELISA technique (11).
sewage seepage into the water supply.
(b) Treatment : (i) Symptomatic cases : At the health
Mode of transmission centre level, symptomatic cases can be treated effectively
(i) Faecal-oral route : This may readily take place with metronidazole orally and the clinical response in
through intake of contaminated water or food. Epidemic 48 hours may confirm the suspected diagnosis. The dose is
water-borne infections can occur if there is heavy 30 mg/kg of body weight/day, divided into 3 doses after
contamination of drinking water supply. Vegetables, meals, for 8-10 days. Tinidazole can be used instead of
metronidazole. Suspected cases of liver abscess should
especially those eaten raw, from fields irrigated with sewage
be referred to the nearest hospital, (ii) Asymptomatic
polluted water can readily convey infection. Viable cysts

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infections : In an endemic area, the consensus is not to treat
have been found on the hands and under finger nails. This
such persons because the probability of reinfection is very
may lead to direct hand to mouth transmission, (ii) Sexual
high (10). They may, however, be treated, if the carrier is a
transmission: by oral-rectal contact is also recognized,
food handler. In non-endemic areas they are always likely to
especially among male homosexuals, (iii) Vectors : such as be treated. They should be treated with oral
flies, cockroaches and rodents are capable of carrying cysts diiodohyroxyquin, 650 mg TDS (adults) or 30-40 mg/kg of
and contaminating food and drink. body weight/day (children) for 20 days, or oral diloxanide
Incubation period furoate, 500 mg TDS for 10 days (adults) (3).
About 2 to 4 weeks or longer. At present there is no acceptable chemoprophylaxis for
amoebiasis. Mass examination and treatment cannot be
PREVENTION AND CONTROL considered as a solution for the control of amoebiasis (10).

1. Primary prevention References

The measures aimed at primary prevention centre round 1. WHO (1969). Techn. Rep. Ser., 421.
2. Jawetz (2010), Melnick and Adelberg's. Medical Microbiology, 25th
preventing contamination of water, food, vegetables and Ed., A Lange Publication.
fruits with human faeces, (a) Sanitation : Safe disposal of 3. STEPHEN J. McPHEE and MAXINE A (2010), Current Medical
human excreta coupled with the elementary sanitary Diagnosis and Treatment, 49th Ed., A Lange Publication.
practice of washing hands after defecation and before eating 4. Bull WHO (1980) 58 (6) 819-830.
is a crucial factor in the prevention and control of 5. Vakil, B.J. (1973), Medical Times, Aug. 1973, Sandoz Publications,
amoebiasis. But there are too many hurdles (both social and Mumbai.
economic) in enforcing it in many developing countries. 6. WHO (1987). Techn. Rep. Ser. No. 749.
With the cooperation of the local community, the sanitary 7. WHO (1981). Techn. Rep. Ser. No. 666.
systems should be selected and constructed (14) taking into 8. Ree,G.H. (1983). Post Graduate Doctor, Middle East Dec. 1983 P. 626
consideration the customs and practices of the population 9. Sargeaunt, P.G. et al (1982) Lancet 1 : 1386 -1388.
and the available resources, (b) Water supply : The 10. Bull WHO (1985) 63 (3) 417-426.
protection of water supplies against faecal contamination is 11. WHO (1980), Scientific Working Group Reports 1978-1980, WHO/
CDD/80.1.
equally important because amoebic cysts may survive for
12. Nanda, R. et al (1984). Lancet 2 : 301.
several days and weeks in water. The cysts are not killed by 13. Palmo, A.M. (1988). Medicine International 54 : 22, 16 June 1988.
chlorine in amounts used for water disinfection. Sand filters 14. Rajagopalan, S. and Shiftman, M.A. (1974). Guide to Simple Sanitary
are quite effective in removing amoebic cysts. Therefore Measures for the control of Enteric Diseases, Geneva, WHO.
water filtration and boiling are more effective than chemical
treatment of water against amoebiasis. (c) Food hygiene : SOIL-TRANSMITTED HELMINTHIASIS
Environmental measures should also include the protection
of food and drink against faecal contamination. Uncooked Soil-transmitted helminth (STHs) infections refer to a
vegetables and fruits can be disinfected with aqueous group of parasitic diseases in humans caused by intestinal
solution of acetic acid (5-10 per cent) or full strength roundworms (ascariasis), hookworms (Necator americanus
vinegar (1). In most instances, thorough washing with and Ancylostoma duodenale) and whipworm (Trichuris
detergents in running water will remove amoebic cysts from trichiura). They are the most common infections worldwide.
by R△J
 ASCARIASIS 285
More than 1.5 billion people, or about 24 per cent of the into adults in 60-80 days. The life span of an adult is between
world's population are infected. Infections are widely 6-12 months, maximum reported being 1.5 years
distributed in tropical and subtropical areas, with the (b) RESERVOIR OF INFECTION : Man is the only reservoir.
greatest numbers occurring in sub-Saharan Africa, the (c) INFECTIVE MATERIAL : Faeces containing the fertilized
Americas, China and east Asia (1). Over 267 million pre­ eggs, (d) HOST : Infection rates are high in children; they are
school children and over 568 million school-age children the most important disseminators of infection. Adults seem to
and 250 million girls and adult women live in areas where acquire some resistance. There is a high degree of
these parasites are intensively transmitted and are in need of host-parasite tolerance. Roundworms rob man of his food
treatment and preventive interventions (1). and may possibly compete for vitamin A in the intestine (3).
They contribute to malnutrition especially in children who
Mode of transmission may show growth retardation, (e) ENVIRONMENT : Ascaris
Soil-transmitted helminths are transmitted by eggs that is a “soil-transmitted” helminth. The eggs remain viable in
are passed in the faeces of infected people, as adult worms the soil for months or years under favourable conditions. Of
live in the intestine where they produce thousands of eggs the various ecological factors regulating the population of
each day. In areas that lack adequate sanitation, these eggs Ascaris eggs, the most important ones are the temperature,
contaminate the soil. This can happen in several ways.: moisture, oxygen pressure and ultra-violet radiation from the
(a) eggs that are attached to vegetables and salads are sunlight (4). A low temperature inhibits the development of
ingested when the vegetables are not carefully cooked, eggs. Clay soils are most favourable for the development of
washed or peeled; (b) eggs are ingested from contaminated ascariasis eggs, in contrast to moist porous soils for those of
water sources; and (c) eggs are ingested by children who hookworms, (f) HUMAN HABITS : Seeding of the soil by
play in contaminated soil and then put their hands in their ascariasis eggs takes place by the human habit of
mouth without washing them. indiscriminate open air defecation. It is the most important
factor responsible for the widespread distribution of ascariasis
In addition, hookworm eggs hatch in the soil, releasing in the world (4). Soil pollution is usually concentrated around
larvae that mature into a form that can actively penetrate houses where small children who have no regular habits
the skin. People become infected with hookworm primarily pollute the house and surrounding areas. Infective eggs can
by walking barefoot on contaminated soil. then easily reach other children who play on the ground and
There is no direct person-to-person transmission, or contaminate their hands and food (4). (g) PERIOD OF

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infection from fresh faeces, because eggs passed in faeces COMMUNICABILITY: Until all fertile females are destroyed
need about three weeks to mature in the soil before they and stools are negative.
become infective. Since these worms do not multiply in the
human host, reinfection occurs only as a result of contact Incubation period
with infective stages in the environment. 18 days to several weeks.
Symptoms
, ASCARIASIS
The symptoms are related to the number of the worms
An infection of the intestinal tract caused by the adult, harboured. People with light infection usually have no
Ascaris lumbricoides and clinically manifested by vague symptoms. Heavier infections can cause a range of
symptoms of nausea, abdominal pain and cough. Live symptoms including intestinal manifestations like diarrhoea,
worms are passed in the stool or vomited. Occasionally, they abdominal pain; general malaise, weakness, impaired
may produce intestinal obstruction or may migrate into the cognitive and physical development. The WHO definition of
peritoneal cavity. heavy infection of roundworm is > 50,000 eggs per gram of
faeces (5).
Geographic distribution and prevalence The larvae migration may cause fever, cough, sputum
Ascaris is cosmopolitan in distribution. It is the most formation, asthma, skin rash, eosinophilia. The adult
common helminthic infestation. It is estimated that about roundworm aggregate masses can cause volvulus, intestinal
820 million people are infected world-wide annually with obstruction or intessusception; and wandering worm can
about 12 million acute cases and 20,000 or more deaths. cause bowel perforation in the ileococcal region, blocking of
Heavy infection is common in children aged 3-8 years (2), common bile duct or may come out with vomit (5).
Epidemiological features HOOKWORM INFECTION
(a) AGENT : Ascaris lumbricoides lives in the lumen of
small intestine, where it moves freely. Sexes are separate. The Hookworm infection is defined as “any infection caused
female measures 20-35 cm in length, and the male by Ancylostoma duodenale or Necator americanus” (6).
12-30 cm. Egg production is very heavy - an estimated They may occur as single or mixed infections in the same
2,40,000 eggs per day by each female, which person.
counterbalances the heavy losses in the environment. The
eggs are excreted in the faeces. They become embryonated in Problem statement
the external environment and become infective in 2-3 weeks. Ancylostoma duodenale and Necator americanus are the
On ingestion by man, the embryonated eggs hatch in the main nematodes causing hookworm infection in man.
small intestine. The resulting larvae penetrate the gut wall Almost eradicated from Europe and the USA (4), hookworm
and are carried to the liver and then to the lungs via the blood infection is still seen in warm, moist climates in tropical and
stream. In the lungs, they moult twice. They break through subtropical regions between 45°N and 30°S of the equator
the alveolar walls and migrate into the bronchioles. They are (e.g., Asia, Africa, Central and South America and the South
coughed up through the trachea and then swallowed by the Pacific). The geographic distribution of these two
human host. On reaching the intestine, they become mature hookworms used to be regarded as relatively distinct, the
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

former being more prevalent in Europe and South-western Environmental factors

Asia, and the latter in tropical Africa and in the Americas. Hookworm larvae live in the upper half-inch (1.2 cm.) of
However, over the past decades both parasites have become the soil. Favourable environmental conditions are, therefore,
widely distributed throughout the tropics and subtropics, crucial for the survival of the hookworm larvae in the soil.
and rigid demarcations are no longer tenable (7). These are : (a) SOIL : The soil must be suitable for the eggs
It is estimated that, the global prevalence of hookworm is and larvae. The type of soil that favours the survival of
about 460 million cases, and the number of years lost due to hookworm larvae is a damp, sandy or friable soil with
ill health or death is estimated to be about 3.2 million (8). decaying vegetation. In general, sandy soil is more
favourable than clay soil, (b) TEMPERATURE A
Epidemiological determinants temperature of 24 to 32 deg. C is considered favourable for
the survival of the larvae. The eggs fail to develop at
Agent factors temperatures below 13 deg. C. Larvae are killed at 45 to
(a) AGENT : Adult worms live in the small intestine, 50 deg. C. (c) OXYGEN : This is required for the growth and
mainly jejunum where they attach themselves to the villi. development of the larvae, (d) MOISTURE : Moisture is
Males measure 8 to 11 mm, and females 10 to 13 mm in necessary for survival; dryness is rapidly fatal,
length with dorsally curved anterior end. Eggs are passed in (e) RAINFALL : A rainfall of 40 inches (100 cm) and above
the faeces in thousands; one female A. duodenale produces is considered a favourable environmental factor. More
about 10,000-30,000 eggs and one female N. americanus important than the total annual rainfall is the number of
about 5,000-10,000 eggs per day (7). High egg production rainy days spread out evenly throughout the year to keep up
ensures constant exposure to infection. the moisture content of the soil. Flooding is an unfavourable
factor, (f) SHADE : Direct sunlight kills the larvae whereas
When deposited on warm, moist soil, a larva rapidly
shade protects them, (g) HUMAN HABITS : The habits of
develops in the egg and hatches after 1 to 2 days. The newly
the human host not only determine the mode and extent of
hatched larva (rhabditiform larva) moults twice in the soil
soil pollution, but also the mode and extent of contact
and becomes a skin-penetrating third stage infective larva
between infected soil and skin or mouth (4). These include
within 5 to 10 days. These lie in wait in the soil to pierce the
indiscriminate defecation, using the same places for
skin of the human host. They move very little horizontally,
defecation, going barefoot, farming practices using
but migrate upwards on blades of grass (4). They can
untreated sewage, children wading in the infected mud with

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survive in shaded, moist soil for up to one month. Infection
bare-feet and hands. These habits are compounded by
occurs when the larva enters the body through the skin,
most commonly through the feet. Larvae of A. duodenale social factors such as illiteracy, ignorance and low standard
of living.
are also infective by mouth. Once inside the body, they
migrate via lymphatics and blood stream to the lungs. They Incubation period (prepatent period)
break into the alveoli, ascend the bronchi and trachea and
are coughed up and swallowed to reach the small intestine, Following infection, the prepatent period for
where they become sexually mature. Adult A. duodenale N. americanus is 7 weeks while that for A. duodenale ns
and N. americanus are believed to be capable of surviving unpredictable, ranging from 5 weeks to 9 months (6). This is
for an average about 1 and 4 years, respectively (6). because the invading larva of A. duodenale is capable of
(b) RESERVOIR : Man is the only important reservoir of remaining arrested or dormant in the tissues of the host for
human hookworm infection, (c) INFECTIVE MATERIAL : as long as 9 months and then again resume development
Faeces containing the ova of hookworms. However, the and migration.
immediate source of infection is the soil contaminated with Effects of the disease
infective larvae, (d) PERIOD OF INFECTIVITY : As long as
the person harbours the parasite. (a) INDIVIDUAL : Hookworm infection causes chronic
blood loss and depletion of body’s iron stores leading to
Host factors iron-deficiency anaemia. This has implications for child
health in terms of retarded physical growth and
(a) AGE AND SEX : All ages and both sexes are development; for the health of mothers in terms of increased
susceptible to infection. In endemic areas, the highest morbidity, low birth weight babies, abortion, stillbirths and
incidence is found in the age group, 15 to 25 years. impaired lactation; and for the health of adults in terms of
(b) NUTRITION : Studies indicate that malnutrition is a diminished capacity for sustained hard work. Hookworm
predisposing factor; the chronic disabling disease does not infection also causes a loss of blood plasma into the small
occur in the otherwise healthy individual who is intestine which can lead to hypoalbuminaemia in some
well-nourished and whose iron intake is adequate. subjects, (b) COMMUNITY : Hookworm infection exerts a
(c) HOST-PARASITE BALANCE : In endemic areas, the significant and harmful effect on various aspects of the
inhabitants develop a host-parasite balance in which the economy and quality of life of a community, especially
worm load is limited. They harbour the parasite without in three major areas. These are nutrition, growth
manifesting clinical signs and symptoms. In some areas, the and development; work and productivity, and medical care
infection rate may be 100 per cent, but most infections are costs.
light and only a small proportion of the people are heavily
infected (6). This delicate balance may be upset by WHIPWORM
malnutrition and intercurrent infections. Little is known
about host immunity, (d) OCCUPATION : It is to be Whipworm is the third most common soil-transmitted
expected that hookworm infection will have a higher helminthiasis in the humans. According to current estimate,
prevalence in agricultural than in town workers, and in nearly 440 million people are infected, and majority of cases
many tropical countries, it is an occupational disease of the are children 4-10 years age. Heavy infection could lead to
farming community. acute symptoms such as diarrhoea and anaemia, and
by R△J
 WHIPWORM

chronic symptoms such as growth retardation and impaired of ascariasis.(d) Pyrantel : Effective in a single dose of
cognitive development. It is quite common in United States, 10 mg/kg of body weight (9) with a maximum of lg.
South-East Asia, to a lesser extent equatorial Africa, Central
and South America (5). Treatment of anaemia and other complications
Anaemia should be treated with iron and folic acid.
Agent factor Patient should be treated for hypoproteinaemia and
Whipworms live in the large intestine, Male worm hypereosinophilia.
measures about 30-45 mm long while female is about
30-35 mm long. Female worm produces about 200-10,000 Preventive chemotherapy (3)
eggs per day for more than 5 years. Embryonization takes The WHO strategy for control of soil-transmitted
21 days. It can withstand cold temperatures but not helminth infection is to control morbidity through periodic
desiccation. The infection is directly from the faeces. Eggs treatment of at-risk people living in endemic areas. The
hatch after being swallowed in the intestine, where shell is people at risk are : (a) preschool-aged children; (b) school
digested by intestinal juices and the larva emerges in the aged children; (c) women of childbearing age including
small intestine. It penetrates the villi and develops for a pregnant women in second and third trimesters and breast­
week until it re-emerges and passes to the cecum and feeding mothers; and (d) adults in certain high-risk
colorectum where it attaches itself to the mucosa and occupations, such as tea-pickers or miners.
becomes adult (5, 7). WHO recommends periodic deworming without previous
individual diagnosis to all at-risk people living in endemic
Incubation period areas. Treatment should be given once a year when
Period from ingestion of egg to appearance of egg in stool prevalence of soil-transmitted helminth infection in the
is 60-90 days (5, 7). community is over 20 per cent and twice a year if the
,* prevalence is over 50 per cent. This reduces the morbidity
Effect of the disease by reducing the worm burden. Periodic deworming can
Majority of infections are mild or asymptomatic. It causes easily be integrated with child health days or
epigestric pain, nausea, vomiting, distension flatulence, supplementation programmes for pre-school children, or can
weight loss. Moderate infection causes growth deficit and be integrated with school health programmes. Schools
provide a particularly good entry point for deworming

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anaemia. Severe infection causes severe chronic diarrhoea
activities, as they allow easy provision of the health and
or dysentery with blood and mucous in stool, dehydration,
hygiene education component - such as promotion of hand
rectal prolapse, colonic obstruction, hypoproteinaemia,
washing and improved sanitation.
chronic iron deficiency, anaemia etc. (5).
The recommended medicines are albendazole (400 mg)
PREVENTION AND CONTROL OF and mebendazole (500 mg). They are effective and can be
SOIL-TRANSMITTED HELMINTHS easily administered by non-medical persons. The drugs are
donated by WHO.
Primary prevention Approximately 267 million pre-school-aged children,
568 million school-aged children and 560 million women of
Methods based on primary prevention are the most reproductive age group in 103 countries or territories were
effective in interrupting transmission. These are : sanitary estimated to be in need of preventive chemotherapy against
disposal of human excreta to prevent or reduce faecal soil transmitted helminthiasis. Of these 436 million children
contamination of the soil, provision of safe drinking water, were treated by preventive chemotherapy; 127 million
food hygiene habits, and health education of the community women of reproductive age group were treated in 2016
in the use of sanitary latrines, personal hygiene and principally through the lymphatic filariasis programme (1).
changing behavioural patterns, measures of personal
The global target is to eliminate morbidity due to soil-
protection such as wearing protective footwear and making
transmitted helminthiasis in children by year 2020. This will
use of health facilities for diagnosis and treatment.
be achieved by regularly treating at least 75 per cent of the
Prevention, to be effective, must take into consideration the children in endemic areas - an estimated 873 million
life cycle of the parasite and the peculiar ecological, children (3).
social and cultural circumstances that prevail in a
community. References
Secondary prevention 1. WHO (2022), Fact Sheet, Soil-Transmitted Helminth Infections,
10th January, 2022.
Effective drugs are available for the treatment of the 2. Maxine A., Papadakis, Stephen J. McPhee, Current Medical Diagnosis
human reservoir. These are piperazine, mebendazole, and Treatment, 53rd ed. 2014, A Lange Publication.
levamisole and pyrantel; the last two drugs are effective in a 3. WHO (2016), Fact Sheet, No. 366, March 2016.
single dose, (a) Albendazole : The usual dose for adults and 4. WHO (1981), Tech. Rep. Ser., No. 666.
children over 2 years is 400 mg as a single dose. 5. Global Health Education Consortium (2012), Soil-Transmitted
Contraindicated in children below 2 years and in pregnancy, Helminths by Sina Helbig et al.
6. WHO (1987), Tech, Rep. Ser., No. 749.
(b) Mebendazole : The usual dose is 100 mg twice daily for
7. Center for Disease Control and Prevention (2011), Neglected Tropical
3 days for all ages above 2 years, (c) Levamisole : It is the Diseases.
levorotatory form of tetramisole and is more active than the 8. WHO (2017), Guideline: Preventive Chemotherapy to Control Soil-
parent compound. For many it is now the drug of choice. Transmitted Helminth Infections in at-risk population groups, 2017.
A single oral dose of 2.5 mg/kg of body weight (maximum 9. WHO (1998), World Health Report 1998, Report of the Director
150 mg) has been recommended. There are usually no side General WHO.
effects. It has been used successfully in the mass treatment 10. WHO (2017), Weekly Epidemiological Record, No. 49,8th Dec., 2017

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288 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

when the ponds contain water (4, 5). Temperature : The

DRACUNCULIASIS larvae develop best between 25 and 30 deg C, and will not
develop below 19 deg C. Therefore, the disease is limited to
Dracunculiasis or guineaworm disease is a vectorborne tropical and subtropical regions (6).
parasitic disease, mainly of the subcutaneous tissues (usually
leg and foot) caused by the nematode parasite, Dracunculus Mode of transmission
medinensis. Although not lethal, this parasitic disease can The disease is transmitted entirely through the
disable its victim temporarily. consumption of water containing cyclops harbouring the
infective stages of the parasite. Guineaworm disease is a
Problem statement totally water-based disease and does not have an alternate
Progress towards the elimination of dracunculiasis in the pathway of transmission.
past decade has been spectacular, with the number of cases
falling worldwide from an estimated 892,005 in 1989 (when Treatment
most endemic countries began to report monthly cases from No drug cures the infection but metronidazole and
each endemic village) to a total of 14 cases in 2021. mebendazole are sometimes used to limit inflammation and
Compared with 2012 (542 cases), the largest decline in the facilitate worm removal. Wet compresses may relieve
number of cases occurred in South Sudan (4). At present only discomfort. Occlusive dressings improves hygiene and limit
Ethiopia (1), Chad (7) and Mali (2), are reporting cases (1). shedding of infectious larvae. Worms are removed by
sequentially rolling them out over a small * stick.
In India, the last reported case was in July 1996. On
When available simple surgical procedure can be tf.'ed to
completion of three years of zero incidence, India was
remove worm. Topical antibiotics may limit bacterial
declared free of guineaworm disease (2). superinfection.
Natural history Eradication
(a) AGENT : The adult parasite inhabits the Guineaworm disease is amenable to eradication. The
subcutaneous tissue mainly of the legs but also of other parts eradication strategy comprises the following elements :
of the body, including the head and neck. The female grows
to a length of 55 to 120 cm, and the male is very short i) Provision of safe drinking water (e.g., piped water,

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(2-3 cm). The gravid female makes it’s way down to the installation of hand pumps).
infected person’s lower limbs near the skin surface. There it ii) Control of cyclops (See Chapter 15).
penetrates into the dermis and induces an inflammatory iii) Health education of the public in matters relating to
reaction and subsequent blister formation. Upon contact boiling or sieving drinking water through a doub?e-
with water, the blister soon ruptures and the parasite thickness cotton cloth for personal protection, and
releases up to one million, microscopic, free-swimming prevention of water contamination by infected
larvae into water. The larvae may remain active in water for persons.
3-6 days. They are picked up by small fresh-water
crustaceans called cyclops. The larvae require a period of iv) Surveillance : Active search for new cases, and
about 15 days for development in cyclops, which is the Guineaworm Eradication Programme
intermediate host.
Refer to chapter 7 for details.
Man acquires infection by drinking water containing
infected cyclops. In the human body, digested by gastric References
juice, the parasites are released. They penetrate the 1. Centers for Disease Control and Prevention (2021), Guineaworm
duodenal wall. Subsequently they migrate through the Epidemiology and Risk Factors.
viscera to the subcutaneous tissues of various parts of the 2. WHO (2000), Weekly Epidemiological Record 2nd June 2000 No. 22.
body. They grow into adults in 10-14 months. 3. WHO (1979). Techn. Rep. Ser., No. 637.
(b) RESERVOIR OF INFECTION : An infected person 4. Muller, R. (1979). Bull WHO, 57 (5) 683.
harbouring the gravid female. The possibility of an animal 5. WHO (1980). WHO Chr., 34 (4) 159.
6. National Guineaworm Eradication Programme, National Health
reservoir exists but not proved (3). Programme series 2, National Institute of Health and family welfare,
(c) HOST FACTORS : Host susceptibility is universal. New Mehrauli Road, New Delhi.
Multiple and repeated infections may occur in the same
individual. The habit of washing and bathing in surface III. ARTHROPOD-BORNE INFECTIONS
water and using step-wells is important.
(d) ENVIRONMENTAL FACTORS : The main link in the
transmission of guineaworm disease is water infested with THE DENGUE SYNDROME
cyclops. The risk of transmission exists where such cyclops-
infested water-sources are frequented by infected persons.
Dengue viruses are arboviruses capable of infecting
Season : The seasonal variations in the incidence of the
humans, and causing disease. These infections may be
disease are marked. Where the step-wells are the source of
asymptomatic or may lead to (a) “classical” dengue fever, or
water supply, peak transmission occurs during the dry
season (March-May) when the contact between open cases (b) dengue haemorrhagic fever without shock, or (c) dengue
of gunieaworm disease and the drinking water is the haemorrhagic fever with shock. The manifestations of the
greatest; and there is little transmission when the wells are dengue syndrome are as shown in Fig. 1.
full during and after rains. Where the ponds are used, Dengue fever is a self-limiting disease and represents the
transmission appears to be confined to June-September, majority of cases of dengue infection. A prevalence of Aedes

by R△J
 THE DENGUE SYNDROME 289
aegypti and Aedes albopictus together with the circulation of monsoon, and it is not uniformly distributed throughout the
dengue virus of more than one type in any particular area year. However, in the southern states and Gujarat the
tends to be associated with outbreaks of DHF/DSS (1). transmission is perennial (4).
Dengue is endemic in 35 states/LJTs. During 2020, about
Problem statement 44,585 cases were reported with 56 deaths. The case fatality
Dengue fever (DF) and its severe forms - dengue rate was 0.12 per cent. As seen from Table 1, the highest
haemorrhagic fever (DHF) and dengue shock syndrome number of cases were reported from Punjab (8,435)
(DSS) - have become major international public health followed by West Bengal (5,166), Kerala (4,399), Karnataka
concerns. Over the past three decades, there has been (3,823), and Uttar Pradesh (3,715) (5).
dramatic global increase in the frequency of dengue fever, All the four serotypes i.e. dengue 1, 2, 3 and 4 have been
DHF and DSS and their epidemics. It is found in tropical isolated in India but at present DENV-1 and DENV-2
and subtropical regions around the world, predominantly in serotypes are widespread (6).
urban and semi-urban areas, and are now spreading to
rural areas. TABLE 1
About 3.9 billion people in 129 countries are at risk of Dengue / DHF situation in India, 2019-2020 (P)
infection with dengue viruses. A recent estimate indicates
390 million dengue infections per year, of which 96 million 2019 2020 (P)
State/UT
manifest clinically with any severity of disease. The number Cases Deaths Cases Deaths
of reported cases have increased from over 2.4 million in Andhra Pradesh 5,286 0 925 0
2010 to 5.2 million in 2019. Not only the number of cases
are increasing as disease is spreading to new areas, but Arunachal Pradesh 123 0 1 0
explosive outbreaks are occurring. The year 2016 was Assam 196 0 33 0
characterized by large dengue outbreaks worldwide. In Bihar 6,712 0 _ 493 2
2015, Delhi, recorded its worst outbreak since 2006 with Chhattisgarh 722 0 57 0
over 15,000 cases.
Goa 992 0 376 0
Worldwide, annually about 500,000 people with DHF Gujarat 18,219 17 1,564 2
require hospitalization. Approximately 90 per cent of

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them are children aged less than five years, and about Haryana 1,207 0 1,377 0
2.5 per cent of those affected die. During epidemics, Himachal Pradesh 344 2 21 0
infection rate among those who have not been previously J&K 439 0 53 0
exposed to the virus are often 40 to 50 per cent, but can also Jharkhand 825 5 79 0
reach 80 to 90 per cent (3). Co-circulation of multiple Karnataka 16,986 13 3,823 0
serotypes/genotypes is evident.
Kerala 4,652 16 4,399 5
Dengue and DHF is endemic in more than 100 countries
Madhya Pradesh 4,189 2 806 0
in the WHO regions of Africa, the Americas, Eastern
Mediterranean, South-East Asia and Western Pacific. The Meghalaya 82 0 4 0
South-East Asia and Western Pacific regions are most Maharashtra 14,907 29 3,356 10
seriously affected. Detection of all four serotypes has now Manipur 359 0 37 0
rendered the countries hyperendemic. The countries of Mizoram 42 0 67 0
South-East Asia region are divided into 3 categories (3).
Nagaland 8 0 1 0
Category A (Bangladesh, India, Indonesia, Maldives, Odisha 3,758 4 496 0
Myanmar, Sri Lanka, Thailand and Timor-Leste) Punjab 10,289 14 8,435 22
a. Major public health problem; Rajasthan 13,706 17 2,023 7
b. Leading cause of hospitalization and death among Sikkim 444 0 11 0
children;
Tamil Nadu 8,527 5 2,410 0
c. Hyperendemicity with all 4 serotypes circulating in
urban areas; and Tripura 114 0 24 0
d. Spreading to rural areas. Telangana 13,331 7 2,173 0
Category B (Bhutan, Nepal) Uttar Pradesh 10,557 26 3,715 6
Uttarakhand 10,622 8 76 1
a. Endemicity uncertain;
b. Bhutan reported first outbreak in 2004; and West Bengal 47,928 0 5,166 0
c. Nepal reported first indigenous case in 2004. A&N Islands 168 0 98 0
Chandigarh 286 0 265 0
Category C (DPR Korea)
Delhi 5,077 0 1,269 0
No evidence of endemicity.
D & N Haveli 1,491 2 n
319
INDIA Daman & Diu 625 2
In India, the risk of dengue has shown an increase in Lakshadweep 0 0 0 0
recent years due to rapid urbanization, lifestyle changes and Puducherry 2,030 2 633 1
deficient water management including improper water All India Total 2,05,243 166 44,585 56
storage practices in urban, peri-urban and rural areas,
leading to proliferation of mosquito breeding sites. The P - Provisional
disease has a seasonal pattern i.e. the cases peak after Source : (5)
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Epidemiological determinants with a 2°C increase in temperature the extrinsic incubation

period of DENV will be shortened and more infected
Agent factors mosquitoes are available for a longer duration. Besides that
(a) AGENT : The dengue virus forms a distinct complex the mosquitoes will bite more frequently because of
within the genus flavivirus based on antigenic and biological dehydration and thus increase man-mosquito contact (3, 6).
characteristics. There are four virus serotypes which are The failure of urban authorities to provide civil amenities
designated as DENV-1, DENV-2, DENV-3 and DENV-4. and poor public health infrastructure raises the potential for
Infection with any one serotype confers lifelong immunity to the vector to breed at high level and makes the environment
that virus serotype (7). Although all four serotypes are transmission conducive. The rural, spread of the vector is
antigenically similar, they are different enough to elicit cross­ relatively recent occurrence associated with the
protection for only a few months after infection by any one development of rural water supply schemes,
of them. Secondary infection with dengue serotype 2 or improved transport systems, scarcity of water and lifestyle
multiple infection with different serotypes lead to severe changes (6).
form dengue DHF/DSS (3). The first infection probably
sensitizes the patient, while the second infection with Dengue in the community (3)
different serotype appears to produce immunological A number of factors that contribute to initiation and
catastrophy. maintenance of an epidemic include: (i) the strain of the
The pathogenesis of severe syndrome involves pre­ virus, which may influence the magnitude and duration of
existing dengue antibody. It is postulated that virus the viraemia in humans; (ii) the density, behaviour and
antibodies are formed within a few days of the second vectorial capacity of the vector population; (iii) the
dengue infection and that the non-neutralizing enhancing susceptibility of the human population (both genetic factors
antibodies promote infection of higher numbers of and pre-existing immune profile); and (iv) the introduction
mononuclear cells, followed by the release of cytokines, of the virus into a receptive community.
vasoactive mediators, and procoagulants, leading to the
disseminated intravascular coagulation seen in the DF/DHF syndrome
haemorrhagic fever syndrome (8). DF/DHF is characterized by the “iceberg” or pyramid
All four serotypes have been associated with epidemics of phenomenon. At the base of the pyramid, most of the cases

telegram-@Cherry_2412
dengue fever (with or without DHF) with varying degree of are symptomless, followed by DF, DHF and DSS. Clusters of
severity. cases have been reported in particular households or
neighbourhoods due to the feeding behaviour of the vector.
(b) VECTOR : Aedes aegypti and Aedes albopictus are
the two most important vectors of dengue. They both carry Affected population
high vectorial competency for dengue virus, i.e., high
The population affected varies from one outbreak to
susceptibility to infecting virus, ability to replicate the virus
another. Actual estimates can be made by obtaining clinical/
and ability to transmit the virus to another host. Aedes
subclinical ratios during epidemics. In a well-defined
aegypti is a highly domesticated, strongly anthropophilic,
epidemic study in North Queensland, Australia, with
nervous feeder (i.e., it bites more than one host to complete
primary infection, 20% to 50% of the population was found
one blood meal) and is a discordant species (i.e., it needs affected.
more than one feed for the completion of the gonotropic
cycle). This habit results in the generation of multiple cases Severity of the disease
and the clustering of dengue cases in the cities. On the
The serotype that produces the secondary infection and,
contrary, Ae. albopictus partly invades peripheral areas of
in particular, the serotype sequence are important to
urban cities. It is an aggressive feeder and concordant
ascertain the severity of the disease. All the four serotypes
species, i.e., the species can complete its blood meal in one
are able to produce DHF cases. However, during sequential
go on one person and also does not require a second blood
infections, only 2% to 4% of individuals develop severe
meal for the completion of the gonotropic cycle.
disease.
Transmission of disease Studies in Thailand have revealed that the DENV-1/
The Aedes mosquito becomes infective by feeding on a DENV-2 sequence of infection was associated with a
patient from the day before onset to the 5th day (viraemia 500 fold risk of DHF compared with primary infection. For
stage) of illness. After an extrinsic incubation period of 8 to the DENV-3/DENV-2 sequence the risk was 150-fold, and a
10 days, the mosquito becomes infective, and is able to DENV-4/DENV-2 sequence had a 50-fold risk of DHF. There
transmit the infection. Once the mosquito becomes infective, is no time-limit to sensitization after a primary infection. The
it remains so for life. The genital tract of the mosquito gets 1997 Santiago de Cuba epidemic clearly demonstrated that
infected and transovarian transmission of dengue virus with the introduction of DENV-2, DHF had occurred 16-20
occurs when virus enters fully developed eggs at the time of years after the primary infection with DENV-1.
oviposition. High-risk patients (3)
Environmental factors The following host factors contribute to more severe
disease and its complications
The population of Aedes aegypti fluctuates with rainfall
and water storage. Its life span is influenced by temperature 1. infants and elderly ;
and humidity, survives best between 16°C-30°C and a 2. obesity;
relative humidity of 60-80 per cent. It breeds in the
3. pregnancy;
containers in and around the houses. Being a domestic
breeder, it is a endophagic and endophilic. However, even 4. peptic ulcer disease;

by R△J
 THE DENGUE SYNDROME 291
5. women who are in menstruation or have abnormal pain in inguinal region, sore throat and general depression.
bleeding; Fever is usually between 39°C and 40°C. Fever is typically
6. haemolytic disease such as G-6PD, thalassaemia and but not inevitably followed by a remission of a few hours to
other haemoglobinopathies; 2 days (biphasic curve). The skin eruptions appear in
80 per cent of cases during the remission or during second
7. congenital heart disease; febrile phase, which lasts for 1-2 days. The rash is
8. chronic diseases such as diabetes mellitus, hypertension, accompanied by similar but milder symptoms. The rash may
asthma, ischaemic heart disease, chronic renal failure, be diffuse flushing, mottling or fleeting pin-point eruptions
liver cirrhosis; and on the face, neck and chest during the first half of the febrile
9. patients on steroid or NSAID treatment. period and a conspicuous rash, that may be maculopapular
or scarlatiniform on 3rd or 4th day. It starts on the chest and
Clinical mainfestations trunk and may spread to the extremities and rarely to the
face. It may be accompanied by itching and hyperaesthesia.
Dengue virus infection may be asymptomatic or may The rash lasts for 2 hours to several days and may be
cause undifferientiated febrile illness (viral syndrome),
followed by desquamation (1). Fever lasts for about 5 days,
dengue fever(DF), or dengue haemorrhagic fever (DHF) rarely more than 7 days after which recovery is usually
including dengue shock syndrome (DSS) as shown in Fig.l
complete although convalescence may be protracted (8).
1. Undifferentiated fever The case fatality is exceedingly low.

Infants, children and adults who have been infected with 3. Dengue haemorrhagic fever
denuge virus, especially for the first time (i.e. primary
Dengue haemorrhagic fever (DHF) is a severe form of
dengue infection), may develop a simple fever
indistinguishable from other viral infection. Maculopapular dengue fever. The course of dengue illness can be divided
rashes may accompany the fever or may appear during into three phases-febrile phase, critical phase and recovery
defervescence. Upper respiratory and gastrointestinal phase, as shown in Fig. 2 (9)
symptoms are common.
1. Febrile phase
2. Classical dengue fever Following an incubation period of four to six days, the

telegram-@Cherry_2412
All ages and both sexes are susceptible to dengue fever. illness commonly begins abruptly with high fever
Children usually have a milder disease than adults. The accompanied by facial flushing and headache. Anorexia,
illness is characterized by an incubation period of 3 to 10 vomiting, epigastric discomfort, tenderness at the right costal
days (commonly 5-6 days). The onset is sudden, with chills margin and generalized abdominal pain are common.
and high fever, intense headache, muscle and joint pains, During the first few days the illness usually resembles
which prevent all movement. Within 24 hours retroorbital classical DF, but maculopapular rash usually rubelliform
pain, particularly on eye movements or eye pressure and type, is less common. It may appear early or late in the
photophobia develops. Other common symptoms include course of the illness. Occasionally, the temperature may be
extreme weakness, anorexia, constipation, altered taste 40°C to 41 °C and febrile convulsions may occur particularly
sensation, colicky pain and abdominal tenderness, dragging in infants (1).

DENGUE VIRUS INFECTION

Asymptomatic Symptomatic

1
Undifferentiated Dengu e fever Dengue haemorrhagic Expanded dengue syndrome/
fever (D F) fever (DHF) Isolated organopathy
(viral syndrome) (with plasma leakage) (unusual manifestation)

1 1
Without With unusual DHF DHF with shock
haemorrhage haemorrhage non-shock Dengue shock
syndrome (DSS)

FIG. 1
Manifestations of the dengue virus infection
Source : (3)
by R△J
292 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Shock occurs when a critical volume of plasma is lost

through leakage. It is often preceded by warning signs of
abdominal pain or tenderness, persistent vomiting, clinical
fluid accumulation, mucosal bleeding, lethargy, restlessness,
liver enlargement more than 2 cm. and oliguria. The body
temperature may be subnormal when shock occurs. With
prolonged shock, the consequent organ hypoperfusion
results in progressive organ impairment, metabolic acidosis
and disseminated intravascular coagulation. This in turn
leads to severe haemorrhage causing the haematocrit to
decrease in severe shock. Instead of the leukopenia usually
seen during this phase of dengue, the total white cell count
may increase in patients with severe bleeding. In addition,
severe organ impairment such as severe hepatits,
encephalitis or myocarditis and/or severe bleeding may also
develop without obvious plasma leakage or shock.
Those who improve after defervescence are said to have
non-severe dengue. Some patients progress to the critical
phase of plasma leakage without defervescence and, in
these patients, changes in the full blood count should be
used to guide the onset of the critical phase and plasma
leakage. Those who deteriorate will manifest with warning
signs. This is called dengue with warning signs. Cases of
dengue with warning signs will probably recover with early
FIG. 2 intravenous rehydration. Some cases will deteriorate to
The course of dengue illness severe dengue.
Source : (10)
3. Recovery phase

telegram-@Cherry_2412
If the patient survives the 24-48 hours critical phase, a
The major pathophysiologic changes that determine the gradual reabsorption of extravascular compartment fluid
severity of disease in DHF and differentiate it from DF are takes place in the following 48-72 hours. General well-being
plasma leakage and abnormal haemostasis, as manifested improves, appetite returns, gastrointestinal symptoms abate,
by a rising haematocrit value and moderate to marked haemodynamic status stabilizes and diuresis ensues. Some
thrombocytopenia. These two clinical laboratory changes patients may have a rash of “isles of white in the sea of red”.
are distinctive and constant findings. Some may experience generalized pruritus. Bradycardia
and electrocardiographic changes are common during this
A positive tournicate test is the most common stage.
haemorrhagic phenomenon. The test is performed by
inflating a blood pressure cuff to a mid point between systolic The haematocrit stabilizes or may be lower due to the
and diastolic pressure for 5 minutes. The test is considered dilutional effect of reabsorbed fluid. White blood cell count
usually starts to rise soon after defervescence but the
positive when 10 or more petechiae per 2.5x2.5 cm
recovery of platelet count is typically later than that of white
(1 inch square) are observed. In DHF, the test usually gives a
blood cell count.
definite positive with 20 petechiae or more (6).
Respiratory distress from massive pleural effusion and
2. Critical phase (10) ascites will occur at any time if excessive intravenous fluids
have been administered. During the critical and/or recovery
Around the time of defervescence, when the temperature phases, excessive fluid therapy is associated with pulmonary
drops to 37.5-38°C or less, and remains below this level, oedema or congestive heart failure.
usually on days 3-7 of illness, an increase in capillary
permeability in parallel with increasing haematocrit levels 4. Severe dengue
may occur. This marks the beginning of the critical phase. Severe dengue is defined by one or more of the following
The period of clinically significant plasma leakage usually (i) plasma leakage that may lead to shock (dengue shock)
lasts 24-48 hours. and/or fluid accumulation, with or without respiratory
Progressive leukopenia followed by a rapid decrease in distress, and/or (ii) severe bleeding, and/or (iii) severe organ
platelet count usually precedes plasma leakage. At this point impairment.
patients without an increase in capillary permeability will As dengue vascular permeability progresses,
improve, while those with increased capillary permeability hypovolaemia worsens and results in shock. It usually takes
may become worse as a result of lost plasma volume. The place arqund defervescence, usually on day 4 or 5 (range
degree of plasma leakage varies. Pleural effusion mostly on days 3-7) of illness, preceded by the warning signs. During
right side and ascites may be clinically detectable depending the initial stage of shock, the compensatory mechanism
on the degree of plasma leakage and the volume of fluid which maintains a normal systolic blood pressure also
therapy. Gall bladder oedema has been found to precede produces tachycardia and peripheral vasoconstriction with
plasma leakage. Hence chest X-ray and abdominal reduced skin perfusion, resulting in cold extremities and
ultrasound can be useful tools for diagnosis. The degree of delayed capillary refill time. Uniquely, the diastolic pressure
increase above the baseline haematocrit often reflects the rises towards the systolic pressure and the pulse pressure
severity of plasma leakage. narrows as the peripheral vascular resistance increases.
by R△J
 THE DENGUE SYNDROME 293
Patients in dengue shock often remain conscious and lucid. - fourfold or greater increase in serum IgG (by
The inexperienced physician may measure a normal systolic haemagglutination inhibition test) or increase in IgM
pressure and misjudge the critical state of the patient. antibody specific to dengue virus.
Finally, there is decompensation and both pressures - detection of dengue virus or antigen in tissue, serum or
disappear abruptly. Prolonged hypotensive shock and cerebrospinal fluid by immunohistochemistry,
hypoxia may lead to multi-organ failure and an extremely immunofluorescence or enzyme-linked immunosorbent
difficult clinical course. assay.
The patient is considered to have shock if the pulse - detection of dengue virus genomic sequences by
pressure is <20 mm Hg in children or he/she has signs of reverse transcription-polymerase chain reaction.
poor capillary perfusion (cold extremities, delayed capillary
refill, or rapid pulse rate). In adults, the pulse pressure of Dengue haemorrhagic fever
<20 mm Hg may indicate a more severe shock. Hypotension
is usually associated with prolonged shock which is often All of following :
complicated by major bleeding. - acute onset of fever of two to seven days duration.
Patients with severe dengue may have coagulation - haemorrhagic manifestations, shown by any of the
abnormalities, but these are usually not sufficient to cause following; positive tourniquet test, petechiae,
major bleeding. When major bleeding does occur, it is ecchymoses or purpura, or bleeding from mucosa,
almost always associated with profound shock since this, in gastrointestinal tract, injection sites, or other
combination with thrombocytopenia, hypoxia and acidosis, locations.
can lead to multiple organ failure and advanced - platelet count < 100,000 cells/mm3
disseminated intravascular coagulation. Massive bleeding
may occur without prolonged shock in instances when - objective evidence of plasma leakage due to increased
acetylsalicylic acid (aspirin), ibuprofen or corticosteriods vascular permeability shown by any of the following :
have been taken. - Rising haematocrit/haemoconcentration >20%
Unusual manifestations, including acute liver failure and from baseline or evidence of plasma leakage such
encephalopathy, may be present, even in the absence of as pleural effusion, ascites or hypoproteinaemia/
severe plasma leakage or shock. Cardiomyopathy and albuminaemia.

telegram-@Cherry_2412
encephalitis are also reported in a few dengue cases.
However, most deaths from dengue occur in patients with Dengue shock syndrome
profound shock, particularly if the situation is complicated by Criteria for dengue haemorrhagic fever as above with
fluid overload. signs of shock including :
- tachycardia, cool extremities, delayed capillary refill,
CRITERIA FOR CLINICAL DIAGNOSIS (3, 6,11) weak pulse, lethargy or restlessness, which may be a
A summary of clinical diagnosis of DF and DHF is as sign of reduced brain perfusion.
follows : - pulse pressure < 20 mmHg with increased diastolic
pressure, e.g. 100/80 mmHg.
Dengue fever
- hypotension by age, defined as systolic pressure
Probable diagnosis <80 mmHg for those aged <5 years, or 80 to
Acute febrile illness with two or more of the following; 90 mmHg for older children and adults.
- headache, Laboratory diagnosis (3, 6)
- retro-orbital pain, Rapid and accurate dengue diagnosis is of a paramount
- myalgia, importance for : (1) clinical management; (2) epidemiological
- arthralgia/bone pain, surveillance; (3) research; and (4) vaccine trials.
Epidemiological surveillance requires early determination of
- rash,
dengue virus infection during the outbreak for urgent public
- haemorrhagic manifestations, health action towards control, as well as at sentinel sites for
- leucopenia (wbc < 5000 cells/mm3), detection of circulating serotypes/genotypes during the inter­
- thrombocytopenia (platelet count < 150,000 cells/mm3), epidemic period for use in forecasting possible outbreak. The
following laboratory tests are available to diagnose dengue
- rising haematocrit (5-10%);
fever and DHF:
and at least one of the following :
1. Virus isolation : Isolation of dengue virus from clinical
- supportive serology on single serum sample: titre > 1280 specimens is possible provided the specimen is taken during
with haemagglutination inhibition test, comparable IgG the first six days of illness and processed without delay.
titre with enzyme-linked immunosorbent assay, or Specimen that are suitable for virus isolation are - acute
testing positive in IgM antibody test, and phase serum, plasma or washed buffy coat from the
- occurrence at the same location and time as patient,autopsy tissue from fatal case (especially liver, spleen,
confirmed cases of dengue fever. lymph nodes and thymus), and mosquitoes collected from the
affected areas.
Confirmed diagnosis
2. Viral nucleic acid detection : Dengue viral genome,
Probable case with at least one of the following : which consists of RNA, can be detected by reverse
- isolation of dengue virus from serum, CSF or autopsy transcriptase polymerase chain reaction (RT-PCR) assay
samples. and real time RT-PCR. In recent years, a number of
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

RT-PCR assays have been reported for detecting dengue CLINICAL MANAGEMENT
virus. They offer better specificity and sensitivity
compared to virus isolation with a much more rapid Grading of the severity of dengue infection
turnaround time. To decide where to treat the patient, it is important to
3. Immunological response and serological tests : classify the severity of dengue infection. The presence of
Following tests are available for diagnosis of dengue thrombocytopenia with concurrent haemoconcentration
infection : differentiates grade I and grade II DHF from DF. Table 3
shows grading of dengue infection.
a. Haemagglutination Inhibition Assay (HIA);
b. Complement Fixation (CF); Guidelines for treatment
c. Neutralization test (NT);
A full blood count of the patient should be done at the
d. IgM capture enzyme-linked immunosorbent assay first visit. A haematocrit test in the early febrile phase
(MAC-ELISA); establishes the patient's own baseline haematocrit. A rapidly
e. Indirect IgG- ELISA, and decreasing platelet count in parallel with a rising
f. IgM/IgG ratio haematocrit compared to the baseline is suggestive of
progress to the plasma leakage/critical phase of the disease.
4. Viral antigen detection : ELISA and dot blot assays In the absence of the patients baseline, age specific
directed against the envelop/membrane (EM) antigens and population haematocrit levels could be used as a surrogate
nonstructural protein 1 (NS1) can be detected in both during the critical phase.
patients with primary and secondary dengue infection upto
6 days after the onset of the illness. Commercial kits for the 1. Management of dengue fever
detection of NS1 antigens are now available; however, these
These are patients who are able to tolerate adequate
kits do not differentiate between the serotypes. Besides
volumes of oral fluids and pass urine at least once every six
providing an early diagnostic marker for clinical
hours, and do not have any of the warning signs,
management, it may also facilitate the improvement of
particularly when fever subsides. Those with stable
epidemiological surveys of dengue infection.
haematocrit can be sent home after being advised to return
5. Rapid diagnostic test (RDT) : A number of commercial to the hospital immediately if they develop any of the

telegram-@Cherry_2412
rapid format serological test-kits for anti-dengue IgM and warning signs, and to adhere to the following action plan :
IgG antibodies have become available in the past few years, (1) Encourage intake of oral rehydration solution (ORS),
some of these producing results within 15 minutes. fruit juice and other fluids containing electrolytes and
Unfortunately, the accuracy of most of these tests is sugar to replace losses from fever and vomiting.
uncertain since they have not yet been properly validated. Adequate oral fluid intake may be able to reduce the
6. Analysis of haematological parameters : Standard number of hospitalizations. (Caution : fluids containing
haematological parameters such as platelet count and sugar/glucose may exacerbate hyperglycaemia of
haematocrit are important and are part of the diagnosis of physiological stress from dengue and diabetes mellitus.)
dengue infection. They should be closely monitored. (2) Give paracetamol for high fever if the patient is
The diagnostic tests are summarized in Table 2. uncomfortable. The interval of paracetamol dosing

TABLE 2
Dengue diagnostics and sample characteristics

ELISA = enzyme-linked immunosorbent assay; HIA = haemagglutination inhibition assay; IgG = immunoglobulin G;
IgM = immunoglobulin M; NS1 Ag = non-structural protein 1 antigen: RT-PCR = reverse transcriptase polymerase chain reaction.
Source : (12)
by R△J
 THE DENGUE SYNDROME 295
TABLE 3
WHO classification and grading of the severity of dengue infection
DF/DHF Grade Symptoms/signs Laboratory findings
DF Fever with two or more of the following Leucopenia (WBC < 5000 cells/cu mm),
- Headache - Thrombocytopenia (platelet count < 150,000 cells/cu.mm),
- Retro-orbital pain - Rising haematocrit (5-10 per cent)
- Myalgia
- Arthralgia
- Rash
- Haemorrhagic manifestations
- No evidence of plasma leakage
DHF I Above criteria for DF and haemorrhagic manifestation Thrombocytopenia : Platelet count < 100,000/cu.mm.
plus positive tourniquet test, evidence of plasma leakage Haematorcit rise 20% or more
DHF II Above signs and symptoms plus some evidence of Thrombocytopenia platelet count < 100,000/cu.mm.
spontaneous bleeding in skin or other organs Haematocrit rise 20% or more
(black tarry stools, epistaxis, bleeding from gums, etc)
and abdominal pain
DHF III Above signs and symptoms plus circulating failure Thrombocytopenia : Platelet count < 100,000/cu.mm.
(weak rapid pulse, pulse pressure < 20 mm Hg or high Haematocrit rise more than 20%
diastolic pressure, hypotension with the presence of
cold clammy skin and restlessness)
DHF IV Signs as grade III plus profound shock with undetectable Thrombocytopenia : Platelet count < 100,000/cu mm.
blood pressure or pulse Haemotocrit rise more than 20%
DHF III and IV are Dengue Shock Syndrome
Source : (3, 6)

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should not be less than six hours. Tepid sponge if the fluids. Haematocrit should be determined daily from the
patient still has high fever. Do not give acetylsalicylic third day until the temperature has remained normal for one
acid (aspirin), ibuprofen or other non-steroidal anti­ or two days. If haematocrit determination is not possible,
inflammatory agents (NSAIDs) as these drugs may haemoglobin determination may be carried out as an
aggravate gastritis or bleeding. Acetylsalicylic acid alternative. The details of IV treatment when required for
(aspirin) may be associated with Reye’s Syndrome. patients are given in Fig. 3.
(3) Instruct the care-givers that the patient should be
brought to hospital immediately if any of the following 3. Management of DHF Grade I and II
occur; no clinical improvement, deterioration around the Any person who has dengue fever with
time of defervescence, severe abdominal pain, persistent thrombocytopenia and haemoconcentration and presents
vomiting, cold and clammy extremities, lethargy or with abdominal pain, black tarry stools, epistaxis, bleeding
irritability/restlessness, bleeding (e.g. black stools or from the gums and infection etc needs to be hospitalized. All
coffee-ground vomiting), not passing urine for more these patients should be observed for signs of shock. The
than 4-6 hours. critical period for development of shock is transition from
Patients who are sent home should be monitored daily by febrile to abferile phase of illness, which usually occurs after
health care providers for temperature pattern, volume of third day of illness. A rise of haemoconcentration indicates
fluid intake and losses, urine output (volume and frequency), need for IV fluid therapy. If despite the treatment, the patient
warning signs, signs of plasma leakage and bleeding, develops fall in BP, decrease in urine output or other
features of shock, the management for Grade III/IV DHF/
haematocrit, and white blood cell and platelet counts.
DSS should be instituted.
2. Management of DHF (Febrile Phase) (6, 11) Oral rehydration should be given along with antipyretics
like paracetamol, sponging, etc. as described above. The
The management of febrile phase is similar to that of DF.
detailed treatment for patients with DHF Grade I and II is
Paracetamol is recommended to keep the temperature
given in Fig. 3.
below 39°C. Copious amount of fluid should be given
orally, to the extent the patient tolerates, oral rehydration 4. Management of DHF Grade III and IV
solution (ORS), such as those used for the treatment of Common signs of complication are observed during the
diarrhoeal disesases and/or fruit juices are preferable to afebrile phase of DHF. Immediately after hospitalization, the
plain water. IV fluid may be administered, if the patient is haematocrit, platelet count and vital signs should be
vomiting persistently or refusing to feed. examined to assess the patient’s condition and intravenous
Patients should be closely monitored for the initial signs fluid therapy should be started. The patient requires regular
of shock. The critical period is during the transition from the and sustained monitoring. If the patient has already received
febrile to the afebrile stage and usually occurs after the third about 1000 ml of intravenous fluid, it should be changed to
day of illness. Serial haematocrit determinations are colloidal solution preferably Dextran 40/haemaccel or if
essential guide for treatment, since they reflect the degree of haematocrit is decreasing, fresh whole blood transfusion
plasma leakage and need for intravenous administration of 10-20 ml/kg/hour should be given.
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

However, in case of persistent shock when, after initial 1. Prophylactic platelet transfusion may be given at level of
fluid replacement and resuscitation with plasma or plasma < 10,000/cu.mm.
expanders, the haematocrit continues to decline, internal 2. Prolonged shock; with coagulopathy and abnormal
bleeding should be suspected. It may be difficult to recognize coagulogram.
and estimate the degree of internal blood loss in the
presence of haemoconcentration. It is thus recommended to 3. In case of systemic massive bleeding, platelet transfusion
give fresh whole blood in small volumes of 10 ml/kg/hour for may be needed in addition to red cell transfusion.
all patients in shock as a routine precaution. Oxygen should
be given to all patients in shock. The detailed graphical Criteria for discharge of patients
presentation of the treatment for patients with DHF Grades 1. Absence of fever for atleast 24 hours without the use of
III and IV is given in Fig. 4 and 5. anti-pyretic drugs.
Indications of red cell transfusion 2. Return of appetite.
1. Loss of blood (overt blood) - 10 per cent or more of total 3. Visible clinical improvement.
blood volume - preferably give whole blood or 4. Good urine output.
components to be used. 5. Minimum of 2-3 days after recovery from shock.
2. Refractory shock despite adequate fluid administration
and declining haematocrit. 6. No respiratory distress from pleural effusion or ascites.
3. Replacement volume should be 10 ml/kg body weight at 7. Platelet count > 50,000/cu.mm.
a time and coagulogram should be done.
4. If fluid overload is present packed cells are to be given. Disease notification
In dengue-endemic countries, cases of suspected,
Indications of platelet transfusion probable and confirmed dengue should be notified as soon
In general there is no need to give prophylactic platelet as possible so that appropriate health measures can be
even at < 20,000/cu.mm. initiated.

telegram-@Cherry_2412

FIG. 3
Volume replacement algorithm for patients with moderate dengue fever
(DHF Grades I & II)
Source : (11, 15)
by R△J
 THE DENGUE SYNDROME
297

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# ABCS = Acidosis, Bleeding, Calcium (Na+ + & K+), Sugar
* Improvement: Het falls, pulse rate and blood pressure stable, urine output rises
** No improvement: Het or pulse rate rises, pulse pressure falls below 20 mmHg,
urine output falls
- Unstable vital signs : urine output falls, signs of shock
- In cases of acidosis, hyperosmolar or Ringer’s lactate solution should not be used
- Serial platelet and Het determinations : drop in platelets and rise in Het are essential for
early diagnosis of DHF
- Cases of DHF should be observed every hour for vital signs and urine output

FIG. 4
Volume replacement algorithm for patients with severe dengue fever
(DHF grade III)
Source : (11, 15)

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

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FIG. 5
Volume replacement algorithm for patients with decompensated shock in dengue
(DHF IV (DSS))
Source : (11, 15)

CONTROL MEASURES dengue virus serotypes 1, 2, 3, and 4 in individuals 9-45

years or 9-60 years of age (depending on the license), living
1. Mosquito control in dengue endemic areas. The lower limit of the indication at
The vectors of DF and DHF (e.g., A. aegypti) breed in and 9 years of age was chosen due to a safety concern in children
around houses and, in principle can be controlled by individual aged 2-5 years identified in the Phase 3 clinical trials.
and community action, using antiadult and antilarval CYD-TDV is available in a single-dose vial or in a multidose
measures. These measures are outlined in chapter 14. (5-dose) vial. It is a freeze-drjed product to be reconstituted
before injection with either a sterile solution of 0.4% sodium
2. Vaccines (13) chloride for the single-dose presentation or a sterile solution
CYD-TDV is a prophylactic, tetravalent, live attenuated of 0.9% sodium chloride for the 5-dose presentation. After
viral vaccine developed by Sanofi Pasteur in December 2015. reconstitution, the 0.5 ml dose is to be administered by the
The vaccination schedule consists of 3 injections of 0.5 ml subcutaneous route. The diluent is provided as a pre-filled
administered at 6-month intervals. The indication from the syringe for single dose presentation or in a vial for the multi­
first licenses is for the prevention of dengue illness caused by dose presentation.The CYD-TDV dengue vaccine contains no
by R△J
 THE DENGUE SYNDROME

adjuvant or preservatives. The shelf life of CYD-TDV is 36 11. Govt, of India (2014), Operational Guidelines National Programme
months when stored between 2°C and 8°C. After for Prevention and Control of Dengue, Ministry of Health and Family
Welfare, New Delhi.
reconstitution with the solvent provided, the vaccine must be 12. WHO (2012), Handbook for Clinical Management of Dengue.
kept at between 2°C and 8°C and protected from light. In 13. WHO (2016), Weekly Epidemiological Record, No. 30, 29th July,
accordance with the WHO multi-dose vial policy, any 2016.
reconstituted doses remaining at the end of session should be 14. WHO (2012), Global Strategy for Dengue Prevention and Control,
discarded within 6 hours of opening/reconstitution or at the 2012-2020.
end of a vaccination session, whichever comes first. 15. Govt, of India (2020), National Guidelines Dengue case management
during COVID-19 Pandemic, 2020, NVBDCP, Ministry of Health and
The manufacturer stipulates that vaccination is contra­ Family Welfare, New Delhi.
indicated in: (1) individuals with a history of severe allergic
reaction to any component of the dengue vaccine or after MALARIA
prior administration of the dengue vaccine or a vaccine
containing the same components; (2) individuals with Malaria is a protozoal disease caused by infection with
congenital or acquired immune deficiency that impairs cell- parasites of the genus Plasmodium and transmitted to man
mediated immunity; (3) individuals with symptomatic HIV by certain species of infected female Anopheline mosquito.
infection or with asymptomatic HIV infection when A typical attack comprises three distinct stages : cold stage,
accompanied by evidence of impaired immune function; hot stage and sweating stage. The clinical features of malaria
(4) pregnant or breastfeeding women; and that vaccination vary from mild to severe, and complicated, according to the
should be postponed in individuals with moderate to severe species of parasite present, the patient’s state of immunity,
febrile or acute disease. the intensity of the infection and also the presence of
concomitant conditions such as malnutrition or other
3. Other measures diseases. The febrile paroxysms occur with definite
Isolation of the patient under bed-nets during the first few intermittent periodicity repeating every third or fourth day
days; individual protection against mosquitoes. depending upon the species of the parasite involved.
The personal prophylactic measures are wearing of full Problem statement
sleeves shirts and full pants; use of mosquito repellent creams,
liquids, coils, mats etc.; use of bed-nets for sleeping infants WORLD

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and young children during day time to prevent mosquito bite. It took almost 30 years from the end of the Global Malaria
The environmental measurements are detection and Eradication Programme (in 1969) for malaria to re-emerge as
elimination of mosquito breeding places, management of a public health priority in global health and development
roof tops, porticos and sunshades, proper covering of stored discourse. Although data from 1969 to 2000 are scarce, this
water, observation of weekly dry day. period was characterized by a sense of failure and
abandonment in the fight against malaria. During these
Global strategy for dengue prevention and 3 decades, hundreds of millions of people were infected with
control 2012-2020 (14) malaria, tens of millions - mostly in sub-Saharan Africa -
died, millions of households failed to emerge out of poverty
Dengue is a global threat that requires a global response
as they struggled with catastrophic health expenditures,
involving all possible partners. The global strategy promotes
hundreds of thousands of pregnant women died during
co-ordination and collaboration among multisectoral
delivery due to malaria-related complications, and millions of
partners on integrated vector management approach and
children were born with low birth-weight, potentially leading
sustained control measures at all levels. The goals are :
to early death or lifelong disability. Millions of children who
a. to reduce dengue mortality by at least 50 per cent by 2020; survived, struggled with learning as they dealt with frequent
b. to reduce dengue morbidity by at least 25 per cent by absenteeism due to multiple episodes of malaria, chronic
2020; and anaemia, seizures or cognitive impairment - consequences of
c. to estimate the true burden of the disease by 2015. infection and severe disease. Huge blows were dealt to the
growth of already weak national economies, and their
References attempts to build viable health systems were hampered by lost
1. WHO (1993), Monograph on Dengue/Dengue Haemorrhagic Feuer, productivity and high demand for health care.
Compiled by Prasert Thongchroen, Regional Publication, SEARO
No.22. Against this background, the first 2 decades of the 21st
2. WHO (2022), Fact Sheet on Dengue, 10th January, 2022. century represent a golden era in the history of malaria
3. WHO (2011), Comprehensive Guidelines for Prevention and Control control. The world pulled together to fight malaria, delivering
of Dengue and Dengue Haemorrhagic Feuer, Revised and expanded one of the biggest returns on investment in global health. The
edition, Regional office of SEAR. unprecedented scale-up of malaria interventions over this
4. Govt, of India (2018), Annual Report 2017-2018, DGHS, Ministry of period has led to considerable reduction in disease incidence
Health and Family Welfare, New Delhi. and mortality. These efforts coincided with other trends and
5. Govt, of India (2021), National Health Profile 2021, DGHS, Ministry of changes that have had a positive impact on malaria, including
Health and Family Welfare, New Delhi.
a period of considerable economic growth and development,
6. Govt, of India (2008), Guidelines for Clinical Management of Dengue
Feuer, Dengue Haemorrhagic Feuer and Dengue Shock Syndrome, infrastructure and housing improvements, rapid urbanization,
Ministry of Health and Family Welfare, New Delhi. and general improvements in health systems and population
7. WHO (2012), Weekly Epidemiological Record, No. 8,24th Feb., 2012. health. The indirect effect of these gains on the overall health
8. Jawetz, Melnick and Adelberg's Medical Microbiology, 24th of populations and economies is substantial (1).
International Ed. (2007), A Lange Medical Publication. Globally, there were an estimated 241 million cases of
9. Govt, of India (2006), National Vector Borne Disease Control malaria in 2020 in 85 malaria endemic countries. Most of
Programme, Ministry of Health and Family Welfare, New Delhi.
10. WHO (2009), Dengue, Guidelines for Diagnosis, Treatment,
the increase (in 2019 there were 227 million cases) coming
Prevention and Control, New edition. from countries in African region. At the Global Technical

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Strategy for malaria 2016-2030 baseline of 2015, there 7. immigrants and their children living in non-endemic
were 224 million estimated malaria cases. The proportion of areas and returning to their home countries to visit
cases due to P vivax reduced from about 8 per cent (18.5 friends and relatives are similarly at risk because of
million) in 2000 to 2 per cent (4.5 million) in 2020 (2). waning or absent immunity.
Malaria case incidence rate reduced from 81 case/1000
population at risk in 2000 to 59/1000 population at risk. The Acquired immunity
case incidence in WHO African region was 222 per 1000 Natural immunity to malaria is acquired gradually with
population at risk in 2019 but increased to 232 in 2020, repeated exposure to Plasmodium infection. Immunity is
mainly due to disruptions of services during the COVID-19 acquired more rapidly against the more severe forms of the
pandemic. WHO South-East Asia Region accounted for disease. Hence, with increasing age, there is progressive
about 2 per cent of the burden of malaria cases globally, a protection first against severe malaria and ensuing mortality,
reduction by 78 per cent, from 23 million in 2000 to about then against uncomplicated malaria and, much more slowly,
5 million in 2020. Similarly incidence reduced by 83 per asymptomatic parasitaemia. In areas of moderate to high
cent from 18 cases/1000 population at risk in 2000 to transmission, malaria mortality rates begin to fall by around
3 cases per 1000 population at risk (2). India accounted for 2 years of age, with the incidence of acute febrile malaria
83 per cent of the cases in the region. falling later in childhood (3).
Globally, malaria deaths reduced steadily over the period Naturally acquired immunity is believed to wane
2000-2019, from 8,96,000 in 2000 to 5,58,000 in 2019. In substantially in people who migrate out of a malaria­
2020, malaria deaths increased by 12 per cent compared to endemic region and are no longer regularly exposed to
2019, to an estimated 6,27,000 due to disruptions of malaria infection for a number of years. The use of available
services because of COVID-19 pandemic (2). preventive interventions can delay the development of
Approximately 95 per cent of malaria cases and deaths naturally acquired immunity. Significant roles for both
occur in sub-Saharan Africa, with the remainder occurring humoral and cell-mediated effectors have been
largely in South-East Asia and South America. Almost all demonstrated in animal models, and both humoral and cell-
malaria deaths are caused by Plasmodium falciparum and mediated immune responses are induced in humans after
most occur in African children under 5 years of age. Adults natural malaria infection (3).
who have lived in areas with high malaria transmission since Malaria affects mainly poor, underserved and

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childhood and remain resident in such areas are generally marginalized populations in remote rural areas which are
not at risk of death from malaria, as they usually have characterized by inadequate control measures and limited
naturally acquired immunity as a result of repeated access to health care. Higher malaria prevalence has been
infections in childhood. Plasmodium vivax is an important reported among ethnic and tribal groups living in remote
cause of malaria morbidity outside sub-Saharan Africa. forested and border areas, as well as among mobile and
Vaccine development efforts have focused on preventing migrant populations.
illness from P falciparum and, to a lesser extent, P vivax.
The childhood deaths result mainly from cerebral malaria
Current WHO guidance defines moderate to high malaria and anaemia. Fatality rates of 10-30 per cent have been
transmission settings as those with an annual incidence reported among children referred to hospital with severe
greater than around 250 cases per 1000 population or a malaria. However, these rates are even higher in rural and
prevalence of P falciparum infection in children aged 2-10 remote areas where patients have restricted access to
years of approximately 10 per cent or more (3). adequate treatment. Malaria also contributes indirectly to
In 2019, in 33 moderate to high transmission countries in illness and deaths from respiratory infections, diarrhoeal
African Region, there were an estimated 33 million disease and malnutrition. Deaths from malaria in countries
pregnancies, of which 35 per cent (12 million) were exposed outside Sub-Saharan Africa occur principally in non-
to malaria infection during pregnancy. It is estimated that immune people who become infected with P. falciparum.
malaria infection during pregnancy in these 33 countries Underreporting of malaria cases and deaths remain a
resulted in 8,22,000 children with low birth-weight (1). major challenge. Drug-resistant parasites, poor treatment­
The specific risk groups for malaria includes the following seeking behaviour and the presence of counterfeit
population (4) : antimalarial drugs further hinder control efforts. Resistance of
P. falciparum to the 4-aminoquinolines and sulfadoxine-
1. young children in stable transmission areas who have pyrimethamine is widespread in almost all countries of SEAR,
not yet developed protective immunity against the with varying levels of severity. Resistance to mafloquine was
most severe forms of the disease; reported from Myanmar and Thailand. Quinine has reduced
2. non-immune pregnant women as malaria causes high susceptibility in Thailand. With progress from mono-to-
rates of miscarriage and can lead to maternal death; multidrug resistance, all malaria-endemic countries that have
3. semi-immune pregnant women in areas of high falciparum malaria adopted the highly effective artemisinin -
transmission. Malaria can result in miscarriage and based combination therapy (ACT).
low birth weight, especially during first and second The coverage of indoor residual spraying with insecticides
pregnancies; (IRS) remains low (42 per cent). Insecticide-treated nets have
4. semi-immune HIV-infected pregnant women in stable been introduced in almost all countries to supplement IRS
transmission areas, during all pregnancies. Women efforts, but the coverage remains extremely low.
with malaria infection of the placenta also have a INDIA
higher risk of passing HIV infection to their newborns;
Malaria is a public health problem in several parts of the
5. people with HIV/AIDS; country. About 95 per cent population in the country resides
6. international travellers from non-endemic areas in malaria endemic areas and 80 per cent of malaria cases
because they lack immunity. reported in the country are confined to areas consisting
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 MALARIA

20 per cent of population residing in tribal, hilly, difficult to control have been identified. An analysis of these factors
reach areas. resulted in the identification of malaria priority areas.
Countrywide malaria situation is as reflected in TRIBAL MALARIA : The population of tribal areas are
surveillance data (as shown in Table 1). The cases have contributing about 50 per cent of P. falciparum cases of the
consistently declined from 2.09 million in 2001 to country (6). Infants, young children and pregnant women
O. 161 million in 2021, similarly Pf cases have declined from have been identified as malaria high risk groups followed by
1.0 million to 0.10 million. Less than 2000 deaths were mobile tribal population engaged in forest-related activities.
reported during all the years within this period with a peak Limited health infrastructure and lack of drugs at village
in 2006 when an epidemic was reported in North East level are the factors responsible for high morbidity and
States. The country SPR has declined from 2.31 to 0.14 and mortality due to malaria.
SFR has declined from 1.11 in 2001 to 0.09 in 2021 (5). RURAL MALARIA : These include irrigated areas of arid
This indicates declining overall endemicity of malaria in the and semiarid plains. Malaria is of moderate to low
country. endemicity. An. culicifacies is the main vector and P. vivax is
India is predominantly characterized by unstable malaria predominant during lean period and P falciparum during
transmission. Transmission is seasonal with increased periodic exacerbation. In these the health infrastructure is
intensity related to rains. Due to the low and unstable moderately developed.
transmission dynamics, most of the population has no or little URBAN MALARIA : 15 major cities including four
immunity toward malaria. As a result, the majority of Indians metropolitans account for nearly 80 per cent of malaria
living in malarious areas are at risk of infection with all age cases covered under urban malaria control scheme. The
groups affected. However, surveys have shown that in some health infrastructure is well developed. In peri-urban areas
foci, mainly in forested areas, transmission is intense and the malaria situation is influenced by poor sanitary conditions
disease burden is to a large extent concentrated in children.
and low socio-economic groups living in unplanned
There are six primary vectors of malaria in India : settlements prone to periodical epidemics.
(1) An. culicifacies is the main vector of rural and peri-urban MALARIA IN PROJECT AREAS : Project areas are those
areas and is widespread in peninsular India. It is found in a areas where construction and developmental activities are
variety of natural and man-made breeding sites. It is highly
taken up and temporary tropical aggregation of labourers
zoophilic. Species A is an established vector for P. Vivax and takes place bringing in different strains of malaria parasite

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P falciparum, whereas species B is completely refractory to
and non-immune population. This results in disturbance in
P. Vivax and partially refractory to P falciparum. It has been
eco-system, prolific increase in vector breeding places and
demonstrated that species B, however, may play a role as a increased man-mosquito contact favouring high malaria
vector of P. falciparum in areas where the cattle population is
transmission. These pockets contribute a large number of
very low or absent; (2) An. stephensi is responsible for
malaria cases which are highly disproportionate to the
malaria in urban and industrial areas. The type form is found
relatively small population groups inhabitating the area.
in urban areas; intermediate form in urban and semi-urban
One or more major vectors are involved in malaria
localities and mysorensis form is present in rural areas (it is transmission. Limited health facilities for prompt treatment is
not a vector); (3) An. fluviatilis is the main vector in hilly
invariably associated with chloroquine resistant malaria
areas, forests and forest fringes in many states, especially in parasite. Hence specific control strategy is required for such
the east; (4) An. minimus is the vector in the foot hills of
areas.
North-Eastern states; (5) An. dirus is an important forest
vector in the North-East; and (6) An. epiroticus is now BORDER MALARIA : These are the high malaria
restricted to the Andaman and Nicobar Islands (6). transmission belts along the international borders and state
borders. These areas have their own problems in regard to
Prevalent major epidemiological types of malaria control because of mixing of population and poor
malaria in India (7) administrative control.
In the course of the stratification exercise, various problems FOREST MALARIA : Forests and settlements in recently
and constraints responsible for the slow progress of malaria deforested areas are known to harbour very efficient malaria
TABLE 1
Countrywide malaria surveillance data 2015-2021
Total malaria P. falciparum Deaths
Year BSE cases cases Pf % API ABER SPR SFR due to
(in millions) (in millions) (in millions) malaria

2001 90.389 2.085 1.005 2.12 9.18 2.31 1.11 1005

2015 121.14 1.17 0.78 66.61 0.92 9.58 0.97 0.64 384
2016 124.93 1.09 0.71 65.53 0.85 9.74 0.87 0.57 331
2017 125.97 0.84 0.53 62.70 0.64 9.58 0.67 0.42 194
2018 124.44 0.34 0.16 47.93 0.32 9.31 0.35 0 17 96
2019 134.23 0.34 0.16 46.36 0.25 9.95 0.25 0.12 77
2020 97.17 0.19 0.12 63.84 0.014 7.08 0 19 0.12 93
2021 114.293 0.16 0.10 63.10 0.12 8.25 0.14 0.09 90
Pf - Plasmodium falciparum BSE - Blood smear examined
API - Annual parasite incidence ABER - Annual blood examination rate
SPR - Slide positivity rate SFR - Slide falciparum rate
Source : (5)

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

vectors. These vectors bite humans in their shelters, but worldwide incidence of infection caused by a specific agent;
return to rest in the forest, avoiding residual insecticides applies to a particular malaria parasite species. Intervention
sprayed indoors in the shelters. Malaria transmission is measures are no longer needed once eradication has been
therefore, more intense and more difficult to control in achieved.
temporary or newly established forest settlements (8).
Epidemiological determinants
FLOODS AND MALARIA : Floods may lead to a rise in
incidence of malaria. Flooding may initially flush out Agent factors
mosquito breeding, but later result in pools of water creating
mosquitogenic conditions. The lag time between the floods (a) AGENT
and possible malaria epidemic is estimated to be around 6-8 Malaria in man is caused by four distinct species of the
weeks (8). malaria parasite - P vivax, P. falciparum, P malariae and
P. ovale. Plasmodium vivax has the widest geographic
Some definitions (8) distribution throughout the world. In India, about
Malaria control: reducing the malaria disease burden to a 50 per cent of the infections are reported to be due to
level at which it is no longer a public health problem. P falciparum and 4-8 per cent due to mixed infection and
Malaria elimination : the interruption of local mosquito- rest due to P vivax. P. malariae has a restricted distribution
and is said to be responsible for less than 1 per cent of the
borne malaria transmission; reduction to ‘zero’ of the
infections in India. The largest focus of P. malariae in India is
incidence of infection caused by human malaria parasites in
reported to be in Tumkur and Hassan districts in Karnataka.
a defined geographical area as a result of deliberate efforts;
P. ovale is a very rare parasite of man, mostly confined to
continued measures to prevent re-establishment of
transmission are required. tropical Africa. It has also been reported in Vietnam. The
severity of malaria is related to the species of the parasite.
Certification of malaria elimination : can be granted by
WHO after it has been proven beyond reasonable doubt that Life history
the chain of local human malaria transmission by Anopheles The malaria parasite undergoes 2 cycles of development
mosquitoes has been fully interrupted in an entire country - the human cycle (asexual cycle) and the mosquito cycle
for at least 3 consecutive years. (sexual cycle). Man is the intermediate host and mosquito
Malaria eradication : permanent reduction to ‘zero’ of the the definitive host (Fig. 1).

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EXOGENOUS PHASE (IN MOSQUITO) ENDOGENOUS PHASE (IN HUMAN)
Sexual cycle (sporogony) Asexual cycle (schizogony)

Sporozoites Sporozoites Exoerythrocytic

pass through body in saliva from mosquito multiplication in liver
cavity, injected into human host parenchymal cells
reach salivary glands

/
Oocyst grows (multiple SPOROGONY SCHIZOGONY
division stage: cyst bursts
to release sporozoites)
Merozoites

Mature schizont
(Enter red cells)
(Segmentes)

(Penetrates to outer layer

of stomach wall of Erythrocytic cycle
mosquito and encysts) CLINICAL MALARIA

Ookinete (motile zygote)

GAMETOGENY

Microgamete Human
(fertilization) 4- blood
Macrogamete enters
mosquito

FIG. 1
Lifecycle of the malaria parasite.
Source : (12)

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 MALARIA 303
(i) Asexual cycle: The asexual cycle begins when an 10-20 days depending upon favourable conditions of
infected mosquito bites a person and injects sporozoites. A atmospheric temperature and humidity. This period is also
considerable amount of new knowledge about the parasite’s referred to as the “extrinsic incubation period”.
life cycle has become available in recent years, concerning
almost all phases of the cycle (9). A brief description is as (b) RESERVOIR OF INFECTION
follows - four phases are described in the human cycle: With the possible exception of chimpanzees in tropical
(a) HEPATIC PHASE: The sporozoites disappear within Africa, which may carry the infection with P malariae, no
60 minutes from the peripheral circulation (10). Many of other animal reservoir of human plasmodia is known to
them are destroyed by phagocytes, but some reach the liver exist (11). A human reservoir is one who harbours the sexual
cells. After 1-2 weeks of development (depending upon the forms (gametocytes) of the parasite. A patient can be a
species), they become hepatic schizonts, which eventually carrier of several plasmodial species at the same time.
burst releasing a shower of merozoites. The number of Children are more likely to be gametocyte carriers than
merozoites produced from a single sporozoite varies adults. The child is thus epidemiologically a better reservoir
considerably with the infecting species. A single than the adult. Certain conditions must be met before a
P falciparum sporozoite may form as many as 40,000 person can serve as a reservoir: (i) the person must harbour
merozoites, whereas sporozoites from pther species of both the sexes of the gametocyte in his blood. If the person
plasmodia produce only 2,000 to 15,000 merozoites (10). In harbours only male or female gametocytes, further
the case of P falciparum, the intrahepatic schizonts rupture development cannot take place in the mosquito vector,
almost simultaneously and there is no persistent tissue phase (ii) the gametocytes must be mature; immature forms do not
(the so-called exo-erythrocytic phase). On the contrary, the undergo further development. It may take 2-4 days for the
intrahepatic schizonts of the other plasmodia do not burst all gametocytes to attain maturity after their appearance in the
at the same time. Some hepatic forms persist and remain blood, (iii) the gametocytes must be viable, i.e., if the patient
dormant in the hepatocytes for considerable periods before receives an antimalarial drug, the gametocytes lose their
they begin to grow and undergo pre-erythrocytic viability or infectivity to mosquitoes (iv) the gametocytes
schizogony, thus liberating merozoites into the blood stream must be present in sufficient density to infect mosquitoes.
causing relapses of these infections. P. vivax and P ovale The number of gametocytes necessary to infect mosquitoes is
may continue to relapse for 2 to 3 years and P malariae may not definitely known, but it is thought by some that there
persist for 10 to 20 years or more. Once the parasites must be at least 12 per cubic mm of blood.

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enter the RBC, they do not reinvade the liver.
(b) ERYTHROCYTIC PHASE: Many of the merozoites are (c) PERIOD OF COMMUNICABILITY
quickly destroyed, but a significant number attach to specific Malaria is communicable as long as mature, viable
receptor sites on the RBC. The merozoites then penetrate gametocytes exist in the circulating blood in sufficient
the RBC and pass through the stages of trophozoite and density to infect vector mosquitoes. In vivax infections,
schizont. The erythrocytic phase ends with the liberation of gametocytes appear in blood 4-5 days after the appearance
merozoites, which infect fresh red blood cells. The cycle is of the asexual parasites; in falciparum infections, they do
repeated over and over again until it is slowed down by the not appear until 10-12 days after the first appearance of
immune response of the host (11). The duration of the asexual parasites. Gametocytes are the most numerous
erythrocytic cycle is constant for each species of malaria during the early stages of the infection when their density
parasite - 48 hours for P falciparum, P vivax and P ovale; may exceed 1,000 per cubic mm of blood. They also tend to
and 72 hours for P malariae. (c) GAMETOGENY: In all occur in waves in peripheral blood.
species of malaria some erythrocytic forms do not divide but
RELAPSES: It is usual for vivax and ovale malaria to
become male and female gametocytes. These are the sexual
relapse more than 3 years after the patient’s first attack.
forms of the parasite which are infective to mosquito.
Recurrences of falciparum malaria usually disappear within
(ii) Sexual cycle: The mosquito cycle (sporogony) begins 1-2 years. P malariae has a tendency to cause prolonged
when gametocytes are ingested by the vector mosquito low-level, asymptomatic parasitaemia (13). The infection is
when feeding on an infected person. The gametocytes known to persist for 40 years or more. It is probable that
continue further development in the mosquito. The first persons harbouring such infections are at least occasionally
event to take place in the stomach of the mosquito is infective to mosquitoes.
exflagellation of the male gametocyte; 4-8 thread-like It is now considered more likely that vivax and ovale
filaments called “micro-gametes” are developed. The female relapses are derived from original, sporozoite-induced, liver
gametocyte undergoes a process of maturation and becomes schizonts which have lain latent long before bursting. In
a female gamete or “macrogamete”. By a process of P falciparum and P malariae infections latent liver schizonts
chemotaxis, microgametes are attracted towards the female do not appear to occur. Relapses in these species, most
gamete, and one of which (microgamete) causes fertilization authorities maintain, are due to a chronic blood infection,
of the female gamete. The resulting zygote is at first a i.e., erythrocytic schizogony persisting at a low level.
motionless body, but within 18-24 hours, it becomes motile.
This is known as Ookinete, which penetrates the stomach Host factors
wall of the mosquito and develops into an oocyst on the
outer surface of the stomach. The oocyst grows rapidly and The main variables of the human element that have an
develops within it numerous sporozoites. When mature, the influence on malaria epidemiology include the following :
oocyst bursts and liberates sporozoites into the body cavity (a) AGE : Malaria affects all ages. Newborn infants have
of mosquito. Many of the sporozoites migrate to the salivary considerable resistance to infection with P falciparum. This
glands of the mosquito, and the mosquito now becomes has been attributed to the high concentration of foetal
infective to man. The period of time required for the haemoglobin during the first few months of life, which
development of the parasite from the gametocyte to suppresses the development of P. falciparum (14). (b) SEX :
sporozoite stage in the body of the mosquito is about Males are more frequently exposed to the risk of acquiring

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304_ EPIDEMIOLOGY OF COMMUNICABLE DISEASES

malaria than females because of the outdoor life they lead. India, the maximum prevalence is from July to November,
Further, females in India are usually better clothed than (b) TEMPERATURE: Temperature affects the life cycle of the
males, (c) RACE : Individuals with AS haemoglobin (sickle­ malaria parasite. The optimum temperature for the
cell trait) have a milder illness with falciparum infection than development of the malaria parasite in the insect vector is
do those with normal (AA) haemoglobin (10). Persons between 20 deg. to 30 deg.C (68 deg. to 86 deg.F). The
whose red blood cells are “Duffy negative” (a genetic trait) parasite ceases to undergo development in the mosquito if
are resistant to P. vivax infection, (d) PREGNANCY : the mean temperature is below 16 deg.C (60.8 deg.F).
Pregnancy increases the risk of malaria in women. Malaria Temperatures higher than 30 deg.C are lethal to the
during pregnancy may cause intrauterine death of the parasite, (c) HUMIDITY: The atmospheric humidity has a
foetus; it may also cause premature labour or abortion. direct effect on the length of life of the mosquito, although it
Primigravid women are at greatest risk (15). (e) SOCIO­ has no effect on the parasite. A relative humidity of
ECONOMIC DEVELOPMENT : Malaria has demonstrated 60 per cent is considered necessary for mosquitoes to live
the relationship between health and socio-economic their normal span of life. When the relative humidity is high,
development. It is generally accepted that malaria has mosquitoes are more active and they feed more voraciously.
disappeared from most developed countries as a result of If the humidity is low, mosquitoes do not live long,
socio-economic development (15). (f) HOUSING: Housing (d) RAINFALL : Rain in general provides opportunities for
plays an important role in the epidemiology of malaria. The the breeding of mosquitoes and may give rise to epidemics
ill-ventilated and ill-lighted houses provide ideal indoor of malaria. Rain increases the atmospheric humidity which is
resting places for mosquitoes. Malaria is acquired in most necessary for the survival of mosquitoes. However, heavy
instances by mosquito-bites within the houses. The site, rain may have an adverse affect in flushing out the breeding
type of construction, nature of the walls, etc. influence the places. Paradoxically in some areas, (e.g., Sri Lanka) severe
selection of control measures (16). (g) POPULATION epidemics of malaria followed years of drought. It was
MOBILITY : People migrate for one reason or other from because, the lesser monsoon rains led to the formation of
one country to another or from one part of a country to small pools of water in river beds, which served as active
another. Labourers connected with various engineering, breeding places for malaria vectors. The relationship
irrigation, agricultural and other projects and periodic between rainfall (total and its distribution) and mosquito
migration of nomads and wandering tribes are outstanding breeding is of fundamental importance (17). (e) ALTITUDE:
examples of internal migration. Some of them may import As a rule, Anophelines are not found at altitudes above

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malaria parasites in their blood and reintroduce malaria into 2000-2500 metres, due to unfavourable climatic conditions,
areas where malaria has been controlled or eliminated. (f) MAN-MADE MALARIA: Burrow pits, garden pools,
Imported malaria has become quite a public health problem irrigation channels and engineering projects like
in Europe, North America, and other temperate parts of the construction of hydroelectric dams, roads, bridges have led
world, owing to the rising tide of air travel, tourism and to the breeding of mosquitoes and an increase in malaria.
migration (12). (h) OCCUPATION Malaria is Malaria consequent on such human undertakings is called
predominantly a rural disease and is closely related to “man-made malaria”.
agriculture practices, (i) HUMAN HABITS : Habits such as
sleeping out of doors, nomadism, refusal to accept spraying Vector of malaria
of houses, replastering of walls after spraying and not using Out of about 45 species of anopheline mosquitoes in India,
measures of personal protection (e.g. bed nets) influence only a few are regarded as the vectors of primary importance.
man-vector contact, and obviously the choice of control These are: An. culicifacies, An. fluuiatilis, An. stephensi,
measures, (j) IMMUNITY: The epidemic of malaria is An. minimus, An. philippinensis, An. sundaicus, and
influenced by the immune status of the population. An. maculatus. The vectors of major importance are
Immunity to malaria in humans is acquired only after An. culicifacies in rural areas and An. stephensi in urban areas.
repeated exposure over several years. Thus in endemic In the absence of a vaccine, vector control is the only
malarious areas a state of collective immunity becomes practical approach to malaria control. A knowledge of
established slowly, so that infants, young children, migrants anopheline biology is essential for understanding the
and travellers from non-endemic areas suffer most from the epidemiology of malaria and its prevention. The main
disease. Those, however, who survive to the adult age show factors which determine the vectorial importance of
less evidence of adverse effects to the attenuated infection. mosquitoes are: (a) DENSITY : To be an effective vector, a
Infants born of immune mothers are generally protected species must be present in adequate density in or near
during the first 3-5 months by maternal IgG antibody; human habitations. A sudden increase in density of vectors,
infants born of semi-immune mothers are only partially may be a cause of epidemic outbreaks. For each vector,
protected. Active immunity is species-specific, that is, there is what is known as “critical density” below which
immunity against one strain does not protect against effective transmission cannot be maintained in a community.
another. People living in endemic areas exposed continually This level varies with different species. In the case of An.
to malaria develop considerable degree of resistance to culicifacies a high density is required for the propagation of
clinical disease, but their partial immunity to malaria malaria; in the case of An. fluuiatilis which is very efficient
declines with time after they leave their endemic countries. vector, a much lower density would suffice, (b) LIFE SPAN:
Semi-immune individuals may harbour malaria parasites The key factor in the transmission of malaria is the life span
without presenting any symptoms of disease. Both humoral of the vector. The vector mosquito must live for at least
and cellular factors play a role in this protection (4). 10-12 days after an infective blood meal to become
infective. The strategy in malaria eradication is to shorten
Environmental factors the life span of mosquitoes to less than 10 days by
India’s geographic position and climatic conditions had insecticides, (c) CHOICE OF HOST : Some mosquitoes
been, for long, favourable to the transmission of malaria, prefer human blood, some animal blood, and some show
(a) SEASON : Malaria is a seasonal disease. In most parts of great variation in their feeding habits. The percentage of

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 MALARIA 305
human blood feeds in the case of An. culicifacies, an Clinical features
important vector in India, has been found to vary from The primary fever is marked by paroxysms which
2-80 per cent (10). In contrast, An. fluuiatilis is a highly correspond to the development of the parasites in the red
anthrophilic species. The anthrophilic species, i.e., those blood cells. The peaks of the fever coincide with the release
that have a high preference for human blood are better into the blood stream of successive broods of merozites.
vectors of malaria than zoophilic species, (d) RESTING
HABITS : After a blood meal, some mosquitoes rest indoors The typical attack comprises three distinct stages, i.e., the
on the walls for quite sometime. This behaviour pattern is cold stage, the hot stage and the sweating stage. These are
known as “endophily”. But there are some species which followed by an afebrile period in which the patient feels
rest outdoors (exophily). A knowledge of the resting habits greately relieved.
(which must be under constant surveillance) is the basis for COLD STAGE : The onset is with lassitude, headache,
organizing rational anti-adult measures. In fact, the concept nausea and chilly sensation followed in an hour or so by
of malaria eradication is based on endophilism (indoor rigors. The temperature rises rapidly to 39-41 °C. Headache
resting habits) of most malarial vectors, (e) BREEDING is often severe and commonly there is vomiting. In early part
HABITS: The breeding habits of mosquitoes vary of this stage, skin feels cold; later it becomes hot. Parasites
considerably. Some breed in moving water (An. fluuiatilis), are usually demonstrable in the blood. The pulse is rapid
some in brackish water (An. sundaicus) and some in wells, and may be weak. This stage lasts for 1/4-1 hour.
cisterns, fountains and overhead tanks (An. stephensi). A HOT STAGE : The patient feels burning hot and casts off
knowledge of the breeding habits is required for conducting his clothes. The skin is hot and dry to touch. Headache is
anti-larval operations, (f) TIME OF BITING : The majority intense but nausea commonly diminishes. The pulse is full
of Indian mosquitoes bite at night excepting the Aedes and respiration rapid. This stage lasts for 2 to 6 hours.
mosquitoes. Anophiline mosquitoes have nocturnal feeding
habits, between dusk and dawn, (g) VECTORIAL SWEATING STAGE : Fever comes down with profuse
CAPACITY : The term vectorial capacity refers to the sweating. The temperature drops rapidly to normal and skin
combined effect of the density of the vector population, its is cool and moist. The pulse rate becomes slower, patient feels
susceptibility to infection, life span and probability of relieved and often falls asleep. This stage lasts for 2-4 hours.
feeding on man. It is distinct from physiological capacity to The febrile paroxysms occur with definite intermittent
transmit infection, (h) RESISTANCE TO INSECTICIDES : A periodicity repeating every third or fourth day depending

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knowledge of the status of vector resistance to insecticides is upon the species of the parasite involved. The classical
also necessary. On this depends the choice of insecticides to 3 stages (cold, hot and sweating) may not always be
be used. When an insect vector is resistant to a given observed due to maturation of generations of parasite at
insecticide, alternative insecticides have to be used. different times. Periods of latency may last several weeks or
months (10, 21). The disease has a tendency to relapse and
Mode of transmission is characterized by enlargement of the spleen and secondary
(a) VECTOR TRANSMISSION: Malaria is transmitted by anaemia. Febrile herpes is common in all malarial patients.
the bite of certain species of infected, female, anopheline In patients with P. falciparum infection the primary fever
mosquitoes. A single infected vector, during her life time, in its first few days is usually irregular or even continuous
may infect several persons. The mosquito is not infective and then the classical 48 hours periodicity becomes
unless the sporozoites are present in its salivary glands, established or the fever may continue to be irregular and the
(b) DIRECT TRANSMISSION: Malaria may be induced hot and cold stages, so typical of other malarial infections
accidentally by hypodermic intramuscular and intravenous are less clearly separated from one another. In persons with
injections of blood or plasma, e.g., blood transfusion, poor immunity the paroxysms are associated with marked
malaria in drug addicts (18, 19). Blood transfusion poses a prostration. Headache, nausea and vomiting are usually
problem because the parasites keep their infective activity more severe, and there is greater tendency towards the
for at least 14 days in blood bottles stored at -4 deg. C (18). development of delirium, haemolytic jaundice and anaemia.
Persons who have lived in an endemic area (including those The mortality is much greater than in other forms of malaria.
who have been taking antimalarials prophylactically) and
anyone who has had malaria should not be accepted as With P vivax infection, symptoms are same but are
blood donor until 3 years afterwards (20). (c) CONGENITAL usually milder and more regularly divided into “hot” and
MALARIA: Congenital infection of the newborn from an “cold” stages than in P. falciparum infections.
infected mother may also occur, but it is comparatively rare. P. ovale infections differ little from that of P. vivax.
However, they tend to be milder than P. vivax and cease
Incubation period after a few paroxysms even if no treatment is given.
This is the length of time between the infective mosquito Clinically, P. malariae attacks resemble those of P. vivax
bite and the first appearance of clinical signs of which fever is but the cycle is of 72 hours instead of 48 hours. The
most common. This period is usually not less than 10 days. tendency for long-term relapses to occur is marked.
The duration of the incubation period varies with the The complications of P falciparum malaria are cerebral
species of the parasite, and in natural infections (in malaria, acute renal failure, liver damage, gastro-intestinal
mosquito-transmitted malaria) this is 12 (9-14) days for symptoms, dehydration, collapse, anaemia, blackwater fever
falciparum malaria, 14 (8-17) days for vivax malaria, 28 etc. The complications of P. vivax, P ovale and P. malariae
(18-40) days for quartan malaria and 17 (16-18) days for infections are anaemia, splenomegaly, enlargement of liver,
ovale malaria. With some strains of P. vivax, the incubation herpes, renal complications etc.
period may be delayed for as long as 9 months; this may
also occur with other species in persons who have been Diagnosis
taking suppressive antimalarial drugs (10). The diagnosis of malaria depends on demonstration of

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

the parasite in the blood. Suspicion of the diagnosis is sample of well-defined group of the population. Only the
aroused by epidemiological and clinical evidence. positive slides are included in the denominator (10).
(e) INFANT PARASITE RATE : It is defined as the percentage
1. Microscopy of infants below the age of one year showing malaria
Two types of blood films are useful in searching for and parasites in their blood films. It is regarded as the most
identification of malaria parasite. The “thin film” and the sensitive index of recent transmission of malaria in a locality.
“thick film”. It is recommended that both types of film be If the infant parasite rate is zero for 3 consecutive years in a
prepared on a single microscope glass slide. The thick film is locality, it is regarded as absence of malaria transmission
more reliable in searching for parasite, as large volume of even though, the Anopheline vectors responsible for previous
blood is examined under each microscope field. When transmission may remain, (f) PROPORTIONAL CASE RATE :
scanty, parasite may be found about 20 times more rapidly Since the morbidity rate is difficult to determine, except in
in thick slide than in thin slide. The thin slide is more conditions when the diagnosis and reporting of each case is
valuable for identifying the species of the parasite present. In carried to perfection, proportional case rate is used (10). It is
it they are seen more clearly. defined as the number of cases diagnosed as clinical malaria
for every 100 patients attending the hospitals and
The advantage of microscopy are : The sensitivity is high. dispensaries. This is a crude index because the cases are not
It is possible to detect malarial parasite at low densities. It related to their time/space distribution.
also helps to quantify the parasite load; It is possible to
distinguish the various species of malaria parasite and their ERADICATION ERA (current incidence levels)
different stages. During the eradication era, the microscopic diagnosis of
malaria cases became the main method of diagnosis. The
2. Serological test parameters used for the measurement of malaria were
The malarial fluorescent antibody test usually becomes mostly parasitological in nature; the commonly used
positive two weeks or more after primary infection, by which parameters were API, ABER, SPR and SFR. The same
time the infection may have been cured. A positive test is parameters are being used at the present time. These
therefore, not necessarily an indication of current infection. parameters are unlikely to reveal the true epidemiological
The test is of the greatest value in epidemiological studies picture, unless the case detection machinery is fully
and in determining whether a person has had malaria in the supervised and very efficient. The following parameters are

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past (22). in use at present:
a. Annual parasite incidence (API)
3. Rapid diagnostic test (RDT)
b. Annual blood examination rate (ABER)
Rapid Diagnostic Tests are based on the detection of
circulating parasite antigens with a simple dipstick format. c. Annual falciparum incidence (AFI)
Several types of RDTs are available. Some of them can only d. Slide positivity rate (SPR)
detect P. falciparum while others can detect other parasites e. Slide falciparum rate (SFR).
also. The latter kits are expensive and temperature sensitive.
RDTs are produced by different companies, so there may be a. Annual parasite incidence (API)
differences in the contents and in the manner in which the
API is given by the formula :
test is done. The users manual should always be read
properly to avoid false negative results (23) Confirmed cases during one year
API = —---------- ------------- -------------- ---------- X 1000
Population under surveillance
Measurement of malaria
API is a sophisticated measure of malaria incidence in a
PRE-ERADICATION ERA community. It is based on intensive active and passive
In the pre-eradication era, the magnitude of the malaria surveillance, and cases are confirmed by blood examination.
problem in a country used to be determined mostly from the Areas with API > 2 per 1000 population per year have been
reports of the clinically diagnosed malaria cases. The classified as high risk areas in India, and thereby eligible for
vector control.
classical malariometric measures are spleen rate, average
enlarged spleen, parasite rate etc. In a control programme, b. Annual blood examination rate (ABER)
the case detection machinery is weak. Therefore, the
classical malariometric measures may provide the needed ABER is given by the formula :
information, i.e. the trend of the disease. *Number of slides examined
(a) SPLEEN RATE : It is defined as the percentage of ABER = ------------ - -----—----------------- x 100
Population
children between 2 and 10 years of age showing enlargement
of spleen. Adults are excluded from spleen surveys, because ABER is an index of operational efficiency. The annual
causes other than malaria frequently operate in causing parasite incidence (API) depends upon the annual blood
splenic enlargement in them. The spleen rate is widely used collection and examination rates. A sufficient number of
for measuring the endemicity of malaria in a community. blood slides must be systematically obtained and examined
(b) AVERAGE ENLARGED SPLEEN : This is a further for malaria parasite to work out accurately annual parasite
refinement of spleen rate, denoting the average size of the incidence (API).
enlarged spleen (24). It is a useful malariometric index. At present, about 100 million fever cases are screened
(c) PARASITE RATE : It is defined as the percentage of every year in India. The aim is to screen 10 per cent of the
children between the ages 2 and 10 years showing malaria population even though the disease transmission is expected
parasites in their blood films, (d) PARASITE DENSITY to reduce. The surveillance system has not undergone any
INDEX : It indicates the average degree of parasitaemia in a change (6).

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 MALARIA 307
c. Annual falciparum incidence (c) Epidemic preparedness and early response
Since the emergence of P falciparum problem in India, (d) Supportive interventions
data are collected separately for total malaria cases and (1) Capacity building
P falciparum cases. (2) Behavioural change communication
(3) Intersectoral collaboration
d. Others
(4) Monitoring and Evaluation
The slide positivity rate and slide falciparum rate are (5) Operational research and applied field research.
useful parameters. They provide information on the trend of
malaria transmission. Early diagnosis and treatment of malaria aims at:
Slide positivity rate : slide positivity rate is the percentage (1) Complete cure;
of slides found positive for malarial parasite, irrespective of (2) Prevention of progression of uncomplicated malaria to
the type of species. severe disease;
Slide falciparum rate : It is the percentage of slides (3) Prevention of deaths;
positive for P falciparum parasite. (4) Interruption of transmission; and
(5) Minimizing risk of selection and spread of drug resistant
VECTOR INDICES malaria parasite.
A malaria survey is not complete unless it includes
investigations relating to the insect vector. Some of the GUIDELINES FOR DIAGNOSIS AND
important vector indices are: (a) HUMAN BLOOD INDEX : It TREATMENT OF MALARIA
is the proportion of freshly-fed female Anopheline IN INDIA-2013 (25, 26)
mosquitoes whose stomach contains human blood. It
indicates the degree of anthrophilism. (b) SPOROZOITE According to the revised drug policy 2013, there is no
RATE : It is the percentage of female anophelines with scope of presumptive treatment in malaria control. The
sporozoites in their salivary glands, (c) MOSQUITO recommended guidelines are as follows :
DENSITY: It is usually expressed as the number of mosquitoes
per man-hour-catch, (d) MAN-BITING RATE (Biting Treatment of Uncomplicated Malaria
density): It is defined as the average incidence of anopheline All fever cases diagnosed as malaria by microscopy or

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bites per day per person. It is determined by standardized RDT should promptly be given effective treatment.
vector catches on human bait (e) INOCULATION RATE : The
man-biting rate multiplied by the infective sporozoite rate is TREATMENT OF P. VIVAX CASES
called the inoculation rate. All these rates are employed in the Positive P vivax cases should be treated with chloroquine
quantitative assessment of malaria and in building up a in full therapeutic dose of 25 mg/kg divided over three days.
composite epidemiological picture of malaria. Vivax malaria relapses due to the presence of hypnozoites in
the liver. The relapse rate in vivax malaria in India is around
APPROACHES AND STRATEGIES OF 30%. For its prevention, primaquine may be given at a dose
MALARIA CONTROL of 0.25 mg/kg daily for 14 days under supervision.
Primaquine is contraindicated in G6PD deficient patients,
As the concept of control replaces that of eradication in infants and pregnant women. Caution should be exercised
many national programmes, a reordering of priorities in the before administering primaquine in areas known to have
selection of control methods must occur. These priorities and high prevalence of G6PD deficiency. Primaquine can lead to
approaches must be based on epidemiological haemolysis in G6PD deficiency. Patient should be advised to
considerations, adverse effects on health, economy, technical stop primaquine immediately if he develops symptoms like
feasibility, functional resources, human resources and dark coloured urine, yellow conjunctiva, bluish
community participation. Recently WHO stressed a number discolouration of lips, abdominal pain, nausea, vomiting etc.
of points relevant to future strategy of malaria control. The and should report to the doctor immediately.
main emphasis is on the need to base it on an epidemiological
approach. These aspects are discussed below. TREATMENT OF P FALCIPARUM CASES
APPROACHES TO MALARIA CONTROL Artemisinin Combination Therapy (ACT) (Artesunate
3 days + sulphadoxine-pyrimethamine 1 day) should be
Strategic Action Plan for malaria control in India, given to all confirmed P falciparum cases found positive by
2007-2012, 2012-2017 and more recently 2017-2022 were microscopy or RDT. This is to be accompanied by single
developed by Directorate of National Vector Borne Disease dose of primaquine (0.75 mg/kg body weight) on Day 2.
Control Programme.
However, considering the reports of resistance to SP drug in
The strategies for prevention and control of malaria and North Eastern states, the Technical Advisory Committee has
its transmission are (7) : recommended to use the coformulated tablet of Artemether
(a) Surveillance and case management (20 mg) + Lumefantrine (120 mg) as per age-specific dose
(1) Case detection (passive and active) schedule for the treatment of Pf cases in North Eastern states.
(2) Early diagnosis and complete treatment This drug is not recommended during the first trimester of
(3) Sentinel surveillance. pregnancy and for children weighing < 5 kg. Production and
sale of Artemisinin monotherapy has been banned in India, as
(b) Integrated vector management it can lead to development of parasite resistance to the drug.
(1) Indoor residual spray (IRS)
(2) Insecticide treated bed-nets (ITNs) and long lasting TREATMENT OF MALARIA IN PREGNANCY
insecticidal nets( (LLINs) ACT should be given for treatment of P. falciparum
(3) Antilarval measures including source reduction. malaria in second and third trimesters of pregnancy, while
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308 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

quinine is recommended in the first trimester. P vivax quinine with tetracycline/doxycycline. These instances should
malaria can be treated with chloroquine. Primaquine is be reported to concerned District Malaria/State Malaria
contraindicated in pregnant woman. Officer/ROHFW for initiation of therapeutic efficacy studies.
TREATMENT OF MIXED INFECTIONS Diagnosis and treatment of malaria (25, 26)
Mixed infections with P. falciparum should be treated as All fever cases diagnosed as malaria by either RDT or
falciparum malaria. microscopy should be promptly given effective treatment.
Resistance should be suspected if inspite of full treatment The medicines chosen will depend upon whether the patient
with no history of vomiting, diarrhoea, patient does not has vivax malaria or falciparum malaria. The flow charts in
respond within 72 hours, clinically and parasitologically. Such different settings for diagnosis and drug selection for the
cases not responding to ACT, should be treated with oral treatment of malaria are shown in Fig. 2, 3 and 4.

A. Where microscopy result is available within 24 hours

Suspected malaria case

______________________ 3K_____________________
Take slide and send for microscopic examination

-;
Result

————x——_ X
Positive for Positive for Positive for Negative
P. uivax P. falciparum mixed infection No anti-
Treat with: In North-Eastern states: Treat with In North-Eastern states: Treat with malarial
CQ 3 days + age-specific ACT-AL for 3 days + age-specific ACT-AL for 3 days + treatment

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PQ 0.25 mg PQ single dose on second day Primaquine 0.25 mg per kg body Treat as per
per kg body In other states: Treat with: ACT-SP for weight daily for 14 days. clinical
weight 3 days + PQ single dose on second In other states: SP-ACT 3 days + diagnosis
daily for day Primaquine 0.25 mg per kg body
14 days weight daily for 14 days.

ACT-AL - Artemisinin-based combination therapy - Artemether - Lumefantrine CQ - Chloroquine

ACT-SP - Artemisinin-based combination therapy (Artesunate + Sulfadoxine-Pyrimethamine) PQ - Primaquine

FIG. 2

B. Where microscopy result is not available within 24 hours and monovalent RDT is used

TfR = Test falciparum rate

Note : If a patient has severe symptoms at any stage, then immediately refer to a nearest PHC or other health facility with indoor patient
management or a registered medical doctor.

FIG. 3

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 MALARIA 3091
C. Where microscopy result is not available within 24 hours and bivalent RDT is used

Suspected malaria case

Do blood test with RDT

Note : (a) If a patient has severe symptoms at any stage, then immediately refer to a nearest PHC or other health facility with indoor patient
management or a registered medical doctor.
(b) PQ is contra-indicated in pregnancy and in children under 1 year (Infant).

FIG. 4

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Treatment of vivax malaria (25, 26) Treatment of falciparum malaria (25, 26)
Diagnosis of vivax malaria may be made by the used Diagnosis of falciparum malaria may be made by the use
of RDT (Bivalent) or microscopic examination of the of RDT (monovalent or bivalent) or microscopic
blood smear. On confirmation, following treatment is to be examination of the blood smear. It is imperative to start
given : the treatment for falciparum malaria immediately on
diagnosis. The treatment for falciparum malaria is as
Drug schedule for treatment ofP vivax malaria:
follows:
1. Chloroquine: 25 mg/kg body weight divided over
three days i.e. In other states (other than North-Eastern states):
10 mg/kg on day 1, 1. Artemisinin based combination therapy (ACT-SP)*
10 mg/kg on day 2 and Artesunate (AS), available as 50 mg tablets are given for
5 mg/kg on day 3. three days, and Sulfadoxine-Pyrimethamine (S-P)
2. Primaquine: 0.25 mg/kg body weight daily for 14 days. tablets, containing 500 mg Sulfadoxine and 25 mg
pyrimethamine are given for one day, as shown in the
Primaquine is contraindicated in infants, pregnant
dosage chart below.
women and individuals with G6PD deficiency.
All tablets for a day should be taken together, swallowed
14 day regimen of Primaquine should be given under
supervision. with water.
In addition, Primaquine (PQ large) tablets should be
Dosage chart for treatment of vivax malaria given on the second day.

Day 1 Day 2 Day 3 Day 4 Dose schedule for treatment of uncomplicated

to 14 P falciparum cases:
Age CQ PQ CQ PQ CQ PQ PQ
(150 (2.5 (150 (2.5 (150 (2.5 (2.5 mg) 1. Artemisinin based combination therapy (ACT-SP) *
mg mg) mg mg) mg mg) Artesunate 4 mg/kg body weight daily for 3 days, plus
base) base) base)
X/2 X/4
Sulfadoxine (25 mg/kg body weight) - Pyrimethamine
Less than 0 y2 0 0 0 (1.25 mg/kg body weight) on first day.
1 year
1-4 years 1 1 1 1 X/2 1 1 * ACT is not to be given in 1st trimester of pregnancy.
5-8 years 2 2 2 2 1 2 2 2. Primaquine * : 0.75 mg/kg body weight on day 2.
9-14 years 3 4 3 4 lX/2 4 4 With the introduction of different coloured blister packs
15 years 4 6 4 6 2 6 6 for different age groups, treatment by the field level staff
or more* has been made easy. The colour code for different age
Pregnancy 4 0 4 0 2 0 0 groups for packing of tablet ACT+SP has been given as
Note : CQ 250 mg tablet is having 150 mg base follows :
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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Dosage chart for treatment of falciparum malaria Primaquine (PQ) prevents transmission of falciparum
with ACT-SP malaria to others by its ability to kill gametocytes. PQ tablets
should be taken after a meal; not on an empty stomach.
Age group 1st day 2nd day 3rd day Children less than the age of one year and pregnant women
(Years) AS SP AS PQ AS should not be given primaquine. As pregnant women having
falciparum malaria require different medicines, they should
0-1* 1 1 1 Nil 1 be directed to go to the nearest PHC or hospital
Pink (25 mg) (250+ (25 mg) 25 (mg)
blister 12.5 mg) immediately, without delay.
1-4 1 1 1 1 1 Treatment of mixed infections
Yellow (50 mg) (500+25 (50 mg) (7.5 mg (50 mg)
blister mg each) base)
(P. vivax + P. falciparum) cases (25, 26)
5-8 1 1 1 2 1 All mixed infections should be treated with full course of
Green (100 mg) (750+37.5 (100 mg) (7.5 mg (100 mg) ACT and Primaquine 0.25 mg per kg body weight daily for
blister mg each) base each) 14 days.
9-14 1 2 1 4 1 In North-Eastern states: Treat with: Age-specific ACT-AL
Red (150 mg) (500+25 (150 mg) (7.5 mg (150 mg) for 3 days 4- Primaquine 0.25 mg per kg body weight daily
blister mg each) base each) for 14 days.
15 & above 1 2 1 6 1 In other states: ACT-SP 3 days + Primaquine 0.25 mg per
White (200 mg) (750+37.5 (200 mg) (7.5 mg (200 mg) kg body weight daily for 14 days.
blister mg each) base each)
* SP is not to be prescribed for children <5 months of age and Dosage chart for treatment of mixed
should be treated with alternate ACT (vivax and falciparum) malaria with ACT-SP
* ACT-AL is not to be prescribed for children weighing less than
5 kg. Age Day 1 Day 2 Day 3 Day
4-14
In North-Eastern states (NE states): AS SP PQ AS PQ AS PQ PQ
tablet tablet (2.5 tablet (2.5 tablet (2.5 (2.5
1. ACT-AL co-formulated tablet of Artemether (20 mg) -
(50 mg) mg) (50 mg) mg) (50 mg) mg)

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Lumefantrine (120 mg) mg)
Less than y2 y2 0 y2 0 y2 0 0
(Not recommended during the first trimester of 1 year
pregnancy and for children weighing <5 kg)
1-4 years 1 i 1 1 1 1 1 1
Recommended regimen by weight and age group
The packing size for different age groups 5-8 years 2 V/2 2 2 2 2 2 2
based on Kg body weight. 9-14 years 3 2 4 3 4 3 4 4
Co-formulated 5-14 kg 15-24 kg 25-34 kg >34 kg 15 years 4 3 6 4 6 4 6 6
tablet ACT-AL (>5 months (>3 to 8 (>9to 14 (> 14 years) or more
to <3 years) years) years)
Total dose of 20 mg/ 40 mg/ 60 mg/ 80 mg/ Treatment of R ovale and P. malariae
ACT-AL 120 mg 240 mg 360 mg 480 mg
twice daily twice daily twice daily twice daily In India these species are very rarely found in few places.
for 3 days for 3 days for 3 days for 3 days P ovale should be treated as P vivax and P malariae should
be treated as P falciparum.
Pack size
General recommendations for the management
No. of tablets 6 12 18 24 of uncomplicated malaria
in the packing
1. Avoid starting treatment on an empty stomach. The first
Give 1 tablet 2 tablets 3 tablets 4 tablets dose should be given under observation. Dose should be
twice daily twice daily twice daily twice daily
for 3 days
repeated if vomiting occurs within 15 minutes by
for 3 days for 3 days for 3 days
opening a new blister pack (discard what remains of old
Colour of Yellow Green Red White pack). If the patient vomits the first dose again, it is
the pack considered a severe case of malaria and refer the patient
immediately to the nearest Block PHC/CHC/Hospital.
2. Primaquine * : 0.75 mg/kg body weight on day 2 Special precaution should be taken in case of a child
under-5 years of age, and in pregnant woman.
Treatment of uncomplicated P falciparum cases in
pregnancy: 2. Explain to the patient or caretaker that : (a) if the
treatment is not completed as prescribed, the disease
1st trimester : Quinine salt 10 mg/kg 3 times daily for may manifest again with more serious features and more
7 days. difficult to treat; (b) to come back immediately, if there is
Quinine may induce hypoglycaemia; pregnant women no improvement after 24 hours, if the situation gets
should not start taking quinine on an empty stomach and worse or the fever comes back; and (c) that regular use
should eat regularly, while on quinine treatment. of a mosquito net (preferably insecticide treated net) is
2nd and 3rd trimester : Area-specific ACT as per dosage the best way to prevent malaria.
schedule given above i.e. ACT-AL in North-Eastern states, 3. Patient should also be examined for concomitant
ACT-SP in other states. illness.
by R△J
 MALARIA 311
Resistance to anti-malarial drugs Treatment of severe malaria
Resistance can be defined as either the ability of a
CLINICAL FEATURES (25)
parasite strain to survive and/or multiply despite the
administration and absorption of a drug given in doses Severe manifestations can develop in P. falciparum
equal to or higher than those usually recommended, but infection over a span of time as short as 12-24 hours and
within the limits of tolerance of the patient. may lead to death, if not treated promptly and adequately.
Severe malaria is characterized by one or more of the
Drug resistance is a complex phenomenon, where, by following features:
genetic mutation, a parasite acquires the ability to resist,
partly or fully, the effects of one or more anti-malarial drugs. (1) Impaired consciousness/coma
When the resistant parasites are exposed to the drug, they
(2) Repeated generalized convulsions
multiply selectively. If parasites are resistant to the drug
being used, the patient may not respond to treatment. One (3) Renal failure (Serum Creatinine >3 mg/dl)
of the commonest reasons for the development of drug (4) Jaundice (Serum Bilirubin >3 mg/dl)
resistance is that the parasites are exposed to insufficient (5) Severe anaemia (Hb <5 g/dl)
amount of the drug due to low prescription dosage, lesser (6) Pulmonary oedema/acute respiratory distress
amount of drug dispensed, incomplete treatment taken by syndrome
the patient, drug vomited out or low absorption of drug due
(7) Hypoglycaemia (Plasma glucose <40 mg/dl)
to any other reason e.g., diarrhoea, poorly stored drug, poor
quality drug when supplied or expiry date medicine. In such (8) Metabolic acidosis
cases, most of the sensitive parasites are killed by even these (9) Circulatory collapse/shock (Systolic BP<80 mm Hg,
small doses, but resistant parasites survive, multiply and < 50 mm Hg in children)
spread to other people by mosquitoes. The new patient then (10) Abnormal bleeding and disseminated intravascular
gets infection from the resistant malaria parasites and does coagulation.
not respond to the drug at all, or responds only partly. (11) Haemoglobinuria
Meanwhile, the earlier patient may appear cured because
most of the parasites were killed by the drug, and the (12) Hyperthermia (Temperature >106°F or 42°C)
(13) Hyperparasitaemia (<5% parasitized RBCs in low

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symptoms abated.
endemic and >10% in hyperendemic areas)
It should be kept in mind that the patient might have had
a fresh reinfection, or in the case of uivax malaria, there Foetal and maternal complications are more common in
might have been a relapse of malaria (25). pregnancy with severe malaria; therefore, they need prompt
attention.
Treatment failure (27)
Microscopic evidence may be negative for asexual
After treatment patient is considered cured if he/she does parasites in patients with severe infections due to
not have fever or parasitaemia till day 28th. Some patients sequestration and partial treatment. Efforts should be made
may not respond to treatment which may be due to drug to confirm these cases by RDT or repeat microscopy.
resistance or treatment failure, specially in falciparum However, if the symptoms clearly point to severe malaria
malaria. If patient does not respond and presents with and there is no alternative explanation, such a case should
following, he/she should be given alternative treatment. be treated accordingly.
Early treatment failure (ETF) : Development of danger Criteria for immediate referral are as follows:
signs or severe malaria on Day 1, 2 or 3, in the presence of (a) Persistence of fever after 24 hours of initial treatment;
parasitaemia; parasitaemia on Day 2 higher than on Day 0, (b) Continuous vomiting and inability to retain oral drug;
irrespective of axillary temperature; parasitaemia on Day 3 (c) Headache continues to increase; (d) Severe dehydration
with axillary temperature >37.5°C; and parasitaemia on (dry, parched skin, sunken eyes etc.); (e) Too weak to
Day 3, >25% of count on Day 0. walk in the absence of any other obvious reason;
Late clinical failure (LCF) : Development of danger signs (f) Change in sensorium e.g. confusion, drowsiness, blurring
or severe malaria in the presence of parasitaemia on any of vision, photophobia, disorientation; (g) Convulsion or
day between Day 4 and Day 28 in patients who did not muscle twitchings; (h) Bleeding and clotting disorder;
previously meet any of the criteria of early treatment failure; (i) Suspicion of severe anaemia; (j) Jaundice; and
and presence of parasitaemia on any day between Day 4 (k) Hypothermia (25).
and Day 28 with axillary temperature >37.5°C in patients Treatment of severe malaria cases (25)
who did not previously meet any of the criteria of early
treatment failure. Severe malaria is an emergency and treatment should be
given as per severity and associated complications which
Late parasitological failure (LPF) : Presence of can be best decided by the treating physicians. Before
parasitaemia on any day between Day 7 and Day 28 with admitting or referring patients, the attending doctor or
axillary temperature <37.5°C in patients who did not health worker, whoever is able to do it, should do RDT and
previously meet any of the criteria of early treatment failure take blood smear, give a parenteral dose of artemisinin
or late clinical failure. derivative or quinine in suspected cerebral malaria cases
Such cases of falciparum malaria should be given and send case sheet, details of treatment history and blood
alternative ACT or quinine with Doxycycline. Doxycycline is slide with patient. Parenteral artemisinin derivatives or
contraindicated in pregnancy, lactation and in children upto quinine should be used irrespective of chloroquine
8 years. Treatment failure with chloroquine in P. vivax resistance status of the area with one of the following
malaria is rare in India. options:
by R△J
312 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Chemotherapy of severe and complicated malaria

Initial parenteral treatment for at least 48 hours: Follow-up treatment, when patient can take oral
Choose one of the following four options medication following parenteral treatment
Quinine : 20 mg quinine salt/kg body weight on admission Quinine 10 mg/kg three times a day with: doxycycline
(IV infusion or divided IM injection) followed by maintenance 100 mg once a day OR clindamycin in pregnant
dose of 10 mg/kg 8 hourly; infusion rate should not exceed women and children under 8 years of age.
5 mg/kg per hour. Loading dose of 20 mg/kg should not - to complete 7 days of treatment.
be given, if the patient has already received quinine.
Artesunate: 2.4 mg/kg IV or IM given on admission Full oral course of area-specific ACT:
(time = 0), then at 12 h and 24 h, then once a day. In North-Eastern states: Age-specific ACT-AL for
3 days 4- PQ single dose on second day
OR
Artemether: 3.2 mg/kg bw IM given on admission In other states: Treat with: ACT-SP for 3 days +
then 1.6 mg/kg per day. PQ single dose on second day
OR
Arteether: 150 mg daily IM for 3 days in adults only
(not recommended for children).
Note : The parenteral treatment in severe malaria cases should be given for minimum of 24 hours once started (irrespective
of the patient's ability to tolerate oral medication earlier than 24 hours).
After parenteral artemisinin therapy, patients will receive a this is a rare toxic manifestation involving the CNS,
full course of area-specific oral ACT for 3 days. Those patients (b) Gastrointestinal : cramps, nausea and vomiting,
who received parenteral Quinine therapy should receive oral (c) Cardiovascular : This is probably the most serious toxic
Quinine 10 mg/kg body weight three times a day for 7 days manifestation which is to be carefully observed during the
(including the days when parenteral Quinine was administered) administration of the drug. Even the first dose may bring about
plus Doxycycline 3 mg/kg body weight once a day, or the warning sign of cyanosis. The surveillance worker/MPW
Clindamycin 10 mg/kg body weight 12-hourly for 7 days must carefully check for all possible toxic symptoms before he

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(Doxycycline is contraindicated in pregnant women and administers the daily dose of primaquine. In the case of
children under 8 years of age) or area-specific ACT as described. appearance of any of the toxic symptoms discussed above,
Note : primaquine treatment should be stopped immediately (29).
- Pregnant women with severe malaria in any trimester can Ch em oprophylaxis
be treated with artemisinin derivatives, which, in contrast
to quinine, do not risk aggravating hypoglycaemia. Chemoprophylaxis against malaria has, with the
- The parenteral treatment should be given for development of drug resistance, become unreliable. Experts
minimum of 24 hours. disagree on whether well-conducted prophylaxis gives an
- Once the patient can take oral therapy; give: additional benefit if effective treatment is readily available.
- Quinine 10 mg/kg three times a day with doxycycline However, experts feel that it can play a useful role in
100 mg once a day or clindamycin in pregnant women reducing the risk of fatal disease (30).
and children under 8 years of age, to complete 7 days Chemoprophylaxis is recommended for travellers from
of treatment, in patients started on parenteral quinine. non-endemic areas and, as a short term measure for
- Full course of ACT to patients started on artemisinin soldiers, police and labour forces serving in highly endemic
derivatives. areas. Chemoprophylaxis should be complemented by
- Use of mefloquine should be avoided in cerebral personal protection where feasible and by other methods of
malaria due to neuropsychiatric complications vector control (30).
associated with it. The recommendations for short-term chemoprophylaxis
Some don'ts in severe malaria case management (less than 6 weeks) are as follows (30) :
Do not use corticosteroids, do not give intravenous (1) Dosing schedules for the children should be based on
mannitol, do not use heparin as anticoagulant, do not body weight.
administer adrenaline or do not overhydrate. (2) Antimalarials that have to be taken daily (e.g.
Doxycycline) should be started the day before arrival in
Toxic hazards of drugs the risk area.
Chloroquine has few side-effects. Nausea, vomiting, (3) Weekly chloroquine should be started 1 week before arrival.
blurring of vision and headaches may occur, but they are mild (4) Weekly mefloquine should preferably be started
and transient. Cases of retinal damage have been reported but 2-3 weeks before departure, to achieve higher pre-travel
only in persons exposed to large cumulative doses over many blood level and to allow side-effects to be detected before
years. It is important to remember that chloroquine should not travel so that possible alternative can be considered.
be given on empty stomach. Despite reports of teratogenicity
(5) All prophylactic drugs should be taken with unfailing
in experimental animals, most authorities accept that
pyrimethamine can safely be taken alone during pregnancy regularity for the duration of the stay in the malaria risk
area, and should be continued for 4 weeks after the last
(28). The teratogenic effect of pyrimethamine in man is not
proved. In regard to primaquine, although in recommended possible exposure to infection, since parasites may still
emerge from the liver during this period.
doses, no serious toxic manifestations have been encountered
so far in India. It is useful to bear in mind the likely toxic The recommendations for the long-term
symptoms, which may be of three types : (a) Plasmocid types : chemoprophylaxis (more than 6 weeks) are as follows :
by R△J
 MALARIA

(1) The risk of serious side-effects associated with long-term TABLE 2

prohylactic use of chloroquine and proguanil is low. Drug regimens for prophylaxis of malaria
However, anyone who has taken 300 mg of chloroquine
Drugs Usual Adult dose
weekly for over five years and requires further amount
prophylaxis should be screened twice-yearly for early Generic name Common trade per tablet For prophylaxis
retinal changes. If daily dose of 100 mg chloroquine have names or capsule
been taken, screening should start after three years (30).
Chloroquine3 Aralen 100 or 300 mg (base) = 3
(2) Data indicate no increased risk of serious side-effects Avlochlor 150 mg tablets of 100 mg
with long-term use of mefloquine if the drug is tolerated Nivaquine (base) or 2 tablets of
in the short-term, as mefloquine does not accumulate Resochin 150 mg once a
during long-term intake. week, on the same
(3) Available data on long-term chemoprophylaxis with day each week
doxycycline is limited. OR
100 mg (base) = 1
Mefloquine is contraindicated in cases with history of tablet of 100 mg
convulsions, neuropsychiatric problems and cardiac conditions. daily for six days
per week
Chemoprophylaxis is still desirable for pregnant women
living in areas where transmission is very intense and leads to Proguanil6 Paludrine 100 mg 200 mg = 2 tablets
parasitaemias, causing low birth weight and anaemia, or to a once a day
high risk of life-threatening malaria attacks. However, the Mefloquine0 Lariam Eloquin 250 mg 250 mg = 1 tablet
choice of safe drugs is becoming increasingly narrow, and it Mephaquin once a week, on
may be necessary to replace chemoprophylaxis by prompt the same day
treatment of clinical episodes or periodic treatments during each week
pregnancy. While the choice of strategy should be guided by Doxycycline4 Vibramycin 100 mg 100 mg =1 capsule
the national malaria control policy, its implementation once a day
should normally be part of antenatal care (31).
a. Also available as suspension.
The recommended regimens for chemoprophylaxis are as b. Recommended only in association with chloroquine.

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given in Table 2. c. The use of the higher treatment dose regimen is recommended
for infections acquired in areas on the Thailand/Cambodia
and Thailand I Myanmar borders only.
ACTIVE INTERVENTION MEASURES d. There is relatively little experience with this drug, and
knowledge of its efficacy and toxicity is limited.
Neither chemotherapy nor chemoprophylaxis will be able
to reduce significantly the malaria prevalence or Source : (30)
transmission. It can be obtained only when proper anti­
mosquito measures are introduced. (a) Anti-adult measures
(i) Residual spraying : The discovery of DDT in 1940s
1. STRATIFICATION OF THE PROBLEM and followed by other insecticides revolutionized malaria
Malaria is a complex disease, and its distribution and control. The spraying of the indoor surfaces of houses with
intensity vary from place to place. Stratification of the residual insecticides (e.g., DDT, malathion, fenitrothion) is
problem has become an essential feature for the planning still the most effective measure to kill the adult mosquito. It
and development of a sound control strategy to maximize has been observed that discontinuation of spraying has very
the utilization of available resources. It can also provide often led to the resurgence of malaria. This implies that
guidelines as to which strategy could be most suited and spraying once applied may need to be continued for an
economical under the existing conditions. For details please indefinite period. If indoor spraying is to have any effect,
refer to chapter 7. then exhaustive coverage is needed. Indoor house spraying
reduces the longevity of the vector.
2. VECTOR CONTROL STRATEGIES Malathion and fenitrothion are organophosphate
Vector control is still one of the primary weapons to insecticides which are being used with increasing frequency
control malaria in endemic areas. The methods used are as for malaria control following the development of vector
shown in Table 3. resistance to DDT (33).
TABLE 3
Malaria vector control measures
Action For individual and family protection For community protection
Reduction of human-mosquito Insecticide-treated nets, repellents, Insecticide-treated nets
contact protective clothing, screening of houses zoo-prophylaxis
Destruction of adult Insecticide-treated nets, indoor residual spraying,
mosquitoes space spraying, ultra low-volume sprays
Destruction of mosquito larvae Peri-domestic sanitation Larviciding of water surfaces, intermittent irrigation,
sluicing, biological control
Source reduction Small-scale drainage Environmental sanitation, water management, drainage
Social participation Motivation for personal and Health education, community participation
family protection
Source : (32)

by R△J
31JL EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(ii) Space application : This is a major anti-epidemic strategy provides comprehensive technical guidance to
measure in mosquito-borne diseases. It involves the countries and development partners for the next 15 years,
application of pesticides in the form of fog or mist using emphasizing the importance of scaling up malaria responses
special equipment. The ultra-low-volume method of and moving towards elimination. It also highlights the urgent
pesticide dispersion by air or by ground equipment has need to increase investments across all interventions -
proved to be effective and economical. Outdoor space including preventive measures, diagnostic testing, treatment
sprays reduce vector population quickly. and disease surveillance - as well as in harnessing
(Hi) Individual protection : Man-vector contact can be innovation and expanding research. By adopting this
reduced by other preventive measures such as the use of strategy, WHO Member States have endorsed the bold
repellents, protective clothing, bed-nets (preferably vision of a world free of malaria and set the ambitious new
impregnated with safe, long-acting repellent insecticides), target of reducing the global malaria burden by 90% by
mosquito coils, screening of houses etc. The methods of 2030. They also agreed to strengthen health systems,
personal protection are of great value when properly address emerging multi-drug and insecticide resistance, and
employed. However, they have rarely been used on a large intensify national, cross-border and regional efforts to scale
scale because of cost. up malaria responses to protect everyone at risk. By taking
forward this strategy, countries will make a major
(b) Anti-larval measures contribution to implementing the post-2015 sustainable
development framework. A major scale-up of malaria
(i) Larvicides : During the first half of the 20th century,
responses will not only help countries reach the health-
anti-larval measures such as oiling the collections of standing
related targets for 2030, but will contribute to poverty
water or dusting them with paris green effectively controlled
reduction and other development goals (36).
malaria (but the measures were eclipsed at the end of World
War II). With the increase in insecticide resistance, the older The three pillars of Global Technical Strategy for malaria
methods of mosquito control have now become promising. 2016-2030, and the goals, milestones and targets are as
Some modern larvicides such as temephos which confer long follows (37):
effect with low toxicity are more widely used. However
larviciding must be repeated at frequent intervals and for this Pillars
reason it is a comparatively costly operation. Pillar 1 Ensure universal access to malaria prevention, diagnosis
and treatment

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(ii) Source reduction : Techniques to reduce mosquito
breeding sites (often called source reduction) which include Pillar 2 Accelerate efforts towards elimination and attainment of
malaria free status
drainage or filling, deepening or flushing, management of
Pillar 3 Transform malaria surveillance into a core intervention
water level, changing the salt content of water and intermittent
irrigation are among the classical methods of malaria control to Goals Milestones Targets
which attention is being paid again (34). Whenever
2020 2025 2030
practicable, measures for the improvement of the environment
by the permanent reduction of sources should be instituted. 1. Reduce malaria At least 40% At least 75% At least 90%
(Hi) Integrated control : In order to reduce too much mortality rates
dependance on residual insecticides, increasing emphasis is globally compared
with 2015
being put on “integrated” vector control methodology
2. Reduce malaria At least 40% At least 75% At least 90%
which includes bioenvironmental and personal protection case incidence
measure (35). This approach is important because there is globally compared
no single and simple method that would ensure control of with 2015
transmission. 3. Eliminate malaria At least At least At least
By mid 1995 all malaria endemic countries in the region from countries in 10 countries 20 countries 35 countries
which malaria was
had adopted the revised malaria control strategy to reduce
transmitted in 2015
morbidity and mortality and to reduce its area of 4. Prevent Re- Re- Re-
distribution, particularly of multidrug resistant malaria. The re-establishment establishment establishment establishment
use of stratification approach by the majority of anti-malaria of malaria in all prevented prevented prevented
programmes in the Region has led to more cost-effective countries that are
interventions. Vector resistance to insecticides has malaria-free
necessitated the use of more expensive pyrethroid, thereby
limiting the coverage. Malaria control added impetus as Malaria vaccines (3)
Roll Back Malaria initiative was launched by WHO, The RTS,S/AS01 vaccine is the first and currently the
UNICEF, UNDP and the World Bank in 1998. only malaria vaccine to be recommended for use by WHO. It
The launch of Roll Back Back Malaria (RBM) in 1998, the is a pre-erythrocytic recombinant protein vaccine. The
United Nations Millenium Declaration in 2000, the Abuja vaccine should be used for the prevention of P. falciparum
Declaration by African Heads of State in 2000 (part of the malaria in children living in region with moderate to high
African Summit on Roll Back Malaria), the World Health malaria transmission. Vaccine is provided in a 4 dose
Assembly in 2005, and the RBM global strategic plan 2005- schedule in children from 5 months of age. There should be
2015 have all contributed to the establishment of goals, a minimum interval of 4 weeks between doses, 3 doses as
indicators and targets for malaria control. primary schedule, with a fourth dose approximately 12-18
months after the 3rd dose to prolong the duration of
protection.
THE GLOBAL TECHNICAL STRATEGY
FOR MALARIA (2016-2030) The vaccine is currently produced as a 2-dose RTS,S
powder to be reconstituted with a 2-dose AS01 adjuvant
Adopted by the World Health Assembly in May 2015, the system suspension. After reconstitution the total volume is

by R△J
 LYMPHATIC FILARIASIS

1 ml (2 doses of 0.5 ml). No preservative is included in

either the RTS,S formulation or the AS01 adjuvant system. | LYMPHATIC FILARIASIS |
The vials should therefore be discarded at the end of the The term “lymphatic filariasis” covers infection with three
vaccination session, or within 6 hours after opening, closely related nematode worms - W. bancrofti, B. malayi and
whichever comes first. The reconstituted vaccine should be B. timori. All three infections are transmitted to man by the
administered by injection into the deltoid muscle in children bites of infective mosquitoes. All three parasites have basically
aged 5 months or older. The vaccine should be stored at similar life cycles in man-adult worms living in lymphatic
2-8°C. The shelf life of the RTS,S/AS01 vaccine is 3 years. vessels whilst their offspring, the microfilariae circulate in
A vaccine vial monitor is on the AS01 vial. peripheral blood and are available to infect mosquito vectors
National Malaria Control Progrmme when they come to feed (1). The disease manifestations range
from none to both acute and chronic manifestations such as
Please see chapter 7. lymphangitis, lymphadenitis, elephantiasis of genitals, legs
and arms or as a hypersensitivity state such as tropical
References pulmonary eosinophilia or as an atypical form such as filarial
1. WHO (2020), World Malaria Report, 2020. arthritis. Though not fatal, the disease is responsible for
2. WHO (2021), World Malaria Report, 2021. considerable suffering, deformity and disability.
3. WHO (2022), Weekly Epidemiological Record, No. 9, 4th March 2022.
4. WHO (2014), Fact Sheet Malaria, No. 94, March 2014. Problem statement
5. Govt, of India (2022), National Vector Borne Disease Control Filariasis is a global problem. It is a major social and
Programme, Dept, of Health and Family Welfare, New Delhi.
economic scourage in the tropics and subtropics of Africa,
6. Govt, of India (2014), Strategic Action Plan for Malaria Control in India
2012-2017, DGHS, Ministry of Health and Family Welfare, New Delhi. Asia, Western Pacific and parts of the Americas, affecting
7. National Malaria Control Strategy (1995), Malaria Research Centre, over 47 countries. More than 863 million people live in areas
22 Sham Nath Marg, New Delhi. where there is a risk of infection, of whom 120 million are
8. Govt, of India (2016), Operational Manual for Malaria Elimination in infected and in need of treatment, including 40 million people
India, Ministry of Health and Family Welfare, New Delhi. with overt disease. This includes 15 million people with
9. WHO (1980). Summary of Scientific Progress in the Field of Malaria lymphoedema and 25 million men with urogenital swelling
published during the last Five Years, MAP/80.1 VBC/80.2, WHO principally scrotal hydrocele. At least 36 million people

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Geneva. remain with these chronic disease manifestations (2, 3).
10. Youmans, G.P. et al (1980). The Biological and Clinical Basis of
Infectious Diseases, 2nd ed. Saunders. About 90 per cent of cases of lymphatic filariasis are
11. Bruce-Chwatt, LJ. (1980). Essential Malariology, William caused by infection with W. bancrofti', other related parasites
Heinemenn, London. that infect humans are Brugia malayi in South-East Asia and
12. Jawetze et.al, 2007, Medical Microbiology, 24th Ed, A Lange Medical B. timori in Indonesia.
Book.
13. Hall, A. P (1976) Brit. Med. J., 1: 323.
The formal goal of the global lymphatic filariasis
14. Pasrol, G. et al (1976) Lancet, 1,1269. programme is to eliminate the disease “as a public health
15. WHO (1986). Techn. Rept. Ser. 735. problem” and 2020 is the informal target date for
16. WHO (1979). Tech Rep. Ser. No. 640. interrupting transmission. The strategy to interrupt
17. WHO (1995), Tech. Rep. Ser., No. 857. transmission of the disease calls for mass administration of a
18. Lariviere, M. (1977). Children in the Tropics No. 106, p. 9. 2-drug regimen (ivermectin or DEC plus albendazole)
19. WHO (1984). Tec^n. Rep.Ser. No.712. administration as a single dose annually for 4-6 years.
20. WHO (1995), World Health, March-April, 1995. Since 2000, the global programme provided a cumulative
21. Council for International Organization of Medical Sciences (1973). total of nearly 6.7 billion treatments to at least 1 billion
Communicable Diseases, Provisional Nomenclature, CIOMS/WHO, people. It represents about 73 per cent of the 1.4 billion
Geneva. people at risk (2).
22. WHO (1986). The clinical Management of Acute Malaria, SEARO, SEA
Ser. No. 9. New Delhi. The current hypothesis is that reducing the prevalence of
23. Govt, of India (2009), Guidelines for Diagnosis and Treatment of microfilaraemia in humans to <1 per cent will stop
Malaria in India, NVBDCP Division, Ministry of Health and Family transmission. One provisional set of guidelines for stopping
Welfare, New Delhi. treatment would require > 5 annual rounds of MDA with
24. WHO (1961) Techn.Rep.Ser. No.205. coverage of > 65 per cent of the total population (4).
25. Govt, of India (2013), National Drug Policy on Malaria, Directorate of
NVBDCP, Ministry of Health and Family Welfare, New Delhi. INDIA
26. Malaria website (2019), Treatment of malaria.
27. Govt, of India (2011), Guidelines for Diagnosis and Treatment of Lymphatic filariasis is a public health problem in 8 states
Malaria in India, NVBDCR National Institute of Malaria Research, New of India. Heavily infected areas are found in Uttar Pradesh,
Delhi. Bihar, Jharkhand, Andhra Pradesh, Odisha, Telangana,
28. Editorial (1976). Lancet, 2:1005. Maharashtra and West Bengal (5).
29. Govt, of India (1977), Role of Medical Officer of PHC in Malaria An estimated 670 million people are at risk of lymphatic
Control, Ministry of Dept, of Family Welfare, Health and Family
Welfare, New Delhi. Mass Mailing Unit. filariasis infection in 272 endemic districts in 16 states and
30. WHO (2010), International Travel and Health. 4 UTs in India. Mapping was carried out using epidemiological
31. WHO (1993), Tech. Rep. Ser., No.839. data supplemented by data from filaria control units, filaria
32. WHO (2006), Tech. Rep. Ser. No. 936. clinics, and survey units under the national filaria control
33. WHO Bull (1985) 63 (2) 353. programme. Morbidity surveys of filaria cases in the
34. WHO (1991), World Health, Sept-Oct 1991. states/UTs revealed 4.94 lakh cases of lymphoedema and
35. WHO (1983). Techn. Rep.Ser. No.688. 1.48 lakh cases of hydrocele till Dec. 2020 (5). The
36. WHO (2015), Global Technical Strategy for Malaria 2016-2030. microfilaria survey reports received from 205 districts
37. WHO (2019), World Malaria Report, 2019. revealed microfilaria rate of about 0.45 per cent (6).
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316 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Mass drug administration (MDA) is being implemented in islands, Thailand and Vietnam, IV. bancrofti Mf are non­
India since year 2004. In 2007 India changed its strategy periodic (sub-periodic), being detectable throughout the
from delivery of DEC alone to delivery of DEC plus 24 hours with a slight peak during day or night. Sub-periodic
albendazole; since that time, the number of people treated B.malayi is found in parts of Malaysia and Indonesia.
with combination therapy has increased steadily. In 2014,
about 86 per cent people at risk were treated with LIFE CYCLE
combination drug (4). India has reduced the prevalence of Man is the definitive host and mosquito the intermediate
microfilaria to less than 1 per cent in 192 out of 250 host of Bancroftian and Brugian filariasis. The adult worms
implementation units. are usually found in the lymphatic system of man. The males
are about 40 mm long and the females 50 to 100 mm long.
Epidemiological determinants The females are viviparous. They give birth to as many as
Agent factors 50,000 Mf per day (8) which find their way into blood
circulation via the lymphatics. The life span of the Mf is not
There are at least 8 species of filarial parasites that are exactly known, probably up to a year or more. The adult
specific to man (7). These are shown in Table 1. The first worms may survive for 15 years or more (8). There is a case
three worms are responsible for lymphatic filariasis; and the on record of a woman, in whom live Mf were present
rest for “non-lymphatic filariasis”. The parasites causing 40 years after she left an endemic area (9).
non-lymphatic filariasis will not be described as they are not
found in India. Table 2 shows the differences between the The mosquito cycle begins when the Mf are picked up by
microfilariae (Mf) of W. bancrofti and B. malayi. the vector mosquito during feeding. The following stages of
development take place in the vector : (a) Exsheathing : The
TABLE 1 larva comes out of the sheath in which it is enclosed, within
Human filarial infections 1 to 2 hours of ingestion. This is known as exsheathing
Organism Vectors Disease produced which takes place in the stomach of the mosquito, (b) First
stage larva : After exsheathing, the larva is able to penetrate
1. Wuchereria bancrofti Culex Mosquitoes Lymphatic filariasis the stomach wall of the mosquito which it does in 6 to 12
2. Brugia malayi Mansonia —”— __ »t__ ___ft_
hours and migrate to the thoracic muscles where it grows
3. Brugia timori Anopheles —”— __n_____rt_
and develops into a sausage-shaped (short, thick) form.

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Mansonia —"— (c) Second stage larva : The larva moults and increases in
4. Onchocerca volvulus Simulum flies Subcutaneous; length (long, thick form) with the development of an
nodules; alimentary canal, but is relatively inactive, (d) Third stage
River blindness larva : There is a final moult to the third stage or infective
5 Loa loa Chrysops flies Recurrent, transient larva (long, thin form) which may be found in any part of
subcutaneous the insect. It is highly active or motile. When it migrates to
swellings the proboscis of the mosquito, it is ready to be transmitted to
6. T. perstans Culicoides Probably rarely any a new host, and the mosquito is said to be infective. Under
clinical illness optimum conditions of temperature and humidity, the
7. T. streptocerca Culicoides __ it__
duration of mosquito cycle (extrinsic incubation period) is
8. Mansonella ozzardi Culicoides __w_
between 10 and 14 days. In the human host, the infective
larvae develop into adult male and female worms.
' TABLE 2
Differences between Mf of IV. bancrofti and B. malayi RESERVOIR OF INFECTION
Mf. IV bancrofti Mf B. malayi Although filarial infections occur in animals, human
filariasis is not usually a zoonosis (sub-periodic B. malayi and
1 General appearance Graceful, sweeping Crinkled, secondary T. perstans are exceptions). Animal reservoirs of Brugia are
curves curves present in monkeys, cats and dogs (8); these animals are
2. Length 244 to 296 p 177 to 230 p believed to acquire their infections from man, and they are not
3. Fee cephalic As long as broad Nearly twice as long regarded as important sources of infection to man (1). There
space as broad
4 Excretory pore
is no evidence that W. bancrofti has animal reservoirs in India.
Not prominent Prominent
5. Caudal end Uniformly tapering Kinkled and two In humans the source of infection is a person with
to a delicate point, terminal nuclei circulating Mf in peripheral blood. In filarial disease (late
No terminal nuclei present obstructive stages) Mf are not found in the blood.
present
The minimum level of Mf which will permit infection of
6. Nuclear column Nuclei discrete Smudged
mosquitoes is not known. It was reported that a man with
PERIODICITY one Mf per 40 cu. mm of blood was infective to 2.6 per cent
of the mosquitoes which fed on him (10). On the other
The Mf of IV. bancrofti and B.malayi occurring in India hand, when mosquitoes were fed on carriers having as many
display a nocturnal periodicity, i.e., they appear in large as 80 or more Mf per 20 cu. mm of blood, the heavily
numbers at night and retreat from the blood stream during infected mosquitoes did not survive when a number of Mf
the day. This is a biological adaptation to the nocturnal began to reach maturity (11).
biting habits of the vector mosquitoes. The maximum
density of Mf in blood is reported between 10 pm and 2 am. Host factors
When the sleeping habits of the host are altered, a reversal Man is a natural host, (a) AGE: All ages are susceptible to
in periodicity has been observed. infection. In endemic areas, filarial infection has been found
In most parts of the world, Mf are nocturnally periodic but even in infants aged less than 6 months. Infection rates rise
in the South Pacific islands and in limited foci in the Nicobar with age up to the age of 20-30 years and then level off.
by R△J
 LYMPHATIC FILARIASIS 317
After a few years at this plateau level, Mf rates may decline Clinical manifestations
in middle and old age. Filarial disease appears only in a Only a small proportion of infected individuals exhibit
small percentage of infected individuals, commonly in the clinical signs. The disease manifestations can be divided into
age group over 10 years (12), although there may be two distinct clinical types : (a) lymphatic filariasis caused by
exceptions, (b) SEX : In most endemic areas the Mf rate is the parasite in the lymphatic system, and (b) occult filariasis
higher in men. (c) MIGRATION : The movement of caused by an immune hyper-responsiveness of the human
people from one place to another has led to the extension host (e.g., tropical pulmonary eosinophilia).
of filariasis into areas previously non-endemic.
(d) IMMUNITY : Man may develop resistance to infection 1. LYMPHATIC FILARIASIS
only after many years of exposure (8). The immunological
The following stages have been described (14);
basis of this resistance is not known (13). (e) SOCIAL
FACTORS : Lymphatic filariasis is often associated with (i) Asymptomatic amicrofiloraemia : In all endemic areas
urbanization, industrialization, migration of people, a proportion of population does not show Mf or clinical
illiteracy, poverty and poor sanitation. manifestations of the disease although they have the same
degree of exposure to infective larvae as those who become
Environmental factors infected. With presently available diagnostic procedures it is
not possible to determine whether persons in this group
(a) CLIMATE : Climate is an important factor in the
have detectable infections or whether they are free from
epidemiology of filariasis. It influences the breeding of
infection.
mosquitoes, their longevity and also determines the
development of the parasite in the insect vector. The (ii) Asymptomatic microfilaraemia : A considerable
maximum prevalence of Cu/ex quinquefasciatus (previously proportion of people are asymptomatic, although their blood
known as C. fatigans) was observed when the temperature is positive for Mf. They may remain without any symptoms
was between 22 to 38 deg. C and optimum longevity when for months - in some instances for years. They are an
the relative humidity was 70 per cent, (b) DRAINAGE: important source of infection in the community. These
Lymphatic filariasis is associated with bad drainage. The carriers are usually detected by night blood examination.
vectors breed profusely in polluted water, (c) TOWN (Hi) Stage of acute manifestations : In the first months and
PLANNING : Inadequate sewage disposal and lack of town years there are recurrent episodes of acute inflammation in
planning have aggravated the problem of filariasis in India lymph glands and vessels. The clinical manifestations
by increasing the facilities for the breeding of

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comprise filarial fever, lymphangitis, lymphadenitis,
C. quinquefasciatus (C. fatigans). The common breeding lymphoedema of the various parts of the body and of
places are cesspools, soakage pits, ill-maintained drains, epididymo-orchitis in the male.
septic tanks, open ditches, burrow pits, etc.
(iv) Stage of chronic obstructive lesions : The chronic
Vectors of lymphatic filariasis stage usually develops 10-15 years from the onset of the
first acute attack. This phase is due to fibrosis and
All three infections (W. bancrofti, B. malayi and B. timori) obstruction of lymphatic vessels causing permanent
are transmitted to man by the bites of infective mosquitoes. structural changes.
No less than 5 genera are involved in different areas of the
In chronic Bancroftian filariasis, the main clinical features
world - Culex, Anopheles and Aedes serve as vectors for
are hydrocele, elephantiasis and chyluria. Elephantiasis may
W. bancrofti; and Mansonia, Anopheles and Coquillettidia
affect the legs, scrotum, arms, penis, vulva and breasts,
serve as the vectors of the Brugia species.
usually in that order of decreasing frequency. The
The main vectors in India are : C. quinquefasciatus prevalence of chyluria is usually very low.
(C. fatigans) for Bancroftian filariasis, and Mansonia
The Brugian filariasis is generally similar to Bancroftian
(Mansonoides) mosquitoes (e.g., M. annulifers and
filariasis, but strangely the genitalia are rarely involved,
M. uniformis) for Brugian filariasis. The breeding of
except in areas where Brugian filariasis occurs together with
Mansonia mosquitoes is associated with certain aquatic
Bancroftian filariasis.
plants such as Pistia stratiotes. In the absence of these
plants, these mosquitoes cannot breed. Not all elephantiasis is caused by lymphatic filarial
infection. Even in endemic areas, a small proportion of
Mode of transmission cases may be due to other causes - i.e., due to obstructions
Filariasis is transmitted by the bite of infected vector following infections (such as tuberculosis), tumours, surgery
mosquitoes. The parasite is deposited near the site of or irradiation (14). In Ethiopia, endemic leg elephantiasis is
puncture. It passes through the punctured skin or may caused by silica in the iliac lymph glands (15).
penetrate the skin on its own and finally reach the lymphatic
system. The dynamics of transmission depends upon the 2. OCCULT FILARIASIS
man-mosquito contact (e.g., infective biting rate). The term occult or cryptic filariasis refers to filarial
infections in which the classical clinical manifestations are
Incubation period not present and Mf are not found in the blood. Occult
The time interval between inoculation of infective larvae filariasis is believed to result from a hypersensitivity reaction
and the first appearance of detectable Mf is known as “pre­ to filarial antigens derived from Mf. The best known example
patent period”. Direct information on the duration of the is tropical pulmonary eosinophilia.
prepatent period is lacking (14).
The time interval from invasion of infective larvae to the Lymphoedema management (16)
development of clinical manifestations is known as the The recommended management of lymphoedema in areas
“clinical incubation period”. This period, most commonly, is where lymphatic filariasis is endemic involves simple activities
8 to 16 months. This period may, however, be longer (14). that have demonstrated their effectiveness in significantly

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

improving the quality of life of patients. These activities include FILARIA SURVEY
providing early detection of lymphoedema, caring for the skin
by washing and drying the affected limb or area, preventing The size of the sample to be examined in a filaria survey
and treating entry lesions and providing lymph drainage by varies with the type of survey, whether it is a routine survey or
elevating the limb and exercising. These are the minimum survey for evaluation. The NICD (National Institute of
activities that need to be undertaken, and there is a standard Communicable Diseases, Delhi) standard is to examine
care beyond this that can be accessed where available. 5-7 per cent of the population for routine surveys, and at least
20 per cent for evaluation studies. The sample must be random,
Since the prevention and management of disability representative and cover all ages and both sexes. Statistical
caused by lymphatic filariasis is now viewed as public health advice should be obtained when surveys are being planned. A
issue, the guidelines for the first level care worker developed standardized schedule for conducting filaria surveys is given in
by WHO to manage acute dermato-lymphangio adenitis a WHO Expert Committee Report on Filariasis (17). A filaria
(ADLA) are as follows: survey comprises the following elements :
1. TREATMENT FOR UNCOMPLICATED ADLA 1. MASS BLOOD SURVEY
a. Give analgesic such as paracetamol (lg given 3-4 The definitive diagnosis of lymphatic filariasis depends
times a day); upon the demonstration of living parasites in the human
b. Give oral antibiotic such as amoxicillin (1.5g in body. This calls for a night blood survey.
3 divided doses or oral penicillin) for at least 8 days.
In case of allergy to penicillin, oral erythromycin (i) The thick film : The thick film made from capillary
(lg given 3 times a day) can be used; blood is still the most commonly used method for
epidemiological assessment. 20 cu. mm of blood is collected
c. Clean the limb with antiseptic;
by a deep finger prick between 8.30 pm and 12 mid-night. A
d. Check for any wounds, cuts, abscesses and interdigital thick smear is prepared on a glass slide, and the slide is dried
infection (especially between the toes). Clean with and serially numbered. The age, sex and other host factors
antiseptic, if any present. If local superficial skin are recorded on the survey card or register. On the next day
infection is found give antibiotic cream, apply or so, the blood films are dehaemoglobanized, stained, dried
antifungal cream if interdigital infection is present; and examined for Mf under low power. The usual technique
e. Give advice about prevention of chronic for enumeration of Mf on slides is to start at one end of the
lymphoedema caused by lymphatic filariasis; smear and work across to the other end, moving the slide

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f. Do not give antifilarial medicine. field by field till the smear is covered.
g. Home management includes drinking plenty of water,
(ii) Membrane filter concentration (MFC) methods : The
rest, elevation of the limb, wriggling the toes, cooling
most sensitive method currently available for detecting low-
the limb with cold water and washing the limb if the density microfilaraemia in the blood is by concentration
patient can do it; and
techniques. It requires collection of blood by venepuncture
h. Follow-up after 2 days at home. If situation does not and filtering large volumes of blood. Although MFC is the
improve, then refer the patient to physician. most sensitive method available, some very-low-density
2. MANAGEMENT OF SEVERE ADLA carriers will still not be detected (14).
a. Refer the patient to physician immediately to receive (Hi) DEC provocation test: Mf can be induced to appear
, recommended antibiotic treatment in blood in the daytime by administering diethylcarbamazine
(DEC) 100 mg orally. Mf begin to reach their peak within
- Intravenous benzylpenicillin (Penicillin G) 5 million 15 minutes and begin to decrease 2 hours later. The blood
units given 3 times a day or intramuscular procain may be examined one hour after administration of DEC.
benzylpenicillin 5 million units given 2 times/day
until fever subsides, then give oral 2. CLINICAL SURVEY
phenoxymethylpenicillin (penicillin V) 750 mg At the same time when blood is collected, the people are
(1.2 million units) to lg (1.6 million units) given examined for clinical manifestations of filariasis which
3 times/day. The minimum total treatment is atleast should be recorded in the suggested schedule.
for 8 days.
- In case of allergy to penicillin give IV erythromycin 3. SEROLOGICAL TESTS
lg 3 times/day until fever subsides, then give oral Serological tests to detect antibodies to Mf and adults
erythromycin lg given 3 times/day or give other using immunofluorescent and complement-fixing techniques
antibiotic according to local situation. cannot distinguish between past and present infection, and
b. Give analgesic / antipyretic such as paracetamol; heavy and light parasite loads in the human hosts (18).
Recent interest has focussed on the direct detection of
c. Do not give any antifilarial medicine.
parasite antigens in patient’s blood or urine (14).
Hydrocele management
4. XENODIAGNOSIS
In the management of hydrocele, the objective of any
lymphatic filariasis disability prevention programme should The mosquitoes are allowed to feed on the patient, and
be to increase access to hydrocelectomy. One of the first then dissected 2 weeks later (9). Where other techniques
activities of the programme should be to detect scrotal may fail, this may succeed in detecting low-density
swelling using an existing community survey (such as microfilaraemia.
enumeration of mass drug administration or other health
initiatives). Individuals with scrotal swelling should be 5. ENTOMOLOGICAL SURVEY
referred to a facililty for diagnosis, and if necessary for This comprises of general mosquito collection from houses,
surgery. dissection of female vector species for detection of

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 LYMPHATIC FILARIASIS

developmental forms of the parasite, a study of the extent and after meals. This amounts to a total of 72 mg of DEC per kg
type of breeding places and other bionomics of mosquitoes. of body weight as a full treatment. For Brugian filariasis,
The data are assembled, analyzed and the results are recommended doses range from 3 to 6 mg of DEC/kg body
expressed in terms of certain parameters (clinical, weight per day, up to a total dose of 36-72 mg DEC/kg body
parasitological and entomological) as described below. weight as a full treatment (14).
DEC is rapidly absorbed after oral administration,
ASSESSMENT OF FILARIA CONTROL reaching peak blood levels in 1-2 hours. It is also rapidly
PROGRAMMES excreted - the blood half-life is only 2-3 hours in alkaline
urine and about 10-20 hours in acid urine.
The effect of filariasis control can be assessed using clinical, DEC causes rapid disappearance of Mf from the
parasitological and entomological methods. These are : circulation. It is effective in killing M/The effect of the drug
1. CLINICAL PARAMETERS on the adult worm is uncertain. It has probably no effect on
the infective stage larvae.
The clinical parameters measured are the incidence of
acute manifestations (adeno-lymphangitis, epididymo- Toxic reactions :
orchitis, etc), and the prevalence of chronic manifestations DEC may produce severe side reactions. The reactions
(lymphoedema, elephantiasis, hydrocele, chyluria, etc). may be of two kinds : (a) those due to the drug itself, e.g.,
headache, nausea, vomiting, dizziness, etc, These reactions
2. PARASITOLOGICAL PARAMETERS are observed a few hours after the first dose of DEC and
These are : (a) MICROFILARIA RATE : It is the percentage generally do not last for more than 3 days, and (b) those
of persons showing Mf in their peripheral blood (20 cu. mm) which are allergic reactions due to destruction of microfilariae
in the sample population, one slide being taken from each and adult worms, e.g., fever, local inflammations around
person. Specify the species of the parasite, (b) FILARIAL dead worms, orchitis, lymphadenitis, transient lymphoedema
ENDEMICITY RATE : It is the percentage of persons and hydrocele. The local reactions tend to occur later in the
examined showing microfilariae in their blood, or disease course of treatment and to last longer. If the drug is given in
manifestation or both, (c) MICROFILARIAL DENSITY : It is spaced doses, systemic reactions are much less frequent and
the number of Mf per unit volume (20 cu. mm) of blood in less intense after the second dose and are rare after
samples from individual persons. It indicates the intensity of subsequent doses. These reactions disappear spontaneously

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infection, (d) AVERAGE INFESTATION RATE : It is the and interruption of treatment is not necessary.
average number of Mf per positive slide, each slide being
made from 20 cu.mm of blood. It indicates the prevalence of b. Filaria control in the community
microfilaraemia in the population. There are three reasons why filariasis never causes
explosive epidemics : (a) the parasite does not multiply in
3. ENTOMOLOGICAL PARAMETERS the insect vector, (b) the infective larvae do not multiply in
These comprise : (a) vector density per 10 man-hour the human host, and (c) the life cycle of the parasite is
catch (b) percentage of mosquitoes positive for all stages of relatively long, 15 years or more. These factors favour the
development (c) percentage of mosquitoes positive for success of control programme (14).
infective (stage III) larvae (d) the annual biting rate - for The administration of DEC can be carried out in various
assessment of transmission (e) types of larval breeding ways :
places, etc.
The above parameters help to measure the conditions (i) Preventive chemotherapy (2)
existing before and after control procedures began, and also Elimination of lymphatic filariasis is possible by stopping
to measure the progress of the control campaign against the spread of the infection. Large-scale treatment involves a
vectors from time to time. single dose of 2 medicines given annually to an entire at-risk
population in the following way: albendazole (400 mg)
CONTROL MEASURES together with either ivermectin (150-200 mcg/kg) or with
diethylcarbamazine citrate (DEC) (6 mg/kg). These medicines
The current strategy of filariasis control is based on : have a limited effect on adult parasites but effectively reduce
1. Chemotherapy the density of microfilariae in the bloodstream and prevent
2. Vector control the spread of parasites to mosquitoes. This recommended
large-scale treatment strategy is called preventive
Many years of experience with DEC chemotherapy has
chemotherapy when conducted annually for 4-6 years, and it
shown that, even after the full regimen of treatment, some
can interrupt the transmission cycle.
microfilariae still persist in the body. Due to this and other
reasons (e.g., toxic effects), it has not been possible to (ii) Selective treatment
prevent the spread of filariasis by the administration of DEC
alone. Chemotherapy must, therefore, be supplemented by DEC is given only to those who are Mf positive. It is
an effective vector control programme, if the disease generally accepted that selective treatment may be more
transmission has to be effectively prevented. suitable in areas of low endemicity than in highly endemic
areas.
1. Chemotherapy The strategy is based on detection and treatment of
human carriers and filaria cases. The recommended dose is
a Diethylcarbamazine 6 mg DEC per kg of body weight daily for 12 doses, to be
Diethylcarbamazine (DEC) is both safe and effective. The completed in 2 weeks (i.e., 6 days in a week). In endemic
dose of DEC that is most generally accepted for the areas, treatment must be repeated at specified intervals,
treatment of Bancroftian filariasis is 6 mg/kg body weight usually every 2 years. This is partly because, despite
per day orally for 12 days, given preferably in divided doses remarkable antimicrofilarial properties, expected microfilaria

by R△J
320 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

clearance with DEC is incomplete at times even after and is required to be diluted with water before use. The
adequate treatment. The other reason is that people living in emulsion is diluted in the ratio of 1:4, (c) Organophosphorus
endemic areas are exposed to reinfection. larvicides : During the past 10 years, organophosphorus
larvicides (e.g., temephos, fenthion) have been widely used
(Hi) DEC-medicated salt with successful results. However, the vector mosquito has
The use of DEC-medicated salt is a special form of mass developed resistance to many of these chemicals. The
treatment using very low doses of the drug over a long frequency of application is once weekly on all breeding places.
period of time. Common salt medicated with 1-4 g of DEC (2) REMOVAL OF PISTIA PLANT : In the case of
per kg has been used for filariasis control in some endemic Mansonia mosquitoes, breeding is best controlled by
areas of W. bancrofti and B. malayi, particularly after an removing the supporting aquatic vegetation such as the
initial reduction in prevalence has been achieved by mass or pistia plant from all water collections and converting the
selective treatment of Mf carriers. Treatment should be ponds to fish or lotus culture. Alternatively, certain
continued for at least 6 to 9 months. In the Lakshadweep herbicides such as phenoxylene 30 or Shell Weed Killer D
islands, this regimen has been shown to be safe, cheap and may be used for destroying the aquatic vegetation.
effective (14).
(3) MINOR ENVIRONMENTAL MEASURES : Larvicidal
The combination of the long life of the adult parasite for operations are complemented by minor engineering
several years and infectiousness of a patient with low operations such as filling up of ditches and cesspools,
parasitaemia represents a serious obstacle to control drainage of stagnant water, adequate maintenance of septic
programmes based on chemotherapy alone (19). tanks and soakage pits, etc. Environmental management is
the most efficient approach to the problem of controlling
c. Ivermectin mosquito breeding.
Ivermectin is a semisynthetic macrolide antibiotic with a
broad spectrum of activity against a variety of nematodes and II. Anti-adult measures
ectoparasites. The dose is 150-200 |xg/kg of body weight The vector mosquitoes of filariasis have become resistant
There is no drug toxicity in normal persons. However, in to DDT, HCH and dieldrin. The use of these compounds for
microfilaraemic patients there may be a variety of reactions indoor residual spraying, tried earlier, has been
as a result of inflammatory response triggered by the cleared discontinued. Pyrethrum, as a space spray, still holds
and dying microfilariae. promise. It is useful as a temporary means of personal

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protection, but has no practical value in present-day vector
2. Vector control control programmes.
Where mass treatment with DEC is impracticable, the III. Personal prophylaxis
control of filariasis must depend upon vector control. Vector
control may also be beneficial when used in conjunction The most effective preventive measure is avoidance of
with mass treatment. The most important element in vector mosquito bites (reduction of man-mosquito contact) by
control is the reduction of the target mosquito population in using mosquito nets. Screening of houses can substantially
order to stop or reduce transmission quickly. The techniques reduce transmission, but it is expensive.
for controlling mosquitoes are given in chapter 14. Briefly
Integrated vector control
they are :
None of the above vector control measures applied alone
I. Antilarval measures is likely to bring about sustained control of filariasis vectors.
The ideal method of vector control would be elimination An integrated or combined approach is needed to control
of breeding places by providing adequate sanitation and filariasis using all the above strategies and approaches in
underground waste-water disposal system. This involves optimum combination.
considerable expenditure amounting to several crores of In filariasis four major breakthroughs have occurred. The
rupees. Because of financial constraints, this may not be first of these is the development of safe, single dose, annual
feasible in developing countries such as India in the near drug treatment. Trials have proved that a single dose of DEC
future. For the time being, therefore, vector control must be is very effective even two years after treatment. A single
based on temporary or recurrent methods. dose of ivermectin has proved to be equally effective.
The current approach in India is to restrict the antilarval A combination of single dose of both drugs reduced
measures to urban areas, because it is operationally difficult microfilaraemia more than 95 per cent, 2 years after
and very costly to cover the vast rural areas of the country. treatment. Secondly, intensive local hygiene on the affected
The urban areas include an extra 3-km peripheral belt limb, with or without the use of antibiotic and antifungal
because the flight range of Culex quinquefasciatus creams, has shown to have dramatic effects by halting the
(C. fatigans) is about 3 km. progression of, or even reversing elephantiasis and
lymphoedema. Thirdly, DEC-medicated tablet or cooking
The anti-larval activities comprise the following (20). salt has been introduced in India. The carefully controlled
(1) CHEMICAL CONTROL : (a) Mosquito laruicidal oil: addition of very low concentration of DEC has long been
Mosquito larvicidal oil (MLO) is active against all preadult recognized as an effective means of eliminating lymphatic
stages. It has been the main chemical used to control filariasis infections in communities. However, the addition
C. quinquefasciatus for some time. Since it has proved to be increases the price of the salt. During 1994, the first
less efficient under field conditions and more expensive than commercially prepared DEC salt went on sale in India, at
other chemical preparations, it is being replaced by pyrethrum about twice the price of ordinary salt. Finally, there has been
oil, temephos and fenthion. (b) Pyrosene oil- E : This is a the development of insecticide sprays and polystyrene beads
pyrethrum-based emulsifiable larvicide. The emulsion to seal latrines and roof-top water-storage tanks, to eliminate
concentrate contains 0.1 to 0.2 per cent pyrethrins by weight or reduce populations of urban culex mosquitoes.

by R△J
 Z1KA VIRUS DISEASE

National Filaria Control Programme her baby during pregnancy or around the time of birth is
Please see chapter 7 for details. also now being seen as a distinct possibility.

Clinical picture
References
1. Lancet (1985), i: 1135.
The incubation period of Zika virus disease is not clear,
2. WHO (2018), Fact Sheet, 8th Oct., 2018. but is likely to be a few days. The symptoms are similar to
3. WHO (2019), Fact Sheet lymphatic filariasis, 6th Oct., 2019. other arbovirus infections such as dengue, and include fever,
4. WHO (2012), Weekly Epidemiological Record, No. 37, 14th Sept., skin rashes, conjunctivitis, muscle and joint pain, malaise,
2012. and headache. These symptoms are usually mild and last for
5. Govt, of India (2022), Annual Report 2021-2022, Ministry of Health 2-7 days. Only one out of four infected people develops
and Family Welfare, New Delhi. symptoms of the disease. Zika virus disease should be
6. Govt, of India (2016), Annual Report 2015-2016, Ministry of Health suspected in patients reporting with acute onset of fever,
and Family Welfare, New Delhi. maculo-papular rash and arthralgia, among those
7. Dissanaike, A.S. (1979). Bull WHO, 57 (3) 349. individuals who travelled to areas with ongoing transmission
8. Nelson, G.S. (1981). Medicine International, 2:77. during the two weeks preceding the onset of illness. Based
9. Carme, B. et al. (1979).Am. J. Trop. Med. Hyg., 28 : 53.
on the available information of previous outbreaks, severe
10. Hawking, F. (1962). Bull WHO, 27 :566.
forms of disease requiring hospitalization is uncommon and
11. Omri, N. (1962). Bull WHO, 27 : 586.
12. Raghavan, N.G.S. (1969). J. Com. Dis., 1 (2) 75-98.
fatalities are rare (1, 3).
13. Subramanyam, D. (1976). J. Com. Dis., 8 : 137-141. Diagnosis
14. WHO (1984). Techn. Rep. Ser., No.702.
15. Price, E.W. and Henderson, W.J. (1979). Trans. R. Soc. Trop. Med. Zika virus is diagnosed through PCR(polymerase chain
Hyg., 73:640-7. reaction) and virus isolation from blood samples. Diagnosis
16. WHO (2006), Weekly Epidemiological Record No. 40, 6th Oct 2006. by serology is not recommended.
17. WHO (1974). Techn. Rep. Ser., No.542.
18. Ottesen, E.A. (1984). Trans. R. Soc. Trop. Med. Hyg., 78 (Suppl) 9-18. Prevention
19. Tmeuse and McMahon, J.E. (1981). Trans. Roy. Soc. Trop. Med. Hyg., Aedes mosquitoes and their breeding sites pose a
75 :835.
20. Govt, of India (2008), Annual Report 2007-08, Ministry of Health and significant risk factor for Zika virus infection. Prevention and
Family Welfare, New Delhi. control relies on reducing mosquitoes through source

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reduction (removal and modification of breeding sites) and
reducing contact between mosquitoes and people.
ZIKA VIRUS DISEASE
Treatment
Zika virus is a mosquito-borne flavivirus that was first Zika virus disease is usually relatively mild and requires
identified in Uganda in 1947 through a network that no specific treatment. People sick with Zika virus should get
monitored yellow fever. The first large outbreak of disease plenty of rest, drink enough fluids, and treat pain and fever
caused by Zika infection was reported from Island of Yap in with paracetamol. If symptoms worsen, they should seek
2007. In July 2015, Brazil reported an association between medical care and advice. There is currently no vaccine
Zika virus infection and Guillain-Barre Syndrome. In available.
October 2015, Brazil reported an association between Zika NCDC, Delhi and National Institute of Virology (NIV),
virus infection and microcephaly (1). Pune, have the capacity to provide laboratory diagnosis of
Zika virus disease in acute febrile stage. These two
Problem statement institutions would be the apex laboratories to support the
Currently, WHO has reported 22 countries and territories outbreak investigation and for confirmation of laboratory
in Americas from where local transmission of Zika virus has diagnosis. Ten additional laboratories would be strengthened
been reported. Zika virus disease has the potential for by ICMR to expand the scope of laboratory diagnosis.
further international spread given the wide geographical RT-PCR test would remain the standard test. As of now there
distribution of the mosquito vector, a lack of immunity is no commercially available test for Zika virus disease (2).
among population in newly affected areas and the high
volume of international travel. As of now, the disease has References
not been reported in India. However, the mosquito that 1. WHO (2016), Weekly Epidemiological Record, No. 24, 17th June
transmits Zika virus, namely Aedes aegypti, that also 2016.
transmits dengue virus, is widely prevalent in India (1, 2). 2. Govt, of India (2016), Guidelines on Zika Virus Disease, 2nd Feb.
2016, Ministry of Health and Family Welfare, New Delhi.
3. WHO (2016), Fact sheet on Zika Virus Disease, Feb. 2016.
Agent factor
Zika virus disease is caused by Zika virus which belongs IV. ZOONOSES
to the genre Flavivirus. This virus is transmitted by the bite
from an infected mosquito hence also called arbovirus. The Zoonotic diseases have been known since antiquity.
reservoir of infection is not known (3). Bubonic plague and rabies were known since biblical times.
The discovery of causative agents during the “golden era” of
Mode of transmission microbiology called attention principally to diseases
Zika virus is transmitted through the bite of an infected exclusively pathogenic to man. Zoonotic diseases were
mosquito from the Aedes genus, mainly Aedes aegypti, overshadowed by diseases peculiar to man alone. Only as
which usually bite during the morning and late afternoon human infections came under better control was attention
hours. Transmission from an infected pregnant mother to drawn to zoonotic diseases.

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

More than 150 zoonoses have been recognized. In recent

years, several new zoonotic diseases have emerged e.g. RABIES
KFD, Monkey Pox etc., Quite apart from the morbidity and
mortality they cause, zoonoses are responsible for great Definition
economic losses, particularly in animals, meat, milk and Rabies, also known as hydrophobia is an acute, highly
other foods and products of animal origin. The developing fatal viral disease of the central nervous system, caused by
countries suffer much more severe losses than do the Lyssavirus type 1. It is primarily a zoonotic disease of warm­
industrialized countries, partly because they have less well- blooded animals, particularly carnivorous such as dogs,
developed public health and veterinary services and partly cats, jackals and wolves. It is transmitted to man usually by
because of their unfavourable climatic and environmental bites or licks of rabid animals. Classical hydrophobia is
conditions. clinically characterized by a long and variable incubation
Zoonoses and human health are matters of particular period, a short period of illness due to encephalomyelitis
concern in India - because nearly 68.86% of India’s ending in death, despite intensive care. It is the only
population is rural and live in close contact with domestic communicable disease of man that is always fatal.
animals, and often not far from wild ones.
Problem statement
Zoonoses have been defined as “Those diseases and
infections [the agents of] which are naturally transmitted (i) GEOGRAPHIC DISTRIBUTION
between [other] vertebrate animals and man.” G.S. Nelson Rabies is an enzootic and epizootic disease of worldwide
has pointed out that it is essential to discuss the direction of importance. Some countries have achieved “rabies free”
transmission, as it is of little value to know that a particular status by vigorous campaigns of elimination, while in others
organism is found in both man and animals. What one is the disease has never been introduced. Geographic
really concerned about is its relative significance of man and boundaries seem to play an important role here. Water
animals, as maintenance hosts of the particular infection. appears to be the most effective natural barrier to rabies.
The zoonoses have been classified in terms of their Australia, China (Taiwan), Cyprus, Iceland, Ireland, Japan,
reservoir hosts, whether these are men or lower vertebrate Malta, New Zealand, the U.K. and the islands of Western
animals. Thus, the term anthropo-zoonoses has been Pacific are all free of the disease. The Liberian peninsula and
applied to infections transmitted to man from lower Finland, Norway and Sweden are also rabies free (1). In
vertebrate animals. The term zooanthroponoses is applied India, Union Territory of Lakshadweep and Andman and

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to infections transmitted from man to lower vertebrate Nicobar islands are free of the disease (2). A “Rabies-free”
animals; however, these terms have also been used area has been defined as one in which no case of
interchangeably for all diseases found in both animals and indigenously acquired rabies has occurred in man or any
man. A third term, amphixenoses, has been used for animal species for 2 years (3). According to WHO reports, in
infections maintained in both man and lower vertebrate many countries rabies is spreading inspite of great advances
animals that may be transmitted in either direction. in research and field control methods.
A classification that is based upon the type of life cycle of Rabies occurs in more than 150 countries and territories.
the infecting organism and that divides the zoonoses into Although a number of carnivorous and bat species serve as
four categories, each with important shared epidemiologic natural reservoir, rabies in dogs is the source of 99 per cent
features, has considerable teaching value. of human infection, and posses a potential threat to more
than 3.3 billion people.
The four categories are :
In a number of countries, human deaths from rabies are
(1) Direct zoonoses are transmitted from an infected likely to be grossly underreported, particularly in the
vertebrate host to a susceptible vertebrate host by youngest age groups. Vast majority of the estimated 55,000
direct contact, by contact with a fomite, or by a deaths caused by rabies each year occur in rural areas of
mechanical vector. The agent itself undergoes little or Africa and Asia. In India alone, 20,000 deaths (that is, about
no propagative changes and no essential 2 per lac population at risk) are estimated to occur annually;
developmental change during transmission. Examples in Africa, the corresponding figure is 24,000 (about 4 per lac
are rabies, trichinosis, and brucellosis. population at risk) (4).
(2) Cyclo-zoonoses require more than one vertebrate
Although all age groups are susceptible, rabies is most
host species, but no invertebrate host, in order to
common in children aged less than 15 years; on an average,
complete the developmental cycle of the agent.
40 per cent of post-exposure immunization are given to
Examples are the human taeniases, echinococcosis,
children aged 5-14 years, and the majority of those
and pentastomida infections.
immunized are male. In the north-western part of the United
(3) Meta-zoonoses are transmitted biologically by Republic of Tanzania, the incidence of rabies was upto
invertebrate vectors. In the invertebrate, the agent 5 times higher in children aged less than 15 years than in
multiplies or develops, or both, and there is always an adults (4). At the global level, more than 15 million people
extrinsic incubation (prepatent) period before receive rabies prophylaxis annually, the majority of whom
transmission to another vertebrate host is possible. live in China and India. It is estimated that in the absence of
Examples are numerous and include arbovirus post-exposure prophylaxis, about 327,000 persons would
infections, plague, and schistosomiasis. die from rabies in Africa and Asia each year (4).
(4) Sapro-zoonoses have both a vertebrate host and a
non-animal developmental site or reservoir. Organic Epidemiological determinants
matter (including food), soil, and plants are
considered to be non-animal. Examples include the Agent factors
various forms of larva migrants and some of the AGENT : The causative agent (Lyssavirus type 1) is a
mycoses. bullet shaped neurotropic RNA containing virus. It belongs

by R△J
 RABIES

to the family rhabdoviridae - serotype 1 (Lyssavirus, type 1) Rarely, rabies may be contracted by inhalation of virus­
and is the causative agent of rabies. Serotype 2, 3 and 4 are containing aerosol or via transplantation of an infected
rabies-related but antigenically distinct viruses; they cause organ. Ingestion of raw meat or other tissues from animals
rabies like disease in man and animals (5). Available anti­ infected with rabies is not a source of human infection.
rabies vaccines may not be effective against the rabies-
related viruses (6). Incubation period
Rabies virus particles contain two distinct, major The incubation period in man is highly variable,
antigens : a glycoprotein (G protein) antigen from the virus commonly 1-3 months following exposure but may vary
membrane and an internal nucleoprotein antigen. The from 7 days to many years (4). The incubation period
glycoprotein seems to be the only antigen capable of depends on the site of the bite, severity of the bite, number
inducing the formation of virus-neutralizing antibodies (7). of wounds, amount of virus injected, species of the biting
The presence of neutralizing antibodies in the blood of man animal, protection provided by the clothing and treatment
and animals is considered an index of protection against undertaken, if any. In general, incubation period tends to be
infection with rabies virus (8). Recently, surface glycoprotein shorter in severe exposures and bites on face, head, neck
of rabies virus has been cloned and expressed in E. coli in a and upper extremities and bites by wild animals. In no other
bid to develop genetically engineered rabies vaccine. specific communicable disease is the incubation period so
variable and dependant on so many factors as in rabies.
The virus is excreted in the saliva of the affected animals.
The virus recovered from naturally occurring cases of rabies Pathogenesis
is called “street virus”. It is pathogenic for all mammals and
Rabies virus replicates in muscle or connective tissue cells
shows a long variable incubation period (20-60 days in
at or near the site of introduction before it attaches to nerve
dogs). Serial brain-to-brain passage of the street virus in
endings and enters peripheral nerves. It spreads from the
rabbits modifies the virus such that its incubation period is
site of infection centripetally via the peripheral nerves
progressively reduced until it becomes constant between
towards the central nervous system; most likely it “ascends”
4-6 days. Virus isolated at this stage is called a fixed virus.
passively through the nerve associated tissue space (7).
A “fixed” strain of virus may be defined as one that has a
Following infection of the central nervous system, the virus
short, fixed and reproducible incubation period (4-6 days)
spreads centrifugally in peripheral nerves to many tissues,
when injected intracerebrally into suitable animals. It does
including skeletal and myocardial muscle, adrenal glands
not form Negri bodies. It no longer multiplies in extra-neural
and skin. The salivary glands invasion is crucial for the

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tissues. The fixed virus is used in the preparation of
transmission of the virus to another animal or human (5).
antirabies vaccine. There is evidence that fixed virus can be
pathogenic for humans and mammals under certain
conditions, as for example parenteral injection of antirabies RABIES IN MAN
vaccine inadequately inactivated (7). Clinical picture
SOURCE OF INFECTION : The source of infection to Rabies in man is called hydrophobia. The disease begins
man is the saliva of rabid animals. In dogs and cats, the virus with prodromal symptoms such as headache, malaise, sore
may be present in the saliva for 3-4 days (occasionally 5-6 throat and slight fever lasting for 3-4 days. About 80% of
days) before the onset of clinical symptoms and during the patients complain of pain or tingling at the site of the bite.
course of illness till death (9, 10). This is the only prodromal symptom which is considered
Host factors reasonably specific (12).
All warm blooded animals including man are susceptible The prodromal stage is followed by widespread excitation
to rabies. Rabies in man is a dead-end infection, and has no and stimulation of all parts of nervous system usually
survival value for the virus. The overwhelming number of involving, in order, the sensory system, the motor system,
victims in India belong to the age group 1-24 years (2). the sympathetic and mental system. The patient is intolerant
Laboratory staff working with rabies virus, veterinarians, to noise, bright light or a cold draught of air (sensory).
dog handlers, hunters and field naturalists face bigger risks Aerophobia (fear of air) may be present and is considered
by some to be pathognomonic of rabies (13). It can be
of rabies than do general public.
elicited by fanning a current of air across the face which
Mode of transmission (11) causes violent spasms of the pharyngeal and neck muscles.
Examination may show increased reflexes and muscle
People are infected following a deep bite or scratch by an spasms (motor) along with dilatation of the pupils and
infected animal. Dogs are the main host and transmitter of increased perspiration, salivation and lachrimation
rabies. They are the source of infection in almost all the (sympathetic). Mental changes include fear of death, anger,
rabies deaths annually in Asia and Africa. irritability and depression.
Bats are the source of most human rabies deaths in the The symptoms are progressively aggravated and all
United States of America and Canada. Bat rabies has also attempts at swallowing liquid become unsuccessful. At later
recently emerged as a public health threat in Australia, Latin stage the mere sight or sound of water may provoke spasm
America and western Europe. However in these regions the of the muscles of deglutition. This characteristic symptom of
number of human deaths due to bat rabies remains small hydrophobia (fear of water) is pathognomonic of rabies and
compared to deaths following dog bites. Human deaths is absent in animals. The duration of illness is 2 to 3 days,
following exposure to foxes, raccoons, skunks, jackals, but may be prolonged to 5-6 days in exceptional cases. The
mongooses and other wild carnivore host species are very rare. patient may die abruptly during one of the convulsions or
Transmission can also occur when infectious material - may pass on to the stage of paralysis and coma. Intensive
usually saliva - comes into direct contact with human mucosa care may allow an occasional patient to survive (10).
or fresh skin wounds. Human-to-human transmission by bite To-date, only three people are on record who have been
is theoretically possible but has never been confirmed. stricken with rabies and have survived (1).

by R△J
324 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Diagnosis much virus as possible from the site of inoculation before it

can be absorbed on nerve endings. Local treatment of
A clinical diagnosis of hydrophobia can be made on the
wounds is of maximal value when applied immediately after
basis of history of bite by a rabid animal and characteristic
exposure (within minutes if possible) but it should not be
signs and symptoms. neglected if several hours or days have elapsed (3). Animal
Rabies can be confirmed in patients early in the illness by experiments have shown that local wound treatment can
antigen detection using immunofluorescence of skin biopsy, reduce the chances of developing rabies by upto 80% (6).
and by virus isolation from saliva and other secretions. The local treatment comprises the following measures :
Immunofluorescence of corneal impression smears has
(a) Cleansing : Immediate flushing and washing the
proved unreliable. Neutralizing antibodies are not usually
wound(s), scratches and the adjoining areas with plenty of
detectable in serum or CSF before the eighth day (5).
soap and water, preferably under a running tap, for at least
Treatment 15 minutes is of paramount importance in the prevention of
human rabies. If soap is not available, simple flushing of the
There is no specific treatment for rabies. Case wounds with plenty of water should be done as first-aid.
management includes the following procedure : In case of punctured wounds, catheters, should be used
(a) The patient should be isolated in a quiet room to irrigate the wounds. This procedure is now standard
protected as far as possible from external stimuli such as worldwide. It does minimize the risk of contracting rabies.
bright light, noise or cold draughts which may precipitate Unfortunately, very few patients get it in right time.
spasms or convulsions, (b) Relieve anxiety and pain by (b) Chemical treatment : Whatever residual virus
liberal use of sedatives. Morphia in doses of 30-45 mg may remains in the wound(s), after cleansing, should be
be given repeatedly. The drug is well tolerated and once the inactivated by irrigation with virucidal agents - either alcohol
diagnosis is established there appears to be no reason to (400-700 ml/litre), tincture or 0.01% aqueous solution of
restrict the administration of a drug which does so much to iodine or povidone iodine.
allay acute suffering, (c) If spastic muscular contractions are (c) Suturing : Bite wounds should not be immediately
present use drugs with curare-like action, (d) Ensure sutured to prevent additional trauma which may help spread
hydration and diuresis, (e) Intensive therapy in the form of the virus into deeper tissues. If suturing is necessary, it
respiratory and cardiac support may be given. should be done 24-48 hours later, applying minimum
Patients with rabies are potentially infectious because the possible stitches, under the cover of rabies immunoglobulin

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virus may be present in the saliva, vomits, tears, urine or locally.
other body fluids. Nursing personnel attending rabid (d) Antibiotics and anti-tetanus measure : The application
patients should be warned against possible risk of of antibiotics and antitetanus procedures when indicated
contamination and should wear face masks, gloves, goggles should follow the local treatment recommended above.
and aprons to protect themselves. Persons having bruises,
cuts or open wounds should not be entrusted to look after 3. Immunization
the patient. Where human cases of rabies are encountered Since their development more than four decades ago,
frequently pre-exposure prophylaxis is recommended.
concentrated and purified cell-culture vaccine (CCV) and
embryonated egg-based vaccine (EEV) have proved to be
PREVENTION OF HUMAN RABIES safe and effective in preventing rabies. These vaccines are
This may be considered under 3 heads. intended for pre-exposure as well as post-exposure
prophylaxis.
a. Post-exposure prophylaxis.
The internationally available cell-culture and
b. Pre-exposure prophylaxis. embryonated egg-based vaccines (CCEEVs) consist of rabies
c. Post-exposure treatment of persons who have been virus that has been propagated in cell substrates such as
vaccinated previously. human diploid cells (embryonic fibroblast cells), fetal rhesus
diploid cells, Vero cells (kidney cells from the African green
POST-EXPOSURE PROPHYLAXIS monkey), primary Syrian hamster kidney cells, primary
chick embryo cells or in embryonated duck eggs. The more
1. General consideration recently developed vaccines based on chick embryo cells
and Vero cells have safety and efficacy records comparable
The vast majority of persons requiring anti-rabies to those of the human diploid cell vaccines and are less
treatment are those who were bitten by a suspected rabid expensive (4).
animal. The aim of post-exposure prophylaxis is to
neutralize the inoculated virus before it can enter the Rabies vaccines prequalified by WHO do not contain
nervous system. Every instance of human exposure should preservatives such as thimerosal. The shelf-life of these
be treated as a medical emergency. It is now well established vaccines is > 3 years, provided they are stored at +2°C to
that irrespective of the class of wound, the combined +8°C and protected from sunlight. Following reconstitution
administration of a single dose of rabies immunoglobulin if with the accompanying sterile diluent, the vaccines should
indicated with a course of vaccine, together with local be used immediately, or within 6-8 hours if kept at the
treatment of the wound is the best specific prophylactic correct temperature.
treatment after exposure of man to rabies. All CCEEVs should comply with the WHO recommended
potency of > 2.5 IU per single intramuscular dose (0.5 ml or
2. Local treatment of wound 1.0 ml volume after reconstitution, depending on the type of
Prompt and adequate local treatment of all bite wounds vaccine).
and scratches is the first requisite and is of utmost The guidelines for the post-exposure treatment by the
importance. The purpose of local treatment is to remove as WHO are given in Table 1.

by R△J
 RABIES 29R

TABLE 1 Abbreviated multisite intramuscular regimen (2-1-1)

Categories of contact and recommended post-exposure Dose : one IM dose (1.0 or 0.5 ml) into deltoid (or thigh)
prophylaxis (PEP) Day 07 21
Sites X2 xi xi
Categories of contact with Post-exposure prophylaxis 4 vials
suspect rabid animal measures 3 visits
t3
Category I - touching or feeding None Rabies immunoglobulin
animals, licks on intact skin
Category II - nibbling of uncovered Immediate vaccination and An alternative for healthy, fully immunocompetent,
skin, minor scratches or abrasions local treatment of the wound
exposed people who receive wound care plus high quality
without bleeding
rabies immunoglobulin plus WHO prequalified rabies
Category III - single or multiple Immediate vaccination and vaccines, is a post-exposure regimen consisting of 4 doses
transdermal bites or scratches, administration of rabies
licks on broken skin; contamination immunoglobulin; local
administered intramuscularly on days 0, 3, 7 and 14.
of mucous membrane with saliva treatment of the wound
from licks, contacts with bats. Intradermal administration for post-exposure
prophylaxis
Source: (11)
The 2-site regimen prescribes injection of 0.1 ml at 2 sites
All category II and III exposures assessed as carrying (deltoid or thigh) on days 0, 3, 7 and 28. The day 14 dose is
a risk of developing rabies require PEP This risk is increased missed. This regimen may be used for people with category
if (ID: II and III exposures in countries where the intradermal route
has been endorsed by national health authorities. The
- the biting mammal is a known rabies reservoir or vector
regimen is as shown below:
species;
- the animal looks sick or has an abnormal behaviour; 2-site intradermal regimen (2 + 2 + 2 + 0 + 2)
- a wound or mucous membrane was contaminated by the Dose : one ID dose = one fifth of IM dose (0.1 ml) ID per site
animal's saliva; Day o 3 7 28

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Sites X2 X2 X2 X2
- the bite was unprovoked;
- the animal has not been vaccinated; and <2 vials
- if biting animal cannot be traced or identified. 4 visits
Rabies immunoglobulin
In developing countries, the vaccination status of the
suspected animal alone should not be considered when
deciding whether to initiate prophylaxis or not. Post-exposure prophylaxis for previously vaccinated
individuals
Post-exposure prophylaxis may be discontinued if the
suspected animal is proved by appropriate laboratory For rabies-exposed patients who can document previous
examination to be free of rabies or, in the case of domestic complete pre-exposure vaccination or complete post­
dogs, cats or ferrets, the animal remains healthy throughout exposure prophylaxis with a CCEEV, 1 dose delivered
a 10 day observation period starting from the date of the intramuscularly or a CVV delivered intradermally on days
bite (4). 0 and 3 is sufficient. Rabies immunoglobulin is not indicated
in such cases. This 1-site 2-day intradermal or intramuscular
Intramuscular administration of vaccine for regimen also applies to people vaccinated against rabies who
post-exposure prophylaxis have demonstrated rabies-virus neutralizing antibody titres of
>0.5 IU/ml. As an alternative to this regimen, the patient may
The post-exposure vaccination schedule is based on be offered a single-visit 4-site intradermal regimen consisting
injecting 1 ml or 0.5 ml (the volume depends on the type of of 4 injections of 0.1 ml equally distributed over left and right
vaccine) into the deltoid muscle (or anterolateral thigh in deltoids or thighs. Vaccination cards recording previous
children aged <2 years) of patients with category II and III immunizations are invaluable for making correct decisions.
exposures. The recommended regimen consists of either a
5-dose or a 4-dose schedule: Immunization of immunocompromised individuals
(i) Essen regimen: the 5-dose regimen prescribes 1 dose on In immunocompromised individuals including patients
each of days 0, 3, 7, 14, and 28; as shown below with H1V/AIDS, a complete series of 5 doses of
intramuscular CCEEV in combination with comprehensive
wound management and local infiltration with human rabies
Dose : one IM dose (1.0 or 0.5 ml) into deltoid (or thigh) immunoglobulin is required for patients with category II and
0 3 7 14 28 III exposures. When feasible, the rabies-virus neutralizing

J. LJ
1 '3 3 5 vials
5 visits
antibody response should be determined 2-4 weeks
following vaccination to assess the possible need for an
additional dose of the vaccine.
Rabies immunoglobulin
Rabies immunoglobulin for passive immunization
(ii) Zareb regimen: the 4-dose abbreviated multisite regimen Rabies immunoglobulin for passive immunization is
prescribes 2 doses on day 0 (1 in each of the 2 deltoid or administered only once, preferably at, or as soon as possible
thigh sites) followed by 1 dose on each of days 7 and 21, after, the initiation of post-exposure vaccination. Beyond the
as shown below^ seventh day after the first dose, rabies immunoglobulin is
by R△J
326 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

not indicated because an active antibody response to the administration of a booster. Mild systemic adverse events
CCEEV is presumed to have occurred. The dose of human following immunization (AEFI), such as transient fever,
rabies immunoglobulin is 20 IU/kg body weight; for equine headache, dizziness and gastrointestinal symptoms, have
immunoglobulin and F (ab')2 products, it is 40 IU/kg body been observed in 5-15% of vaccinees.
weight. All of the rabies immunoglobulin, or as much as
anatomically possible (but avoiding possible compartment Contraindications and precautions (4)
syndrome), should be administered into or around the For pre-exposure prophylaxis, previous severe reaction to
wound site or sites. The remaining immunoglobulin, if any, any components of the vaccine is a contraindication to
should be injected intramuscularly at a site distant from the further use of the same vaccine. Because rabies is a lethal
site of vaccine administration. Rabies immunoglobulin may disease, no contraindications exist to post-exposure
be diluted to a volume sufficient for all wounds to be prophylaxis following high-risk exposure. This is also the
effectively and safely infiltrated. case for post-exposure prophylaxis during infancy or
Most of the new equine immunoglobulin preparations are pregnancy, and for immunocompromised individuals,
potent, highly purified, safe and considerably less expensive including children with HIV/AIDS. People taking
than human rabies immunoglobulin. However they are of chloroquine for malaria treatment or prophylaxis may have
heterologous origin and carry a small risk of anaphylactic a reduced response to intradermal rabies vaccination. These
reaction (1/45,000 cases). There are no scientific grounds patients should receive the vaccine intramuscularly.
for performing a skin test prior to administering equine
immunoglobulin because testing does not predict reactions, NERVOUS TISSUE VACCINES
and it should be given whatever the result of the test. The Nervous tissue vaccines are crude products capable of
treating physician should be prepared to manage causing severe and even fatal reactions. Although
anaphylaxis which, although rare, could occur during any apparently effective, they are generally of low or variable
stage of administration (14). potency and are usually administered to exposed subjects in
a large number of doses. The current trend is to limit or
Guide for pre-exposure prophylaxis (PrEP) (14) abandon completely the production of nervous tissue
PrEP may be performed with any of the modern cell- vaccines and replace them by safer and more effective
derived vaccines and is recommended for anyone at inactivated cell-culture vaccines in both developed and

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increased risk of exposure to rabies virus. Traditionally, PrEP developing countries. Government of India has stopped
is recommended for anyone who is at continual, frequent or producing nervous tissue vaccine since 2004.
increased risk of exposure to the rabies virus either as a
result of their residence or occupation (for example RABIES IN DOGS
laboratory workers dealing with rabies virus and other
lyssaviruses, veterinarians and animal handlers). Travellers In developing countries over 90% of human deaths from
with extensive outdoor exposure and children living in rural rabies are caused by dog bites and dog rabies control is the
high-risk areas are at particular risk. key that can lock the door against human rabies.
PrEP schedule requires intramuscular doses of 1ml or INCUBATION PERIOD
0.5 ml, depending on the vaccine type, or intradermal The incubation period in dogs ranges from 3-8 weeks,
administration of 0.1 ml volume per site (one site each day) but it may be as short as 10 days or as long as a year or
given on days 0, 7 and 21 or 28. To lead to significant more (15).
savings, intradermal PrEP sessions should involve enough
individuals to utilize all opened vials within 6-8 hours. CLINICAL PICTURE
Booster doses of rabies vaccines are not required for Rabies in dogs may manifest itself in two forms - Furious
individuals living in or travelling to high-risk areas who have rabies and Dumb rabies.
received a complete primary series of pre-exposure or post­
exposure prophylaxis with a CCV. Periodic booster injections (a) Furious rabies : This is the typical “mad-dog
are recommended as an extra precaution only for people syndrome”, characterized by (i) a change in behaviour : In
whose occupation puts them at continual or frequent risk of animals, the cardinal sign is a change in behaviour. The
exposure. If available, antibody monitoring of personnel at animal loses its fear of people, becomes very aggressive,
risk is preferred to the administration of routine boosters. bites without provocation and bites unusual objects like
For people who are potentially at risk of laboratory exposure sticks, straw and mud (it) running amuck: i.e., tendency to
to high concentrations of live rabies virus, antibody testing run away from home and wander aimlessly and biting
should be done every 6 months. Those professionals who humans and animals who may come in its way (Hi) change
are not at continual risk of exposure through their activities, in voice : i.e., the dog barks or growls in a hoarse voice or
such as certain categories of veterinarians and animal health often unable to bark because of paralysis of laryngeal
officers, should have serological monitoring every 2 years. muscles (iv) excessive salivation and foaming at the angle of
Because vaccine-induced immunity persists in most cases for the mouth, and (v) Paralytic stage : The animal enters into a
years, a booster would be recommended only if rabies virus paralytic stage, towards the later stages of illness. There is
neutralizing antibody titres fall to <0.5 IU/ml. paralysis of the whole body leading to coma and death.
(b) Dumb rabies : In this type, the excitative or irritative
Adverse events following immunization (4) stage is lacking. The disease is predominantly paralytic. The
In general, CCEEVs have been shown to be safe and well dog withdraws itself from being seen or disturbed. It lapses
tolerated. However, in 35-45% of vaccinees, minor and in to a stage of sleepiness and dies in about 3 days.
transient erythema, pain and/or swelling may occur at the Once the symptoms of rabies develop in an animal, it
site of injection, particularly following intradermal rarely survives more than a week (16).
by R△J
 RABIES 327
LABORATORY DIAGNOSIS and ownerless dogs combined with a programme of swift
The head of the animal is cut off and sent to the nearest mass immunization, in the shortest possible time, of at least
testing laboratory, duly packed in ice in an airtight 80% of the entire dog population of the area.
container. Alternatively, the brain may be removed with Other methods include (i) registration and licensing of all
anti-septic precautions and sent in 50% glycerol-saline for domestic dogs (ii) restraint of dogs in public places
examination (17). This should be done by a qualified or (iii) immediate destruction of dogs and cats bitten by rabid
trained person soon after the death of the animal. animals (iv) quarantine for about 6 months of imported dogs
and (v) health education of people regarding the care of
Laboratory examination is made by : (a) FLUORESCENT
dogs and prevention of rabies.
ANTIBODY TEST : This is a highly reliable and the best
single test currently available for the rapid diagnosis of The discovery that foxes could be immunized against
rabies viral antigen in infected specimens. This test can rabies by placing modified live virus vaccine directly into the
establish a highly specific diagnosis within a few hours (3). mouths has generated a new control technique. So far no
The accuracy of the test is considered equal to that of suitable oral bait is developed for use in dogs (1).
isolation of the virus by animal inoculation. If the brain is
negative by FRA test, one can assume that the saliva Oral vaccines
contains no virus, and the bitten person need not be treated. The successful introduction of oral vaccines for the
Further, fluorescent antibody titres in clinical rabies have immunization of foxes is a great advancement in the rabies
been well in excess of 1:10,000 a feature which helps to prophylaxis of wild life. An attempted live rabies vaccine
distinguish between rabies and vaccine reaction (18). harmless but immunizing to foxes, is placed in baits and
(b) MICROSCOPIC EXAMINATION : Although FRA test has distributed over the foxes habitat. Successful control of wild
largely supplanted other methods of diagnosis, the animal’s rabies particularly foxes has been achieved in
microscopic examination of brain tissue for Negri bodies is Canada, Germany and Switzerland by the use of “oral
still a useful method for rapid diagnosis of rabies. The vaccine baits.” The technique holds much promise for the
microscopic examination for Negri bodies identifies 75-90% future control of rabies not only in foxes but also in other wild
of cases of rabies in dogs, (c) MOUSE INOCULATION life species.
TEST : Intracerebral mouse inoculation is still one of the
References

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most useful tests in the laboratory diagnosis of rabies.
Suckling mice are generally more sensitive for virus 1. Debbie, J.G. (1988). W.H. forum, 9 (4) 536.
isolation. A 10% emulsion of suspected brain tissue is 2. Sehgal and R. Bhatia (1985) Rabies : Current Status and Proposed
prepared in normal saline and centrifuged at 2000 rpm for Control Programmes in India, NICD, Delhi.
5-10 minutes. 0.03 ml of the supernatant fluid is injected 3. WHO (1984). Techn. Rep. Ser. No.709.
intracerebrally using a tuberculin syringe into at least 4 mice. 4. WHO (2010), Weekly Epidemiological Record, No. 32, 6th Aug., 2010.
If infected they show signs of rabies between 6-8 days. The 5. Warrell, D.A., andM.J. Warell (1988) Medicine International53:2194
virus can be identified by the FRA test or by the presence of May 1988.
Negri bodies, (d) CORNEAL TEST : Rabies virus antigen 6. Molyneux M.E. (1985) Medicine Digest 11 (4) 5; York house, 37 Queen
square London, U.K.
can be detected in live animals in corneal impressions or in 7. WHO (1973) Techn. Rep. Ser. No. 523.
frozen sections of skin biopsies by the FRA test. A positive 8. J.B. Campbell, et al (1968). Bull WHO, 38 : 373.
result is indicative of rabies, but a negative result does not 9. Christie, A.B. (1980). Infectious Diseases : Epidemiology and Clinical
rule out the possibility of infection (3). Practice, Churchill Livingstone.
10. Vaughn, J.B. et al (1965). JAMA, 193 : 363.
Immunization of dogs 11. WHO (2018), Rabies Fact Sheet Ho. 99, 13 Sept. 2018.
Prophylactic vaccination of dogs against rabies is one of 12. Warrel, D.A. (1976). Tr. Roy. Soc. Trop. Med. andHyg. 70 : 188.
the most important weapons in rabies control (7). Studies 13. Plokin, S.A. (1979) in Nelson’s Textbook of Paediatrics, 11th ed,
Saunders.
have shown that, in general, 80-90% of the dog population 14. WHO (2010), Current Strategies for Human Rabies Pre and Post­
is accessible for vaccination, thus confirming that the Exposure Prophylaxis, 3rd Sept, 2010.
concept of controlling rabies through mass vaccination is a 15. Kaplan, M.M. and Koprowski, H. (1980). Sci American, 242 (1) 120.
sound one (19). All dogs should receive primary 16. Central Research Institute, Kasauli (1979) Principles and Practice of
immunization at the age of 3-4 months and booster doses Antirabies Treatment and Control of Rabies, Govt, of India.
should be given at regular intervals, according to the type of 17. Fischman, H.R. (1980) in Maxcy-Rosenau : Public Health and
vaccine used. Preventive Medicine, 11th ed, Appleton - Century Crofts, New York.
18. WHO (1975) Wkly Epi Rec. No.33.
(1) BPL inactivated nervous tissue vaccine (Single dose) : 19. The work of WHO 1986-87 P-176.
This is based on 20% suspension of infected sheep brain. 20. Bull WHO (1985) 63 (4) 661.
The dose is 5 ml for dogs and 3 ml for cats. Revaccination is
advised after 6 months, and subsequently every year.
YELLOW FEVER
(2) Modified live virus vaccine : This is based on 33%
chick embryo suspension infected with modified virus. The Yellow fever is a zoonotic disease caused by an arbovirus.
dose is 3 ml by single injection, and boosters every 3 years. It affects principally monkeys and other vertebrates in
As with the vaccines for human use, the adult-brain vaccines tropical America and Africa and is transmitted to man by
for use in animals should be replaced as soon as possible by certain culicine mosquitoes. It shares clinical features with
cell-culture vaccines (20). other viral haemorrhagic fevers (e.g., dengue HF, Lassa
fever) but is characterized by more severe hepatic and renal
Control of urban rabies involvement. The spectrum of disease varies from clinically
Since dog is the major source of infection, the most indeterminate to severe cases. Severe cases develop
logical and cost-effective approach is elimination of stray jaundice with haemorrhagic manifestations (black vomit,
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328 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

epistaxis, melena) and albuminuria or anuria, shock, transported from endemic areas to receptive areas, also gives
agitation, stupor and coma (1). In general death occurs a cause for concern (3).
between the fifth and tenth day of illness. The case fatality
rate may reach 80 per cent in severe cases. Survivors exhibit Modes of transmission
long-lasting immunity. There are three known cycles of transmission, the jungle,
intermediate and the urban cycles (2).
Problem statement
47 countries in Africa and Latin America, with a - Sylvatic (or jungle) yellow fever. In tropical rainforests,
combined population of more than 900 million, are at risk of yellow fever occurs in monkeys that are infected by wild
yellow fever. In Africa, an estimated 508 million people live mosquitoes. The infected monkeys then pass the virus to
other mosquitoes that feed on them. The infected
in 32 countries at risk. The remaining are in 13 countries of
mosquitoes bite humans entering the forest, resulting in
Latin America, with Bolivia, Brazil, Colombia, Ecuador and
occasional cases of yellow fever. The majority of
Peru at greatest risk (2).
infections occur in young men working in the forest (e.g.
There were an estimated 84,000-170,000 cases and for logging).
29,000-60,000 deaths worldwide in the year 2013. Small
- Intermediate yellow fever. In humid or semi-humid parts
number of imported cases occur in countries free of yellow
of Africa, small-scale epidemics occur, Semi-domestic
fever. Although disease has never been reported in Asia, the
mosquitoes (that breed in the wild and around
region is at risk because the conditions required for
households) infect both monkeys and humans. Increased
transmission are present there (2).
contact between people and infected mosquitoes leads to
Epidemiological determinants transmission. Many separate villages in an area can suffer
cases simultaneously. This is the most common type of
Agent factors outbreak in Africa. An outbreak can become a more severe
(a) AGENT : The causative agent, Flavivirus fibricus epidemic if the infection is carried into an area populated
formerly classified as a group B arbovirus, is a member of with both domestic mosquitoes and unvaccinated people.
the togavirus family. It shares group-specific antigens with - Urban yellow fever. Large epidemics occur when
other members of the genus (e.g., West Nile, dengue). Under infected people introduce the virus into densely

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natural conditions, the virus is pantropic but after continued populated areas with a high number of non-immune
culture in tissues, as in chick embryo, it loses all its people and Aedes mosquitoes. Infected mosquitoes
pathogenic properties but retains its antigenicity. transmit the virus from person to person.
(b) RESERVOIR OF INFECTION : In forest areas, the
reservoir of infection is mainly monkeys and forest Treatment
mosquitoes. In urban areas, the reservoir is man (subclinical There is no specific treatment for yellow fever, only
and clinical cases) besides Aedes aegypti mosquitoes. supportive care to treat dehydration and fever. Associated
(c) PERIOD OF COMMUNICABILITY : (i) MAN : Blood of bacterial infections can be treated with antibiotics.
patients is infective during the first 3 to 4 days of illness, Supportive care may improve outcomes for seriously ill
(ii) MOSQUITOES : After an “extrinsic incubation period” of patients, but it is rarely available in poorer areas.
8 to 12 days, the mosquito becomes infective. The virus
multiplies in the insect vector. After becoming infective, the Incubation period
mosquito remains so for life. Transovarian transmission of 3 to 6 days (6 days recognized under International Health
the virus in mosquitoes has been shown to occur in adverse Regulations).
conditions (e.g., during extended dry seasons), in the
absence of susceptible hosts (1). CONTROL OF YELLOW FEVER
Host factors Jungle yellow fever
(a) AGE AND SEX : All ages and both sexes are Jungle yellow fever continues to be an uncontrollable
susceptible to yellow fever in the absence of immunity disease. The virus maintains itself in the animal kingdom.
(b) OCCUPATION : Persons whose occupation brings them Mosquito control is difficult and can be considered only in
in contact with forests (wood cutters, hunters) where yellow restricted areas. Vaccination of humans with 17D vaccine is
fever is endemic are exposed to the risk of infection the only control measure.
(c) IMMUNITY : One attack of yellow fever gives lifelong
immunity; second attacks are unknown. Infants born of Urban yellow fever
immune mothers have antibodies up to 6 months of life. (1) VACCINATION Rapid immunization of the
population at risk is the most effective control strategy for
Environmental factors yellow fever. For international use, the approved vaccine is
(a) CLIMATE : A temperature of 24 deg.C or over is the 17D vaccine. It is a live attenuated vaccine prepared
required for the multiplication of the virus in the mosquito. It from a non-virulent strain (17D strain), which is grown in
should be accompanied by a relative humidity of over 60 per chick embryo and subsequently freeze-dried.
cent for the mosquitoes to live long enough to convey the The sensitivity of the lyophilized 17D vaccine to heat is a
disease, (b) SOCIAL FACTORS : In Africa, urbanization is major drawback to the use of this vaccine, in mass campaigns
leading to the extension of yellow fever. In addition, the in tropical countries. It has to be stored between +5 and
expanding population is encroaching on areas that were -30 deg.C, preferably below zero deg. C until reconstituted
previously sparsely populated, thereby bringing man closer to with the sterile, cold physiological saline diluent provided.
the jungle cycles of yellow fever. The increasing number of Reconstituted vaccine should be kept on ice, away from
people who travel and the greater speed with which they are sunlight, and discarded if not used within half an hour.
by R△J
 YELLOW FEVER

The vaccine is administered subcutaneously at the missing link in the chain of transmission is the virus of yellow
insertion of deltoid in a single dose of 0.5 ml irrespective of fever which does not seem to occur in India.
age. Immunity begins to appear on the 7th day and lasts The virus of yellow fever could get imported into India in
possibly for life (2). two ways: (i) through infected travellers (clinical and
The risk of death from yellow fever is much higher than subclinical cases), and (ii) through infected mosquitoes.
the risks related to the vaccine. People who should not be Measures designed to restrict the spread of yellow fever are
vaccinated include (2) : specified in the “International Health Regulations” of
(a) children aged under 9 months for routine immunization WHO (8). These are implemented by the Government of India
(or under 6 months during an epidemic); through stringent aerial and maritime traffic regulations.
Broadly these comprise :
(b) pregnant women - except during a yellow fever outbreak
when the risk of infection is high; (i) TRAVELLERS : All travellers (including infants)
exposed to the risk of yellow fever or passing through
(c) people with severe allergies to egg protein; and endemic zones of yellow fever must possess a valid
(d) people with severe immunodeficiency caused by international certificate of vaccination against yellow fever
symptomatic HIV/AIDS or other causes, or in the before they are allowed to enter yellow fever “receptive”
presence of thymus disorder. areas. If no such certificate is available, the traveller is placed
Mild post-vaccinial reactions (e.g., myalgia, headache, on quarantine, in a mosquito-proof ward, for 6 days from
low-grade fever) may occur in 2-5 per cent of vaccinees, the date of leaving an infected area. If the traveller arrives
5 to 10 days after vaccination. Anaphylaxis is very rare, before the certificate becomes “valid”, he is isolated till the
occurring mainly in those allergic to eggs (4). certificate becomes valid.
Cholera and yellow fever vaccines together or within (ii) MOSQUITOES : The aircraft and ships arriving from
3 weeks interfere with each other, so whenever possible, endemic areas are subjected to aerosol spraying with
they should be given 3 weeks or more apart (5). prescribed insecticides on arrival for destruction of insect
vectors. Further, airports and seaports are kept free from the
(2) VECTOR CONTROL : The other principal method of breeding of insect vectors over an area extending at least
preventing yellow fever is through intensive vector control. 400 metres around their perimeters. The “aedes aegypti
The objective of vector control is to reduce rapidly the index” is kept below 1.
vector population to the lowest possible level and thereby

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stop or reduce transmission quickly. This approach has International certificate of vaccination (10)
proved successful in the Americas to prevent urban
India and most other countries require a valid certificate
epidemics.
of vaccination against yellow fever from travellers coming
The vector, Aedes mosquito is peri-domestic in habits. It from infected areas. A few countries (including India) require
can be controlled by vigorous anti-adult and anti-larval this even if the traveller has been in transit. It rests with each
measures. The long-term policy should be based on country to decide whether a certificate of vaccination against
organized “source reduction” methods (e.g., elimination of yellow fever shall be required for infants under one year of
breeding places) supported by health education aimed at age, after weighing the risk of importation of yellow fever by
securing community participation. unvaccinated infants against the risk to the infant arising
Personal protection against contact with insects is of from vaccination. In this regard, India requires vaccination of
major importance in integrated vector control. Such infants (> 9 months of age) too. The validity of the certificate
protection may include the use of repellents, mosquito nets, begins 10 days after the date of vaccination. For the purpose
mosquito coils and fumigation mats (7). of international travel, the vaccination must be given at an
officially designated centre, and the certificate must be
(3) SURVEILLANCE : A programme of surveillance validated with the official stamp of the Ministry of Health,
(clinical, serological, histopathological and entomological) Government of India. The certificate is valid only if it
should be instituted in countries where the disease is conforms with the model prescribed under the International
endemic, for the early detection of the presence of the virus Health Regulations. On the other hand, for their own
in human populations or in animals that may contribute to protection, travellers who enter endemic areas should
its dissemination. receive vaccination against yellow fever (10).
For the surveillance of Aedes mosquitoes, the WHO uses
an index known as Aedes aegypti index. This is a house New yellow fever vaccination requirement for
index and is defined as “the percentage of houses and their travellers
premises, in a limited well-defined area, showing actual In May 2014, the World Health Assembly adopted an
breeding of Aedes aegypti larvae” (8). This index should not amendment of International Health Regulations (2005),
be more than 1 per cent in towns and seaports in endemic which stipulates that the period of protection afforded by
areas to ensure freedom from yellow fever (9). yellow fever vaccination, and the term of validity of the
certificate will change from 10 years to the duration of the life
International measures of the person vaccinated. On 11th July 2016, the amendment
India is a yellow fever “receptive” area, that is, “an area entered into force and is legally binding upon all IHR states.
in which yellow fever does not exist, but where conditions This lifetime validity applies automatically to all existing and
would permit its development if introduced”. The new certificates, beginning 10 days after the date of
population of India is unvaccinated and susceptible to vaccination. Accordingly, as of 11th July 2016, revaccination
yellow fever. The vector, Aedes aegypti is found in or a booster dose of yellow fever vaccine will not be required
abundance. The climatic conditions are favourable in most for international travellers as a condition of entry into a State
parts of India for its transmission. The common monkey of Party, regardless of the date that their international certificate
India (Macacus spp) is susceptible to yellow fever. The of vaccination was initially issued (11).

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

In India, the lifetime validity of yellow fever vaccination

applies automatically. The list of yellow fever endemic NIPAH VIRUS INFECTION
countries are as follows: Nipah Virus is a zoonotic virus, an emerging infectious
In Africa : Angola, Benin, Burkina Faso, Burundi, disease caused by virus of the family Paramyxoviridae,
Cameroon, Central African Republic, Chad, Congo, Cote genus Henipavirus. It gets its name from the village in
d’Ivoire, Democratic Republic of the Congo, Equatorial Malaysia where the person from whom the virus was first
Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, isolated succumbed to the disease in the year 1999 (1).
Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger,
Nigeria, Rwanda, Senegal, Sierra Leone, Sudan, South Problem statement
Sudan, Togo and Uganda; and in the Americas: Argentina, Nipah virus infection was initially isolated and identified
Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, in 1999 during an outbreak of encephalitis and respiratory
Panama, Paraguay, Peru, Suriname, Trinidad and Tobago illness among pig farmers in Malaysia and Singapore. In
(Trinidad only), and Venezuela (Bolivarian Republic of). 2001, it was again identified as the causative agent in the
Note : When a case of yellow fever is reported from any outbreak of human disease in Bangladesh and India. Since
country, that country is regarded by the Government of then it has been reported almost annually in Bangladesh
India as a country with risk of yellow fever transmission and and many times in India. A recent outbreak in India was in
is added to the above list (10). Kerala in the month of May 2018, recorded 19 cases with 17
deaths (2).
Epidemic preparedness and response
WHO recommends that every at-risk country have at Mode of transmission
least one national laboratory where basic yellow fever blood Transmission of nipah virus to humans may occur after
tests can be performed. A confirmed case of yellow fever in direct contact with infected bats, infected pigs or from other
an unvaccinated population is considered as an outbreak. A nipah virus infected people (as reported in Bangladesh and
confirmed case in any context must be fully investigated. India), where it is seen in the family and caregivers of the
Investigation teams must assess and respond to the outbreak infected patients. Transmission also occurs from direct
with both emergency vaccination campaigns and longer- exposure to infected bats. Example is consumption of raw
term immunization plans (2). date palm sap contaminated with infectious bat secretions,
and excretions (3).

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The Elimination of Yellow Fever Epidemic (EYE)
Strategy (2) Fruit bats of the family Pteropodidae, particularly species
belonging to Pteropus genus are the natural host for nipah
The EYE Strategy was developed by WHO, UNICEF and virus. There is no apparent disease in fruit bats (1).
GAVI, in response to increased threat of yellow fever urban
outbreaks with international spread. It is guided by three Incubation period
strategic objectives :
Usually 4 to 14 days.
1. Protect at-risk populations ;
2. Prevent international spread of yellow fever; and Clinical manifestations
3. Contain outbreaks rapidly. Human infection ranges from asymptomatic infection to
These objectives are underpinned by five competencies acute respiratory infection and fatal encephalitis. Infected
of success: , people initially develop fever, headache, myalgia, vomiting
and sore throat. This can be followed by dizziness,
1. Affordable vaccines and sustained vaccine market; drowsiness, altered consciousness and neurological signs
2. Strong political commitment at global, regional and that indicate acute encephalitis. Some people can also
country levels; experience atypical pneumonia and severe respiratory
3. High-level governance with long-term partnerships; problems, including acute respiratory distress. Encephalitis
and seizures occur in severe cases, progressing to coma
4. Synergies with other health programmes and sectors;
within 24 to 48 hours. Most people who survive acute
and
encephalitis make a full recovery. Long term neurologic
5. Research and development for better tools and practices. conditions have been reported in survivors. Approximately
20% of patients are left with residual neurological
References consequences such as seizure disorder and personality
1. WHO (1986). Bull WHO 64 (4) 511-524. changes. A small number of people who recover
2. WHO (2018). Fact Sheet Yellow Fever, 1st May 2018. subsequently relapse or develop delayed onset encephalitis.
3. WHO (1972). WHO. Chr., 26 (2) 60-65. The case fatality rate is estimated at 40% to 75%. This rate
4. WHO (2010), Weekly Epidemiological Record, No. 5,29th Jan. ,2010. can vary by outbreak depending on local capabilities for
5. Immunization Practices. Advisory Committee, US countries for epidemiological surveillance and clinical management (2).
Disease Control (1984) Ann. /nt. Med., 100 : 540-42.
6. Med Digest (1985) Feb. P29.
Diagnosis
7. WHO (1985) Tech. Rep. Ser., No. 720 P31.
8. WHO (2005). International Health Regulations, Second Annotated The main tests are real time polymerase chain reaction
Edition. (RT-PCR) from bodily fluids and antibody detection via
9. WHO (1971). Tech. Rep. Ser., No.479. ELISA. Other tests used include polymerase chain reaction
10. Govt, of India (2013), Bureau of Immigration, Health Regulation, assay, and virus isolation by cell culture (1).
Ministry of Home Affairs, Immigration Visa - Foreigners Registration
and Tracking. Treatment
11. WHO (2016). International Travel and Health, New Yellow Fever
Vaccination Requirements for Travellers. No drug or vaccine specific to nipah virus is available.

by R△J
 JAPANESE ENCEPHALITIS

Intensive supportive care is recommended to treat severe responsible for this group of illness in India are the sindbis,
respiratory and neurological complications. chikungunya and dengue viruses, (b) HAEMORRHAGIC
FEVERS : The second group is that of haemorrhagic fevers,
Prevention generally associated with moderate or high mortality. Viruses
In the absence of a vaccine, the only way to reduce or responsible for haemorrhagic fevers in India are the dengue,
prevent infection in people is by raising awareness of the risk chikungunya and KFD viruses, (c) ENCEPHALITIDIS : The
factors and educating people about the measures they can third group is that of encephalitidis or meningoencephalitis
take to reduce exposure to nipah virus. which is associated with a considerable and sometimes high
mortality. The disease reported now frequently in some parts
References of India is the Japanese encephalitis.
1. WHO (2018), Fact sheet Nipah Virus, 30th May 2018.
2. Communicable Disease Watch, 3 June -16 July 2018, vol. 15. 1. The dengue syndrome
3. Centers for Disease Control and Prevention, Saving lives, Protecting This is detailed separately at page 288.
people.
2. Japanese encephalitis
OTHER ARBOVIRAL DISEASES Japanese encephalitis (JE) is a mosquito-borne
encephalitis caused by a group B arbovirus (Flavivirus) and
During the past few years, a large number of arthropod-
transmitted by culicine mosquitoes. It is a zoonotic disease,
borne viruses (arboviruses) have been isolated from sick
i.e., infecting mainly animals and incidentally man. The
persons, animals and arthropods throughout the world.
envelope glycoprotein of the JE virus contains specific as
Arthropod-borne viruses are defined as viruses “which are
well as cross-reactive, neutralizing epitopes. The major
maintained in nature principally, or to an important extent
through biological transmission between susceptible genotypes of this virus have different geographical
vertebrate hosts by haematophagous arthropods; they distribution, but all belong to the same serotype and are
multiply in the tissues of arthropods, and are passed on to similar in terms of virulence and host preference. Following
new vertebrates by the bites of arthropod after a period of an infectious mosquito bite, the initial viral replication
extrinsic incubation” (1). occurs in local and regional lymph nodes. Viral invasion of
the central nervous system occurs probably via blood.
Yellow fever is historically the most prominent among the
diseases in this group. In recent years, a number of other JE is the leading cause of viral encephalitis in Asia and

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arboviruses have emerged as important public health occurs in almost 24 Asian and Western Pacific countries.
problems in both tropical and temperate zones. The number Largely as a result of immunization, its incidence has been
of arboviruses known in India had risen from two (dengue declining in Japan, the Korean peninsula and in some
and sandfly fever) in 1951 to over 40 (2). regions of China, but the disease is increasingly reported
from Bangladesh, India, Nepal, Pakistan, northern Thailand
CLASSIFICATION and Vietnam. Transmission occurs principally in rural
The huge family of heterogeneous arboviruses is divided agricultural location where flooding irrigation is practised.
into no less than 7 major groups, and 18 smaller groups (3). Transmission is seasonal and mainly related to the rainy
Many remain unclassified. The current trend is to name the season in South-East Asia Region (2).
viruses after the places where they were discovered. Some of The annual incidence of clinical disease varies both
the arboviruses known to be prevalent in India are as shown across and within countries, ranging from <10 to >100 per
in Table 1. • 100,000 population. A recent estimate puts nearly 68,000
TABLE 1 clinical cases of JE globally each year, with upto 20,400
Some Arboviruses known to be prevalent in India deaths due to JE (3). The vast majority of cases occur
among children less than 15 years of age. Nearly 10 per cent
Group A OTHERS of cases are among those above 60 years, perhaps reflecting
(Alphaviruses) Umbre waning protective immunity.
Sindbis Sathuperi The disease is rare in other parts of the world, and when
Chikungunya Chandipura seen, is generally associated with travellers returning from
Chittor
Ganjam endemic areas (3).
Group B Minnal Major outbreaks of JE occur every 2-15 years. JE
(Flauiuiruses) Venkatapuram transmission intensifies during the rainy season, when vector
Dengue Dhori population increases. However, there has not yet been any
KFD Kaisodi evidence of increased JE transmission following major
JE Sandfly fever floods. The spread of JE in new areas has been correlated
West Nile African Horse sickness with agricultural development supported by irrigation
Vellore programmes (3).
CLINICAL SYNDROMES PROBLEM IN INDIA
Although arboviruses are many, only a small number of Recognition of JE, based on serological surveys, was first
them are known to be capable of infecting man, and a much made in 1955 in Tamil Nadu. JE has been reported from
smaller number capable of producing disease. A high different parts of the country. The disease is endemic in
proportion of the infections is inapparent. For convenience, 21 states. Assam, Bihar, Uttar Pradesh, Karnataka, West
three clinical syndromes have been described : (a) FEBRILE Bengal, Tripura and Tamil Nadu report out-breaks every year
GROUP : This is the most common group which comprises a and contribute about 55 per cent of cases and deaths.
large number of relatively undifferentiated fevers, generally In India about 375 million population is at risk. JE is
benign with or without rashes and joint pains. Viruses reported under the umbrella of Acute Encephalitis Syndrome

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(AES), therefore, the data reported from states are for total JEINMAN
AES including JE cases (4). The state-wise reported cases of The incubation period in man, following mosquito bite is
Acute encephalitis syndrome are as shown in Table 2. not exactly known. Probably, it varies from 5-15 days. Not
TABLE 2 all individuals bitten by infected mosquitoes develop
State-wise reported cases and deaths due to disease. The ratio of overt disease to inapparent infection is
Acute encephalitis syndrome in India 2018-2020 (P) about 1:250. Thus cases of encephalitis represent only the
tip of the iceberg compared to the large number of
2018 2019 2020 (P) inapparent infections. Encephalitis cases due to JE may
State show a scattered distribution.
Cases Deaths Cases Deaths Cases Deaths
Assam 1492 183 2652 353 595 96 The course of the disease in man may be divided into
Bihar 124 33 292 82 172 23 three stages : (a) PRODROMAL STAGE : The onset of illness
Jharkhand 544 0 912 3 485 0 is usually acute and is heralded by fever, headache,
Karnataka 380 5 397 4 310 0 gastrointestinal disturbances, lethargy and malaise. The
Manipur 283 3 1177 6 29 4 duration of this stage is usually 1-6 days, (b) ACUTE
Meghalya 243 6 711 9 230 1 ENCEPHALITIC STAGE : Fever is usually high, 38 to
Odisha 1720 10 1962 8 373 3 40.7 deg. C. The prominent features are fever, nuchal
Tamil Nadu 1287 5 1007 2 333 4 rigidity, focal CNS signs, convulsions signs of raised intra­
Tripura 311 0 325 2 244 0 cranial pressure, difficulty of speech, dystonia, ocular
Uttar Pradesh 3080 230 2185 126 1646 83 palsies, hemiplegia, quadriplegia,.extra-pyramidal signs like
West Bengal 1762 146 1618 89 867 26 coarse tremors and altered sensorium progressing in many
cases to coma, (c) LATE STAGE AND SEQUELAE : This
India Total 11,388 636 14,995 710 5,487 248 stage begins when active inflammation is at an end, i.e., the
temperature and ESR touch normal. Neurological signs
P - Provisional become stationary or tend to improve. Convalescence may
Source : (5) be prolonged and residual neurological deficits may not be
uncommon (3). The case fatality rate varies between
Epidemiological features 20-40 per cent. The average period between the onset of
illness and death is about 9 days (3).

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Unlike the dengue viruses, JE virus infects several
extrahuman hosts, e.g., animals and birds. Available Confirmation of a suspected case of JE requires
evidence indicates that the basic cycles of transmission are : laboratory diagnosis. The aetiological diagnosis of JE is
mainly based on serology using IgM-capture ELISA which
(a) Pig Mosquito —» Pig
detects specific IgM in the cerebrospinal fluid or in the blood
(b) The Ardeid bird —> Mosquito —> Ardeid bird of almost all patients within 7 days of onset of disease. Other
The disease is transmitted to man by the bite of infected methods include conventional antibody assays on paired
mosquitoes. Man is an incidental “dead-end” host. Man to sera for the demonstration of a significant rise in total
man transmission has not so far been recorded. JE-specific antibody, as well as a dot-blot IgM assay,
suitable for use in the field. The virus is rarely recovered in
(a) Animal hosts : Among the animal hosts, pigs have tissue culture from blood or CSF, but may be found in
been incriminated as the major vertebrate hosts for JE virus. encephalitic brain at autopsy. JE-viral RNA is rarely
In some places, upto 100 per cent of pigs may be infected demonstrated in the CSF (8).
with JE virus. Infected pigs do not manifest any overt
symptoms of illness but circulate the virus so that Control of JE
mosquitoes get infected and can transmit the virus to man.
The pigs are thus considered as “amplifiers” of the virus (6). (a) VACCINATION : Vaccination of population at risk has
Cattle and buffaloes may also be infected with the JE virus; been recommended. Currently, the three types of JE
although they may not be natural hosts of JE virus, they act vaccines in large-scale use are : (i) the mouse brain-derived,
as “mosquito attractants.” Horses are the only domestic purified and inactivated vaccine, which is based on either
animals so far known which show signs of encephalitis due the Nakayama or Beijing strains of the JE virus and
to JE virus infection, (b) Birds : Some species of birds such produced in several Asian countries; (ii) the cell culture-
as pond herons; cattle egrets and perhaps poultry and ducks derived, inactivated JE vaccine based on the Beijing P-3
appear to be involved in the natural history of JE virus (6). strain, and (iii) the cell culture-derived, live attenuated
vaccine based on the SA 14-14-2 strain of the JE virus. The
MOSQUITO VECTORS mouse-brain derived, inactivated vaccine has been used
successfully to reduce the incidence of JE in a number of
Culicine mosquitoes, notably C.tritaeniorhynchus, countries, and is likely to be used nationally and
C. vishnui and C. gelidus along with some anophelines have internationally for some more years. Drawbacks of the
been incriminated as the vectors of JE. Among these, mouse-brain vaccine are the limited duration of the induced
C.tritaeniorhynchus and vishnui has been implicated as the protection, the need for multiple doses, and, in most
most important vector in South India (7). These mosquitoes
countries, the relatively high price per dose. The cell culture-
generally breed in irrigated rice fields, shallow ditches and
derived vaccines are manufactured and widely used in
pools. The rice fields are probably the most important
China, where the inactivated vaccine is gradually being
breeding places. These mosquitoes are zoophilic, feeding
primarily on vertebrate hosts. Female mosquitoes get replaced by the live attenuated vaccine. Several other
infected after feeding on a viraemic host, and after 9-12 promising JE vaccine candidates are in advanced stages of
days incubation period, they can transmit the virus to other development.
hosts. The immunization schedules of the 3 licensed JE vaccines

by R△J
 JAPANESE ENCEPHALITIS

that are currently in large-scale use vary with the profile of of NVBDCP developed surveillance guidelines for endemic
the respective vaccines and depend on local epidemiological states and advised that all the JE cases be reported under
circumstances and recommended schedules of other Acute Encephalitis Syndrome (AES) as they have common
childhood vaccines. When immunizing children 1-3 years of similar clinical manifestations. Their case management
age the mouse brain-derived vaccine provides adequate usually follows a common protocol along with situation
protection throughout childhood following 2 primary doses specific treatment. Diagnosis of JE will depend on
4 weeks apart, and boosters after 1 year and subsequently at laboratory investigations. The case definitions and case
3-yearly intervals until the age of 10-15 years. The vaccine classification in the programme are as follows (12) :
is given subcutaneously in doses of 0.5 ml for children under
3 years and one ml for children more than 3 years of age. Case definition of suspected case
Protective immunity develops in about one month time after - Acute onset of fever, not more than 5-7 days duration.
the second dose. The vaccine is best used in the inter­ - Change in mental status with/without
epidemic period. It should be offered to the most vulnerable - New onset of seizures (excluding febrile seizures)
and high-risk groups (6, 7). Equally good childhood
protection is obtained by a single dose of the cell-culture - Other early clinical findings - may include irritability,
based, live attenuated vaccine (SA-14-14-2) followed by a somnolence or abnormal behaviour greater than that
single booster given at an interval of about 1 year. This seen with usual febrile illness.
vaccine is available in India and is an integral part of
Universal Immunization Programme in 83 endemic districts Case classification
in Uttar Pradesh, Assam, West Bengal and Karnataka Laboratory-confirmed case
targeting children in age group 1-15 years (9). The
importance of achieving long-term protection is underlined A suspected case with any one of the following markers:
by the observation that in some areas an increasing - Presence of IgM antibody in serum and/or CSF to a
proportion of the JE cases occur in individuals older than specific virus including JE/Enterovirus or others
10 years of age (8). - Four fold difference in IgG antibody titre in paired sera
Given the most infrequent occurrence of JE in infancy - Virus isolation from brain tissue
and the likely interference with passively acquired maternal - Antigen detection by immunofluroscence

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antibodies during the first months of life, vaccination is not
recommended for children before the age of 6 months (8). - Nucleic acid detection by PCR
For travellers aged more than one year, visiting rural In the sentinel surveillance network, AES/JE is to be
areas of endemic countries for at least 2 weeks, the diagnosed by IgM Capture ELISA, and virus isolation to be
established current practice is to administer 3 primary doses done in National Reference Laboratory.
at days 0, 7 and 28; alternatively 2 primary doses preferably Probable cases
4 weeks apart. When continued protection is required,
boosters should be given after one year and then every 3 Suspected case in close geographic and temporal
years (8, 10). relationship to a laboratory-confirmed case of AES/JE in an
outbreak.
The vaccination of swine is extremely important for both
public health and economic reasons. It prevents viraemia in Acute Encephalitis Syndrome (AES) due to other agent
these animals, and hence eliminates their role as amplifiers
A suspected case in which diagnostic testing is performed
of the virus. An inactivated vaccine and more recent
and an aetiological agent other than AES/JE is identified.
modified live virus vaccines are all in current use. However,
it is difficult to maintain vaccination coverage in the swine Acute Encephalitis Syndrome (AES) due to unknown
of a given region because the population is renewed so agent
rapidly (11).
A suspected case in which no diagnostic testing is
(b) VECTOR CONTROL : The vector mosquito(es) of JE performed/no aetiological agent is identified/test results are
are widely scattered and not easily amenable to control. An indeterminate.
effective way to deal with them is to resort to aerial or
ground fogging with ultra-low-volume (ULV) insecticides While the above classifications are useful for clearer
(e.g., malathion, fenitrothion). All the villages reporting definitions of AES cases, for practical purposes, the two key
cases should be brought under indoor residual spray. The definitions to be used are "suspected JE cases" for those that
spraying should cover the vegetation around the houses, meet the criteria for AES, and "confirmed JE cases" for those
breeding sites and animal shelters in the affected villages. AES cases which have laboratory confirmation for JE. In an
Uninfected villages falling within 2 to 3 km radius of the epidemic situation fever with altered sensorium persisting for
infected villages should also receive spraying as a preventive more than two hours with a focal seizure or paralysis of any
measure. Villages within the proximity of infected villages part of body, is encephalitis. Presence of rash on body
should be kept under surveillance. The use of mosquito nets excludes Japanese Encephalitis. AES with symmetrical signs
should be advocated. and fever is likely to be cerebral Malaria.
The causes of AES are as shown in Fig. 1.
GUIDELINES FOR MANAGEMENT OF AES Management of Acute Encephalitis Syndrome, including
INCLUDING JAPANESE ENCEPHALITIS IN Japanese Encephalitis, is essentially symptomatic. To reduce
INDIA (2014) (12) severe morbidity and mortality, it is important to identify
early warning signs and refer patients to health facility and
Following an outbreak of JE in Gorakhpur and Basti to educate the health workers about the first line of
divisions in eastern Uttar Pradesh during 2005, Directorate treatment for management of the case at the grassroot level.

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

AES

r
JE
I
Non JE viral

I
— Arbovirus ---------------------------- WNE ■ Parasitic (Malaria)
(Arthropod is vector) (West Nile encephalitis in Protozoal (Amoebic)
Single stranded RNA virus — VEE (Venezuelan horses) North America) — Siprochetal (Syphilis)
of Flaviviridae family Not found
— Tick borne encephalitis and others in INDIA — Trypanosomiasis
(Mosquito is vector)
Dawson — Acute TB meningitis
— Bacterial
Enteroviral encephalitis — Fungal (Cryptococcal)
Coxsackie A&B Toxin
Echo — Chemicals (no fever)
Dengue Others Unknown cause
Herpes
- Varicella

Causes of Acute Encephalitis Syndrome

Source : (13)

Fig. 2 summarizes the guidelines for management of a tubercular meningitis, toxoplasmosis, amoebiasis, fungal
case of AES at PHC and FRLJ level and management of infection or neurocysticercosis; the patient should be given
circulation as blood pressure should be maintained at about specific treatment for that particular disease.
95th centile for the age of the patient with the help of
dopamine drip. Failure of autoregulation of the brain makes 3. Kyasanur forest disease
the cerebral circulation depend solely on systemic blood Kyasanur forest disease (KFD) is a febrile disease

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pressure. Avoid fluid overload. The ultimate decision associated with haemorrhages caused by an arbovirus
regarding the management depends upon the attending flavivirus and transmitted to man by bite of infective ticks.
physician.
HISTORY
Treatment of specific cause KFD was first recognized in 1957 in Shimoga district of
If laboratory investigation shows a non-JE cause, like Karnataka State in South India. Local inhabitants called the
herpes-zoster, varicella, malaria, pyogenic meningitis, disease “monkey disease” because of its association with

At Community Level (PHC)

TREATMENT DANGER SIGN

FIG. 2
Management of AES including Japanese Encephalitis
Source : (12)

by R△J
 JAPANESE ENCEPHALITIS

dead monkeys. The disease was later named after the locality especially nymphal stages. There is no evidence of man to
- Kyasanur Forest - from where the virus was first isolated. man transmission.
PROBLEM STATEMENT (f) INCUBATION PERIOD
Earlier the disease was found to be limited mainly to an Estimated to be between 3 and 8 days.
area around the original focus (Shimoga district) covering
about 800 sq.km. Newer foci have since been recognized. CLINICAL FEATURES
The disease is now restricted to four districts (Shimoga, The disease appears with a sudden onset of fever,
North Kannada, South Kannada and Chikamagaluru) in headache and severe myalgia, with prostration in some
Karnataka State in India covering over 6,000 sq.km. (14). patients. The acute phase lasts for about 2 weeks.
Serological surveys in different parts of India revealed Gastrointestinal disturbances and haemorrhages from nose,
antibodies to KFD or a closely related virus in human and gums, stomach and intestine may occur in severe cases.
animals, particularly in cattle in Kutch and Saurashtra (15).
In a number of cases, there is a second phase
According to the reports, the disease continues to be characterized by mild meningoencephalitis after an afebrile
active in its endemic foci. About 400-500 cases occur every period of 7 to 21 days. It is manifested by a return of fever,
year. The Karnataka Government has established a severe headache followed by neck stiffness, coarse tremors,
surveillance system which monitors the occurrence of KFD in abnormal reflexes and mental disturbances. The case fatality
humans and mortality in monkeys in known epidemic areas, rate has been estimated to be 5 to 10 per cent (14).
as well as neighbouring areas. Deaths of monkeys are
considered as heralders of this disease in endemic areas (16). Diagnosis is established only after detecting the presence
of the virus in the blood and/or serological evidence.
Epidemiological determinants
CONTROL
(a) AGENT (a) CONTROL OF TICKS : Since KFD is a tick-borne
The agent KFD virus is a member of group B togaviruses disease, control of ticks should be undertaken. For control of
(flaviviruses). It is antigenically related to other tick-borne ticks in forests, application can be made by power equipment
flaviviruses, particularly the Far Eastern tick-borne or by aircraft-mounted equipment to dispense carbaryl,
encephalitis and Omsk haemorrhagic fever. Unlike in many fenthion, naled or propoxur at 2.24 kg of active ingredient per

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other arbovirus infections, KFD has a prolonged viraemia in hectare (18). The spraying must be carried out in “hot spots”,
man for about 10 days or more. i.e., in areas where monkey deaths have been reported, within
50 metres around the spot of the monkey deaths, besides the
(b) NATURAL HOSTS AND RESERVOIRS endemic foci. Since the heavy tick population in the forest
areas is attributed partly to the free roaming cattle, restriction
Small mammals particularly rats and squirrels are the
of cattle movement is thought to bring about a reduction in
main reservoirs of the virus (14). Birds and bats are less
vector population, (b) VACCINATION : The population at risk
important hosts. The monkeys are recognized as amplifying
should be immunized with killed KFD vaccine, (c) PERSONAL
hosts for the virus. However, they are not effective
maintenance hosts because most of them die from KFD PROTECTION : Protection of individuals exposed to the risk
of infection by adequate clothing and insect repellents such as
infection. Cattle provide Haemaphysalis ticks with a plentiful
source of blood meals, which in turn leads to a population dimethylphthalate (DMP, DEET) should be encouraged. They
should examine their bodies at the end of each day for ticks
explosion among the ticks. Thus cattle are very important in
maintaining tick populations but play no part in virus and remove them promptly. The habit of sitting or lying down
on the ground should be discouraged through health
maintenance (14). Man is an incidental or dead-end host,
and plays no part in virus transmission. education.
4. Chikungunya fever
(c) VECTORS
A dengue-like disease caused by a group A virus, the
The virus has a complex life cycle involving a wide chikungunya virus and transmitted by Aedes mosquitoes. It is
variety of tick-species. At least 15 species of hard ticks of the manifested by high fever and severe articular pains in the
genus Haemaphysalis, particularly H. spinigera and limbs and spinal column. The virus was first isolated from
H. turtura are known to transmit the disease. KFD has also patients and mosquitoes during an epidemic in Tanzania in
been isolated from soft ticks (17). The highest number of 1952-53. Chikungunya is a local word meaning “doubling
human and monkey infections occur during drier months, up” owing to excruciating joint pains. The virus occurs widely
particularly from January to June. This period coincides in sub-Saharan Africa, India and in many areas in Asia.
with the peak nymphal activity of ticks.
After re-emergence of chikungunya in the year 2006,
(d) HOST FACTORS clinically suspected cases declined till the year 2014.
(i) Age : Majority of cases affected were between 20 and However, the disease shows an upward trend since 2015.
40 years, (ii) Sex : Attack rate was greater in males than in Chikungunya is endemic in 24 states and 6 UTs.
females, (iii) Occupation : The attacked people were mostly During 2020, a total of 43,424 suspected cases were
cultivators who visited forests accompanying their cattle or reported from 28 states. The maximum number of cases
cutting woods and (iv) Human activity : The epidemic period were from states as shown in Table 3.
correlates well with the period of greatest human activity in The incubation period of chikungunya fever is 4-7 days,
the forest, i.e., from January until the onset of rains in June. following which the disease has a sudden onset with fever,
chills, cephalalgia, anorexia, lumbago and conjunctivitis.
(e) MODE OF TRANSMISSION Adenopathy is also common. 60 to 80 per cent patients have
The transmission cycle involves mainly monkeys and a morbilliform rash, occasionally with purpura, on the trunk
ticks. The disease is transmitted by the bite of infective ticks, and limbs. The cutaneous eruption may recur every 3 to
by R△J
336 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

TABLE 3 adult. Targeted residual spraying and space spraying/fogging

Top 10 states reporting suspected cases of when there is an outbreak is recommended to rapidly reduce
Chikungunya, India (2018-2020) the adult mosquito population. (b) PERSONAL
2018 2019 2020 (P)
PROTECTION : Personal preventive measures to avoid
States Cases Cases Cases mosquito bites include clothing minimizing skin exposure,
use of repellents, as well as window screens. The use of
Karnataka 20,411 43,698 16,111 insecticide - treated bed nets is limited by the fact that Aedes
Gujarat 10,601 8,084 8,120 mosquito bites during daytime. Eventually economic
Maharashtra 9,884 5,150 4,258 development will reduce mosquito-borne diseases by
Puducherry 2,876 7,084 3,980 improving standard of living (e.g. people living in houses
Kerala 77 109 2,302 with solid floors and roofs, window screen and air
Rajasthan 254 365 1,015 conditioning) (20). (c) VACCINE : No vaccine has yet been
Tamil Nadu 284 623 1,461 developed that is considered suitable for use.
Telangana 1,954 5,352 364
Madhya Pradesh 3,211 2,749 1,871 5. West nile fever
Tripura 683 1,105 454 An acute febrile illness caused by a group B arbovirus.
India 57,813 81,914 43,424 The disease is endemic in Africa, the Middle East, South-
West Asia and India, and transmitted by certain species of
P - Provisional
Culex mosquitoes. Clinically, it is manifested by a sudden
Source : (5) onset of fever, severe headache and malaise lasting several
days. In children, a maculopapular rash of short duration
7 days. Other symptoms are coffee-coloured vomiting, may appear. In the aged, a fatal meningo-encephalitis may
epistaxis and petechiae. A prominent symptom, seen be produced.
especially in adult patients is arthropathy, from which the
disease gets its name. The arthropathy is manifested by 6. Sandfly fever
pain, swelling and stiffness, especially of the
Sandfly fever is known to occur in the arid regions of
metacarpophalangeal, wrist, elbow, shoulder, knee, ankle
West Pakistan and Middle East. Its occurrence in India was
and metatarsal joints. It appears between 3rd and 5th day
thought to be doubtful. However, in 1967, the sandfly fever

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after the onset of clinical symptoms, and it can persist for
virus was isolated in Aurangabad (Maharashtra) from febrile
many months and even years. No deaths have been
cases. The virus was also isolated from sandflies (21). The
attributed to chikungunya fever (11).
control of sandfly fever is based on the control of insect
There is no specific treatment of chikungunya infection vector.
and it is usually self limiting. Analgesics, antipyretics like
paracetamol, diclofenac sodium, chloroquine along with References
fluid supplementation are recommended to manage 1. WHO (1967), Tech. Rep. Ser., No.369
infection and relieve fever, joint pains and swelling. Drugs 2. WHO (2010), International travel and Health, 2010.
like aspirin and steroids should be avoided. 3. WHO (2019), Fact Sheet Japanese Encephalitis, May 2019.
The disease occurs in the rainy season, when the 4. Govt, of India (2020), Annual Report 2019-2020, Ministry of Health
and Family Welfare, New Delhi.
mosquito vector population is at its peak. Research
5. Govt, oflndia (2021), National Health Profile 2021, Ministry of Health
suggests that the virus has a wild cycle, similar to that of and Family Welfare, New Delhi.
yellow fever, operating between jungle primates and 6. WHO (1979), Japanese Encephalitis, Technical Information and
mosquitoes, including Aedes africanus and members of the Guidelines for Treatment, SEA/CD/79, WHO, New Delhi.
A. furcifer-taylori group. 7. National Institute of Virology, Pune (1980). Japanese Encephalitis in
India, ICMR, New Delhi.
DIAGONSIS 8. WHO (2006), Weekly Epidemiological Record, No. 34/35, 25th Aug.
The virus can be isolated from the blood of febrile 2006.
patients by the intracerebral inoculation in suckling mice or 9. Govt, of India (2012), Annual Report 2011 -2012, DGHS, Ministry of
Health and Family Welfare, New Delhi.
on VERO cells. 10. WHO (2005), International travel and health 2005.
In serologic diagnosis, which is the approach most 11. Pan American Health Organization (2003), Zoonoses and
commonly used, sero-conversion is demonstrated by Communicable Diseases Common to Man and Animal 3rd Ed., Vol. II.
comparing acute - and convalescent - phase sera in the 12. Govt, of India, WHO (2014), Operational Guidelines National
haemagglutination inhibition, serum neutralization, or Programme for Prevention and Control of Japanese Encephalitis/
Acute Encephalitis Syndrome, Ministry of Health and Family Welfare,
complement fixation test. The enzyme-linked New Delhi.
immunosorbent assay (ELISA) is used to detect IgM. A 13. Govt, of India (2009), Guidelines, Clinical Management of Acute
reverse-transcription polymerase chain reaction (RT-PCR) / Encephalitis syndrome including Japanese Encephalitis, DNVBDCP,
nested PCR technique has also been shown to be useful in DGHS, Ministry of Health and Family Welfare, New Delhi.
rapidly diagnosing the disease (11). 14. WHO (1985), Tech. Rep. Ser., 721.
15. NICD (1985), Man ual of Zoonosis.
CONTROL 16. Govt, of India (2006), Health Information oflndia 2005, Ministry of
Health and Family Welfare, New Delhi.
(a) VECTOR CONTROL : The Aedes aegypti mosquito
17. Singh K.R.P. (1971), Indian. J. Med. Res., 59 : 312.
should be the main target of control activities. It requires
18. WHO (1984), Chemical methods for the Control of arthropod vectors
active community involvement to keep water storage and pests of Public Health importance.
containers free of mosquitoes and to eliminate the other 19. WHO (2006), Weekly Epidemiological Record No. 43,27th Oct. 2006.
breeding places of mosquitoes in and around houses and 20. WHO (2018), Managing epidemics, Key facts about major deadly
dwellings (4). Vector control strategies should address all life diseases, Version 1.
stages of the Aedes mosquito from the egg to larva and 21. WHO (1975), Wkly Epid Rec., No. 23, 6 June 1975.
by R△J
 BRUCELLOSIS 337
all favour the spread of brucellosis. The infection can travel
BRUCELLOSIS long distances in milk and dust. The environment of a
cowshed may be heavily infected. The organism can survive
Brucellosis is one of the major bacterial zoonoses, and in for weeks, or months in favourable conditions of water,
humans is also known as Undulent fever, Malta fever or urine, faeces, damp soil and manure.
Mediterranean fever. It is occasionally transmitted to man by
direct or indirect contact with infected animals. It is caused Mode of transmission
by different species of the brucella group of organisms and Transmission is usually from infected animals to man.
characterized by intermittent or irregular febrile attacks, with There is no evidence of transmission from man to man (3).
profuse sweating, arthritis and an enlarged spleen. The The routes of spread are :
disease may last for several days, months or occasionally (a) Contact infection : Most commonly, infection occurs
years. Brucellosis is both a severe human disease and a by direct contact with infected tissues, blood, urine, vaginal
disease of animals with serious economic consequences. discharge, aborted foetuses and especially placenta.
Infection takes place through abraded skin, mucosa or
Problem statement conjunctiva (mucocutaneous route). This type of spread is
Brucellosis is a recognized public health problem with largely occupational and occurs in persons involved in
worldwide distribution. It is endemic wherever cattle, pigs, handling livestock and slaughter house workers.
goats and sheep are raised in large numbers. Important (b) Food-borne infection : Infection may take place
endemic areas for brucellosis exist in Mediterranean zones, indirectly by the ingestion of raw milk or dairy products
Europe, Central Asia, Mexico and South America. Eastern (cheese) from infected animals. Fresh raw vegetables can
Mediterranean countries have experienced an increase in also carry infection if grown on soil containing manure from
the number of cases. The disease is now rare in most infected farms. Water contaminated with the excreta of
European countries, North America and Australia (1). infected animals may also serve as a source of infection.
Animal brucellosis is reported from practically every State (c) Air-borne infection : The environment of a cowshed
in India. However, no statistical information is available may be heavily infected. Few people living in such an
about extent of infection in man in various parts of the environment can escape inhalation of infected dust or
country (2). aerosols. Brucellae may be inhaled in aerosol form in

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The prevalence of human brucellosis is difficult to slaughter houses and laboratories, so these infections are
estimate. Many cases remain undiagnosed either because notified as occupational.
they are inapparent or because physicians in many countries
are unfamiliar with the disease. Incubation period
Highly variable. Usually 1-3 weeks, but may be as long
Epidemiological determinants as 6 months or more.
Agent factors Pattern of disease
(a) AGENT : The agents are small, gram-negative rod­ Brucella infection in man can vary from an acute febrile
shaped, non-motile, non-sporing and intracellular disease to a chronic low-grade ill-defined disease, lasting
coccobacilli of the genus Brucella. Four species infect man : for several days, months or occasionally years.
B.melitensis, B.abortus, B.suis, and B.canis. B.melitensis is
the most virulent and invasive species; it usually infects The acute phase is characterized by a sudden or insidious
goats and occasionally sheep. B.abortus is less virulent and onset of illness with (i) swinging pyrexia (upto 40-41 deg C),
is primarily a disease of cattle. B.suis is of intermediate rigors and sweating, (ii) arthralgia/arthritis (usually
virulence and chiefly infects pigs. B.canis is a parasite of monoarticular) involving larger joints such as hip, knee,
dogs, (b) RESERVOIR OF INFECTION : Main reservoirs of shoulder and ankle, (iii) low back pain, (iv) headache,
human infection are cattle, sheep, goats, swine, buffaloes, insomnia, (v) small firm splenomegaly and hepatomegaly,
horses and dogs. In animals the disease can cause abortion, (vi) leucopenia with relative lymphocytosis (4). The most
premature expulsion of the foetus or death. Cross infections striking aspect of the clinical picture is the severity of the
can often occur between animal species. The infected illness and the absence of clinical signs. The acute phase
animals excrete Brucella in the urine, milk, placenta, uterine subsides within 2-3 weeks. If the patient is treated with
and vaginal discharges particularly during a birth or tetracycline, the symptoms may disappear quickly, but the
abortion. The animals may remain infected for life. infection, being intracellular, may persist giving rise to
subacute or relapsing disease.
Host factors In a few patients (upto 20 per cent), symptoms recur for
Human brucellosis is predominantly a disease of adult prolonged periods. Diagnosis is established by isolation of
males. Farmers, shepherds, butchers, and abattoir workers, the organism from cultures of blood, bone marrow, exudates
veterinarians and laboratory workers are particularly at and biopsy specimens during the acute phase of the disease;
special risk because of occupational exposure. Immunity and by serological tests.
follows infection.
Control of brucellosis
Environmental factors (a) IN THE ANIMALS
Brucellosis is most prevalent under conditions of The most rational approach for preventing human
advanced domestication of animals in the absence of brucellosis is the control and eradication of the infection
correspondingly advanced standards of hygiene. from animal reservoirs which is based on the combination of
Overcrowding of herds, high rainfall, lack of exposure to the following measures : (a) Test and slaughter : Case finding
sunlight, unhygienic practices in milk and meat production, is done by mass surveys. Skin tests are available. The
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

complement fixation test is also recommended. Those floodings (2). Although the global burden of disease is
animals infected with brucellosis are slaughtered, with unknown, more than 1 million cases of leptospirosis are
full compensation paid to farmers. This is the only estimated to occur worldwide each year including almost
satisfactory solution aimed at eradication of the disease. 60,000 deaths (3). The incidence in some areas may be as
(b) Vaccination : Vaccine of B. abortus strain 19 is commonly high as 975 cases per lac population. During the past
used for young animals. A compulsory vaccination decade, the occurrence of outbreak has highlighted the
programme for all heifers in a given community on a yearly strong links between leptospirosis and extreme weather
basis can considerably reduce the rate of infection. events in Guyana, India, Philippines and Thailand etc (4).
Systematic vaccination for a period of 7 to 10 years may
result in the elimination of the disease. Control of the Epidemiological determinants
infection caused by B. melitensis in goats and sheep has to
be based mainly on vaccination (5). (c) Hygienic measures :
Agent factors
These comprise provision of a clean sanitary environment (a) AGENT : Leptospira are thin and light motile
for animals, sanitary disposal of urine and faeces, veterinary spirocheates 0.1-0.2 gm wide and 5-15 gm long with
care of animals and health education of all those who are hooked ends. Only the strains of L. interrogans are
occupationally involved. pathogenic. The organisms are visible by dark-field
illumination and silver staining. At present, 23 sero-groups
(b) IN THE HUMANS and 200 serovars have been recognized from various parts of
(a) Early diagnosis and treatment: In uncomplicated cases the world. They are serologically related with cross reactivity,
the antibiotic of choice is tetracycline. For adults in the acute (b) SOURCE OF INFECTION : Leptospira are excreted in the
stage, the dose is 500 mg every 6 hours for about 3 weeks. In urine of infected animals for a long time, often for an entire
patients with skeletal or other complications, intramuscular life time in cases of rodents, (c) ANIMAL RESERVOIRS :
streptomycin 1 g daily in addition to tetracycline usually Leptospirosis affects wild and domestic animals worldwide
achieves a cure, (b) Pasteurization of milk : This is a useful especially rodents such as rats, mice and voles. Most domestic
preventive measure which will render milk and milk products animals including cattle, sheep, goats, water buffalo, pigs and
safe for consumption. Boiling of milk is effective when horses may be infected through grazing in areas
pasteurization is not possible, (c) Protective measures : The contaminated by the urine of the carrier host. Pet animals,
aim is to prevent direct contact with infected animals. particularly dogs may also be infected. Infection may spread

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Persons at risk such as farmers, shepherds, milkmen, abattoir from wild animals to domestic livestock, and then to humans.
workers should observe high standards of personal hygiene. Rats and small rodents - particularly R. norvegicus and Mus
They should exercise care in handling and disposal of musculus are the most important reservoirs (5).
placenta, discharges and foetuses from an aborted animal. Host factors
They should wear protective clothing when handling
carcasses. Exposed areas of the skin should be washed and (a) AGE AND SEX : Males suffer more frequently from
soiled clothing renewed, (d) Vaccination : Human live leptospirosis than females because of greater occupational
vaccine of B. abortus strain 19-BA is available (5). exposure to infected animals and contaminated
environment. Leptospirosis infections occur more frequently
Brucellosis would disappear if it were eradicated from in persons 20-45 years of age group. Leptospirosis rarely
animals. The national and international centre for occurs in young children and infants, possibly, because of
brucellosis is located at FAO/WHO Brucella Reference minimal exposure (6). (b) OCCUPATION : Human infections
Centre, Indian Veterinary Research Institute, Izatnagar, are usually due to occupational exposure to the urine of
(Uttar Pradesh). infected animals, e.g, agricultural and livestock farmers,
References workers in rice fields, sugarcane fields, and underground
sewers, abattoir workers, meat and animal handlers,
1. WHO (1996). World Health Report 1996, Report of the Director- veterinarians etc. (5). Leisure time activities such as
General WHO.
swimming and fishing may also carry risks, (c) IMMUNITY :
2. DGHS, NICD (1985) Manual on Zoonoses.
A solid serovar specific immunity follows infection.
3. WHO (1976) Techn. Rep. Ser., No.598.
4. J.V. ZammitMaempel (1984). Medlnt2 : 85 Feb 1984 Middle Eastern Environmental factors
edition.
5. T. Fujlkuva (1985) World Health July, 1985 P. 13. Leptospirosis infection is unique in that it is acquired
through contact with an environment contaminated by urine
and faeces from carrier (reservoir) animal or other infected
LEPTOSPIROSIS animals. Leptospira shed in the urine can survive for weeks
in soil and water, so environmental contamination may
Leptospirosis is essentially animal infection by several reach high levels in areas where carrier animals frequently
serotypes of Leptospira (Spirocheates) and transmitted to urinate (7). The association of poor housing, limited water
man under certain environmental conditions. The disease supply, inadequate method of waste disposal, all combine to
manifestations are many and varied, ranging in severity make the disease a significant risk for the poor population in
from a mild febrile illness to severe, and sometimes fatal both urban and rural areas. Soil salinity and water logging
disease with liver and kidney involvement. Weils disease is are inter-linked problems. The salinity of the soil and
one of the many manifestations of human leptospirosis. alkaline pH provides favourable environment for survival of
Problem statement leptospires for months. The soil of endemic areas in general
has lower base saturation and mean annual soil temperature
Leptospirosis is considered to be the most widespread of at the depth of 50 cm is 22°C or more and the difference
the disease transmissible from animal to man (1). It has high between mean summer (June-August) and mean winter
prevalence in warm humid tropical countries. Out breaks (December-February) temperature is less than 5°C. This
mostly occur as a result of heavy rainfall and consequent favours the survival of leptospires for long duration (6).
by R△J
 LEPTOSPIROSIS 339
Mode of transmission and ELISA tests are also available. The IgM ELISA is
(a) DIRECT CONTACT : Leptospira can enter the body particularly useful in making an early diagnosis, as it is
through skin abrasions or through intact mucous membrane positive as early as 2 days into illness (9). Now Leptodipstick
test is also available.
by direct contact with urine or tissue of infected animal,
(b) INDIRECT CONTACT : Through the contact of the
broken skin with soil, water or vegetation contaminated by
Control
urine of infected animals or through ingestion of food or (a) ANTIBIOTICS : Penicillin is the drug of choice but
water contaminated with leptospirae. (c) DROPLET other antibiotics (tetracycline, amoxycillin, ampicillin and
INFECTION : Infection may also occur through inhalation as doxycycline) are also effective. The dosage of penicillin is
when milking infected cows or goats by breathing air 6 million units daily intravenously.
polluted with droplets of urine (8). (b) ENVIRONMENTAL MEASURES : This includes
Direct man to man infection is rare (5). preventing exposure to potentially contaminated water,
reducing contamination by rodent control and protection of
Incubation period workers in hazardous occupation. Measures should be taken
Usually 10 days with a range of 4 to 20 days. to control rodents, proper disposal of wastes and health
education etc.
Clinical picture (6)
Vaccination
The clinical spectrum of leptospirosis is very wide, with
mild anicteric presentation at one end to severe leptospirosis Immunization of farmers and pets prevent disease. In
with severe jaundice and multiple organ involvement on the some countries for instance Italy, USSR and China, where
other. Many infections may go unnoticed because of lack of certain occupations carry a high risk of infection, vaccines
significant clinical illness. are available. It is important that they should incorporate
strains of the serotypes that predominate in the particular
Clinical types of leptospirosis are as follows: area since immunity to one type of Leptospira may not
1. Anicteric leptospirosis : It is the milder form of the protect against infection by another (8).
disease. Patient presents with fever with chills, myalgia,
conjunctival suffusion, headache, renal manifestation References

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(some form of renal involvement is invariable), 1. WHO (1978), World Health, Oct. 1978.
pulmonary manifestations (cough and chest pain are 2. WHO (2000), Weekly Epidemiological Record, No. 27, 7th July 2000.
primary manifestations and haemoptysis may occur), 3. CDC (2018), Center for Disease Control and Prevention, Fact Sheet,
and haemorrhagic tendencies. All the clinical features 30th Jan. 2018.
either decrease or disappear within two or three days, 4. WHO (2011), Weekly Epidemiological Record, No. 6, 4th Feb 2011.
and then they may reappear and may progress to severe 5. WHO (2018), Managing epidemics, Key facts about major deadly
diseases, Version 1.
disease (6).
6. National Centre for Disease Control (2015), Programme for
2. Icteric leptospirosis : It is the more severe form of Prevention and Control of Leptospirosis. National Guidelines,
leptospirosis. The patient has jaundice and presents with Diagnosis, Case Management, Prevention and Control of
fever, myalgia (calf muscle tenderness becomes more Leptospirosis, DGHS, New Delhi.
evident), headache, conjunctival suffussion, acute renal 7. WHO (1985), World Health, July 1985.
failure, nausea, vomiting, diarrhoea, abdominal pain, 8. Coghlan, J.D., Post Graduate Doctor, May 1983.
hypotension and circulatory collapse, pulmonary 9. Lawrence M. Tierney, Jr. et al. Current Medical Diagnosis and
Treatment, 38th Ed. 1999, International edition.
insufficiency. Combined renal and liver failure associated
with leptospirosis is referred to as Weil's disease (6).
PLAGUE
Leptospirosis during pregnancy can cause foetal
complications including foetal death or abortion. The case Plague is primarily and basically a zoonoses, caused by
fatality rate for leptospirosis is approximately 5 per cent to Y. pestis, involving rodents and fleas. It exists in natural foci,
15 per cent among patients with severe illness. Among and is transmitted by infected flea bites to humans living or
patients with severe pulmonary haemorrhagic syndrome, intruding into the same ecological environment. Plague
the case fatality can exceed 50 per cent (3). occurs in many forms - enzootically, epizootically,
sporadically and in epidemics of all types including
Diagnosis anthroponotic and primary pneumonic forms. Despite the
It is not possible to diagnose leptospirosis with certainty enormous body of knowledge regarding plague, this
on clinical grounds alone. Because of the wide spectrum of communicable disease continues to pose a threat in many
signs and symptoms, the diagnosis is made by isolation of areas.
leptospires from blood during the acute illness and from
urine after the first week (8). Early in the disease, the Problem statement
organism may be identified by dark-field examination of the
patient’s blood or by culture on a semisolid medium. Culture WORLD
takes 1-6 weeks to become positive. The organism may also Plague is often seen as a problem of the past or an ancient
be grown from the urine from 10th day to 6 weeks. disease that is unlikely to reappear. But continued outbreaks
Diagnosis is usually made by means of serological tests, of throughout the world attest to its tenacious presence. Plague
which several are available. Agglutination tests (microscopic continues to be a threat because vast areas exist where wild
using live organism, and macroscopic using killed antigen) rodents are infected, particularly in endemic countries in
become positive after 7-10 days of illness and peak at Africa, Asia and the Americas. Although plague is
3-4 weeks and may persist at high level for many years. predominantly a rural disease, there have been outbreaks
Indirect haemagglutination, immunoflourescent antibody among urban populations in Madagascar, Democratic
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Republic of Congo and Peru. Plague is a major concern in (d) IMMUNITY : Man has no natural immunity. Immunity
countries where it remains endemic given its inherent after recovery is relative.
communicability, its rapid clinical course and high mortality
if left untreated. Environmental factors
The development of rapid diagnostic tests have (a) SEASON : Outbreaks of plague are usually seasonal
contributed to better case-management and surveillane in in nature. In northern India, the “plague season” starts from
Africa and other continents. September until May. The disease tends to die out with the
The data shows that from 2010 to 2015, a total of 3,248 onset of hot weather. Researches indicated that the curious
cases of human plague, including 584 deaths, were reported phenomenon of “plague season” depended primarily on the
globally (1). field rodent factors; from May onwards all species of rodents
in the fields commenced aestivation, closing themselves in
In 2004, India reported a localized outbreak of bubonic their burrows and living on stored food reserves. Then the
plague (8 cases and 3 deaths) in the Dangud village, District epizootic ceased to advance and at the same time infection
of Uttarkashi. of village rats came to an end. When the field rodents again
Absence of human plague may simply mean that there became active, that is mid-October, when the monsoon
has been reduced human contact with plague bacteria floods had dried up, the epizootic revived in the fields
circulating in nature. Therefore, there is a need to continue followed by human plague (4). On the contrary, in south
to make concerted effort to strengthen surveillance and India, there was no definite plague season. The disease was
improve control measures in order to manage human plague found to be active all the year round. This is attributed
in endemic countries. partly to the topographic and climatic conditions in the
south, favourable for the breeding of the field rodents,
Epidemiological determinants (b) TEMPERATURE AND HUMIDITY : A mean temperature
of 20 to 25 deg. C, and a relative humidity of 60 per cent
Agent factors and above are considered favourable for the spread of
(a) AGENT : The causative agent, Y. pestis is a gram­ plague, (c) RAINFALL : Heavy rainfall, especially in the flat
negative, non-motile, cocco-bacillus that exhibits bipolar fields tend to flood the rat burrows. This factor may be
staining with special stains (e.g., Wayson’s stain). The bacilli responsible for keeping certain states (e.g., Bengal) free
occur in great abundance in the buboes, blood, spleen, liver from plague (5). (d) URBAN AND RURAL AREAS: Plague

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and other viscera of infected persons, and in the sputum of had failed to gain a foothold in many towns of India perhaps
cases of pneumonic plague. The virulence of the organism is due to untoward ecological conditions and lack of efficient
related to its ability to produce exotoxin, endotoxin, flea vectors (as in Chennai and Assam) (5). (e) HUMAN
fraction 1 and many other antigens and toxins. It has been DWELLINGS: Rats, frequent dwelling houses and where
shown that plague bacilli can survive, and indeed multiply in housing conditions are poor, there may be an abundance of
the soil of rodent burrows where micro-climate and other rats and rat fleas all the year round, and contact with man
conditions are favourable (2). occurs readily.
(b) RESERVOIR OF INFECTION : Wild rodents (e.g.,
field mice, gerbils, skunks and other small animals) are the Vectors of plague
natural reservoirs of plague. These are found in mountains, The commonest and the most efficient vector of plague is
deserts, cultivated areas and forests in temperate and the rat flea, X. cheopis, but other fleas may also transmit the
tropical regions. Over 200 species of these small animals infection, e.g., X. astia, X. brasiliensis and Pulex irritans
may carry plague (3). In any given focus, rodent reservoirs (human flea). Both sexes of the flea bite and transmit the
may vary. disease.
In India, the wild rodent, Tatera indica has been
incriminated as the main reservoir, not the domestic rat, Blocked flea
Rattus rattus, as once thought. Generally the disease is A flea may ingest upto 0.5 cu.mm of blood which may
maintained and spread by the resistant species of wild contain as many as 5,000 plague bacilli. The bacilli multiply
rodents, i.e., rodents which have become immune to plague. enormously in the gut of the rat flea and may block the
The susceptible rodents die of the disease. proventriculus so that no food can pass through. Such a flea
(c) SOURCE OF INFECTION : Infected rodents and fleas is called a “blocked flea”. A blocked flea eventually faces
and case of pneumonic plague. starvation and death because it is unable to obtain a blood
meal. It makes frantic efforts to bite and suck blood over and
Host factors over again; and in so doing, it inoculates (regurgitates)
(a) AGE AND SEX : All ages and both sexes are plague bacilli into the bite wound each time it bites.
susceptible. (b)HUMAN ACTIVITIES : Man may come into A blocked flea, therefore, becomes an efficient transmitter of
contact with natural foci in the course of hunting, grazing, plague. A partially blocked flea is more dangerous than a
cultivation, harvesting and construction activities or while completely blocked flea because it can live longer. Infected
engaging in outdoor recreation. These activities offer fleas may live upto an year, and certain species survive in
numerous opportunities to flea-man contact. Social the burrow micro-climate for as long as 4 years (2).
upheavals like war may also account for outbreaks, as had
happened in Vietnam, (c) MOVEMENT OF PEOPLE : Flea indices
Plague is associated with movement of people and cargo by Flea indices are useful measurements of the density of
sea or land. Rats and rat fleas are transported in this way. fleas. They are also useful in evaluating the effectiveness of a
Further, in these days of jet travel, it is possible for a person spraying programme. The following flea indices are widely
to acquire the disease and become ill thousands of miles used in rat flea surveys : (a) TOTAL FLEA INDEX : It is
away where plague would be least suspected. the average number of fleas of all species per rat.
by R△J
 PLAGUE

(b) CHEOPIS INDEX : It is the average number of X. cheopis achieved through the usual simple chain of “Rat-flea-rat”
per rat. It is a specific flea index. It is a more significant index transmission. Probably several other mechanisms are
than the total flea index. If this index is more than ‘one’, it is involved. They include : (a) latent infection in rodents,
regarded as indicative of potential explosiveness of the especially hibernating rodents, has been demonstrated; such
situation, should a plague outbreak occur (6). (c) SPECIFIC animals may relapse and become bacteraemic, so initiating
PERCENTAGE OF FLEAS : It is the percentage of different an epizootic, (b) development of resistance to plague
species of fleas that are found on rats, (d) BURROW INDEX : infection by some rodents with subsequent localization of
It is the average number of free-living fleas per species per plague bacillus in some organ; such an animal may become
rodent burrow (7). a source of infection if eaten by another susceptible rodent.
Flea indices do not in themselves indicate an imminent (c) survival of rat fleas for as long as 4 years in rat burrows
plague epidemic. They serve as a warning that more under optimum micro-climatic conditions. This is considered
stringent control measures are needed to protect the human the most likely mechanism of maintaining the natural focus.
population. (d) variations in the pathogenecity of Y pestis, and
(e) survival and even multiplication of plague bacilli in the
soil of rodent burrows. All these factors may combine to
PLAGUE IN RODENTS keep the infection alive in natural foci.
1. Rodents
4. Epizootic process
Plague is primarily a disease of rodents in which man
becomes accidentally involved. Approximately, 1,700 species The epizootic and enzootic process in each natural plague
of rodents are known, of which over 200 species are focus has its specific cyclic and periodical pattern.
associated with plague. These are found in mountains, Researches into the epidemicity of plague indicated that the
deserts, cultivated areas and forests throughout the world (8). field rodents spread the infection very slowly from burrow to
burrow, and from field to field taking months to cover
Rodents may be classified into two distinct groups : several miles. In this process they infect the village rats
(a) WILD RODENTS : They are the reservoir of plague in (commensal rodents). The commensal rodents especially the
nature. The common wild rodents in India are : Tatera peridomestic species (e.g., R. norvegicus) act as “Liaison
indica, Bandicota bengalensis varius, B. bengalensis kok rodents” between man and field rodents. An outbreak of
(Gunomys kok), B. indica, Millardia meltada, M. gleadoivi human plague is always preceded by rodent plague. After

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and Mus booduga. In India, tatera indica has been the death of house rats, the fleas leave the dead rats and are
incriminated as the main reservoir of plague, not the forced to seek man for food. An unusual mortality among
domestic rat (R. rattus) as once thought. rodents should arouse suspicion of plague and should be
investigated immediately.
(b) COMMENSAL RODENTS : These are the rodents
which live close to man. They may be further divided into 5. Silent periods
domestic and peridomestic species. The domestic species
include Rattus rattus, Rattus norvegicus and Mus musculus. Silences of long duration (10 years or more) followed by
The domestic species seldom live in fields. The peridomestic sudden explosive outbreaks of rodent or human plague have
species live in both fields and houses; R. norvegicus which been repeatedly confirmed in some natural foci (9).
frequents sewers, drains as well as houses is a typical A number of explanations for this phenomenon have been
example of a peri-domestic species in India. Characteristics put forward. It has been suggested that plague disappears
which are easily ascertainable of Rattus rattus and completely for long periods and that it is reintroduced from
R. norvegicus are given elsewhere (see chapter 15). other areas by infected rodents, fleas or migrating birds. On
the other hand, the plague bacillus can survive and indeed
2. Epizootiology multiply in the soil of rodent burrows, where micro-climatic
conditions are suitable. It has been demonstrated that
Plague is epizootic and enzootic in wild rodents. Two healthy rodents re-occupying and excavating such burrows
ecological cycles have been described : may become infected through contact with contaminated
a. WILD PLAGUE : Wild plague is defined as “plague soil (2, 10).
existing in nature, independent of human populations and
their activities” (2). The disease spreads among wild rodents 6. Plague in rodents
by wild rodent fleas. The epizootic wipes out the susceptible Animal disease is similar to that in man. The disease is
population. Those that survive (i.e., resistant species) inapparent or mild in resistant species (11).
maintain the enzootic in natural foci.
b. DOMESTIC PLAGUE : Is defined as “plague that is 7. Investigations
intimately associated with man and rodents living with him, (1) COLLECTION AND FORWARDING OF DEAD
and has a definite potential for producing epidemics (2). RATS : Rodents (house or field) found dead regardless of its
stage of decomposition should be carefully packed in several
3. Natural foci
layers of packing paper or preferably in plastic bags. Such
Worldwide, rodent plague is still firmly entrenched in its rodents should not be handled with naked hands. The neck
natural foci. A “natural focus” of plague has been defined as of the bag should be tied to avoid escape of ectoparasites.
“a strictly delimited area where ecological conditions ensure The bag should then be placed in a wooden box or tin. The
the persistence of the aetiological agent for considerable empty space left in the box or tin should be filled with
periods of time, and where epizootics and periods of absorbent cotton or sawdust to eliminate chances of leakage
quiescence alternate, without introduction of infection from of effluents outside the box. The box is labelled giving
outside” (2). details of collection and sent to the nearest laboratory.
The long persistence of plague in some natural foci is not (2) AUTOPSY AND COLLECTION OF SMEARS : The rat is

by R△J
342 EPIDEMIOLOGY OF COMM,UNICABLE DISEASES

held with a pair of tongs, and dipped in a solution of 5. Man —> man
5 per cent cresol. The animal is laid on its dorsum, stretched This results when a primary case of bubonic
and the limbs nailed on a wooden board. The abdomen is plague develops secondary pneumonic plague
swabbed with lysol or spirit. The skin is lifted and cut up to and infects contacts via the respiratory route.
the chest. The instruments used are then put back into
boiling water. Using another set of instruments, small Incubation period
portions of the viscera (spleen, liver, lungs, bubo) are cut (a) bubonic plague 2 to 7 days
and the freshly cut surface is first blotted on a blotting paper
so as to remove excess of blood or plasma. Then the same (b) septicaemic plague ..................... 2 to 7 days
surface of the tissue is gently pressed on the glass slides so as (c) pneumonic plague ...................... 1 to 3 days
to make thin impressions (never rub the tissue on the slides).
If the rat is completely decomposed and no tissue is left, Disease in man
smears should be obtained from the bone marrow. The There are three main clinical forms : (a) Bubonic
smears are dried, treated with alcohol for three minutes and plague : This is the most common type of the disease. The
fixed by exposure to open flame. The fixed smears may be infected rat fleas usually bite on the lower extremities and
sent for examination. Persons handling infected rats are inoculate the bacilli. The bacilli are intercepted by the
exposed to the risk of pneumonic plague and this danger regional lymphatic glands where they proliferate. Typically
should be borne in mind. (3) ANIMAL INOCULATION : It the patient develops sudden fever, chills, headache,
may be difficult to isolate the plague bacilli by cultural prostration and painful lymphadenitis. Usually within a few
methods owing to gross contamination of the carcass. In days greatly enlarged tender lymph nodes (buboes) develop
such cases, small portions of liver or spleen are taken, in the groin and less often in the axilla or neck, depending
ground in a mortar with a little saline and inoculated into a upon the site of the bite by the flea. When suppuration takes
guinea pig or a white mouse. If there is plague infection, the place it is considered a favourable sign. Bubonic plague
guinea pig will die in 7 days and the white mouse in cannot spread from person to person as the bacilli are locked
48 hours. (4) PATHOLOGICAL CHANGES : The up in the buboes and do not find a way or easy exit.
pathological changes in an animal infected with plague are (b) Pneumonic plague : Primary pneumonic plague is
as follows: (a) there is oedema and necrosis at the site of rare; it generally follows as a complication of bubonic-
injection, (b) the lymph nodes are enlarged, (c) the spleen is septicaemic plague. The incidence of pneumonic plague is

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enlarged and congested, and shows necrotic patches, usually below 1 per cent (5). Pneumonic plague is highly
(d) liver shows mottling, (e) lungs also show necrotic lesions, infectious and spreads from man to man by droplet
and (f) there is subcutaneous congestion and haemorrhages. infection. The plague bacilli are present in the sputum.
(c) Septicaemic plague : Primary septicaemic plague is
rare except for accidental laboratory infections. However,
HUMAN PLAGUE bubonic plague may develop into septicaemic plague in the
face of an overwhelming infection.
Mode of transmission
Laboratory investigations
Human plague is most frequently contracted from :
(a) the bite of an infected flea, (b) occasionally by direct The absolute confirmation of plague infection in human
contact with the tissues of the infected animal or (c) by beings, rodents or fleas requires the isolation and
droplet infection from cases of pneumonic plague. The identification of the plague bacillus. The important
laboratory methods of diagnosis include the following :
dissemination of plague by plague patients (by the bite of
(a) Staining : It is important to prepare smears of the
the human flea, Pulex irritans) is a rare and exceptional
clinical material (e.g., bubo fluid, sputum) which should be
occurrence.
fixed with alcohol and then stained with Giemsa’s or
There are at least 5 basic types of transmission cycles in Wayson’s stain to demonstrate bipolar bacilli in the
plague. These cycles are as follows (8) : specimen, (b) Culture : Blood for culture should be
collected from all patients. Under ideal circumstances,
1. Commensal rats —> rat fleas —>man appropriate culture media should be inoculated on the spot
This is the basic cycle in epidemic bubonic plague. with blood, bubo fluid or sputum to ensure speedy isolation
2. Wild rodents-^ wild rodent fleas or direct contact —>man of the plague bacilli. When this is not possible, the specimen
The disease is transmitted from rodent to rodent must be transported to the laboratory in Cary-Blair
via wild rodent fleas or contaminated soil. Man transport medium, (c) Serology : Acute and convalescent
contracts the infection from infectious wild rodent specimens of blood sera should be collected for antibody
fleas or by direct contact with infected rodents. studies, (d) Other methods : These include inoculation of
guinea pigs or mice or immunofluorescent microscopic test.
3. Wild rodents, peridomestic rodents, commensal rodents
—> wild rodent fleas, peridomestic rodent fleas,
PREVENTION AND CONTROL
commensal rodent fleas —>man
Plague foci impinge upon the habitats of 1. Control of cases
peri-domestic or commensal rodents. Interaction
of the rodents and their fleas convey the infection (a) EARLY DIAGNOSIS : During epidemic situations,
to man. diagnosis of plague can be made readily on clinical grounds,
e.g., acute fever and painful lymph node enlargement
4. Man —> human flea (Pulex irritans) —»man developing into buboes in the inguinal and other regions of
This variety may be encountered in certain areas. the body. In other situations, “rat falls” (dead rats) provide a

by R△J
 PLAGUE

useful warning of a possible outbreak. It is essential that circumstances, vaccination should be only for the
plague-suspected humans and rodents be examined prevention, not the control of human plague (2). To be
bacteriologically to confirm the presence of plague. It is effective, vaccination should be carried out at least a week
often possible to arrive at a prima facie diagnosis by the before an anticipated outbreak, and the vaccine should be
examination of smears that show the characteristic bipolar given in 2 doses.
stained plague bacilli (8). (b) NOTIFICATION : If a human In 1897, Haffkine developed a killed plague vaccine
or rodent case is diagnosed, health authorities must be while working in India and inoculated himself with his
notified promptly. Case notification is required by experimental vaccine (14). The vaccine used currently is
International Health Regulations (13). (c) ISOLATION : that of Haffkine, modified by Sokhey. It is a formalin-killed
Although most bubonic plague patients are non-infectious, vaccine. Virulent strains of Y. pestis are grown in casein
isolation is recommended whenever possible. All patients hydrolysate broth for 2 weeks at 27 deg. C and killed by
with pneumonic plague including suspected cases should be treatment with 0.1 per cent formalin for 3 days at 37 deg. C.
isolated, (d) TREATMENT : Treatment must be started The final vaccine is a suspension of 2000 million killed
without waiting for confirmation of the diagnosis (2). Unless organisms per ml (15).
promptly treated, plague may have a mortality of nearly The vaccine is given subcutaneously in two doses of
50 per cent, and pneumonic plague 100 per cent. The drug 0.5 and 1.0 ml at an interval of 7 to 14 days. A single dose
of choice is streptomycin (30 mg per kg of body weight will not result in dependable protection. However, in an
daily) administered intramuscularly in two divided doses for emergency, when it is desired to carry out primary
7 to 10 days. Tetracycline orally (30-40 mg per kg of body immunization by means of a single injection, the dose
weight daily) is an alternative drug, and is sometimes given should be double the second dose, that is, 3 ml for adult
in combination with streptomycin (12). Gentamycin males (15). Immunity starts 5 to 7 days after inoculation,
administered as a 2 mg/kg body wt. loading dose, then and lasts for about 6 months. Booster doses are
1.7 mg/kg body wt. every 8 hours intravenously is effective. recommended six-monthly for persons at continuing risk of
Penicillin is rather ineffective. Sulphonamides may be used if infection (e.g., geologists, biologists and anthropologists).
other drugs are not available, (e) DISINFECTION : The recommended doses of the vaccine are given in Table 3.
Disinfection of sputum, discharges and articles soiled by the The reactions after inoculation (pain, tenderness, headache,
patient should be carried out. Dead bodies should be etc) appear in a few hours and subside in 1 to 2 days. The
handled with aseptic precautions. vaccine is indicated for travellers to hyperendemic areas

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besides persons at special risk.
2. Control of fleas TABLE 3
The most effective method to break the chain of Dosage of plague vaccine
transmission (rodent flea —» man) is the destruction of rat n■ • i x-
fleas by the proper application of an effective insecticide. Flea Primary inoculation Booster dose
Age and Sex six-monthly
control must precede or coincide anti-rodent measures. The 1st dose 2nd dose
choice of insecticide is dictated by the results of prior Adult males 1.0 ml 1.5 ml 1.0 ml
susceptibility tests. In general DDT and BHC should be used Adult females 0.75 ml 1.0 ml 0.75ml
as dusts containing 10 per cent and 3 per cent of the active
Children
ingredient respectively. In areas where resistance to one or
1-4 years 0.2 ml
both of these insecticides occurs, dusts of carbaryl (2%) or
5-10 years 0.3 ml Double the Same as the
malathion (5%) should prove effective. About 2 to 3 g of
11-16 years 0.4 ml J first dose first dose
insecticide formulation will be needed for each sq. metre of
Infants under 6 months
surface requiring treatment (8). Generally the organochlorine are not immunized.
insecticides remain effective for 2 to 4 months.
Source : (15)
Before spraying is to be done, the inhabitants of premises
should be asked to remove all foodstuffs and eating and 5. Chemoprophylaxis
cooking vessels from their houses. Spraying is done inside the
houses covering the entire floor area, bottoms of all walls up Chemoprophylaxis is a valuable preventive measure,
to 3 feet above floor level, back of the doors, roofing of highly recommended. It should be offered to all plague
thatched houses, crevices of walls, rat runs, clothing, bedding, contacts, medical, nursing and public health personnel
cats, dogs and other pets. Rat burrows should be insufflated exposed to the risk of infection. The drug of choice is
with the insecticidal dust with the help of a dust blower. tetracycline. For adults, the dose is 500 mg 6-hourly for
Insecticidal spraying up to a radius of 5 miles around each 5 days (16). A cheaper alternative is sulfonamide, 2 to
infected locality is considered adequate (8). Within 48 hours 3 gram daily for 5 to 7 days.
of application, the “flea index” should drop down to zero (8).
6. Surveillance
3. Control of rodents Plague has a potential for spread into susceptible areas.
Continuous mass destruction of rodents is an important Therefore, in areas where natural plague foci exist or where
plague-preventive measure. The long-term policy for the there is a history of past infection, surveillance is essential.
control of rodents should be based on improvement of Surveillance should cover all aspects of rodent and human
general sanitation, improvement of housing and quality of plague, e.g., microbiology, serology, entomology,
life. The various antirodent measures are given elsewhere. mammalogy, epidemiology and ecology. On the basis of
information provided by surveillance, effective control
4. Vaccination measures must be established (14). Surveillance of plague in
Immunization with plague vaccine is a valuable its natural foci should, therefore, replace quarantine
preventive measure. The WHO recommends that under all measures which have been shown to be ineffective (2).

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

7. Health education the control and prevention of plague. An organizational

Health education is an essential part of any plague basis should be established for rapid emergency services in
the event of an epidemic.
control programme. Education should aim at providing the
public with the facts about plague and at enlisting their Reporting of cases and outbreaks of plague (17)
cooperation. Emphasis must be placed on the need for the
prompt reporting of dead rats and suspected human cases The WHO should be informed promptly of the
so that preventive measures can be taken. Medical occurrence of any epidemic or isolated case of plague. The
practitioners should keep plague in mind in differential report should include details about the administrative area
diagnosis of any cases of fever with lymphadeno-pathy, or and exact locality involved. This preliminary notification
when multiple cases of pneumonia occur (2). should be followed up as soon as possible by a more
detailed report containing the following information :
Epidemiological investigations (17) (a) The locality and administrative area, shown on a map
The determination of the source of infection and the if possible
distribution, prevalence, and potential spread of plague in (b) The date, the first case was noticed
human population is the main objective of epidemiological (c) The period during which field investigations were
surveillance. This means that those engaged in surveillance made
must evaluate human plague in its relationship with
epizootic factors and that the investigations must be based (d) The number and types of cases of plague detected :
on direct contact with villages and other communities - clinical diagnosis only (presumptive)
affected by plague. While the collection of demographic - laboratory diagnosis (confirmed)
data and information on such subjects as population - recovered and confirmed serologically
movements and local occupations, customs, and habits is
important, special attention must be given to the factors - types of cases - bubonic, pneumonic, etc.
bringing man into contact with the vertebrate reservoirs and - age of patient with a confirmed diagnosis of
vectors of y. pestis. plague
Some of the responsibilities of the surveillance team are - number of deaths
as follows : (e) The contacts of known cases

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(1) to make a detailed study of all cases of human - serological test results
plague, giving special attention to dwellings where - throat swab results
cases have occurred, in order to establish the
rodent/vector source of the infection or the (f) Chemotherapy applied
occurrence of man-to-man transmission; - number of frank cases
(2) to keep complete and uniform records of each - number of contacts
case of plague, using standardized forms, and to (g) Vertebrate host population
issue questionnaires to the population at risk;
- identification of domestic rodents
(3) to isolate strains of Y pestis and subject them to
detailed biochemical analysis, samples being - identification of wild rodents
lyophilized for later study; - results of laboratory test for plague
(4) to make a serological survey of the target (h) Vector population
population; such surveys are of value in - identification of X. cheopis
investigation of possible cases of subclinical - identification of other species of flea
plague, of recovered untreated infections, and of
asymptomatic pharyngeal infection in “carriers”; - results of laboratory tests for infection
(5) to investigate changes in the human population, - results of insecticide resistance tests
social or economic activities, and other features of - control measures applied.
natural foci where there is close contact between
human populations and commensal rodents; References
(6) to keep a watch on containerized cargoes of grain 1. WHO (2017), Fact Sheet on Plague, Oct., 2017
and other food crops originating in areas with 2. WHO (1970). Tech. Rep. Ser. No. 447.
3. WHO (1982). Vo/. 60.
natural plague foci and destined for national or
4. WHO (1960). WHO Chr. 14 : 422.
international trade; 5. Seal, S.C. (1960). Bull WHO 23 : 286.
(7) to undertake surveillance in cooperation with 6. WHO (1974). Tech. Rep. Ser. No. 553.
adjacent countries when natural foci are common 7. WHO (1972). Tech. Rep. Ser. No. 501.
to two or more countries; 8. Bahmanyar, M. et al (1976). Plague manual Geneva, WHO.
9. WHO (2002), Weekly Epidemiological Record, No. 9,1st March, 2002.
(8) to give special attention, in the case of seaports or 10. WHO (1970). WHO Chr. 24 (8) 371-373.
airports, to the proximity of natural foci where 11. WHO (1982). Tech. Rep. Ser. No. 682.
there is contact between wild and commensal 12. Akier, A.K. (1982). Bull WHO, 62 (2) 165-169.
rodents, the proximity of epidemics, and the 13. WHO (1983). Int Health 3rd annotrated ed Geneva, WHO.
transport of cargo from enzootic areas. 14. WHO (1980). Bull WHO R753.
15. Banker, D.D. (1969). Modern Practice in Immunization, The Indian
The surveillance team should also be prepared to assist Journal of Medical Sciences Mumbai.
the national or community health service in organizing and 16. Issacson, M. (1981). Medicine International, 3 : 127.
carrying out the treatment of human cases and measures for 17. WHO (1974), WHO Chronicle, Vol.28, No.2, February 1974, p.71.

by R△J
 HUMAN SALMONELLOSIS

animals. The source of the infecting agent could be

HUMAN SALMONELLOSIS contaminated food, animals, man or the environment.

The term “salmonellosis” covers a complex group of (a) Foods

foodborne infections affecting both man and animals (1). Foods of animal origin, particularly commercially
The disease causes illness and even death in humans, as well prepared foods such as meat, poultry and egg products are
as economic losses in the animal and food industries. The considered to be the primary sources of salmonellosis. Most
term “food poisoning” is also commonly applied to of these foods, e.g., meat and poultry become contaminated
salmonellosis. during slaughter. Every food that is produced or processed
(including chocolates, spices, coconut) in a contaminated
Problem statement environment may become contaminated. Cross­
Salmonellosis is a global problem (2). Human contamination of cooked foods from raw ingredients,
salmonellosis represents 60 to 80 per cent of all reported kitchen utensils or surfaces has been described frequently as
cases of foodborne diseases (3). a cause of salmonellosis (5). Eggs may be infected directly
While the incidence of typhoid fever has declined, the through shell-cracks. Recent investigations suggest that
incidence of other Salmonella infections has increased in the salmonellae may penetrate the ovaries of egg-laying
developed countries. The problem is aggravated by the chickens. What food will ultimately become the vehicle
widespread use of animal feeds containing antimicrobial varies from country to country (6). For example, in the USA,
drugs that favour drug-resistant salmonellae and their beef is the main source of salmonella infection, while
potential transmission to humans. The disease can occur in England and Wales poultry accounts for more than
sporadically or in small outbreaks in the general population 50 per cent of Salmonellosis outbreaks (2).
and usually from food contaminated at its source. The extent (b) Animals
of the problem is not clear in developing countries where
diarrhoeal diseases are widespread (2). Animals are the hosts and the principal vectors of
zoonotic salmonellosis. Many animals including cattle,
Epidemiological determinants swine, rodents and fowl are naturally infected with a variety
of salmonellae and have the bacilli in their tissues (meat),
Agent factors eggs or excreta. Carriers occur among both man and

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animals.
AGENT : Salmonellae comprise a large and important
group of bacteria. This group is now known to comprise (c) Environment
more than 2,500 serotypes capable of infecting humans (4), Salmonellae are widely distributed in the environment -
but in most countries only a small number of them (usually in dust, water, manure, sewage, sludge, vegetables, insects,
about 10) are endemic at any one time (5). birds, fish, rodents and other mammals. They can survive in
Compared with other gram-negative rods, salmonellae soil for months (6). They may even multiply in the warm
are relatively resistant to various environmental factors. environment provided by the high ambient temperatures of
They have been shown to be resistant to drying, salting, many countries. Man may be infected from these sources.
smoking and freezing even for years. This explains why Multidrug resistant strains of salmonella are now
these organisms survive in many kinds of food. As a result, encountered frequently. Resistance to fluoroquinolones and
salmonellae have been isolated from divergent foods such as third generation cephalosporins is a serious development,
chocolates, biscuits, coconuts and spices. The bacterium is which results in severe limitation of the possibilities for
sensitive to heat and will not survive temperatures above effective treatment of human infections (4).
70 deg C.
From an epidemiological point of view, salmonellae can Mode of transmission
be classified into three main groups (2). By ingestion of contaminated food or drink. In addition,
(i) those which infect only man - e.g., S. typhi, man can contract infection following direct contact with
S. paratyphi A and C. domestic animals especially such as dogs, pigeons, rats,
(ii) those that are host-adapted for particular species mice and insects. Once man is infected, he becomes a
of animals, e.g., S. cholera~suis in swine, S. dublin source (case or carrier) and the infection may spread to
in cattle, S. abortus equi in horses, S. gallinarum in others by the faecal-oral route.
poultry, etc. Some of these are also pathogenic for Transmission is facilitated by food handling methods,
man, e.g., S. cholera-suis, S. dublin. local customs, cooking and food habits, food processing,
(iii) those with no particular host preference and can storage and distribution methods, and prevailing sanitary
infect both man and animals - e.g., S. conditions.
typhimurium, S.enteritidis. In this group
(approximately 2,200 serovars) are the principal Incubation period
agents of salmonellosis that occurs today (2). 6 to 72 hours (usually).
They can be transmitted from animals to man and
vice versa. S. typhimurium is responsible for upto Clinical features
50 per cent or more of all human salmonella
The disease arises from the ingestion of the living
infections all over the world. S. enteritidis has also
emerged as an important pathogen. organisms. Recent studies indicate that Salmonella spp.
possess both invasive and cholera-like enterotoxic
RESERVOIR AND SOURCES OF INFECTION : The main properties (6). Clinically, the disease may manifest by one of
reservoir of Salmonella is the intestinal tract of man and the three syndromes :

by R△J
346 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(i) Enteric fever : S. typhi, S. paratyphi A and C are excepted). Increasingly, it is realized that rickettsial diseases
human pathogens, and are not considered zoonotic agents are under-diagnosed and that they contribute substantially
(2). S. paratyphi B, while predominantly found in man has to the acute febrile burden and preventive illness in many
also been isolated from turkeys, chickens, cattle, sheep, populations (1). -
swine, mice and monkeys. This syndrome (enteric fever) is
dealt with separately (see page 276 under typhoid fever). Classification
(ii) Salmonella enterocolitis (gastroenteritis) : This is the Rickettsial diseases may be grouped on the basis of
most common manifestation of Salmonella infection. 6 to 48 clinical features and epidemiological aspects as follows
hours after ingestion of Salmonellae there is nausea, (Table 1).
headache, vomiting and diarrhoea. Low grade fever is
TABLE 1
common. Most infections are mild with diarrhoea as the only
Rickettsial diseases
symptom. In severe cases there may be dehydration
requiring replacement of fluids and electrolytes. The episode Rickettsial Insect Mammalian
Diseases agent vectors reservoirs
usually resolves in 2 to 3 days, but the stools often remain
loose for several weeks. The excretion of salmonella may be 1. Typhus group
prolonged by antimicrobial therapy. Blood cultures are a. Epidemic typhus R. prowazekii Louse Humans
usually negative but stool cultures are positive for salmonella b. Murine typhus R. typhi Flea Rodents
and may remain positive for several weeks after clinical c. Scrub typhus R. tsutsugamushi Mite* Rodents
recovery. Death is rare and occurs primarily in neonates, 2. Spotted fever group
infants and elderly. a. Indian tick R. conorii Tick* Rodents,
(Hi) Septicaemia with focal lesions : Non-typhoid typhus dogs
salmonellae (e.g., S. cholera-suis) may occasionally invade b. Rocky mountain R. rickettsii Tick* Rodents,
spotted fever dogs
the blood stream leading to generalized or localized infection
c. Rickettsial pox R. akari Mite* Mice
presenting itself as pyrexia of unknown origin. Focal
infection may result in osteomyelitis, pyelonephritis, 3. Others
a.Q fever C. burnetii Nil Cattle, sheep,
arthritis, meningitis, cholecystitis and endocarditis. Stool goats
cultures are negative but blood cultures are positive. b. Trench fever Rochalimaea Louse Humans

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quintana
Prevention and control
Since salmonellosis is zoonotic in origin, preventive *Also serves as arthropod reservoir, by maintaining the rickettsiae
measures should begin at the farm and embrace all the through ovarian transmission.
elements of the food chain through live animals, animal Source : (2)
products, processing, final food preparation to consumption.
Approaches indicated at the farm level are : (i) disease Causal agents
control, e.g., immunization of farm animals against
Rickettsiae are small bacteria that are obligate
salmonellosis, (ii) the use of hygienic animal feed, and
intracellular parasites. They are pleomorphic, appearing
(iii) ensuring a sanitary environment for the animals. The
either as short rods, or as cocci and they occur singly, in
aim is to raise “salmonella-free” animals.
pairs, in short chains, or in filaments. With Giemsa’s stain
The other approaches include : hygienic slaughtering and they stain blue and are readily visible under microscope.
milking, pasteurization of milk and eggs; proper disposal of They grow readily in the yolk sac of the embryonated egg.
liquid and solid wastes, cold storage facilities, and health Rickettsial growth is enhanced by the presence of
education and training. sulfonamides.
Since the health sector alone cannot solve the problem of
salmonellosis, responsibility for prevention and control Clinical features
measures may fall to agriculture, veterinary and other Excepting for Q fever, in which there is no skin lesion,
ministries, outside the health sector (1, 7). rickettsial infections are characterized by fever, headache,
malaise, prostration, skin rash and enlargement of the
References spleen and liver. Tetracycline is the drug of choice for
1. WHO (1982). Economic aspects of communicable diseases, EURO68. specific treatment of all rickettsial diseases. Long-acting
2. WHO (1988). Salmonellosis control: the role of animals and product antibiotics (doxycycline, minocycline) now make single dose
hygiene, TRS 774. treatment possible (3).
3. WHO (1988). WH Forum; 9 (1) 123.
4. WHO (2005). Fact Sheet No. 139, Drug-resistant Salmonella. Diagnostic procedures
5. WHO (1976). TRS 598 (Microbiological aspects of food hygiene).
6. Velimirovic, B. et al (1984). Infectious diseases in Europe, Afresh look These include : (a) isolation of rickettsiae. (b) established
WHO, Copenhagen. serological tests such as indirect fluorescent antibody (IFA)
7. WHO (1984) TRS 705 (The role of food safety in health and develop). test, the complement fixation test, and the Weil Felix
reaction. The newer techniques include ELISA and the
RICKETTSIAL ZOONOSES fluorescent antibody staining of frozen tissue sections from
rickettsial lesions.
(Rickettsial diseases)
Among the major groups of rickettioses, the commonly
Rickettsial zoonoses are a group of specific reported diseases in India are scrub typhus, murine flea-
communicable diseases caused by rickettsial organisms and born typhus, Indian tick typhus and Q fever. These are
transmitted to man by arthropod vectors, (Q fever considered in more detail :

by R△J
 RICKETTSIAL ZOONOSES J
SCRUB TYPHUS (benzyl benzoate) and application of mite repellents
(diethyltoluamide) to exposed skin surfaces (5). No vaccine
exists at present.
Distribution
Of the diseases caused by rickettsiae in man, the most MURINE TYPHUS
widespread is scrub typhus. It exists as a zoonoses in nature (Endemic or flea-borne typhus)
between certain species of trombiculid mites and their small
mammals (e.g., field mice, rats, shrews). Scrub typhus is
endemic in Northern Japan, South East Asia, the Western Distribution
Pacific Islands, Eastern Australia, China, Maritime areas and Murine typhus (MT) is a zoonoses. It is worldwide in
several parts of South-Central Russia, India and Sri Lanka. distribution especially in areas of high rat infestation. It
More than 1 million cases occur annually. Most travel- appears to be more prevalent in South-East Asian and
acquired cases of scrub typhus occur during visits to Western Pacific countries than previously recognized. In
rural areas in endemic countries for activities such as USA, cases tend to be scattered. Successful isolation of the
camping, hiking or rafting, but urban cases have also been causative agent from rats, fleas and bandicoots was made at
described (4). many places in India. Focal infections are often associated
with docks and shipping places where rats abound.
Epidemiological determinants
Agent factors
Agent factors
(a) AGENT : Rickettsia typhi (R. mooseri).
(a) AGENT : The causative agent of scrub typhus is (b) RESERVOIR OF INFECTION : Rats are the reservoir
Rickettsia tsutsugamushi. There are several serologically (Rattus rattus and R.norvegicus). Infection in rats is
distinct strains, (b) RESERVOIR : The true reservoir of inapparent, long-lasting and non-fatal.
infection is the trombiculid mite (Leptotrombidium delinese
and L.akamushi). The infection is maintained in nature Mode of transmission
transovarially from one generation of mite to the next. The
nymphal and adult stages of the mite are free-living in the The infection spreads from rat to rat (X. cheopis) and
soil; they do not feed on vertebrate hosts. It is the larva possibly by the rat louse (6). The actual mode of transmission
is not by the bite of the rat flea, but by (i) inoculation into skin

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(chigger) that feed on vertebrate hosts and picks up the
rickettsiae. The larval stage serves both as a reservoir, of faeces of infected fleas, and (ii) possibly by inhalation of
through ovarian transmission, and as a vector for infecting dried infective faeces. There is no direct man to man
humans and rodents. transmission. Once infected the flea remains so for life. The
flea cannot transmit the rickettsiae transovarially. The
Mode of transmission transmission cycle may be shown as below :
By the bite of infected larval mites. The transmission Rat —> Rat flea —> Rat —> Rat flea —> Rat
cycle may be depicted as below :
Mite —> Rats and mice —> Mite Rats and mice Man

Incubation period
Man
1 to 2 weeks, commonly 12 days.
The disease is not directly transmitted from person to
person. Clinical features
Incubation period The clinical features resemble that of louse-borne typhus,
but milder and rarely fatal. The Weil Felix reaction with
Usually 10 to 12 days; varies from 6 to 21 days.
Proteus OX-19 becomes positive in the 2nd week.
Clinical features
Control measures
Scrub typhus resembles epidemic typhus clinically. The
(a) TREATMENT : Tetracycline is the only drug of choice.
onset is acute with chills and fever (104°-105°F), headache,
Since rickettsial growth is enhanced in the presence of
malaise, prostration and a macular rash appearing around
sulfonamides, these drugs should not be given.
the 5th day of illness. Generalized lymphadenopathy and
(b) CONTROL OF FLEAS : Residual insecticides (e.g.,
lymphocytosis are common. One typical feature is the
BHC, malathion) are effective against rat fleas. Rodent
punched-out ulcer covered with a blackened scab (eschar) control measures should be implemented in the affected
which indicates the location of the mite bite. The pyrexia
areas. No murine typhus vaccine is currently available.
falls by lysis in the 3rd week in untreated cases. The
Weil Felix reaction is strongly positive with the Proteus
strain OXK. INDIAN TICK TYPHUS

Control measures Epidemiological determinants

(a) TREATMENT : Tetracycline is the drug of choice.
With proper therapy the mortality is nil. (b) VECTOR Agent factors
CONTROL : Clearing the vegetation where rats and mice (a) AGENT : The causative agent is Rickettsia conorii, a
live; application of insecticides such as lindane or chlordane member of the spotted fever group of rickettsiae, the best
to ground and vegetation, (c) PERSONAL PROPHYLAXIS : known member of which is R. rickettsii the causative agent
Impregnating clothes and blankets with miticial chemicals of Rocky Mountain spotted fever, (b) RESERVOIR OF

by R△J
348 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

INFECTION : The tick is the reservoir of infection. It is Mode of transmission

infective at all stages of its life cycle and remains infective for
Q fever differs from other rickettsial infections in that
life (commonly 18 months). Various tick genera (e.g.,
there is no arthropod involved in its transmission to man.
Rhipicephalus, Ixodes, Boophilus, Haemaphysalis) have
Transmission results from : (i) inhalation of infected dust
been incriminated as vectors. Infection in nature is
from soil previously contaminated by urine or faeces of
maintained by transovarian and trans-stadial passage. The
diseased animals. The organism can also be transmitted
rickettsiae can be transmitted to dogs, various rodents and
through aerosols, (ii) the organism can also gain entry into
other animals, which assist in maintaining the disease cycle.
the body through abrasions, conjunctivae or ingestion of
Mode of transmission contaminated foods such as meat, milk and milk products. In
most countries, the respiratory route is regarded as most
Man is only an accidental host. He acquires infection by important.
the bite of an infected tick. Contamination of skin with
crushed tissues or faeces of an infected tick may also cause Incubation period
infection. The cycle of transmission is as follows : Usually 2 to 3 weeks.
Tick —» Tick —> Tick —» Tick
Clinical features
Dog Man The disease has an acute onset with fever, chills, general
■J/ malaise and headache. The clinical picture is one of
influenza or non-bacterial pneumonia rather than a typhus
Tick —> Man fever. There is no rash or local lesion. The infection can
cause pneumonia, hepatitis, encephalitis and rarely
Incubation period endocarditis. Inapparent infections also occur.
Usually 3 to 7 days.
Control measures
Clinical features (a) TREATMENT : Chronic Q fever requires prolonged
The patient usually gives history of a recent tick-bite and treatment for 18 months or longer. Doxycycline is the drug
a careful examination will reveal a lesion or eschar at the site of choice, (b) PREVENTIVE MEASURES : Pasteurization or

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of the bite. After an interval of 3 to 7 days, there is an acute boiling of milk to inactivate the causative agent; providing
onset of fever, which may persist for 2 to 3 weeks, malaise sanitary cattle sheds; adequate disinfection and disposal of
and headache. A maculopapular rash appears on the third products. An inactivated Coxiella vaccine has also been
day. Unlike the rash in other rickettsial diseases, the rash prepared to protect occupationally exposed workers. Several
appears first on the extremities (ankles and wrist), moves purified vaccines are under development (8).
centripetally and involves the rest of the body. The clinical
syndrome may be confused with atypical measles. OTHER RICKETTSIAL INFECTIONS
Control measures
1. Epidemic typhus
(a) TREATMENT : Broad spectrum antibiotics have
proved to be effective, (b) PERSONAL PROPHYLAXIS : Epidemic or louse borne typhus was in the past the most
formidable disease caused by rickettsiae. It was the cause of
Known tick-infested areas should be avoided. Daily
devastating epidemics among military and refugee
inspection of the body for ticks is particularly important for
populations and in areas affected by famine. The advent of
those who are exposed to the risk of infection. Disinfection
modern insecticides has considerably reduced the
of dogs will minimize the tick population. Health education
prevalence of epidemic typhus today.
of the people in the mode of transmission by ticks, and the
means of personal protection is equally important. No cases of this disease have been reported from South
East Asia since 1978 or from the Western Pacific since 1969
Q FEVER (1). It is still endemic in Africa (notably Burundi, Rwanda
and Ethiopia) and South America (notably Peru, Bolivia,
and Ecuador). All of them are known endemic areas of the
Distribution disease.
Q fever is a highly infectious zoonotic disease with world­ The infection is transmitted from man to man by the
wide distribution. It occurs mainly in persons associated with infected louse (P corporis and P capitis). The louse gets
sheep, goats, cattle or other domestic animals. infected by feeding on an infectious patient during the
febrile stage. The organisms multiply in the cells lining the
Agent factors intestinal tract of the louse and begin to appear in 3 to
(a) AGENT : The causative agent is Coxiella burnetii. It is 5 days in the louse faeces. Man acquires the disease not by
found in ticks which act as vectors as well as reservoir, the bite of the louse, but : (i) by scratching and inoculating
(b) ANIMAL HOSTS : Cattle, sheep, goats, ticks and some himself with the infected louse faeces (ii) by crushing an
wild animals are natural reservoirs. Infected animals shed infected louse on his person, and (iii) possibly by inhalation
the disease agent in the faeces and urine and heavily of infected louse faeces or dust. The infected louse after
contaminate the soil. The placenta of infected cows and 10-14 days of existence dies of the infection. In humans, the
sheep contains the infectious agent which may create organisms can persist for many years as latent infection
infectious aerosols during parturition. Camels, horses, dogs without any symptoms, and the disease may appear later as
and many other domestic animals have been shown to be Brill-Zinsser disease, and can be transmitted to other
capable of acting as maintenance hosts (7). humans by the louse.

by R△J
 TAENIASIS 349
The control measures comprise anti-louse measures and Hosts of infection
improvements in personal hygiene and living conditions. T. saginata and T. solium pass their life cycles in two
Under the International Health Regulations, louse-borne hosts. In man, the adult parasites live in the small intestine.
typhus is subject to international surveillance. The adult T. saginata measures 5 to 12 metres in length, and
may be up to 24 metres; T. solium measures 2 to 6 metres.
2. Rickettsialpox
Man gets the infection through the bite of certain infected TABLE 1
mites, which are found on mice (Mus musculus). Hosts of infection
Transovarial transmission occurs in the mite. The mouse acts
Parasite Definitive Intermediate host
as true reservoir as well as vector. Rickettsialpox may be
confused with atypical cases of chickenpox. 1. T. saginata Man Cattle (C. bovis)
2. T. solium Man Pig (C. cellulosae)
3. Trench fever
This disease is limited to central Europe. The vector is The larval stage of T. saginata (C. bovis) mainly occurs in
louse and the disease is transmitted by louse faeces. Man is cattle. The pig is the main host for the larval stage of
the only known reservoir. T. solium (C. cellulosae) but man may also be infected. This
may lead to muscular, ocular and cerebral cysticercosis.
References The adult stages of T. saginata and T. solium may persist
1. WHO (1983). Bull WHO 61: 443. for several years in infected humans. Mixed infections of
2. Jawetz E et al (1986). Reiuew of Medical Microbiology 17th ed. Lange both the parasites can occur. Although the life span of
Med. Publ. California. C. cellulosae in man is not known, it is suspected to be some
3. WHO (1975). The work of WHO, Geneva. years.
4. Current Medical Diagnosis and Treatment, by Maxine A Padakis etc.,
2014 ed., A Lange Publication. Mode of transmission
5. WHO (1982). Bull WHO, P162.
6. Saah, J.J. and Hormick, R.B. (1979). In Principles and Practice of These infections are acquired : (a) through the ingestion
Infectious Diseases, G.L. Mandell et al (eds), John Wiley, New York. of infective cysticerci in undercooked beef (T. saginata) or
7. Sehgal, S and R. Bhatia eds (1985). Manual on Zoonosis NICD, 29- pork (T. solium); (b) through ingestion of food, water or

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Sham Nath Marg, Delhi-54. vegetables contaminated with eggs; and (c) reinfection by
8. Kazar, J. et al (1982). Bull WHO, 60 (3) 389-394. the transport of eggs from the bowel to the stomach by
retroperistalsis is considered to be rare.
TAENIASIS Incubation period
For the adult tapeworm, from 8 to 14 weeks.
A group of cestode infections which are important zoonotic
diseases. Three parasites of importance in taeniasis are Taenia Clinical illness
saginata, T. solium and T. asiatica. These are classified as The impact of tapeworm infection in man is difficult to
‘‘cyclo-zoonoses” because they require more than one quantify because in the vast majority of cases, they do not
vertebrate host species (but no invertebrate host) to complete lead to clinical illhealth, except occasional abdominal
their developmental cycles. discomfort, anorexia and chronic indigestion.
Humans can become infected with T. saginata or Straying of proglottids may sporadically cause
T. asiatica when they consume beef meat or pig liver tissue, appendicitis or cholangitis. The most serious risk of T. solium
respectively, which has not been adequately cooked, infection is cysticercosis.
infection with the T. solium tapeworm occurs when humans
eat raw or undercooked, infected pork. Tapeworm eggs pass Human cysticercosis
with the faeces and are infective for pigs. Infection in Human infection is caused by the ingestion of eggs of
humans with the T. Solium causes few clinical symptoms. T. solium in contaminated water or food (hetero-infection) or
However, infection with the larval parasite in the tissue regurgitated eggs from the small intestine (auto-infection).
(human cysticercosis) can result in devastating effect on The eggs disintegrate and the infective stages leave the
human health. The larvae may develop in the muscle, skin, intestine via the hepatic portal system, and are dispersed
eyes and the central nervous system (neurocysticercosis). throughout the body where they develop to form cysticerci.
Neurocysticercosis is the most frequent preventable cause of Cysticerci that develop in the central nervous system (neuro­
epilepsy worldwide, and is estimated to cause 30 per cent cysticercosis), represent a serious threat to the individual and
of all epilepsy cases in countries where the parasite is even to the community, if this condition is prevalent. As a
endemic (1). result of mechanical pressure, obstruction or inflammation, a
Cysticercosis mainly affects the health and livelihood of variety of pathological changes are produced, leading to
communities in developing countries of Africa, Asia and epilepsy, intracranial hypertensive syndromes,
Latin America. In 2010, the WHO added T. solium hydrocephalus, psychiatric diseases or death (2).
cysticercosis to the list of major Neglected Tropical Diseases.
In 2015, the WHO Foodborne Disease Burden Control measures
Epidemiology Reference Group identified T. solium as a The methods usually employed for control are :
leading cause of deaths from food-borne diseases resulting (a) treatment of infected persons, (b) meat inspection,
in a considerable total of 2.8 million DALYs lost and an (c) health education, and (d) adequate sewage treatment
estimated 2.56-8.30 million symptomatic and asymptomatic and disposal (1, 2). Early detection and early treatment of
neurocysticercosis (1). T. solium cases is essential to prevent human cysticercosis.
by R△J
350 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Effective drugs (e.g., praziquantel and niclosamide) are Geographic distribution

available for the treatment of these infections. Surgical
Hydatidosis has been recognized as a public health
removal of symptom-producing cysts is indicated although
problem of nearly global dimensions. It is found in all
cure can seldom, if ever, be complete. In many countries,
sheep-raising countries, e.g., Australia, New Zealand,
T. solium has been controlled by meat inspection and by the
Tasmania, Middle East countries, Turkey, Greece, USSR,
proper housing and feeding of pigs. Thorough cooking of
Cyprus, Latin America and the Far East etc. It is believed
beef and pork is the most effective method to prevent food-
borne infections. Education of the public to prevent that there are relatively few countries in which cestodes of
pollution of soil, water and food with human faeces, and the genus Echinococcus are entirely absent (1). Foci are also
washing of hands before eating and after defecation, are known to exist in India where the highest prevalence is
important health educational messages. Improvement of reported in Andhra Pradesh and Tamil Nadu, than in other
living conditions, especially safe treatment of sewage used parts of the country. The prevalence of the disease is
for farming, should be aimed at. reported to be high in food animals in India.
More than 1 million people are living with cystic
Treatment echinococcosis and alveolar echinococcosis worldwide at
Praziquantel and niclosamide have replaced former any one time. For cystic echinococcosis, there is an average
taenicides (i.e., mepacrine). They are safe and effective in of 2.2 per cent post-operative death rate for surgical patients
more than 90 per cent of patients. Praziquantel is given in a and about 6.5 per cent of cases relapse after the
single dose of 10 mg/kg. body wt. It achieves cure rates of interventions, thereby requiring prolonged recovery time. In
about 99 per cent. At this dose, side effects are minimal. 2015, WHO Foodborne Disease Burden Epidemiology
With a single dose of 4 tablets (2 grams) of niclosamide, cure Reference Group estimated echinococcosis to be the cause
rates are over 90 per cent. This drug is given in the of 19,300 deaths and around 871,000 DALYs lost globally
morning-empty stomach. The tablets must be chewed each year. Annual cost associated with cystic echinococcosis
thoroughly and swallowed with water. Eating may be are estimated to be US $ 3 billion for treating the cases and
resumed after 2 hours. It usually produces no side effects. losses to the livestock industry (1).
Pre and post-treatment purges are not used for either drug
to treat T. saginata. For the treatment of T. solium, give Epidemiological determinants
moderate purgative 2-3 hours after the drug to rapidly

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eliminate segments and eggs from the bowels to avoid- Agent factors
theoretical possibility of cysticercosis (3). Echinococcus species are small tapeworms, rarely more
TREATMENT FOR CYSTICERCOSIS (3) : The than 7 mm in length. The scolex bears four suckers, and
treatment should be individualized, based on the number there are two rows of hooks, one small and one large on the
and location of cysts and their viability. Medical treatment is rostellum. The number of proglottids varies from 2 to 6.
more effective for parenchymal cysts and less effective for At present four species are regarded as valid.
intraventricular, subarachnoid, or recemose cysts. (a) E. granulosus : of worldwide distribution, is for the
Albendazole and praziquantel are both effective in the most part, maintained in the domestic transmission cycle
treatment. 10-15 mg/kg body wt/day of albendazole is given involving the dog as final host. In man the infective larva
twice daily with a fatty meal. The duration of treatment is causes hydatidosis, the “unilocular” type of echinococcosis.
unsettled. Seven to 14 days may be sufficient for some (b) E. multilocularis : is restricted to the northern
patients, but a longer course (up to 28 days) is advisable at hemisphere. It has been detected increasingly in various
present. It can be repeated as necessary. Up to 3 months of countries (e.g. Iran, Turkey). In man, the metacystode
treatment may be needed for ventricular and subarachnoid causes the “alveolar” type of the disease, (c) E. oligarthus : a
cysts. Praziquantel is given in 50 mg/kg/day in three divided species occurring in Central and South America is suspected
doses for 15 days. to cause disease in man, and (d) E. Vogeli : a species
Albendazole is the drug of choice because co­ occurring in Central and South America, has been shown to
administration of albendazole and a steroid (to treat cause polycystic hydatidosis.
inflammation) results in increased albendazole absorption,
whereas combined use of praziquantel and steroid greatly Life cycle
decreases plasma level of praziquantel. Both the drugs are Basically it is a “dog-sheep” cycle with man as an
given with fatty meals as this increases absorption four-fold accidental, intermediate host. The adult tapeworm lives in
to five-fold. the small intestine of dogs (definitive host) for 2 to 4 years.
References The eggs are voided in the faeces and contaminate the soil,
vegetation and drinking water. They are highly resistant and
1. WHO (2018) Fact Sheet Taeniasis/Cysticercosis, 15th February 2018. can survive for several months in pastures, gardens and
2. WHO (1981) Tech. Rep. Ser. 666. around households. Sheep, cattle and other intermediate
3. Current Medical Diagnosis and Treatment 2004, Ed. by Lawrence M.
Tierney, Jr. Stephen J. Mcphee, Maxine A. Papadakis, Lange hosts become infected when they ingest vegetation which
publication. has become contaminated with faeces from infected dogs.
Ingested eggs hatch in the intestine and the larvae penetrate
HYDATID DISEASE the intestinal lining and migrate to various organs of the
body. Most frequently, they lodge in such organs as liver,
Hydatid disease is a zoonoses - a group of cestode lungs and brain and develop into hydatid cysts. The life
infections which are important zoonotic diseases of man. The cycle is completed when sheep (cattle) viscera containing
disease in man is caused by the metacystode stage (infective hydatid cysts are eaten by dogs. Infected dogs begin to pass
larva) of the canine intestinal tapeworm Echinococcus; the eggs of the parasite approximately 7 weeks after infection.
adult worms are found in dogs and other carnivores. Man does not harbour the adult worm (1).

by R△J
 HYDATID DISEASE

Host factors relatively simple method with a high sensitivity superior to

It is becoming increasingly evident that human that of some other serological procedures (1). The
behaviour, especially in relation to dogs and cats, intradermal (Casoni) test is still in wide use, since it is simple
uncontrolled slaughter of food animals, indiscriminate to perform. This test often lacks specificity.
disposal of offal and carcasses, and eating habits of the
people play an important part in the epidemiology of the Treatment
disease. Human infection is acquired usually in childhood There is no specific treatment excepting surgical removal
through contact with infected dogs. The impact of of cysts which is not without considerable risk in as much as
hydatidosis can be described only in terms of human the accidental penetration of one of the cysts can lead to
suffering, cost of medical diagnosis, hospitalization and anaphylactic shock which may prove fatal.
surgery, man-hours lost, as well as in terms of temporary or Mebendazole (Vermox) has been tried and found very
permanent incapacity. The retarded growth of animals, and effective in mice. It may well become the drug of choice.
reduction in the quality and yield of meat, milk and wool
and condemnation of offal are also very great (2). Hydatid Prevention and control (4)
disease is an occupational disease of certain groups, e.g.,
shepherds and their families in endemic areas and 1. Wash fruits and raw vegetables before eating.
shoe-makers. 2. Wash hands before eating or smoking, after handling
dogs and after contact with items that are likely to be
Mode of transmission soiled with dog faeces.
Human infection occurs by ingestion of the eggs of 3. Discourage dogs from licking people's faces, and do not
Echinococcus inadvertently with food, unwashed vegetables kiss dogs.
or water contaminated with faeces from infected dogs.
Infection can also take place while handling or playing with 4. Do not allow dogs to defecate near vegetable gardens or
infected dogs, e.g., hand to mouth transfer of eggs, or by children’s play areas.
inhalation of dust contaminated with infected eggs. The 5. Reduce the amount of disease in dogs
disease is not directly transmissible from person to person. - Ensure dogs are kept away from the areas where
The disease is maintained in the “dog-sheep” cycle. animals are slaughtered and are not allowed to

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Other animal combinations may also be involved, e.g., dog­ scavenge on carcasses.
goat, dog-cattle, and dog-camel. Carnivores get infected by - Prevent dogs from eating uncooked offal.
eating viscera containing hydatid cysts. The disease is not
directly transmissible from one intermediate host to another. - Dispose of infected offal by deep burial or burning to
prevent it from being consumed by dogs or other
Incubation period canines.
Variable, from months to years depending upon the - Reduce dog populations on farms to the occupational
number and location of cysts and how rapidly they grow. need for them.
- Seek advice from your veterinarian about effective
Clinical features treatment to prevent infection in working, pet or
In man, symptoms of hydatid disease are usually visiting dogs. This is particularly important for dogs in
manifested several years after exposure. The cysts grow rural areas or those that may have contact with
slowly from 5 to 20 years before they are diagnosed. The wildlife or feral animals.
size of the cyst may vary from a pinhead to that of a small
football. It has been estimated that more than 70 per cent of References
the cysts become located in the right lobe of the liver, and 1. WHO (2018), Fact Sheet, Echinococcosis, 8th February, 2018
the rest in lungs, brain, peritoneum, long bones and kidney. 2. WHO (1974). WHO Chr. 28 (3) 110.
The cysts are filled with watery fluid and contain a large 3. Jawetz, Melnick and Adelberg's Medical Microbiology (2014), 26th
number of tapeworm heads. If the cyst ruptures, the brood Ed., A Lange Publication.
capsules can spill out of the cyst, metastasize to other sites 4. Queensland Govt. (2017), Health Condition! 14! 165!81! Hydatid-
Disease.
and develops into a hydatid, thus ingestion of a single egg
can give rise to several hydatid cysts, each containing
several brood capsules (3). LEISHMANIASIS
Cysts of small size are generally asymptomatic. Large
cysts, however, cause pressure symptoms (e.g., jaundice in Leishmaniasis are a group of protozoal diseases caused
liver cysts). In vital organs they may cause severe symptoms by parasites of the genus Leishmania, and transmitted to
and death. man by the bite of female phlebotomine sandfly. They are
responsible for various syndromes in humans - kala-azar or
Diagnosis visceral leishmaniasis (VL), cutaneous leishmaniasis (CL),
(a) Clinical : Based on the history of residence in an muco-cutaneous leishmaniasis (MCL), anthroponotic
endemic area, close association with dogs and the presence cutaneous leishmaniasis (ACL), zoonotic cutaneous
of a slowly growing cystic tumour, (b) X-ray : A plain X-ray leishmaniasis (ZCL), post-kala-azar dermal leishmaniasis
permits the location of the cyst. Modern techniques of (PKDL), etc (1). The visceral type of disease, kala-azar, is
diagnosis include ultrasonography, MRI and CAT scan. still an important disease in India. The majority of the
(c) Serological : Serological tests with a high degree of leishmaniasis are zoonoses involving wild or domestic
sensitivity and specificity have been introduced such as the mammals (rodents, canines). Some forms (e.g., Indian kala-
indirect immunofluorescent test. ELISA is regarded as a azar) are considered to be nonzoonotic infections (2).
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Problem statement TABLE 2

The epidemiological profile of VL and PKDL cases in
WORLD endemic states (India-2016)
Leishmaniasis is endemic in many countries in tropical
and subtropical regions. The 3 main forms of the disease are
distributed as follows (3):
1. Visceral leishmaniasis (VL), also known as Kala-azar is
fatal if left untreated in over 95% of cases. It is
characterized by irregular bouts of fever, weight loss,
enlargement of the spleen and liver, and anaemia. Most
cases occur in Brazil, East Africa and in South-East Asia.
An estimated 50,000 to 90,000 new cases of VL occur
worldwide each year. In 2020, more than 95% of new Source: (2)
cases reported to WHO occurred in 10 countries : Brazil,
Ethiopia, India, Kenya, Somalia, South Sudan, Sudan, Epidemiological determinants
China, Yemen and Eritrea.
Agent factors
2. Cutaneous leishmaniasis (CL), is the most common form
(a) AGENTS : The leishmania are intracellular parasites.
of leishmaniasis and causes skin lesions, mainly ulcers,
on exposed parts of the body, leaving life-long scars and They infect and divide within macrophages. At least
serious disability. About 95% of CL cases occur in the nineteen different leishmania parasites have been associated
Americas, the Mediterranean basin, the Middle East and with human infection. Further, the majority of these offer no
Central Asia. In 2020 over 85 per cent of new CL cases cross immunity of one against the other (6). Leishmania
occurred in 8 countries: Afghanistan, Algeria, Brazil, donovani is the causative agent of kala-azar (VL); L. tropica
Colombia, Iraq, Libya, Peru, Pakistan, Tunisia and the is the causative agent of cutaneous leishmaniasis (oriental
Syrian Arab Republic. It is estimated that between sore); and, L. braziliensis is the causative agent of muco­
600,000 to 1 million new cases occur worldwide cutaneous leishmaniasis. But this distinction is not absolute;
annually. visceral forms may produce cutaneous lesions, and
cutaneous forms may visceralize (7). The life cycle is

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3. Muco-cutaneous lesihmaniasis leads to partial or total completed in two different hosts - a vertebrate and an
destruction of mucous membranes of the nose, mouth insect; in the former, it occurs in an amastigote form (called
and throat. Over 90% of muco-cutaneous leishmaniasis “leishmania bodies”) and in the latter as a flagellated
cases occur in Bolivia (the Plurinational State of) Brazil,
promastigote. (b) RESERVOIRS OF INFECTION : There is a
Ethiopia and Peru.
variety of animal reservoirs, e.g., dogs, jackals, foxes,
Kala-azar situation is worsening due to the occurrence of rodents and other mammals. Indian kala-azar is considered
asymptomatic cases, post-kala-azar dermal leishmaniasis to be a non-zoonotic infection with man as the sole
(PKDL), undernutrition, and kala-azar/HIV coinfection. reservoir. This assumption is based largely on the absence of
Case fatality rate has decreased perhaps due to improved evidence (8).
case management in endemic countries.
Host factors
INDIA
(a) AGE : Kala-azar can occur in all age groups including
Kala-azar is endemic in 54 districts in Bihar (33), infants below the age of one year. In India, the peak age is
Jharkhand (4), West Bengal (11) and Uttar Pradesh (6). 5 to 9 years (IL (b) SEX: Males are affected twice as often as
About 130 million population is at risk of the disease. The females, (c) POPULATION MOVEMENT : Movement of
present situation is shown in Table 1. While both cutaneous population (migrants, labourers, tourists) between endemic
(ZCL and ACL) and visceral (VL) disease occur in India, and non-endemic areas can result in the spread of infection.
kala-azar is by far the most important leishmaniasis in (d) SOCIO-ECONOMIC STATUS : Kala-azar usually strikes
India (5). Kala-azar has been declared as notifiable disease the poorest of the poor. Poverty increases the risk for kala-
in Bihar and West Bengal (5). azar. Poor housing and domestic sanitary conditions (e.g.
lack of waste management, open sewerage) may increase
TABLE 1 sandfly breeding and resting sites, as well as their access to
State-wise Kala-azar cases and deaths in India (2018-2020) humans. Sandflies are attracted to crowded housing as these
provide a good source of blood-meal. Human behaviour,
State
2020 2019 2018 such as sleeping outside or on the ground, may increase risk.
Cases Deaths Cases Deaths Cases Deaths As a disease it more often debilitate than kills, and makes
people become dependants on others; (e) MALNUTRITION:
Bihar 1,502 0 2,537 0 3,569 0
Diets lacking protein-energy; iron, vitamin A and
West Bengal 60 3 87 6 96 3 zinc increases the risk that an infection will progress to kala-
Uttar Pradesh 55 3 97 0 110 0 azar (3). (f) OCCUPATION : The disease strongly associates
Jharkhand 431 0 544 0 758 0 with occupation. People who work in various farming
practices, forestry, mining and fishing have a great risk of
India 2,052 6 3,269 6 4,539 3 being bitten by sandflies, (g) IMMUNITY : Recovery from
Source : (4) kala-azar and oriental sore gives a lasting immunity. During
the active phase of kala-azar, there is impairment of cell
The epidemiological profile of VL and PKDL cases in mediated immunity, this is reflected in the negative skin
these 4 endemic states are as shown in Table 2. reaction to leishmanin test.
by R△J
 LEISHMANIASIS 353
Environmental factors years after apparent cure of kala-azar. The lesions consist of
multiple nodular infiltrations of the skin, usually without
(a) ALTITUDE : Kala-azar is mostly confined to the
ulceration. Parasites are numerous in the lesion.
plains; it does not occur in altitudes over 2000 feet
(600 metres), (b) SEASON : In the past epidemics, two 2. Cutaneous leishmaniasis
peaks, one in November and another in March-April were
reported. Generally there is high prevalence during and after Several forms of cutaneous leishmaniasis have been
rains, (c) CLIMATE CHANGES : Kala-azar is climate described - Anthroponotic or urban cutaneous leishmaniasis
sensitive, and is strongly affected by changes in rainfall, (ACL), Zoonotic or rural cutaneous leishmaniasis (ZCL),
temperature and humidity. Global warming and land Diffuse cutaneous leishmaniasis (DCL), etc (1). The disease
degradation together affect the epidemiology of kala-azar in may be mistaken for leprosy. The agent is restricted to skin.
many ways. It can have strong effects on vector and The disease is characterized by painful ulcers in the parts of
reservoir hosts by altering their distribution and influence the body exposed to sandfly bites (e.g., legs, arms or face)
their survival. Drought famine and flood resulting from reducing the victim’s ability to work.
climate changes can lead to massive displacement and 3. Muco-cutaneous leishmaniasis
migration of people to areas with transmission of kala-azar,
and poor nutrition could compromise their immunity (3). Ulcers similar to the oriental sore (CL) appear around the
(d) RURAL AREAS : The disease is generally confined to margins of mouth and nose. It can mutilate the face so badly
rural areas, where conditions for the breeding of sandflies that victims may become social outcasts.
readily exist compared to urban areas, (e) VECTORS : In
India, P. argentipes is a proven vector of kala-azar. Laboratory diagnosis
Cutaneous leishmaniasis is transmitted by P. papatasi and 1. Rapid diagnostic test
P sergenti. Sandflies breed in cracks and crevices in the soil
and buildings, tree holes, caves etc. Overcrowding, The rapid dipstick test has become the mainstay in the
ill-ventilation and accumulation of organic matter in serological diagnosis of Kala-azar, and is the method of
the environment facilitate transmission. Their habits choice for diagnosis of the disease.
are primarily nocturnal. Only the females bite, The rk39 - rapid diagnostic test is based on the
(f) DEVELOPMENT PROJECTS : Ironically many recombinant k39 protein. It is an epitope apparently
development projects are exposing more people to

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conserved on amastigotes of Leishmania species that cause
leishmaniasis. Forest clearing, and cultivation projects, large visceral infection. The test is simple to perform and yields
water resource schemes, and colonization and resettlement result within five minutes. However, the test should not be
programmes are bringing human beings into areas of high used in Kala-azar relapse cases, Kala-azar reinfection cases
vector and reservoir concentration (3). and Kala-azar and HIV co-infection cases.
Kala-azar dipstick test strip is a membrane, pre-coated
Mode of transmission with a recombinant VL antigen on the test line region and
In India, Kala-azar is transmitted from person to person chicken anti-protein A on the control line region. It is a
by the bite of the female phlebotomine sandfly, P argentipes immunochromatographic assay for qualitative detection of
which is a highly anthrophilic species. Transmission may antibodies to L. donovani in human serum. During testing
also take place by contamination of the bite wound or by the serum sample reacts with the dye conjugate. The mixture
contact when the insect is crushed during the act of feeding. then migrates upwards on the membrane
Cutaneous leishmaniasis is transmitted by P papatasi and chromatographically by capillary action to react with rk39
P sergenti. antigen on the membrane and generates a red line. Presence
After an infective blood meal, the sandfly becomes of this red line indicates a positive result while its absence
infective in 4 to 25 days (extrinsic incubation period). This is indicates a negative result.
the time required for the development of the parasite in the Regardless of the presence of antibody to VL antigen, as
insect vector. Transmission of kala-azar has also been the mixture continues to migrate across the membrane to the
recorded by blood transfusion (7), and is also possible by immobilized chicken antiprotien A region, a red line at the
contaminated syringes and needles (9). control line will always appear. The presence of this red line
serves as a verification for sufficient sample volume and
Incubation period proper flow, and is a control for the reagent. If no lines
The incubation period in man is quite variable, generally appear at control and test line areas, the test is invalid. The
1 to 4 months; range is 10 days to 2 years. test is also invalid if no control line appears, even though a
test line is seen (10).
Clinical features
2. Parasitological diagnosis
1. Kala-azar (VL) The demonstration of the parasite LD bodies in the
The classical features of kala-azar are fever, aspirates of the spleen, liver, bone marrow, lymph nodes or
splenomegaly and hepatomegaly accompanied by anaemia in the skin (in the case of CL) is the only way to confirm VL
and weight-loss. A family history of the disease is also or CL conclusively. The parasite must be isolated in culture
common. Darkening of the skin of the face, hands, feet and to confirm the identity of the parasite.
abdomen is common in India (kala-azar = black sickness).
Atypical features of the disease (e.g., lymphadenopathy) 3. Aldehyde test
may also occur. Kala-azar, if left untreated, has a high The aldehyde test of Napier is a simple test widely used in
mortality. India for the diagnosis of kala-azar. 1 to 2 ml of serum from
PKDL : Post-kala-azar dermal leishmaniasis, caused by a case of kala-azar is taken and a drop or two of 40 per cent
L. donovani, is common in India. It appears one to several formalin is added. A positive test is indicated by jellification
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

to milk-white opacity like the white of a hard-boiled egg so c. Relapse : any reappearance of kala-azar signs and
that in ordinary light newsprint is invisible through it. If it symptoms within a period of six months after the
occurs within 2 to 20 minutes, it is said to be strongly end of treatment.
positive. Reaction after 30 minutes is not significant. The d. Treatment failure : non-response or relapse.
test usually becomes positive 2 to 3 months after onset of e. Final cure : an initially cured patient who is
the disease, and reverts to negative 6 months after cure. symptom-free at six months after the end of
Therefore, this test is good for surveillance but not for treatment.
diagnosis. The test is non-specific and demands the use of
venous blood. Further, the test is positive in many other 3. Case definition of PKDL
chronic infections in which albumin to globulin ratio is a. Probable PKDL : a patient from kala-azar endemic
reversed. area with multiple hypopigmented macules, papules
or nodules, who is RDT positive.
4. Serological tests b. Confirmed PKDL : a patient from kala-azar endemic
Of the numerous serological tests available, Direct area with multiple hypopigmented macules, papules,
Aggutination test (DAT), rk39 dipstick test, ELISA and the plaques or nodules, who is parasite positive in slit­
indirect fluorescent antibody test (IFAT) are considered most skin smear (SSS) or biopsy.
suitable (10). Being a simple test where blood samples can
be collected on a filter paper strip and examined at leisure in Treatment outcome in PKDL
laboratory, the ELISA test has a wide potential both for a. Initial cure : Clinical improvement at the end of
diagnosis as well as for epidemiological field surveys. treatment - defined as a considerable reduction in the
number and size of skin lesions.
5. Leishmanin (Montenegro) test
b. Final cure : Clinical cure 12 months after the end of
This test is based on skin reaction. Leishmanin is a treatment - defined as a complete resolution of macules,
preparation of 106 per ml washed promastigotes of papules, plaques and nodules.
leishmania, suspended in 0.5 per cent phenol saline or
merthiolate. Sterile and standardized preparations are Key Indicators in the kala-azar elimination
available commercially. An intradermal injection of 0.1 ml
initiative (11)
on the flexor surface of the forearm is given and examined

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after 48 to 72 hours. Induration is measured and 1 Detection rate (%)
recorded. An induration of 5 mm or more is considered
positive. The test is usually positive 4 to 6 weeks after Number of new cases of KA detected
onset in the case of CL and MCL. It is usually negative in per year in the district, UHC or subdistrict
the active phase of kala-azar and becomes positive in x 100
Total population in the same area
75 per cent patients within one year of recovery. The test is
not species-specific. The test remains a valuable tool for 2. Treatment completion rate (%)
distinguishing immune from non-immune subjects. From Number of patients that took a
this information, it may be possible to infer the endemicity full course of first-line drugs
or epidemicity of the infection and to identify groups at risk xlOO
of infection (10). All new KA cases that started treatment
in a given period
6. Haematological findings
3. Coverage rate of vector control (%)
These include progressive leucopenia, anaemia and
reversed albumin-globulin ratio, with greatly increased IgG. Number of households protected
The WBC:RBC ratio is 1:1500 or even 1:2000 (normal x 100
All households at risk
1:750). ESR is increased.
ICMR has developed a new kit to diagnose Kala-azar, Monitoring clinical outcomes (11)
which was launched on 3rd Sept. 2014. The test needs the
sample of urine or oral fluid of the subject in question. It is 1. Final cure rate (%)
mixed with the given solution in the 'tube' - part of the kit. Number of patients with final cure
Dip the stipulated strip in the solution thus created. Those x 100
Total number who started treatment
infected would get two or one red bond on the strip once it
comes out. Absence of the red bond means negative result. 2. Treatment failure rate (%)
Some definitions (11) Total number of non-response +
relapse + KA - related deaths
1. Case definition of kala-azar : A case of kala-azar is x 100
defined as a person from an endemic area with fever of Total number who started treatment
more than 2 weeks duration and with splenomegaly, who
is confirmed by an RDT or a biopsy.
3. Loss to follow-up rate (%)
2. Treatment outcome definitions of kala-azar Number of defaulters +
Number of loss to follow-up
a. Cure : a patient is considered clinically cured if he/ x 100
she has completed full treatment and there are no Total number who started treatment
signs and symptoms of kala-azar. 4. Mortality (%)
b. Non-response : Signs and symptoms persist or recur
despite satisfactory treatment for more than two Number of deaths
x 100
weeks. Total number who started treatment

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 LEISHMANIASIS

CONTROL MEASURES Dosage guide for children (2-11 years)

In the absence of an effective vaccine, the control Body Daily dosage Number of capsules
measures comprise the following : weight (after meal)
9-11 kg 20 mg 2 capsules of Miltefosine 10 mg
1. Control of reservoir
12-16 kg 30 mg 3 capsules of Miltefosine 10 mg
Since man is the only reservoir of kala-azar in India,
active and passive case detection and treatment of those 17-20 kg 40 mg 4 capsules of Miltefosine 10 mg
found to be infected (including PKDL) may be sufficient to 21-25 kg 50 mg 1 capsule of Miltefosine 50 mg
abolish the human reservoir and control the disease. 26-31 kg 60 mg 1 capsule of Miltefosine 50 mg
House-to-house visits and mass surveys may be undertaken & 1 capsule of Miltefosine 10 mg
in endemic areas for early detection of cases.
32-39 kg 80 mg 1 capsule of Miltefosine 50 mg
TREATMENT GUIDELINES (2017) & 3 capsules of Miltefosine 10 mg

Following drugs are used for the treatment of kala-azar in 40 kg and 100 mg 2 capsules of Miltefosine 50 mg
Indian programme (2, 7) : above

- Single dose Liposomal Amphotericin B (LAMB) injection Miltefosine dosage guide for persons (>12 years)
intravenously across all age groups in dose of 10 mg/kg
bw including paediatric, pregnant & elderly patients. Weight Morning dose Evening dose
- Miltefosine capsules of 10 mg (paediatric) and 50 mg (after meal) (after meal)
(adults) in the age group between 2-65 years. Not to be More than 25 kg 1 capsule of 1 capsule of
given to pregnant and lactating women and women who Miltefosine 50 mg Miltefosine 50 mg
refuse contraception during treatment with Miltefosine.
Less than 25 kg 1 capsule of Drug not to be
Dosages are: patients > 12 years, weight > 25 kgs- Miltefosine 50 mg given at evening
100 mg daily in two doses of 50 mg each after meals for
28 days, and patients > 12 years, weight < 25 kgs, National Road Map on Kala-azar elimination was
' only one capsule of 50 mg daily x 28 days. Children developed in August 2014 with specific time line, roles and

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2-11 years miltefosine to be given at 2.5 mg/kg once responsibility for states and district level vector borne
daily after meals x 28 days. diseases consultants and technical supervisors.
- Amphotericin B deoxycholate injection intravenously at
a dose of 1 mg/kg b.w. on alternate days x 15 doses. Animal reservoirs
- Combination of Paromomycin injection intramuscular & If animal reservoirs (e.g., dogs) are involved, appropriate
Miltefosine in a dose of 11 mg/kg b.w. x 10 days together control measures against them should be undertaken. In
with Miltefosine for 10 days. Not to be given to chronic many endemic countries, extensive dog and rodent control
kidney patients, pregnant and lactating women, and programmes have contributed greatly to the reduction in the
those not inclined to contraception during treatment. number of human cases.
- HIV-coinfected patients - LAMB 40 mg /kg b.w as total 2. Sandfly control
dose of 3-5 mg/kg bw daily or intermittently for 10
doses, on days 1-5, 10, 17, 24, 31 and 38. The application of residual insecticides has proved
effective in the control of sandflies. DDT is the first choice
- PKDL - In order of preference: First drug of choice, since the vector of kala-azar, P. argentipes is susceptible to
miltefosine 100 mg orally per day x 12 weeks. DDT. (P. papatasi in north Bihar has been shown to be
- Amphotericin ’B’ deoxycholate injection 1 mg/kg bw over resistant to DDT, but fortunately, it is not the vector of kala-
4 months in 60-80 doses. azar in India). Insecticide spraying should be undertaken in
Given the high efficacy, safety, ease of use and assured human dwellings, animal shelters and all other resting places
compliance, Liposomal Amphotericin B (LAMB) is used as upto a height of 6 feet (2 metres) from floor level. DDT (two
the first line of treatment. The drugs used in order of rounds per year) at the rate of 1-2 g per sq. metre is
preference at all levels are: considered sufficient to control transmission. Spraying
should be preceded and followed by an assessment of
- Liposomal Amphotericin B intra venous (LAMB) single susceptibility. Any sign of resistance in vector should lead to
dose 10 mg/kg bw an immediate change in insecticide. BHC should be kept as
- Combination regimens (e.g. Miltefosine capsules plus a second line of defence.
Paromomycin inj IM) Spraying should be repeated at regular intervals to keep
- Amphotericin B emulsion down the density of sandflies. For long-lasting results,
- Miltefosine capsule insecticidal spraying should be combined with sanitation
measures, viz elimination of breeding places (e.g., cracks in
- Amphotericin B deoxycholate inj in multiple doses mud or stone walls, rodent burrows, removal of firewood,
- Amphotericin B emulsion inj in selected districts on pilot bricks or rubbish around houses), location of cattle sheds
project. and poultry at a fair distance from human dwellings, and
Miltefosine is relatively safe oral drug for the treatment of improvement of housing and general sanitation.
Kala-azar. The treatment is provided as Directly Observed
Treatment (DOT) with patient coding system being followed 3. Personal prophylaxis
for each patient registered at the treatment centre. The dose The risk of infection can be reduced through health
guide is as follows education and by the use of individual protective measures

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

such as avoiding sleeping on floor, using fine-mesh nets 41 endemic countries about 1.9 million people suffer from
around the bed. Insect repellents (in the form of lotions, visual impairment due to trachoma, of these 1.2 million are
creams, or sticks) for temporary protection and keeping the irreversibly blind, and about 190.2 million are at risk of
environment clean. There are no drugs for personal infection (4). In 2016, more than 260,000 people with
prophylaxis. trachoma were provided with curative surgery and
85 million in endemic communities were treated with
References antibiotics to eliminate trachoma (4).
1. WHO (1984). Tech. Rep. Ser., No.701. The incidence and prevalence of trachoma has shown a
2. Govt, of India (2017), Accelerated Plan for the Kala-azar elimination significant decrease in many endemic countries of SEAR
2017, Directorate NVBDCR during the past few decades. This decrease has been mainly
3. WHO (2022), Fact Sheet, Leishmaniasis, 8th January, 2022.
due to improved sanitation, water and housing, and
4. Govt, of India (2021), National Health ProfHe 2021, Ministry of Health
and Family Welfare, New Delhi. implementation of control measures. However, trachoma,
5. Govt, of India (2020), Annual Report 2019-2020, Ministry of Health particularly in its active form, still remains a public health
and Family Welfare, New Delhi. concern in some parts of Myanmar, in the western region of
6. Lainson, R. (1983). In Proceedings of the Indo-UK Workshop on Nepal and in a few rural areas in India (5). It is estimated to
Leishmaniasis ICMR, N.D. be responsible for 0.1 per cent of visual impairment and
7. Govt, of India (2015), Operational Guidelines on Kala-azar visceral blindness in India (6).
Leishmaniasis, Elimination in India - 2015, Ministry of Health and
Family Welfare, New Delhi. Epidemiological determinants
8. Sanyal, R.K. et al (1979). J. Comm Dis, 11 (4) 149-169.
9. WHO (2010), International travel and Health, 2010. Agent factors
10. Govt, of India (2010), Guidelines of Kala-azar, Division of National
Vector Borne Disease Control Programme, Ministry of Health and (a) AGENT : The classical endemic trachoma of
Family Welfare, New Delhi. developing countries is caused by C. trachomatis of immune
11. WHO, TDR (2010), Indicators for Monitoring and Evaluation of Kala- types A, B, or C. The sexually-transmitted C. trachomatis
azar Elimination Programme, Aug. 2010, for Bangladesh, India and (serotypes D,E,F,G,H,1,J or K) may also infect, causing an
Nepal. eye disease difficult to differentiate from endemic trachoma.
Milder cases of this are usually called “inclusion
V. SURFACE INFECTIONS conjunctivitis”. These strains rarely produce permanent

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visual loss - but they cause respiratory infections
(pneumonia) in infants and genital tract infections in adults
TRACHOMA (2). Other pathogenic organisms (e.g., Morax-Axenfeld
diplobacillus, the Koch-Weeks bacillus, the gonococcus)
Trachoma is a chronic infectious disease of the often contribute to the disease process. The Morax-Axenfeld
conjunctiva and cornea, caused by Chlamydia trachomatis, diplobacillus is the most innocuos; the Koch-Weeks bacillus
but other pathogenic microorganisms often contribute to the is the most widespread, and the gonococcus the most
disease. Trachoma inflammation may undergo spontaneous dangerous (7). C. trachomatis, originally believed to be a
resolution or may progress to conjunctival scarring which virus, is an obligatory intracellular bacteria, now classified as
can cause inward deviation of eyelashes (trichiasis) or of the Chlamydia, (b) RESERVOIR : Children with active disease,
lid margin (entropion). The abrasion of the cornea by chronically infected older children and adults, (c) SOURCE
eyelashes frequently result in corneal ulceration, followed by OF INFECTION : Ocular discharges of infected persons and
scarring and visual loss. fomites, and (d) COMMUNICABILITY: Trachoma is a disease
From the public health point of view, trachoma is classified of low infectivity. It is infective as long as active lesions are
as blinding and non-blinding (1). A community with blinding present in the conjunctiva, but not after complete
trachoma can be recognized by the presence of persons with cicatrization.
lesions such as entropion, trichiasis and corneal ulcers. It is Host factors
the blinding trachoma that requires urgent control measures.
Non-blinding trachoma often becomes blinding trachoma (a) AGE: In endemic areas, children may show signs of the
when other ocular pathogens interact synergistically and disease at the age of only a few months. But typically,
enhance the risk of damage to eye sight (2). children from the age of two to five years are the most
infected, and this contributes not only to the high rate of
Diagnosis blindness but also to the rate of occurrence among children,
In epidemiological studies, more stress is now put on the (b) SEX : Prevalence equal in younger age groups. In older
upper tarsal conjunctiva as a convenient index of age groups, females have been found to be affected more
trachomatous inflammation in the eye as a whole (2). For than males. The explanation for this may be that women
the purpose of diagnosis in the field, cases must have at remain more in contact with children who infect them.
least 2 of the following diagnostic criteria (3). Further, females are more exposed to irritating factors such as
smoke than males, (c) PRE-DISPOSING FACTORS : Direct
a. follicles on the upper tarsal conjunctiva
sunlight, dust, smoke and irritants such as kajal or surma may
b. limbal follicles or their sequelae, Herbert’s pits predispose to infection.
c. typical conjunctival scarring (trichiasis, entropion)
d. vascular pannus, most marked at the superior Environmental factors
limbus (a) SEASON : Seasonal epidemics are associated with
vastly increased number of eye-seeking flies. The incidence of
Problem statement active trachoma is found generally high in India during
Trachoma is a major preventable cause of blindness in April-May and again during July-September. The higher
developing countries. According to recent estimates, in temperature and rainfall favours the increase in fly population.

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 TRACHOMA

(b) QUALITY OF LIFE : Trachoma is associated with poor moderate trachoma in children under 10 years is an
quality of life. The disease thrives in conditions of poverty, indication for mass or blanket treatment. The treatment
crowding, ignorance, poor personal hygiene, squalor, illiteracy consists of the application twice daily of tetracycline
and poor housing. As living conditions improve the disease 1 per cent ointment to all children, for 5 consecutive days
tends to regress, (c) CUSTOMS : The custom of applying kajal each month or once daily for 10 days each month for
or surma to the eyes is a positive risk factor. 6 consecutive months, or for 60 consecutive days (2). An
alternative antibiotic is erythromycin.
Mode of transmission From the practical point of view, one of the main
In communities where trachoma is endemic, eye-to-eye difficulties is the need for repeated applications of the
transmission can be considered as a rule (8). This may occur antibiotic over long periods of time. Emphasis is now being
by direct or indirect contact with ocular discharges of placed on the active participation of the community itself in
infected persons or fomites, e.g., infected fingers, towels, trachoma control activities and on the utilization of primary
kajal or surma. Eye-seeking flies (e.g., Musca spp., health care workers. This makes possible a wider coverage
Hippelatus spp.) play some role in spreading the infection by and a greater efficacy of the programme.
mechanical transmission. In countries where only sporadic
cases of trachoma occur, genital localization of (b) Selective treatment
C. trachomatis (urethral, cervical) may lead to venereal In communities with a low to medium prevalence,
transmission (7). treatment should be applied to individuals by case finding
It has been shown that trachoma is a familial disease. rather than by community-wide coverage, the principals of
When one case is detected, others will almost certainly be treatment remaining the same. For the selective treatment to
found in the family group. There is a continuous feedback of be effective, the whole population at risk must be screened for
infection, partly as a result of grandfathers or sisters and case finding.
brothers tending small children (8).
3. Surgical correction
Incubation period Antibiotic ointment is just one component of a trachoma
5 to 12 days. control programme. Individuals with lid deformities
(trichiasis, entropion) should be actively sought out, so that
CONTROL OF TRACHOMA necessary surgical procedures can be performed and

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followed-up. It has an immediate impact on preventing
Trachoma control still requires long-term efforts. It blindness.
requires proper planning and organization, which should
include the following elements : 4. Surveillance
Once control of blinding trachoma has been achieved,
1. Assessment of the problem provision must be made to maintain surveillance, which may
The primary objective of a programme for the control of be necessary for several years after active inflammatory
trachoma is the prevention of blindness. Control programmes trachoma has been controlled. Since trachoma is a familial
should be focussed on communities with a substantial disease, the whole family group should be under
prevalence of “blinding trachoma” - as indicated by the surveillance.
presence of: (a) corneal blindness (b) trachomatous trichiasis
and entropion, and (c) moderate and severe trachomatous 5. Health education
inflammation. Such communities are likely to be found in In the long run, most of the antibiotic treatment must be
countries with blindness rates that are above 0.5 per cent. The carried out by the affected population itself. To do this, the
first task, therefore, is to undertake an epidemiological survey population needs to be educated. The mothers of young
to identify and delimit communities with blinding trachoma; children should be the target for health education. Measures of
assess the magnitude of the problem, local conditions and personal and community hygiene should also be incorporated
other causes of blindness and to obtain information on in programmes of health education. Thus real primary
existing facilities. The basic principles of these surveys are set prevention could only come through health education for the
out in the WHO publication : “Methods of Assessment of total elimination of transmission. This would require a
Avoidable Blindness” (9). permanent change in the behaviour patterns and in
2. Chemotherapy environmental factors. The final solution would be the
improvement of living conditions and quality of life of the
In trachoma control, the main activity is people (10).
chemotherapeutic intervention. The objective of
chemotherapy is to reduce severity, lower the incidence and 6. Evaluation
in the long run decrease the prevalence of trachoma. The
antibiotic of choice is 1 per cent ophthalmic ointment or oily Lastly evaluation. Trachoma control programme must be
suspension of tetracyclines. Erythromycin and rifampicin evaluated at frequent intervals. The effect of intervention
have also been used in the treatment of trachoma. can be judged by the changes in the age-specific rates of
Treatment may be given to the entire community - this is active trachoma and in the prevention of trichiasis and
known as mass treatment (or blanket treatment). In some entropion.
programmes, selective treatment is chosen, in which case, The 28th World Health Assembly in 1975, in a resolution
the whole population at risk is screened, and treatment is requested the Director General of WHO “to encourage
applied only to persons with active trachoma (10). Member countries to develop national programmes for the
prevention of blindness especially aimed at the control of
(a) Mass treatment trachoma, xerophthalmia, onchocerciasis and other causes .
A prevalence of more than 5 per cent severe and With this came the re-orientation of strategies away from

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

single cause prevention, to the adoption of the concept of the disease incidence to such low levels that it ceases to be a
integrated delivery of eye care as part of primary health public health problem. The disease is easily preventable
care. In this context, many countries have now integrated through (2) (1) clean delivery and umbilical cord care
their trachoma control programmes into National practices to ensure infection is not contracted by mother or
Programmes for the Prevention of Blindness, to give newborn during the delivery process; (2) delivery of
simultaneous introduction of other specific measures for appropriate doses of TTCV to pregnant women through
dealing with all causes of avoidable blindness. antenatal care services and other routine contacts;
The trachoma control programme in India which was (3) vaccination campaigns with TTCV targeting all women of
launched in 1963. Later on, it was integrated with reproductive age in high-risk areas; and (4) strengthening
the National Programme for Control of Blindness (see surveillance to identify women at risk, reasons for the risk,
chapter 7). and potential clustering.
In the 1980s, over 1 million deaths every year were
References attributable to tetanus, with an estimated 787,000 deaths in
1. Dawson, C.R. et al (1975). Bull WHO, 52 : 279. 1988 from NT alone. Recognizing, the substantial burden of
2. WHO (1984). Strategies for the Prevention of Blindness in National NT in developing countries, the 42nd World Health
Programmes. A Primary Health Care Approach. Assembly adopted a resolution to eliminate NT by 1995,
3. WHO (1962). Techn. Rep. Ser., No. 234. through the increased availability of TTCV, clean deliveries
4. WHO (2018), Fact sheet Trachoma, 16th Feb., 2018. and improved surveillance. The elimination of NT was
5. WHO (1996), World Health Report 1996, Fighting Disease, Fostering defined as <1 case per 1000 live births in every district. In
Development, Report of the Director General, WHO.
6. Govt, of India (2018), Annual Report 2017-2018, Ministry of Health
the early 1990s, it was estimated that maternal tetanus
and Family Welfare, New Delhi. accounted for about 5% of maternal mortality, or
7. Govt of India (1992), Present Status of National Programme for control 15,000- 30,000 deaths every year. As a result, in 1999, the
of Blindness (NPCB) 1992, Ophthalmology Section, DGHS, New Delhi. elimination of maternal tetanus (MT) was added to the goals
8. Tarizzo, M.L. (1973). Field Methods for the Control of Trachoma, of the elimination programme for neonatal tetanus, and the
WHO, Geneva. programme title was changed to Maternal and Neonatal
9. Tarizzo, M.L. (1976). World Health, Feb-March, 1976. Tetanus Elimination (MNTE). Since NT is linked to the
10. WHO (1980). Methods of Assessment of Avoidable Blindness, WHO
Offset Publ. No.54. immunization status of mothers, elimination of NT has been

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adopted as a proxy for the elimination of MT (2).
TETANUS The implementation of various initiatives under the MNTE
programme led to a significant reduction in cases of
MNT. These initiatives included promotion of maternal
An acute disease induced by the exotoxin of Clostridium tetanus immunization along with safe delivery and avoidance
tetani and clinically characterized by muscular rigidity which of unsafe abortion and umbilical cord care practices.
persists throughout illness punctuated by painful paroxysmal According to WHO estimates, substantial progress has been
spasms of the voluntary muscles, especially the masseters made in the past decade in reducing neonatal incidence and
(trismus or “lock-jaw”), the facial muscles (risus deaths from an estimated 787,000 deaths in 1988 to 34,000
sardonicus), the muscles of the back and neck in 2015, a reduction of about 96 per cent (3).
(opisthotonos), and those of the lower limbs and abdomen
(l). The mortality tends to be very high, varying from Maternal and Neonatal tetanus elimination in
40 to 80 per cent.
India (2)
Problem statement k mix of strategies has been implemented in India to
facilitate clean deliveries by training auxiliary nurse,
WORLD midwives and other cadres of trained birth attendants who
Tetanus is now comparatively rare disease in the work at the village level, in addition to increasing routine TT
developed countries. Neonatal tetanus (NT) is a killer protection. The Indian Ministry of Health & Family Welfare
disease, second only to measles among the nine target in collaboration with WHO India, UNICEF and other
diseases of the EPL In the absence of high quality treatment, partners, designed and implemented the following strategies
the case-fatality rate can be as high as 80-90 per cent. It to control neonatal tetanus:
tends to occur in areas with poor access to health care, - acceleration of TT immunization coverage through the
hence it often remains hidden within the community. WHO-recommended high risk approach, and
Maternal and neonatal tetanus (MNT) is an important strengthening routine TT immunization of pregnant
preventable cause of neonatal and maternal mortality, women, and supplemental TT immunization activities
particularly in developing countries. Although easily targeting women of child-bearing age in high-risk
prevented by maternal immunization with tetanus toxoid districts;
containing vaccines (TTCV) and aseptic obstetric and - systematic vaccination of pregnant women attending
postnatal umbilical cord care practices, both maternal and antenatal care (ANC) with TT vaccine;
neonatal tetanus persist as public health problems. Most - promotion of institutional deliveries focusing on poor
cases occur in poor, remote and isolated communities where pregnant women with an institutional stay for 48 hours,
unhygienic obstetric and postnatal practices prevail along through training of traditional birth attendants;
with poor access to health services.
- intensive communication programme targeting
The spores of tetanus are very resistant and remain in the communities to reduce harmful cord care practices
environment in extremes of temperature for long periods. (promotion of the 5 cleans - hand, delivery surfaces,
Hence, technically it is not possible to eradicate tetanus, instruments for cutting the umbilical cord, cord tie and
including NT. However, MNT can be eliminated by reducing caring of the umbilical cord); and
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 TETANUS 359
- distribution of disposable delivery kits to skilled birth principal action is to block inhibition of spinal reflexes (7)
attendants for each pregnancy. (d) PERIOD OF COMMUNICABILITY : None. Not
The launch of the national rural health mission (NRHM) transmitted from person to person.
in 2005 also helped to strengthen these initiatives. Strategies
to improve clean delivery included the innovative Janani Host factors
Suraksha Yojana (JSY), a conditional cash transfer scheme, (a) AGE : Commonly, tetanus is a disease of the active
to encourage women to give birth in a health facility. Other age (5 to 40 years). This period predisposes to all kinds of
interventions to improve TT protection and reduce maternal trauma and therefore, the risk of acquiring the disease is
and neonatal mortality under the NRHM included: pretty high. Tetanus occurring in the new-born is known as
- Integrating and extending outreach services through “neonatal tetanus”. Infants typically contact the disease at
village health and nutrition days, including vaccination birth, when delivered in non-aseptic conditions - especially
of children, adolescents and pregnant women with TT when the umbilical cord is cut with unclean instruments or
containing vaccines; when the umbilical stump is dressed with ashes, soil or
cowdung, (b) SEX : Although a higher incidence is found in
- Intense 3-week refresher training for all skilled birth
males, females are more exposed to the risk of tetanus,
attendants; especially during delivery or abortion leading to “puerperal
- Operationalization of selected sub-centres and tetanus”. Males appear to be more sensitive to tetanus toxin
community health centres to provide 24-hour services than females (8). (c) OCCUPATION : Agricultural workers
7 days per week for obstetric and neonatal care; are at special risk because of their contact with soil,
- Strengthening of facility-based neonatal care by setting (d) RURAL-URBAN DIFFERENCES : The incidence of
up newborn care corners in health facilities where tetanus is much lower in urban than in rural areas. Within
deliveries take place, special neonatal care units in the urban areas, there may be vast differences in the
district hospitals and new born stabilization units in first incidence of tetanus. For example, it was observed in one
referral units for the care of sick neonates; town that tetanus was more frequent on the outskirts where
floors were earthen and animals lived close to human
- Engagement of more than 896,411 accredited social
health activists (ASHA) to generate demand and beings, than in the centre of the town where there were
facilitate use of health-care services by communities and paved and mosaic floors, (e) IMMUNITY : No age is immune
unless protected by previous immunization. The immunity

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poor women.
resulting from 2 injections of tetanus toxoid is highly
As a result, safe deliveries rose from 52 per cent in 2007 effective and lasts for several years. As a general rule,
to 76 per cent in 2009. Janani Shishu Suraksha Karyakram, patients who have recovered from tetanus must be actively
launched in 2011 also helped. India’s successful immunized, because the amounts of toxin responsible for
implementation of a mix of strategies, and experience and the disease in man do not stimulate protective immunity (7).
knowledge gained from polio eradication efforts has led to a Immunity lasting for a few weeks (less than 6 months) can be
substantial decline in the number of MNT cases in the transferred to the baby, if the mother is immunized during
country. As of December 2014, 30 of the 36 states/UTs were pregnancy or if she already has a high level of immunity at
validated as having achieved MNT elimination and in May the time she becomes pregnant. Tetanus is one disease in
2015, India was officially certified as achieving maternal and which herd immunity does not protect the individual.
neonatal elimination (4).
Environmental and social factors
Epidemiological determinants
Tetanus is a positive environmental hazard (9). Its
Agent factors occurrence depends upon man’s physical and ecological
(a) AGENT : C. tetani is a gram-positive, anaerobic, surroundings - the soil, agriculture, animal husbandry - and
spore-bearing organism. The spores are terminal and give not on the presence or absence of infection in the
the organism a drum-stick appearance. The spores are population. The environmental factors are compounded by
highly resistant to a number of injurious agents, including social factors such as unhygienic customs and habits (e.g.,
boiling, phenol, cresol and autoclaving for 15 minutes at application of dust or animal dung to wounds); unhygienic
120 deg. Centigrade (5). They germinate under anaerobic delivery practices (e.g., using unsterilized instruments for
conditions and produce a potent exotoxin cutting the umbilical cord); ignorance of infection and lack
(“tetanospasmin”). The spores are best destroyed by steam of primary health care services. In the developed countries,
under pressure at 120 deg. C for 20 minutes or by gamma urbanization, industrialization and mechanization of
irradiation, (b) RESERVOIR OF INFECTION : The natural agriculture have interfered with the normal process of
habitat of the organism is soil and dust. The bacilli are found distribution of C. tetani and have reduced the morbidity
in the intestine of many herbivorous animals, e.g., cattle, rate, as has occurred, for example in UK, USA and Germany
horses, goats and sheep and are excreted in their faeces. during the last 40 years (8).
The spores survive for years in nature. The bacilli may be
found frequently in the intestine of man without causing ill- Mode of transmission
effects. The spores are blown about in dust and may occur in Infection is acquired by contamination of wounds with
a wide variety of situations, including operation theatres, tetanus spores. The range of injuries and accidents which
(c) EXOTOXIN : Tetanus bacilli produce a soluble exotoxin. may lead to tetanus - comprise a trivial pin prick, skin
It has an astounding lethal toxicity, exceeded only by abrasion, puncture wounds, burns, human bites, animal
botulinum toxin. The lethal dose for a 70 kg man is about bites and stings, unsterile surgery, intra-uterine death, bowel
0.1 mg (6). The toxin acts on 4 areas of the nervous system : surgery, dental extractions, injections, unsterile division of
(a) the motor end plates in skeletal system (b) the spinal umbilical cord, compound fractures, otitis media, chronic
cord (c) the brain, and (d) the sympathetic system (5). Its skin ulcers, eye infections, and gangrenous limbs (7).

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360_ EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The sequence of events are : introduction of spores, b. MONOVALENT VACCINES

germination and elaboration of the exotoxin and binding to Purified tetanus toxoid (adsorbed) has largely supplanted
the receptor. plain toxoid because it stimulates a higher and longer-
lasting immunity response than plain toxoid (13). However,
Incubation period the latter may be employed for purposes of booster injection
The incubation period is usually 6 to 10 days. However, it when rapid protection is indicated.
may be as short as one day or as long as several months (5).
A primary course of immunization consists of two doses
Long incubation is probably explained by the spores lying
of tetanus toxoid adsorbed (each dose 0.5 ml, injected into
dormant in the wounds. Incubation is also prolonged by
the arm) given at intervals of 1-2 months. The longer the
prophylaxis (7).
intervals between the two doses, the better is the immune
Types of tetanus response. The first booster dose (the third in order) should
be given a year after the initial two doses. The opinion was
(a) TRAUMATIC : Trauma is a major and important cause expressed that no more than one additional booster dose
of tetanus. Sometimes tetanus may result from most trivial (a total of 4 doses altogether) given 5 years after the third
or even unnoticed wounds, (b) PUERPERAL : Tetanus dose is required in adults (including pregnant women) in
follows abortion more frequently than a normal labour. developing countries (14). Frequent boosters must be
A post-abortal uterus is a favourable site for the germination avoided.
of tetanus spores, (c) OTOGENIC : Ear may be a rare portal
of entry. Foreign bodies such as infected pencils, matches, Reactions following the injections of tetanus toxoid are
and beads may introduce the infection. Otogenic tetanus is a uncommon. They are less likely to occur with a refined and
paediatric problem, but cases, may occur in adults also, adsorbed toxoid such as Purified Tetanus Toxoid
(d) IDIOPATHIC : In these cases there is no definite history (Aluminium Phosphate Adsorbed). However, in persons
of sustaining an injury. Some consider it to be the result of giving history of allergy usual precautions should be
microscopic trauma. Others hold the view that it is due to observed. Purified tetanus toxoid should be stored between
the absorption of tetanus toxin from the intestinal tract. 2 and 8 deg. C. It must not be allowed to freeze at any time.
A third view is that the tetanus spores may be inhaled and 2. Passive immunization (10, 11)
may start the infection, (e) TETANUS NEONATORUM : In
many countries, neonatal tetanus kills about 85 per cent of Temporary protection against tetanus can be provided by

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those afflicted. The common cause is infection of the an injection of human tetanus hyperimmunoglobulin (TIG) or
umbilical stump after birth, the first symptom being seen ATS. (i) HUMAN TETANUS HYPERIMMUNOGLOBULIN : It
about the 7th day. Therefore, tetanus is known as “8th day is the best prophylactic to use. The dose for all ages is 250 IU.
disease” in Punjab (6). In any country where hygiene is It does not cause serum reactions. It gives a longer passive
poor, neonatal tetanus may be common. protection upto 30 days or more compared with 7-10 days
for horse ATS. Human tetanus Ig is now available in India - it
is produced by the Serum Institute of India, Pune, (ii) ATS
PREVENTION (EQUINE) : If human antitoxin is not available, equine
antitoxin (anti-tetanus serum or ATS) should be used. The
1. Active immunization (10, 11, 12) standard dose is 1500 IU, injected subcutaneously after
Tetanus is best prevented by active immunization with sensitivity testing. ATS gives passive protection for about
tetanus toxoid. It stimulates the production of the protective 7-10 days. Being a foreign protein, ATS is rapidly excreted
antitoxin. The aim should be to vaccinate the entire from the body and there may be very little antibody at the end
community and ensure a protective level of antitoxin of 2 weeks. Because of this drawback, ATS may not cover the
approximately 0.01 IU/ml serum throughout life. All persons tetanus incubation period in all cases. Horse ATS has other
should be immunized regardless of age. disadvantages too - (i) It causes sensitivity reaction in many
people because it contains foreign proteins. A person
Two preparations are available for active immunization receiving ATS for the first time may tolerate it well, but there
a. Combined vaccine ~ DPT is a possibility that subsequent injections of horse serum may
lead to allergic reactions varying in severity from rash to
b. Monovalent vaccines
anaphylactic shock. It is estimated that the incidence of
i) Plain or fluid (formal) toxoid serious systemic reactions to ATS is 5 to 10 per cent of the
ii) Tetanus vaccine, adsorbed (PTAP, APT) persons who receive it. It is well to remember that local tests
for sensitivity are unreliable as to general sensitivity to horse
a. COMBINED VACCINE serum, (ii) Another drawback of ATS is that it stimulates the
formation of antibodies to it and hence a person who has
Tetanus vaccine is offered routinely to infants (Expanded once received ATS tends to rapidly eliminate subsequent
Immunization Programme) in combination with diphtheria doses. As such the value of second and subsequent doses of
vaccine and killed B. pertussis organisms as DPT vaccine. ATS becomes questionable. In practice, therefore, ATS
According to the National Immunization Schedule (see page becomes less and less reliable as a prophylactic. These
135), the primary course of immunization consists of 3 doses drawbacks have been responsible for the growing
of DPT, at intervals of 4-8 weeks, starting at 6 weeks of age, unpopularity of ATS as an agent for immediate protection
followed by a booster at 18 months of age, and a second against tetanus.
booster at 5-6 years of age and a third booster (Only TT)
after 10 years of age. 3. Active and passive immunization
Pentavalent vaccine: At present pentavalent vaccine is Simultaneous active and passive immunization is widely
being given at 6th, 10th and 14th weeks of age instead of carried out in non-immune persons. The patient is given
DPT vaccine. The DPT vaccine is used for booster dose. 1500 units of ATS or 250 units of Human Ig in one arm,

by R△J
 TETANUS 361
and 0.5 ml of adsorbed tetanus toxoid (PTAP or APT) into stump. Operational research has shown that training of birth
the other arm or gluteal region. This should be followed 6 attendants alone can reduce death due to neonatal tetanus
weeks later by another dose of 0.5 ml of tetanus toxoid, and by 90 per cent (15).
a third dose one year later. The purpose of antitoxin is for Tetanus toxoid will protect both the mother and her child. In
immediate temporary protection, and the purpose of toxoid unimmunized pregnant women, two doses of tetanus toxoid
is for long-lasting protection. should be given, the first as early as possible during pregnancy
and the second at least a month later and at least
4. Antibiotics 3 weeks before delivery. According to the National
Active immunization with tetanus toxoid is the ideal Immunization Schedule (see page 135), these doses may be
method of tetanus prophylaxis, but it is of no immediate given between 16-36 weeks of pregnancy, allowing an interval
avail to a person who is non-immune and has sustained of 1-2 months between the 2 doses. In previously immunized
injury. ATS as an agent for immediate protection against pregnant women, a booster dose is considered sufficient.
tetanus has its drawbacks. For these reasons, antibiotics are There is no need for a booster at every consecutive pregnancy,
indicated in the prophylaxis against tetanus. A single because of the risk of hyper-immunization and side-effects.
intramuscular injection of 1.2 mega units of a long-acting In areas where the incidence of neonatal tetanus is high,
penicillin (e.g., benzathine penicillin) will provide a the primary 2-dose course can be extended to all women of
sustained concentration of the drug for 3 to 4 weeks, which child-bearing age, particularly if the present coverage of
is sufficient to kill any vegetative forms of tetanus bacilli that
antenatal care is low.
may emerge from the sporulating stage. Penicillin has no
effect on tetanus spores. For patients who are sensitive to In developing countries, the majority of pregnant women
penicillin, a 7-day course of erythromycin estolate 500 mg are not seen antenatally. Since a pregnant woman coming
6-hourly by mouth will kill vegetative forms of for an antenatal visit may in fact never return again,
C. tetani but not spores. Antibiotics should be given as soon immunization should be given regardless of the month of
as possible after an injury, before a lethal dose of toxin is pregnancy as there is no evidence to suggest that tetanus
produced in the wound, which may be as soon as 6 hours toxoids are dangerous or harmful to the foetus. The golden
after injury. Antibiotic prophylaxis should not be relied upon rule is that no pregnant mother should be denied even one
for patients seen later than 6 hours after injury. Moreover, it dose of tetanus toxoid if she is seen late in pregnancy.
is not certain whether the antibiotic can reach the bacilli, if The infants born to the mothers who have not previously

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there is dead tissue present in the wound. Therefore, received 2-doses of tetanus toxoid are exposed to the risk of
antibiotic alone is ineffective in the prevention of tetanus; it neonatal tetanus. They can be protected by injection of
is not a substitute to immunization. antitoxin (heterologous serum, 750 IU), if it is administered
Prevention of neonatal tetanus within 6 hours of birth.
Neonatal tetanus is well controlled in some industrialized Prevention of tetanus after injury (12)
countries through clean delivery practices alone. Over the
All wounds must be thoroughly cleaned soon after injury
last decade, most programmes in developing countries have
- removal of foreign bodies, soil, dust, necrotic tissue. This
concentrated on training the traditional birth attendants,
providing home delivery kits and educating pregnant procedure will abolish anaerobic conditions which favour
women about the “five cleans” - clean hands, clean delivery germination of tetanus spores.
surface and clean cord care i.e., clean blade for cutting the A useful scheme for the prevention of tetanus in the
cord, clean tie for the cord and no application on the cord wounded is given in Fig. 1.

All wounds receive surgical toilet

Wounds less than 6 hours old, clean, non-penetrating Other wounds

and with negligible tissue damage.

1 n 1 1
Immunity category Treatment Immunity category Treatment
A Nothing more required A Nothing more required
B Toxoid 1 dose B Toxoid 1 dose
C Toxoid 1 dose C Toxoid 1 dose + Human Tet. Ig
D Toxoid complete course D Toxoid complete course +
Human Tet. Ig

A = Has had a complete course of toxoid or a booster dose within the past 5 years.
B = Has had a complete course of toxoid or a booster dose more than 5 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.

FIG. 1
Recommendations for prevention of tetanus in the wounded

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362 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

When ATS is given, adrenaline solution 1 in 1000 for plantar ulcers; loss of fingers or toes, nasal depression,
intramuscular injection in the dosage of 0.5 to 1 ml and foot-drop, claw toes and other deformities.
hydrocortisone 100 mg for intravenous injection must be kept
available in case of a generalized anaphylactoid reaction (11). Problem statement
A test dose of ATS (0.1 ml in a tuberculin syringe) should be
given subcutaneously (not intradermally) and the patient WORLD
observed carefully (not casually) at least for half an hour for In 1991, WHO member states resolved to decrease the
any evidence of general reaction (not only local reaction), level of leprosy in the world by over 90 per cent. This has
e.g., alteration in pulse, fall in blood pressure, dyspnoea and now been accomplished, and the overall target for the global
distress. If there is reaction, the rest of the antitoxin should be elimination of leprosy as a public health problem has been
given in gradually increasing fractions after treatment with attained (1). The fall in prevalence rate is largely explained
adrenaline. In patients with history of allergy, e.g., asthma, by an improvement in the management of cases, very low
eczema, food or drug idiosyncracy, the above test should be rates of relapse, high cure rates, absence of drug resistance
preceded by a dose of 0.05 ml of 1 in 10 dilution of the ATS. If and shorter duration of treatment with MDT (2).
there is reaction, ATS should be withheld. The achievement can be summarized as follows (3) :
Lastly, it should be pointed out that tetanus may (1) Over the past 20 years, more than 16 million leprosy
occasionally occur inspite of active or passive immunization patients have been cured.
or both. Nevertheless, the aim is to provide as much
protection as possible in the light of our present scientific (2) The prevalence rate of the disease has dropped from
knowledge. 21.1 cases per 10,000 population in 1985 to 16.6 per
million population by end of 2020.
References (3) The global burden of leprosy has declined dramatically
1. WHO (1973), Council for International Organizations of Medical from 5.2 million cases in 1985 to 127,558 cases at the
Sciences (1973). Communicable Diseases, Provisional International end of 2020.
Nomenclature, c/o WHO, Geneva. (4) The new case detection rate was 16.4 per million
2. WHO (2016), Weekly Epidemiological Record, No. 44, 30th Oct., population at the end of 2020. The ten year trend shows
2016. a slow decrease in detection rate of new cases globally.
3. WHO (2018), Fact sheet Tetanus, 9th May, 2018.
(5) Currently the emphasis is on 23 countries of global

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4. Govt, of India (2016), Annual Report 2015-2016, Ministry of Health
and Family Welfare, New Delhi. priority.
5. Weinstein, Louis (1973). N. Eng. J. Med., 289 : 1293. Although significant progress has been made in controlling
6. Gordon, J.E. et al (1961). J. Indian M.A., 37 : 157. the disease and reducing the disease burden, much remains
7. Warrel, David A (1981). Medicine International, 3 : 118. to be done in order to sustain the gains and further reduce the
8. Bytchenko, B. (1966). Bull WHO, 34 : 71. impact of the disease, especially the burden due to the
9. Cvetanovic, B. et al (1978). Bull WHO, Supplement No.l to Vol 56,
p.29. physical, mental and socio-economic consequences of
10. Adams, E.B. et al (1969). Tetanus, Blackwell. leprosy on persons affected and their families. There is a
11. Sen, B. (1972). J. Indian M.A., 59 : 294. growing need to develop more effective tools and procedures
12. Smith, J.W.G. et al (1975). Brit. Med. J. 3 : 453-455. for early recognition and management of leprosy reactions
13. White, W.G. et al (1969). Lancet, 2 : 94. and nerve damage. Most programmes need to initiate
14. WHO (1982). Prevention of Neonatal Tetanus, SEARO Tech. Publ. activities to improve the quality of life of persons affected by
No.3. leprosy through prevention of disability and community­
15. WHO (1992), World Health Statistics, Quarterly Report,
Communicable Disease, Vol. 45, No. 2/3. based rehabilitation measures. One of the long-term needs is
to develop reliable diagnostic tests for early diagnosis and an
effective vaccine for the prevention of leprosy.
LEPROSY WHO has been regularly collecting data on several
indicators from various WHO regions and member states.
Leprosy (Hansen’s disease) is a chronic infectious disease The indicators and reported data is as follows (3) :
caused by M. leprae. It affects mainly the peripheral nerves. It
1. 127,396 new cases of leprosy were detected during
also affects the skin, muscles, eyes, bones, testes and internal
2020. As in previous years, SEAR accounted for 66.6 per
organs. The disease manifests itself in two polar forms, namely
cent of the global leprosy burden, where India and
the lepromatous leprosy and tuberculoid leprosy, lying at the
Indonesia contributed 72.5 per cent of the new leprosy
two ends of a long spectrum of the disease. Between these two
cases globally and 91.725 per cent regionally.
polar types occur the borderline and indeterminate forms
depending upon the host response to infection. 2. Among the new cases detected in 2020, the proportion
of multibacillary cases of leprosy was about 67.3 per
Leprosy is clinically characterized by one or more of the cent.
following cardinal features :
3. The proportion of female cases among newly detected
a. hypopigmented patches cases in 2020 was 38.6 per cent (49,208 cases).
b. partial or total loss of cutaneous sensation in the 4. The proportion oLchildren below 15 years of age was
affected areas (the earliest sensation to be affected 6.8 per cent (8,629 cases).
is usually light touch) 5. The number of new cases with grade-2 disabilities were
c. presence of thickened nerves, and 7,198 (0.9 per cent).
d. presence of acid-fast bacilli in the skin or nasal 6. The number of new child cases with grade-2 disabilities
smears. were 308.
The signs of advanced disease are striking : presence of 7. The number of relapse cases in 2020 were 2,990.
nodules or lumps especially in the skin of the face and ears; 8. The number of retreatment cases were 10,432.

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 LEPROSY

In view of the changing trends in leprosy, the Director Out of the total 65,147 new cases detected, a total of
General of WHO placed the management of the Global 79,898 cases were recorded under treatment during 2020.
Leprosy Programme under the Regional Director, SEAR,
considering that this region has the highest burden of Epidemiological determinants
disease globally. The office and staff of the Global Leprosy
Programme moved from Geneva to New Delhi on Agent factors
July 1st 2005. The WHO has evolved the Global Strategy (a) AGENT : Leprosy is caused by M. leprae. They are
for further reducing the leprosy burden and sustaining acid-fast and occur in the human host both intracellularly
leprosy control activities 2010-2015, and more recently and extracellularly. They occur characteristically in clumps
Global Leprosy Strategy 2016-2020: “Accelerating towards or bundles (called globi). They have an affinity for Schwann
a leprosy-free world”. cells and cells of the reticulo-endothelial system. They
remain dormant in various sites and cause relapse. The
The Global leprosy strategy 2016-2020:
bacterial load is the highest in the lepromatous cases. As
'Accelerating towards a leprosy-free world” many as 2 to 7 billion were estimated in one gram of
The Global Leprosy Strategy 2016-2020: “Accelerating leproma (5). Numerous antigens (more than 20) Have been
towards a leprosy-free world” was released in April 2016. detected in M. leprae by electrophoretic techniques. Some
The strategy is based on the principles of initiating action, of these are shared by those of pathogenic and non-
ensuring accountability and promoting inclusion. It is built pathogenic mycobacteria, e.g., BCG, M. smegmatis,
around 3 pillars: to strengthen government ownership, M. vaccae, M. tuberculosis, etc. Most interesting of these
coordination and partnership; to stop leprosy and its antigens is the phenolic glycolipid (PGL) which may be the
complications; and to stop discrimination and promote specific M. leprae antigen. Recent years have witnessed the
inclusion. In endorsing the global strategy, 3 key targets successful transmission of M. leprae to some experimental
have been agreed by all national programmes : (1) zero animals. Currently large quantities of M. leprae are being
grade 2 disability (G2D) among children diagnosed with produced by multiplication in the 9-banded armadillo and
leprosy; (2) the reduction of new leprosy cases with G2D to nude mouse. Despite repeated claims, M. leprae has not yet
<1 case per million population and (3) zero countries been conclusively shown to grow in artificial medium (6). It
with legislation allowing discrimination on the basis of is perhaps mainly for this reason that progress in research
leprosy (3/. Early detection and complete treatment has lagged behind than that of many other diseases.

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with MDT remains the fundamental principle of leprosy
control. (b) SOURCE OF INFECTION : It is generally agreed that
multibacillary cases (lepromatous and borderline
INDIA lepromatous cases) are the most important source of
Leprosy is widely prevalent in India. Although the disease infection in the community. The inapparent infections are
is present throughout the country, the distribution is uneven. also source of infection. The role of individuals with
After introduction of MDT in the country, the recorded tuberculoid forms of the disease as sources of infection is not
leprosy case load has come down from 57.6 cases per clear. The current view is that all patients with “active
10,000 population in 1981 to less than one case per leprosy” must be considered infectious (7). Until recently
10,000 population at national level in December 2005, and man was considered to be the only host and source of
the country achieved the goal of leprosy elimination at infection. There is now evidence that natural infections with
national level. M. leprae are present in wild animals, e.g., armadillos,
Based on the reports received from the states/UTs for the mangabey monkeys and chimpanzees. It is not yet known if
year 2020-2021, the current leprosy situation in the country leprosy in wild animals is a threat to public health.
is as follows (4A) : (c) PORTAL OF EXIT : It is widely accepted that the nose
A total of 65,147 new cases were detected during the is a major portal of exit. Lepromatous cases harbour millions
year 2020, which gives annual new case detection rate of M. leprae in their nasal mucosa which are discharged
(ANCDR) of 4.56 per lakh population. A total of 79,898 when they sneeze or blow the nose. The bacilli can also exit
cases were on record as on March 2021, giving a prevalence through ulcerated or broken skin of bacteriologically positive
rate (PR) of 0.41 per 10,000 population. The detailed cases of leprosy (8).
information on new leprosy cases detected during 2020-21 (d) INFECTIVITY : Leprosy is a highly infectious disease
indicates the proportion of multibacillary cases was 58.1 per but of low pathogenicity (9). It is claimed that an infectious
cent, proportion of female cases was 39 per cent, child case patient can be rendered non-infectious by treatment with
proportion was 5.8 per cent, 2.41 per cent patients were dapsone for about 90 days (10) or with rifampicin for
with grade-II disability, giving disability rate of 1.1 per 3 weeks (12). Local application of rifampicin (drops or
million population). spray) might destroy all the bacilli within 8 days (11).
34 states/UTs had already achieved the level of leprosy (e) ATTACK RATES : Among household contacts of
elimination i.e. PR of less than 1 case per 10,000 lepromatous cases, a varying proportion - 4.4 per cent to
population. Chhattisgarh and Dadra & Nagar Haveli has PR 12 per cent - is expected to show signs of leprosy within
of 2-5 per 10,000 population. 5 years (11). This occurs despite treatment of the index case,
As on 31st March 2019, 514 districts out of 708 have most, if not all, cases having been infectious for long
ANCDR less than 10 per lakh population, 72 districts have periods, before treatment is sought.
more than 20 per lakh population, and only 12 districts are
with more than 50 per lakh population (of which 3 are in Host factors
Chhattisgarh, 1 in Gujarat, 2 in Maharashtra, 1 in Dadra & (a) AGE : Infection can take place at any time depending
Nagar Haveli and 5 in Odisha. Three districts reported upon the opportunities for exposure. Incidence rates
ANCDR of more than 90 per lakh population. generally rise to a peak between 20 and 30 years of age and

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364 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

then fall (12). In areas where leprosy is rare, the first contact normally secreted by activated T cells to make other T cells
may not take place early in life and consequently, the proliferate. If exogenous interleukin-2 is added, the process
disease may appear late. However, the presence of leprosy may be reversed. However, further studies are needed to
in child population is of considerable epidemiological find out whether administration of IL-2 would benefit the
importance. A high prevalence of infection among children lepromatous patient (16).
means that the disease is active and spreading. (g) GENETIC FACTORS : There is now evidence that
(b) SEX : Both the incidence and prevalence of leprosy human lymphocyte antigen (HLA) linked genes influence
appear to be higher in males than in females in most regions the type of immune response that develops (6).
of the world. Sex difference is found least in children below
15 years, and more marked among adults; more marked Environmental factors
among lepromatous cases than among non-lepromatous The risk of transmission is predominantly controlled by
cases. The excess of cases in males has sometimes been environmental factors (10) : (a) the presence of infectious
attributed to their greater mobility and increased cases in that environment. There is evidence that humidity
opportunities for contact in many populations. favours the survival of M. leprae in the environment.
(c) MIGRATION : In India leprosy was considered to be M. leprae can remain viable in dried nasal secretions for at
mostly a rural problem. However, because of the movement least 9 days and in moist soil at room temperature for
of population from rural to urban areas, leprosy is creating a 46 days (6), (b) overcrowding and lack of ventilation within
problem in the urban areas also (13). households.
(d) THE PREVALENCE POOL (14): The prevalence pool Mode of transmission
of leprosy in a population in general is in a constant flux The mode of transmission of leprosy has not been
resulting from inflow and outflow. The inflow is contributed established with certainty. The following theories are
by the occurrence of new cases, relapse of cured cases, and frequently debated :
immigration of cases. The outflow is mainly through cure or
inactivation of cases, death of cases, and emigration of (A) DROPLET INFECTION : There is more and more
cases. Of the various factors that influence the prevalence evidence that leprosy may be transmitted via aerosols
pool, the importance of inactivation of disease and mortality containing M. leprae (droplet infection). With the realization
are less well recognized. of the importance of the nose as a portal of exit, there has
been increased emphasis on the respiratory tract as the

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(e) INACTIVATION OF DISEASE (14) : Where leprosy portal of entry. The possibility of this route of transmission is
treatment facilities exist, inactivation or cure due to specific based on (a) the inability of the organisms to be found on
treatment is an important mode of elimination of cases from the surface of the skin; (b) the demonstration of a large
the prevalence pool. Even in the absence of specific treatment, number of organisms in the nasal discharge; (c) the high
a majority of patients, particularly of the tuberculoid and proportion of morphologically intact bacilli in the nasal
indeterminate types, tend to get cured spontaneously. An secretions; and (d) the evidence that M. leprae could survive
earlier study in India had shown that over a period of 20 years, outside the human host for several hours or days (14).
the extent of spontaneous regression among children with (B) CONTACT TRANSMISSION : Numerous studies
tuberculoid leprosy was about 90%. A study in Culion Island indicate that leprosy is transmitted from person-to-person by
in the Philippines showed that among children self-healing close contact between an infectious patient and a healthy
occurred in 77.7% of cases (Lara & Nolasco, 1956). A later but susceptible person. This contact may be direct or indirect
study in South India involving long-term follow-up of a high (e.g., contact with soil, and fomites such as contaminated
endemic population showed that among newly detected clothes and linen).
tuberculoid cases of all ages and both sexes, the rate of
inactivation was 10.9% per year, the bulk of inactivation in the Now that it is known that leprosy bacilli can survive for
study being spontaneous (Noordeen, 1975). long periods of time in the soil under favourable
environmental conditions, the hypothesis that leprosy can be
(f) IMMUNITY : It is a well-established fact that only a few transmitted by indirect contact has been strengthened (17).
persons exposed to infection develop the disease. A large In epidemiological studies, the first lesions were found in feet
proportion of early lesions that occur in leprosy heal and legs of patients from hilly areas in India, where injury to
spontaneously. Such abortive and self-healing lesions the skin is common. In the Philippines 91 per cent of the first
suggest immunity acquired through such lesions. Subclinical lesions were seen in extremities open to injury (13). These
infections are far more common than was thought earlier; observations lend support to indirect transmission. Although
they are also believed to contribute to active immunity.. contact transmission has been a long-favoured hypothesis,
A certain degree of immunity is also probable through leprologists opine that skin-to-skin contact is really not
infections with other related mycobacteria (15). necessary to acquire infection, and that the disease is
It is now recognized that cell-mediated immunity (CMI) is transmissible with far less than intimate contact (7, 9).
responsible for resistance to infection with M. leprae. In (C) OTHER ROUTES : Bacilli may also be transmitted by
lepromatous leprosy, there is a complete breakdown of CMI; insect vectors, or by tattooing needles. These transmission
in these cases the lepromin test is negative. CMI does not channels cannot be ruled out (17). However, there is no
however, exclude the participation of humoral response. evidence that any of these transmission routes is important
Antibodies have been demonstrated throughout the in nature (6).
spectrum of leprosy; they are more pronounced at the
lepromatous end. Similarly an increase of immunoglobulins Incubation period
of IgG and IgM classes is noted towards the lepromatous end Leprosy has a long incubation period, an average of 3 to
(16). Leprosy workers have found that the anergy of 5 years or more. Symptoms can take as long as 20 years to
lepromatous leprosy is due to suppression of T cell appear. Failure to recognize early symptoms or signs may
production of interleukin-2 (T-cell growth factor). This is contribute to an assumed prolonged incubation period in

by R△J
 LEPROSY 365
some patients. Some leprologists prefer the term “latent specific CMI is effective in elimination/controlling the
period” to incubation period because of the long duration of infection in the body, lesions heal spontaneously or it
the incubation period. produces pauci-bacillary (PB) type of leprosy. If CMI is
Knowledge of incubation period of relapses is also deficient; the disease spreads uncontrolled and produces
essential, as this will define the duration of surveillance after multi bacillary (MB) leprosy with multiple system
treatment has been stopped. involvement. Sometimes, the immune response is abruptly
altered, either following treatment (MDT) or due to
Pathogenesis of leprosy (12) improvement of immunological status, which results in the
inflammation of skin or nerves and even other tissues, called
Onset of leprosy is insidious. It affects nerves, skin and as Lepra reaction leading to temporary and permanent
the eyes, it may also affect mucosa (mouth, nose, pharynx), disabilities/deformities. Pathogenesis of leprosy is
testis, kidney, voluntary/smooth muscles, reticulo­ summarized in Fig. 1.
endothelial system and vascular endothelium.
Bacilli enter the body usually through respiratory system. Classification
It has low pathogenicity, only a small proportion of infected Leprosy is a disease bedevilled by classifications, e.g., the
people develop signs of the disease. Though infected, Madrid classification (18), Ridley-Jopling classification (19),
majority of the population do not develop the disease. After the Indian classification (20), etc. These classifications are
entering the body, bacilli migrate towards the neural tissue based on clinical, bacteriological, immunological and
and enter Schwann cells. Bacteria can also be found in histological status of patients.
macrophages, muscles cells and endothelial cells of blood The Indian and Madrid classification systems are the most
vessels. widely used in field leprosy programmes; they are not
After entering Schwann cells or macrophages, fate of the essentially different, as the following comparison shows :
bacterium depends on the resistance of the infected
individual towards the organism. Bacilli start multiplying Indian classification Madrid classification
slowly (about 12-14 days for one bacterium to divide into indeterminate type indeterminate
two) within the cells, get released from the destroyed cells tuberculoid type tuberculoid; flat; raised
and enter other unaffected cells. During this state, person borderline type borderline
remains free from signs and symptoms of leprosy. lepromatous type lepromatous

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pure neuritic type
As the bacilli multiply, bacterial load increases in the
body and infection is recognized by the immunological The Indian classification has an additional form, the pure
system. Lymphocytes and histiocytes (macrophages) invade neuritic in which no skin lesions exist.
the infected tissue. At this stage, clinical manifestation may The classification system of Ridley and Jopling (21)
appear as involvement of nerves with impairment of divides leprosy cases into five groups according to their
sensation and/or skin patch. If it is not diagnosed and position on an immuno-histological scale : tuberculoid (TT),
treated in the early stages, further progress of the disease is borderline tuberculoid (BL), borderline (BB), borderline
determined by the strength of the patient’s immune lepromatous (BL) and lepromatous (LL). The neuritic type
response. of leprosy does not find a place in the Ridley and Jopling
Specific and effective cell mediated immunity (CMI) classification. This classification can be used only when full
provides protection to a person against leprosy. When research facilities are available.

M. Leprae

Enters Transient Bacillemia

Schwann cells, cooler places (cutaneous nerves &

peripheral nerve trunks of limbs and face)

Strong immunological Weak immunological

response response

Nerves only : Pure neural leprosy M. Leprae multiply in Schwann cells or

Escape to skin : Skin lesions appear engulfed Histiocytes - wandering macophages,
Lesions may heal spontaneously affects other organs of the body

FIG. 1
Pathogenesis of leprosy

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Clinical classification for control programme without cap will be needed. Explain to the person what you
After making a diagnosis of leprosy, one should group the are going to do and demonstrate it. Touch the skin with the
patient based on certain characteristics. This is important tip of the pen lightly and ask the individual to point to the
because, it helps in selecting the correct combination of spot touched with his index finger. Repeat this procedure a
drugs for a given patient. few times until the patient is familiar and comfortable with
the procedure. Now ask the patient to close his eyes and
Criteria for classification (12) repeat the procedure (first on the normal skin then over the
affected area). While testing lesions over inaccessible areas
MB (Multi-bacillary)
(back, buttocks) the patient may be asked to count on each
Characteristics PB (Pauci-bacillary)
touch. Do not use other “instruments” like pin, cotton wool,
Skin lesions 1-5 lesions 6 and above feather, etc. When testing for sensation, touch the skin
Peripheral nerve No nerve / only one More than one lightly with the pen. Do not stroke. The pen should be
nerve involvement nerve involvement perpendicular to the surface of the skin. Do not keep asking
Skin smear Negative at all sites Positive at any site the patient whether he feels the touch. You may get
misleading results. Proceed from the normal skin to the
Diagnosis of leprosy (12) patch. Give only one stimulus at a time. Vary the pace of
A case of leprosy is diagnosed by eliciting cardinal signs testing.
of leprosy through systematic clinical (and wherever
required bacteriological) examination. At least one of the c. Nerve examination (12)
following cardinal (unique and very important) signs must Resource person should demonstrate nerve examination
be present to diagnose leprosy. from head to toe and also use video clips. The cardinal sign
a. Hypo-pigmented or reddish skin lesion(s) with definite is : “Involvement of the peripheral nerves, as demonstrated
sensory deficit; by definite thickening with a loss of sensation with or
without weakness/paralysis of the corresponding muscles of
b. Involvement of the peripheral nerves, as demonstrated
the hands, feet or eyes”. Examination of nerves in all the
by definite thickening with loss of sensation and
patients is very important for diagnosis, grouping and for
weakness /paralysis of the corresponding muscles of the
prevention of deformity. This involves two aspects :
hands, feet or eyes;

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(a) palpation of the nerves for thickening, tenderness and
c. Demonstration of M. leprae in the lesions. consistency; and (b) assessment of nerve function - sensory
The first two cardinal signs can be identified by clinical and motor. The commonly affected nerves are as shown in
examination alone, while the third can be identified by Fig. 2.
examination of the slit skin smear. Before the introduction of MDT, most leprosy cases were
diagnosed by medical officer or specialized leprosy workers,
1. CLINICAL EXAMINATION and it often led to delay in diagnosis and initiation of
Clinical examination includes careful interview of the treatment. Since the introduction of MDT, many procedures
patient to get detailed history and examination of skin and have been simplified, so that leprosy patients can be
nerves. detected by health workers in the field.

a. Case history
The leprosy history should elicit the following :
- Name, sex, age (year of birth), address, occupation etc.,
- Presenting complaints and their duration (A patch of a
few days or that which is present since birth or an itchy
patch is unlikely to be leprosy);
- History of recurrence (a recurrent lesion which “comes
and goes” will not be due to leprosy);
- Any deformity, the time of its onset, and nature of its
progress;
- Treatment history - treatment taken, what drugs for
leprosy and how long;
- Any other associated illness (jaundice, cough, swelling of
the feet at present or in the recent past);
- Any other person in the family or close contacts having
similar disease or had the disease and was treated.

b. Physical examination
(i) A thorough inspection of the body surface (skin) to the
extent permissible, in good natural light for the presence
of suggestive, or tell tale evidence of leprosy

Testing the sensation over skin (12) : FIG. 2

It is very important to pick up the skill of eliciting sensory Sites of nerve involvement
loss in skin patch. A light ballpoint pen (with plastic body) Source : (21)

by R△J
 LEPROSY
367
2. BACTERIOLOGICAL EXAMINATION Bacterial index (12)
Skin smears are useful for diagnosing multibacillary Bacterial index (BI) is the only objective way of
leprosy and were originally used for distinguishing between monitoring the benefit of treatment. The Bacteriological (or
paucibacillary and multibacillary leprosy. However, the Bacterial) Index indicates the density of leprosy bacilli in
quality of skin smears and of microscopy is probably the smears and includes both living (solid-staining) and dead
weakest link in most leprosy elimination programmes. In (fragmented or granular) bacilli. According to Ridley's
view of this situation, and since it is possible to classify logarithmic scale, it ranges from zero to 6+ and is based
leprosy without skin smear results, it should not be a pre­ on the number of bacilli seen in an average microscopic field
requisite for implementing the MDT (22). of the smear using an oil-immersion objective.
A brief account of method of skin smear and nasal smear 0 No bacilli in any of the 100 oil-immersion fields
examination is as follows : 1+ 1-10 bacilli, on average, in 100 oil-immersion fields
(i) Skin smears : Material from the skin is obtained from 2+ 1-10 bacilli on average, in 10 oil-immersion fields
an active lesion, and also from one of the ear lobe by the 3+ 1-10 bacilli, on average, in each oil-immersion field
“slit and scrape” method. Conventionally, two sites are
examined. The skin is cleaned with ether or spirit and 4+ 10-100 bacilli, on average, in each oil-immersion
allowed to dry. A fold of the skin is nipped between the field
thumb and forefinger (of left hand in an operator). Enough 5+ 100-1000 bacilli, on average, in each oil-immersion
pressure should be applied to stop or minimize bleeding. field
Holding the point of knife vertical to the apex of the skin 6+ More than 1000 bacilli, on average, in each
fold, it is pushed into the skin to a depth of about 2 mm or oil-immersion field
so, to reach the dermis. A tiny incision is made 5 mm or so
The BI of the patient is calculated by adding up the index
in length. If blood exudes, it should be wiped off with a small
from each site examined and dividing the total by the
dry cotton-wool swab. The knife blade is rotated
number of sites examined.
transversely to the line of the cut 90° and the knife point is
used to scrape first on one side and then on the other side of (e.g. Right ear 5 + Left ear 5 +
the incision 2 or 3 times to obtain a tissue pulp from below Back 4+ Chin 4+
the epidermis. This material is transferred on to a glass slide 5+5+4+4 18

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and spread over an area of about 8 mm diameter. Six Bacteriological Index = 4.5 +
4 "4
smears can conveniently be made on one microscopic slide.
The sites of the smear should be accurately recorded so that When the bacteriological Index is BI 1+ and BI 2 + , at
the same sites can be used for successive sets of smears least 100 oil immersion fields should be examined. When
made for assesing the effect of treatment. The wound is the index is BI 3 + , BI 4+, BI 5+ and BI 6 + , at least 25
dressed and closed with a piece of sticking tape applied over oil-immersion fields should be examined (23).
the site. Morphological index
(ii) Nasal smears or blows : Nasal smears can be best During the course of microscopic examination of smears,
prepared from early morning mucus material. The patient it is possible to distinguish and count the number of solid
blows his nose into a clean dry sheet of cellophane or staining organisms (organisms that stain completely) and
plastic. The smear should be made straightaway and fixed. irregularly staining bacilli. The MI is calculated after
This should be done in the early morning from the first examining 200 pink-stained free standing (i.e. not in
blowing of the nose. Nose-blowing smears are used for clumps) bacilli. The percentage of solid staining bacilli in a
assessing the patient’s infectivity. In patients with untreated stained smear is referred to as morphological index (MI).
lepromatous leprosy, nose-blow smears may show a higher The total of the Mis for all sites divided by the number of
percentage of solid-staining bacilli than skin smears. sites gives the average MI for the body. The criteria for
(Hi) Nasal scrapings : An alternative is to use a nasal calling the bacilli solid rods are (20) :
mucosal scrapper. After going in 4.5 cm, the blade is rotated a. uniform staining of the entire organism
towards the septum and scraped a few times and withdrawn. b. parallel sides
A small ball of cotton is introduced into the nostril to absorb
any blood that may ooze out. Nasal scrapings are not c. rounded ends, and
recommended as a routine, because they are painful, and d. length 5 times that of the width.
non-pathogenic atypical mycobacteria may be present in the
nose of healthy persons. Leprosy bacilli are not found in It has been widely believed that only solid-staining
nasal mucosa if they are absent in skin lesions. During organisms are viable. Accurate evaluation of the MI requires
much skill and experience. It is a valuable indicator of the
treatment, M. leprae may disappear from the nasal mucosa
patient’s response to treatment with drugs, during the first
before they disappear from the skin lesions (23).
few months and helps to signal drug resistance.
The skin or nasal smear is immediately fixed by lightly
passing the underside of the slide over the spirit lamp flame Solid-fragmented-granular (SFG) percentage (23)
and transported to the laboratory for staining with Ziehl- The procedure for recording the percentages of solid,
Neelsen method. fragmented and granular bacilli is basically the same as that
The glass slides used should be absolutely clean. They used for determining the MI. Since percentages of solid,
should not be reused for making smears a second time as fragmented and granular bacilli are mentioned separately.
organisms from a previous examination may give a false SFG percentages give a better picture of the bacterial
positive result (20). Before a smear is declared negative, at morphology than the MI, and are a more sensitive indicator
least 200 fields should be examined (7). of the patient's response to treatment.

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

3. FOOT-PAD CULTURE 7-10 days following the injection and reaching its maximum
The only certain way to identify M. leprae is to inoculate in 3 or 4 weeks. The test is read at 21 days. At the end of
the material into the foot-pads of mice and demonstrate its 21 days, if there is a nodule more than 5 mm in diameter at
multiplication. Mouse foot-pad inoculation is 10 times more the site of inoculation, the reaction is said to be positive. The
sensitive at detecting M. leprae than are slit-skin smears (24). nodule may even ulcerate and heal with scarring if the
antigen is crude.
The drawback of this technique is that it is time consuming
and requires 6 to 9 months before the results are obtained. It may be noted that the diameter of the red area in the
Newer In vitro methods such as macrophage culture have early reaction, and the diameter of the nodule in the late
been evolved, which take only 3 to 4 weeks to obtain results. reaction are measured. The early reaction is induced by the
soluble constituents of the leprosy bacilli; and the late
Mouse foot-pad technique has been successfully used for reaction by the bacillary component of the antigen. It
(i) detecting drug resistance (ii) evaluating the potency of indicates cell-mediated immunity.
anti-leprosy drugs, and (iii) detecting the viability of the
bacilli during treatment. In the first 6 months of life, most children are lepromin
negative; some may become positive by the end of first year.
4. HISTAMINE TEST Data obtained from different parts of the world indicate that
in endemic areas, lepromin reaction is already positive in
The histamine test is a very reliable method for detecting
20 per cent of children under 5 years of age, and this
at an early stage peripheral nerve damage due to leprosy.
proportion increases to around 60 per cent or more in the
The test is carried out by injecting intradermally 0.1 ml of a
10-14 years age group, and to 80 per cent or more in
1:1000 solution of histamine phosphate or chlorohydrate
persons over 19 years of age (27). BCG vaccination is
into hypopigmented patches or in areas of anaesthesia. In
capable of converting the lepra reaction from negative to
normal persons, it gives rise to a wheal surrounded by an
positive in a large proportion of individuals.
erythematous flare within a few minutes (Lewis triple
response). In cases of leprosy where the nerve supply is Value of the lepromin test
destroyed, flare response is lost. Histamine test is
recommended when difficulty is experienced in the Lepromin test is not a diagnostic test. The two drawbacks
diagnosis, as for example, indeterminate leprosy (25). that stand in the way of this test being used for diagnosis
are : (i) positive results in non-cases, and (ii) negative results
in lepromatous and near-lepromatous cases (13).

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5. BIOPSY
When the examinations detailed above do not yield The test has been generally accepted as a useful tool in
diagnosis, histopathological examination may be necessary. evaluating the immune status (CMI) of leprosy patients. It is
It allows a more accurate classification of the disease. It also of considerable value in confirming the results of
gives information about the bacterial content of the skin. classification of cases of leprosy on clinical and
bacteriological grounds. In other words, the test is widely
6. IMMUNOLOGICAL TESTS used as an aid to classify the type of disease.
There are now available different kinds of immunological The test is also of great value in estimating the prognosis
tests. These may be classified as (26) : in cases of leprosy of all types. The test is usually strongly
positive in the typical tuberculoid cases, and the positivity
a. tests for detecting cell mediated immunity (CMI) getting weaker as one passes through the spectrum to the
b. tests for humoral antibodies (serological tests). lepromatous end, the typical lepromatous cases being
lepromin negative indicating a failure of CMI. It is known
a. TESTS FOR DETECTING CMI that lepromin negative individuals are at a higher risk of
developing progressive multibacillary leprosy, but those who
(i) LEPROMIN TEST are lepromin positive either escape the clinical disease (the
The test is performed by injecting intradermally 0.1 ml of majority) or develop paucibacillary disease (the minority).
lepromin into the inner aspect of the forearm of the
(ii) LTT and LMIT
individual. As a routine, the reaction is read at 48 hours and
21 days (7). Two types of positive reactions have been s In recent years, newer In vitro tests such as lymphocyte
described : transformation test (LTT) and leucocyte migration inhibition
test (LMIT) have been developed. They give a measure of
(a) EARLY REACTION : The early reaction is also known
the cell mediated immunity. These tests have been used to
as Fernandez reaction. An inflammatory response develops
detect subclinical infection. A disadvantage of these highly
within 24 to 48 hours and this tends to disappear after
sophisticated tests is that they cannot be applied on a mass
3 to 4 days. It is evidenced by redness and induration at the
scale under field conditions (28).
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. b. TESTS FOR HUMORAL RESPONSES TO
The early positive reaction indicates whether or not a M. LEPRAE
person has been previously sensitized by exposure to and Probably the most important recent advance in the study of
infection by the leprosy bacilli. In this sense, the early the epidemiology of leprosy is the development of serological
reaction is much superior to the late reaction. The early tests. These tests are expected to have value in detecting
reaction has been described as delayed hypersensitivity subclinical infections, preclinical manifestations and
reaction to “soluble” constituents of the leprosy bacilli. The follow-up efficacy of drug treatment. These tests include :
reaction corresponds to the Mantoux reaction in tuberculosis,
caused by the soluble antigens (PPD) of the tubercle bacilli. (i) FLA-ABS test
(b) LATE REACTION : This is the classical Mitsuda The Fluorescent Leprosy Antibody Absorption Test is
reaction. The reaction develops late, becomes apparent in now widely used for identification of subclinical infection.

by R△J
 LEPROSY

Studies revealed that FLA-ABS test is 92.3 per cent and the facilities available for providing the needed health
sensitive and 100 per cent specific in detecting M. leprae care. A rough estimate of the prevalence can be determined
specific antibodies in all types of leprosy irrespective of the by examining all school-age children; the total prevalence will
type and duration of the disease (29). be about 4 times the number of cases found (26). Estimates of
the prevalence of leprosy are essential for planning and
(ii) Monoclonal antibodies implementing an anti-leprosy programme and also for
Monoclonal antibodies against M. leprae antigens have evaluating the results of the programme.
been produced. It has been shown that these antibodies
recognize specific and non-specific epitopes of M. leprae II. Early case detection
antigens. If antibodies against specific antigens are found, The aim of case detection is to identify and to register all
they will become reagents of choice for identifying cases of leprosy as soon as possible after they become
M. leprae. An antibody competition test (SACT) based on evident (6). Ideally, patients should seek medical care
this approach has been found to be quite sensitive for voluntarily. However, because leprosy is frequently
detection of M. leprae antibody (30).
symptomless in the early stages, patients do not know they
(iii) Others have the disease. By the time patient becomes aware of the
disease and reports voluntarily, there is usually a lag period
There are numerous other sensitive tests which include
of 2 to 3 years (32). Because of the social stigma, some
the radio-immune assay and ELISA tests. The ELISA test is
patients are afraid to disclose themselves. It is, therefore,
based on a phenolic glycolipid (PGL) antigen.
necessary to devise active methods of case detection (7).
For the present, the only practical approach is to use Even in countries, with a satisfactory case-finding
FLA-ABS test till some other more sensitive and specific programme, new cases could still be found (9). The current
tests are available for use on a large scale (31). trend is to involve the primary health care workers (village
health guides, multipurpose workers) in case detection with
LEPROSY CONTROL the active participation of the community (9). These workers
need to be adequately trained to make a tentative diagnosis
The introduction of multidrug therapy has infused a new of leprosy. The desirability of confirming the diagnosis by
hope that the disease could be brought under effective laboratory methods is not mandatory. It is important that
control in the not too distant future. A revised strategy of

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criteria for identifying cases are valid, unambiguous and
leprosy control has emerged based on multidrug therapy. reproducible as far as possible. If data are to be compared
The following elements are considered as a minimum between different areas and different times, it is important
requirement for all leprosy control programmes : that diagnostic criteria used for leprosy around the world is
1. Medical measures standardized.
I. estimation of the problem Case-finding methods : The choice of case-finding
II. early case detection methods should be related to the prevalence rate of leprosy in
III. multidrug therapy the region : (a) CONTACT SURVEY : In areas where the
IV. surveillance prevalence of leprosy is generally low, (less than 1 case
per 1000 population), the technique of choice is examination
V. immunoprophylaxis of all contacts (e.g., household contacts, especially children
VI. chemoprophylaxis and persons reported to be suspected cases). These
VII. deformities examinations will have to be arranged with discretion so as
VIII. rehabilitation not to cause alarm, (b) GROUP SURVEYS : When the
IX. health education prevalence is about 1 per 1000 or higher, additional case
finding methods should be employed such as screening of
2. Social support
preschool and school children, people living in slums, military
3. Programme management recruits, industrial labour and other selected groups for all
4. Evaluation types of skin diseases; this technique (“skin camps”) may
bring out additional cases of leprosy. It should be noted that
The three main goals of leprosy control are (7) : (a) to the value of school surveys as a case finding method will be
interrupt transmission of the infection, thereby reduce the considerably diminished if the school enrolment is less than
incidence of the disease so that it no longer constitutes a 70 per cent of all children in the 6-14 years age group (11).
public health problem; (b) to treat patients in order to (c) MASS SURVEYS : Total population surveys for
achieve their cure and where possible, complete examination of each and every individual, family by family
rehabilitation; and (c) to prevent the development of by house-to-house visits are recommended only in
associated deformities. Ultimate prevention is achieved by hyperendemic areas, i.e., areas where the prevalence of
breaking the chain of transmission. leprosy is about 10 or more per 1000 population. In mass
surveys, a coverage of not less than 95 per cent of the
1. MEDICAL MEASURES population should be obtained (9). Mass surveys require high
I. Estimation of the problem quality team work. They should be multipurpose covering not
The first step in a leprosy control programme is to define only leprosy but also possibly other diseases. They should
the size of the problem or disease load in the community by have the full backing of the administration and whole-hearted
means of epidemiological surveys. Random sample surveys participation of the local community.
are good enough to collect baseline data. The survey should Records : The case information should be collected for all
bring out not merely the prevalence of leprosy, but also the patients in a standardized manner. The WHO has already a
age and sex distribution of cases, the various forms of leprosy standard computer-based proforma for data collection from

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

individual patients (see Annex 3 of WHO Expert Committee (v) Regular treatment : A patient may be considered to
Report No. 716, page 58) which should be followed or have had regular treatment if he or she has received MDT
suitably adapted. The Government of India had also for at least two-thirds of the months in any interval of time.
approved a set of forms for keeping records and submitting For example, regular treatment for 12 months, implies that
reports. the patient has had at least 8 full months of combined
Leprosy is an “iceberg” disease. The problem is one of therapy during that 12-month period.
discovering the subclinical cases, as considerable proportion (vi) Newly diagnosed case : A person who has been
of these cases lie outside the scope of existing case detection diagnosed as a leprosy case, and who has not taken MDT in
technology. the past.
III. Multidrug therapy (uii) Defaulter case : A defaulter is a leprosy patient on
MDT, who has not collected treatment for 12 consecutive
In the absence of primary prevention by a leprosy months.
vaccine, the strategy of leprosy control is based on effective
chemotherapy (secondary prevention). Till recently, Any patient who has been categorized as a defaulter
chemotherapy of leprosy has relied almost entirely on should be removed from the register (36).
dapsone (DDS). Due to dependence on dapsone (uiii) Relapsed case : A patient whose therapy was
monotherapy for many years, drug-resistant leprosy bacilli terminated, having successfully completed an adequate
(both primary and secondary resistance) have emerged in all course of multidrug therapy, but who subsequently develops
parts of the world. This has led to relapse of the disease even new signs and symptoms of the disease, either during the
in those in whom the disease had been arrested and the surveillance period or thereafter, is considered to have
spread of dapsone-resistant strains to susceptibles “relapsed” (6).
jeopardizing the whole strategy of leprosy control (33). In
order to cope with this problem, a WHO Study Group on Drugs
Chemotherapy of Leprosy, has recommended multiple In multidrug regimens, only bactericidal drugs are used.
drug therapy for both multibacillary and paucibacillary At present, only a small number of such drugs are available :
leprosy (33). these are rifampicin, dapsone, clofazimine, ethionamide
and protionamide. A brief account of these drugs is given
OBJECTIVES

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below :
The main objectives of multidrug chemotherapy of
leprosy are (33) (a) Rifampicin
a. to interrupt transmission of the infection in the Rifampicin (RMP) is the only drug that is highly
community by sterilizing infectious patients as bactericidal against M. leprae. A single dose of 1500 mg or
rapidly as possible with bactericidal drugs; 3-4 consecutive daily doses of 600 mg appear to kill 99 per
b. to ensure early detection and treatment of cases to cent of viable organisms (35). Further the drug is effective
prevent deformities, and when given at monthly intervals, which is a big advantage.
c. to prevent drug resistance. The drug is expensive but safe.
The toxic effects of RMP are anorexia, nausea, abdominal
The multidrug treatment has the additional advantage of pain and occasionally vomiting. It is hepatotoxic. The
curtailing the duration of treatment of leprosy considerably. patient should be kept under supervision for 1 hour, after
Shorter therapy has the added advantages of patient the administration of the drug since shock and collapse are
compliance, cost-effectiveness and decreased work load. known to occur.
DEFINITIONS RMP is now an essential drug in the chemotherapy of
leprosy. Given alone, resistance to the drug develops. Hence
Following the introduction of multidrug therapy, some it is given in combination with other anti-leprosy drugs.
changes in terminology have taken place. The following
working definitions have been proposed by WHO (6). (b) Dapsone
(i) Case of leprosy : A “case” of leprosy is a person Dapsone (DDS) has been in use all over the world for the
showing clinical signs of leprosy with or without control of leprosy for more than 30 years. It continues to be
bacteriological confirmation of the diagnosis, and who has an important drug in the multidrug chemotherapy of
not yet completed a full course of treatment with MDT. This leprosy. It is cheap and effective in the dosage employed
definition is for estimating the prevalence of leprosy. (1-2 mg/kg of body weight). When given orally, it is
(ii) Paucibacillary leprosy : A person having 1-5 skin completely absorbed from the gut and fairly well tolerated. It
lesions and/or only one nerve involvement (34). has shown to be weak bactericidal against M. leprae (37).
(Hi) Multibacillary leprosy : A person having 6 or more The common adverse effects following DDS administration
skin lesions and/or more than one nerve involvement (34). are haemolytic anaemia, methaemoglobinaemia,
(iv) Adequate treatment: Adequate treatment implies the agranulocytosis, hepatitis, peripheral neuropathy, psychosis
completion of a regimen of multidrug therapy within a and lepra reaction. A rare syndrome, known as DDS-
reasonably short period of time : (a) for paucibacillary cases, syndrome consisting of fever, enlarged lymph glands,
adequate treatment implies that the patient has received exfoliative dermatitis, hepatitis and maculopapular rash has
6 monthly doses of combined therapy within 9 months, also been reported. Since dapsone is a haemolytic drug, care
(b) for multibacillary cases, adequate treatment implies that should be taken that the haemoglobin level is not less than 60
the patient has received 12 monthly doses of combined per cent, and the dosage of DDS is strictly weight-based. Iron
therapy within 18 months. tablets are prescribed routinely to correct anaemia.

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(c) Clofazimine RECOMMENDED REGIMENS OF CHEMOTHERAPY
Clofazimine (CLF) was originally synthesized for the
treatment of tuberculosis, but was subsequently found to The proper application of multidrug therapy is crucial to
have far greater value in leprosy. It has both anti-leprosy the success of leprosy control. The regimens recommended
and anti-inflammatory properties. CLF though less effective by WHO have been widely accepted in many countries.
than dapsone has the added advantage in suppressing and They are as below (12).
preventing reactions. CLF is relatively expensive and is
reasonably free from toxic effects in the usual dosage. It is a. Multibacillary leprosy
used as the third drug, whenever possible in leprosy The WHO has recommended the following combination of
chemotherapy. drugs for treatment of adult multibacillary cases of leprosy :
Clofazimine may be unacceptable to some patients • Rifampicin 600 mg, once monthly, given under
because it may give rise to darkish red coloration to skin, supervision
mucous membranes, urine and sweat. These symptoms are • Dapsone 100 mg daily, self-administered
not serious. They would disappear after the drug is stopped.
If totally unacceptable, it may be replaced by ethionamide • Clofazimine 300 mg once monthly supervised;
or protionamide. and 50 mg daily, self-administered.

Where clofazimine is totally unacceptable owing to the

(d) Ethionamide and protionamide
colouration of skin, its replacement by 250 to 375 mg self­
These are bactericidal drugs killing 98 per cent of viable administered daily doses of ethionamide or protionamide
bacilli in 4 to 5 days. They are virtually interchangeable and has been suggested.
gives rise to cross-resistance with each other. They are both
more expensive and more toxic than dapsone. The WHO b. Paucibacillary leprosy
(30) has recommended that ethionamide or protionamide
Paucibacillary cases should also receive combined
should be used as the third drug in the treatment of therapy in view of primary dapsone resistance which is
multibacillary leprosy in those patients, who find clofazimine becoming widespread. The recommended standard regimen
unacceptable. for adults is :

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(e) Quinolones • Rifampicin 600 mg once a month, supervised
These drugs work by inhibiting DNA synthesis during • Dapsone .... 100 mg (1-2 mg/kg of body weight)
bacterial replication. Ofloxacin, a fluorinated quinolone is daily, self-administered
the most preferred drug in this group. Oral ofloxacin is
98 per cent bioavailable with elimination half-life of about The standard treatment regimen for children aged 10-14
5 to 8 hours. 22 doses of ofloxacin kill about 99.9 per cent years is as follows :
of viable M. leprae (38). This is the basis of very short term
clinical trials of a combination of 400 mg ofloxacin and a. Multibacillary leprosy
600 mg rifampicin daily for 28 days. • Rifampicin 450 mg once a month, given under
Side-effects include nausea, diarrhoea and other supervision
gastrointestinal complaints and a variety of central nervous • Dapsone 50 mg daily, self administered
system complaints. • Clofazimine 150 mg once a month supervised;
and 50 mg every other day.
(f) Minocycline
This is the most lipid-soluble of the tetracyclines and b. Paucibacillary leprosy
inhibits bacterial protein synthesis. In clinical trials, the • Rifampicin 450 mg once a month, supervised
clearance of viable M. leprae from the skin by minocycline
was faster than that reported from dapsone or clofazimine e Dapsone 50 mg daily, self administered
and similar to that for ofloxacin. Minocycline may strengthen
Children under the age of 10 years should receive
MDT, for multibacillary patients and thereby shorten the
duration of treatment needed to treat leprosy effectively appropriately reduced doses of the above drugs.
(33). The standard dose is 100 mg daily. The side-effects
include discoloration of teeth in infants and children,
Duration of treatment
occasional pigmentation of the skin and mucous membrane, The treatment duration varies according to the type of
various gastrointestinal symptoms and central nervous disease. The recommendations are as follows
system complaints. It should not be given to infants, children Multibacillary leprosy - MB blisterpacks for 12 months,
and during pregnancy (22). within 18 months
(g) Clarithromycin Paucibacillary leprosy - PB blisterpacks for 6 months,
within 9 months
Clarithromycin is a member of the macrolid group of
antibiotics and displays a significant bactericidal activity A defaulter who returns to the health centre for treatment
against M. leprae. In patients with lepromatous leprosy, should be given a new course of MDT when he or she shows
daily administration of 500 mg of clarithromycin killed one or more of the following signs (36):
99 per cent of viable M. leprae within 28 days, and 99.9 per - reddish and/or raised skin lesions;
cent by 56 days. Side-effects include nausea, vomiting and — appearance of new skin lesions (since the previous
diarrhoea. examination);
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

- new nerve involvement (e.g. changes in skin across) appear under the skin of the limbs or trunk, while the
sensation) since the previous examination; original leprosy skin patches remain as they were. In
- lepromatous nodules; addition, ENL reactions cause a general feeling of fever and
malaise, while reversal reactions cause less systemic upset.
- signs of reversal reaction or ENL. Common differentiating features are as shown in Table 1.
For registration purposes, returning defaulters are not Because of the high risk of permanent damage to the
considered as newly detected cases. peripheral nerve trunks, reversal reaction needs to be
MDT is not contraindicated in patients with HIV infection. diagnosed as soon as possible, and treated adequately. The
Management of leprosy and of lepra reactions is same as drug of choice is prednisolone, the cheapest and most
that of any other leprosy patient. The response of such widely available corticosteroid.
patients to MDT is also similar (36). Most reversal reactions and neuritis can be treated
Since leprosy is exacerbated during pregnancy, it is successfully under field conditions, with a standard 12-week
important that MDT be continued. The evidence so far course of prednisolone. The potential risk of serious adverse
indicates that MDT is safe during pregnancy. Small effects caused by long-term corticosteroid therapy must not
quantities of anti-leprosy drugs are excreted through breast be ignored, particularly under field conditions. The more
milk, but there is no report of adverse reaction as a result of common problems of prolonged steroid therapy include
this, except for mild discolouration of the infant’s skin weight gain, peptic ulcer, diabetes, hypertension, reactivation
caused by clofazimine (39). of tuberculosis, osteoporosis and psychiatric disorders.
ENL varies in severity, duration and organ involvement.
Lepra reaction (40) Acute or subacute neuritis, with or without loss of nerve
During the course of leprosy, immunologically mediated function, is one of the major criteria in distinguishing mild
episodes of acute or subacute inflammation known as and severe ENL. Mild ENL can be treated with analgesic or
reactions may occur. Because peripheral nerve trunks are antipyretic drugs such as aspirin, while severe ENL can be
often involved, unless reactions are promptly and treated with prednisolone, as for reversal reaction.
adequately treated, such episodes can result in permanent Clofazimine is also effective for ENL, but is less potent
deformities. than cortico-steroids and often takes 4-6 weeks to develop
Lepra reactions are usually diagnosed by clinical its full effects, so it should never be started as the sole agent

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examination only. Inflammatory changes in skin lesions or for the treatment of severe ENL.
appearance of new lesions, patches or nodules with acute
onset, draw the attention of patient to report. Some cases Signs of a severe reversal reaction
develop signs of nerve damage without changes in skin If any of the following signs are found, the reaction
lesions. should be treated as severe :
There are two types of reaction : Reversal reaction - Loss of nerve function - that is, loss of sensation or
(or Type 1) and Erythema Nodosum Leprosum (ENL or muscle weakness in the area supplied by nerve.
Type 2). Both types can occur before the start of multi-drug - Pain or tenderness in one or more nerves.
treatment, during treatment, or after treatment has been
completed. Both types can be mild or severe. Only severe - Silent neuritis/quiet nerve paralysis i.e. signs of nerve
reactions are treated with corticosteroids. damage without symptoms.
Distinguishing between the two types of reactions is - A red, swollen skin patch on the face, or overlying
usually not difficult. In a reversal reaction, the leprosy skin another major nerve trunk.
lesions themselves become inflamed, red and swollen. In an - A skin lesion anywhere that becomes ulcerated.
ENL reaction, new inflamed, red nodules (about 1-2 cm - Marked oedema of the hands, feet or face.

TABLE 1
Difference between reversal reaction and ENL
AT

Type I (Reversal Reaction) Type II (ENL)

1. Delayed hypersensitivity. 1. Antigen antibody reaction.
2. Occurs in both PB and MB cases in unstable types like BT.BB.BL. 2. Seen in MB cases only (BL and LL type).
3. Skin lesions suddenly become reddish, swollen, warm, painful, 3. Red, painful, tender, sub-cutaneous nodules - ENL may
and tender. New lesions may appear. appear, commonly on face, arms, legs, bilaterally
symmetrical. They appear in crops and subside within few
days even without treatment (Evanescent skin nodules).
Nodules are better felt than seen and these are recurrent
(episodic)
4. Nerves close to skin may be enlarged, tender and painful 4. Nerves may be affected but not as common or severe and
(neuritis) with loss of its functions (loss of sensory, motor or acute as in Type I
autonomic) which may appear suddenly.
5. Other organs - not affected 5 Other organs like eyes, testis, and kidney may be affected.
6. General symptoms - not common. 6. Fever, joints pain, red eyes with watering may be associated.
7. Eye-Lagophthalmos and corneal anaesthesia due to neuritis. 7 Iritis/iridocyclitis

Source : (12, 40)

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 LEPROSY 373
Signs of a severe ENL reaction because of the risk of recurrence. Each person must
If any of the following signs is found, the reaction should understand that a reaction or new nerve damage may recur.
be treated as severe : They must know how to recognize the early signs of nerve
damage and be aware of how important it is to return
- Pain or tenderness in one or more nerves, with or promptly to the clinic for treatment. These signs include pain
without loss of nerve function. or tingling sensations, further loss of feeling or loss of muscle
- Ulceration of ENL nodules. strength and inability to close the eye.
- Pain of eyes with or without redness and loss of visual Patients still on MDT should have their nerve function
acuity. checked monthly by the health worker when they come to
- Painful swelling of the testes (orchitis) or of the fingers collect their treatment. Any deterioration should be noted
(dactylitis). and the person referred. Patients who have already
- Marked arthritis or lymphadenitis. completed MDT, by the time they come to the end of a course
of steroids, should be asked to come back three months and
Treatment of Lepra reactions (moderate to severe cases) six months after the end of the course for review and nerve
function assessment. Patients who still have lagophthalmos
It includes bed rest, rest to affected nerves by splint,
(weakness of eyelids) after completion of treatment with
analgesics, prednisolone. Each case of reaction should be
steroids should be referred to ophthalmic surgeon.
assessed for his/her fitness to put on prednisolone as per
check list given above (12, 40). Groups requiring special precautions when prescribing
Prednisolone regimen Add Clofazimine in ENL steroids
40 mg daily for first 2 weeks One capsule (100 mg)
The following groups of people require special
30 mg daily for weeks 3 and 4 3 times a day x 4 weeks precautions when steroids are prescribed. One must not give
steroids to people with tuberculosis, diabetes, deep ulcers,
20 mg daily for weeks 5 and 6 One capsule (100 mg) osteomyelitis, corneal ulcers or other serious conditions
15 mg daily for weeks 7 and 8 2 times a day x next 4 weeks
without starting treatment for the underlying condition.
10 mg daily for weeks 9 and 10 One capsule (100 mg) once
5 mg daily for weeks 11 and 12 a day x third month Pregnant women

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For neuritis, treatment with Prednisolone should be prolonged to All pregnant women should be treated at referral level, so
four weeks from 20 mg onwards as to minimize the steroid dose they are given and thus
avoid harmful effects, such as growth retardation on the
Prednisolone tablets issued must be entered in foetus. If steroids are given in the third trimester, this may
'Prednisolone card'. Tapering of prednisolone may be done cause adrenal suppression in the newborn infant. Ideally,
according to its response. Patient must be instructed on salt such infants should be monitored in a referral centre for a
restriction, no prednisolone intake on empty stomach and few days after birth. The dose of prednisolone to be given
reporting adverse effects/symptoms immediately. during pregnancy are as follows :
Adding Clofazimine for Type II reaction may be extremely - PB cases : start at 30 mg daily instead of 40 mg and limit
useful for reducing or withdrawing corticosteroids in patients the course to ten weeks rather than the usual twelve
who have become dependent on them. Total duration of weeks regime.
Clofazimine therapy should not exceed 12 months. - MB cases : starting at 30 mg daily but lasting for twenty
If a patient develops lepra reaction during the treatment, weeks.
do not stop MDT (rather complete the course of MDT).
Lepra reactions, which occur after completion of treatment, Children
should also be managed as mentioned earlier. MDT should All children under the age of twelve should be treated at
not be restarted for such cases. Response to treatment referral level, so as to minimize the effects of steroids on their
should be monitored and assessed, including check on growth. Children can be given a course similar to that for
adverse effects of prednisolone. pregnant women, but the starting dose of prednisolone
Before starting the steroid treatment, the patient should should not exceed 1 mg per kilogram of body weight per day.
be asked questions about epigastric pain and diarrhoea, Giving children steroids on alternate days may reduce the
with or without blood and or mucous; and examined for effect on their growth. A suitable regimen for PB cases would
fungal infection, scabies, and worm infestations, as all these be 30 mg of prednisolone daily for two weeks, then 30 mg on
conditions may be made worse by steroids. Treatment of all alternate days for two weeks with a gradually reducing dose
these conditions can be started at the same time as steroids over the total course of ten weeks. For MB cases, one should
are started (40). double the duration of each stage of the course.
Before starting the steroid treatment the patient should be
Diabetes
explained the reason for treatment; the duration of the
treatment; importance of taking daily dose and that the Patients who show symptoms that suggest diabetes or
treatment should not be stopped suddenly (the dosage is whose urine tests positive for glucose should be referred to
decreased gradually) and importance of completing the full confirm whether the diagnosis is correct and, if it is
course of treatment; and possible side-effects. confirmed, for management of the diabetes condition.
Steroids may increase the diabetic’s requirement for insulin.
Follow-up after treatment with steroids A person taking steroids may also develop diabetes for
People who have been given a course of steroids for the first time. This possibility must be considered when
reaction or nerve damage should be followed up closely patient develops typical symptoms of diabetes during the

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

treatment with steroids. The condition usually resolves itself have already developed permanent deformities. In order to
when steroids are stopped. avoid these problems, national leprosy programmes should
try to ensure that patients are taught to recognize the early
Ulcers or osteomyelitis signs of reactions, and to report promptly for treatment;
Patients with deep or dirty ulcers or osteomyelitis should health workers are able to diagnose and treat reactions and
be referred for surgical treatment and antibiotics. Starting to refer patients when necessary; and adequate stocks of
steroids before such treatment may lead to a worsening of prednisolone are maintained at the peripheral level (22).
the sepsis and more permanent damage, including the need
for amputation. One should suspect osteomyelitis if the IV. Surveillance
person’s hand or foot is warmer than normal, with or Clinical surveillance of cases after completion of
without swelling. Any person with a wound discharging pus treatment is an important part of the current
should be referred for surgical advice and debridement recommendations for multidrug therapy; it is essential for
(removal of dead and infected tissue) before taking steroids, the assurance of long-term success of treatment and for the
or osteomyelitis may develop. early detection of any relapses.
(a) Paucibacillary leprosy : It is recommended that
Eye involvement
paucibacillary cases be examined clinically at least once a year
Patients who have corneal damage or iritis should be for a minimum of 2 years after completion of treatment (6).
referred for specialist diagnosis and management at a centre
(b) Multibacillary leprosy : It is recommended that
properly equipped for eye care. Corneal ulcers and keratitis
multibacillary cases be examined clinically at least once a
are inflammatory conditions of the cornea. They are often
year for a minimum period of 5 years after completion of
caused by exposure, as a result of the person being unable to
therapy (8).
close the eye properly. Steroids, whether taken by mouth or
locally applied, may make these conditions worse. Iritis, A patient who has completed the required period of
uveitis, iridocyclitis and scleritis are all types of inflammation surveillance following the course of multidrug therapy and
inside the eye and they can all occur as part of a Type-2 shows no evidence of relapse is considered to have
reaction. These conditions cause pain, redness, photophobia completed surveillance. The phrase “release from control”
and loss of vision, although the symptoms are not always should not be applied in the context of multidrug therapy (6).

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severe. The treatment includes atropine eye ointment to
prevent adhesion. V. Immunoprophylaxis
The fact that a scientifically valid tool for the detection of
Tuberculosis infection is not yet available which could deepen the
If tuberculosis is suspected, the diagnosis must be understanding of how leprosy is transmitted, and could lead
confirmed and treatment started before giving steroids. to the development of an effective vaccine and other
The crucial elements in the management of leprosy interventions. Trials in different population groups with BCG
reactions and thereby, the prevention of disabilities are early vaccine either alone or in combination with other vaccine
diagnosis of reactions together with prompt and adequate (from killed Mycobacterium leprae or atypical
treatment. Usually the diagnosis of leprosy reactions is Mycobacteria), have shown protective efficacy ranging
relatively straightforward, but occasionally, in paucibacillary between 28 per cent and 60 per cent. High BCG coverage
patients who have completed treatment, differentiation of a remains an important contribution to reducing the disease
reversal reaction from relapse may be difficult. Nevertheless, burden due to leprosy (41).
it is essential that this distinction must be made correctly.
The differences are as summarized in Table 2. VI. Chemoprophylaxis
As a consequence of all these factors, the diagnosis and Chemoprophylaxis in chronic infectious diseases has an
treatment of leprosy reactions may often be delayed and, by established benefit, particularly when given to persons who are
the time the patients arrive at the referral centres, they may known to be at higher risk of developing the disease. The

TABLE 2
Differences between reversal reaction and relapse
Reversal reaction Relapse
Time interval Generally occurs during chemotherapy or within Usually occurs only when chemotherapy has
3 years of stopping treatment been discontinued, after an interval of usually
more than 3 years
Onset Abrupt and sudden Slow and insidious
Old lesions Existing lesions become oedematous, erythematous Lesion may show erythema and infiltration, but
or tender no tenderness
New lesions Several new lesions appear New lesions are minimal
Ulceration Lesions may ulcerate Ulceration does not occur
Nerve involvement Multiple nerve involvement common, painful Nerve involvement may occur only in a single
and tender nerve; usually no pain or tenderness
General condition May have fever, joint pains, malaise Not usually affected
Response to steroid treatment Rapid Nil

Source : (24, 41)

by R△J
 LEPROSY 375
immediate contacts of a case of leprosy, especially Patients at high risk of developing disability
multibacillary, are known to have a higher risk of developing People with the following features are more likely to
the disease than compared to the general population. It is develop lepra reaction and neuritis compared to others and
important, therefore, to consider possible interventions to thus subjected to developing disability -
prevent the occurrence of leprosy among household contacts.
However, there must be robust trial evidence to demonstrate - Multi-bacillary leprosy
that the drug/s used for chemoprophylaxis are safe, effective - Past or present thickened/painful/tender nerve trunk
and cost-efficient in terms of the number of new cases - Skin lesion on face
prevented. - Adolescents, pregnancy, old age
On account of lack of consistent results from various - Any inter-current infection
studies using various drugs (dapsone, acedapsone, Stages of involvement of nerve
rifampicin) it is too premature to advise chemoprophylaxis as
a public health measure. Further research is needed to use Stage I : Stage of nerve involvement - Nerves become
this as a routine tool to prevent the occurrence of disease swollen (thickened) due to inflammatory
among contacts (41). response and tender, but no loss of function. This
condition is reversible if action is taken early.
VII. Disability Stage II : Stage of nerve damage - Along with thickened
and painful peripheral nerves, associated with loss
It is estimated that approximately 25 per cent of the of function (loss of autonomic, sensory and motor
patients who are not treated at an early stage of disease functions). This condition is reversible if suitable
develop anaesthesia and/or deformities of the hands and action is taken early preferably within 6 months.
feet. As a single disease entity, leprosy is one of the foremost
causes of deformities and crippling. Stage III: Stage of nerve destruction - In long standing
case of nerve involvement (usually more than
The deformities may result due to the disease process one year) nerve, may become fibrosed, thin and
(e.g. loss of eye brows, other facial deformities), or those atrophic. Involved nerve is completely
resulting from paralysis of some muslces due to damage to destroyed and its function cannot be recovered
peripheral nerve trunk (e.g. claw-hand, foot-drop, to any useful degree.
lagophthalmos), or those resulting from injuries or infections
There are two types of disabilities in leprosy :

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to hands and feet (e.g. scar contractures of fingers,
mutilation of hands and feet, corneal ulceration). Fig. 3 1. Primary : These disabilities occur as a result of nerve
shows the process of disability in hands, feet and eyes. damage - e.g. loss of sensation, paralysis,
dryness
2. Secondary: These occur as a result of neglected
Nerve damage primary disability - e.g. ulcer, contracture.
A disability is defined as lack of ability to perform an
activity.
T

Loss of sensation Loss of motor A deformity is a visible consequence of an impairment

function inside the body.
▼ The findings of the examination are first noted in the
Injury/pressure Weakness Disability Assessment Form separately for right and left eyes,
hands and feet. Thereafter each eye, each hand and each
foot is given its own grade. Deformities are classified into
▼ ▼
three grades. The criterias are as follows (12, 42) :
Ulcer Contracture
Examination WHO Sensory Voluntary
of parts Disability testing muscle testing
Grades
0 Sensation Muscle power
present normal
Hands 1 Sensation Muscle power
absent normal
2 Sensation Muscle power
absent weak or paralyzed
0 Sensation Muscle power
present normal
Feet 1 Sensation Muscle power
absent normal
2 Sensation Muscle power
absent weak or paralyzed
Vision Lid Gap Blinking
0 Normal No lid gap Present
Eye 2 Cannot Gap present/ Absent
FIG. 3 count red eye/
Process of deformity in hands, feet and eyes fingers at corneal ulcer
Source : (12) 6 metres or opacity

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376 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

The highest grade given in any of the part is used as the governmental health, education, vocational, social and
Disability Grade for that patient. Eye, hand and feet score other services”.
i.e. sum of all the individual disability grades for two eyes, Rehabilitation measures may appear to be simple; they
two hands and two feet 0-12, should be recorded at each require planned and systematic actions - medical, surgical,
examination. social, educational and vocational - consistently over years
Table 3 shows deformities occurring in patients with with sustained counselling and health education for training
leprosy. or retraining of the individual to the highest possible level of
TABLE 3 functional ability. For this purpose, coordinated efforts by
Deformities occurring in leprosy the Departments of Health, Education and Social Welfare,
as well as voluntary organizations are necessary.
Face Mask face, facies leonina, sagging face,
lagophthalmos, loss of eyebrows (superciliary IX. Health education
madarosis) and eyelashes (ciliary madarosis),
corneal ulcers and opacities, perforated nose, No anti-leprosy campaign is complete without health
depressed nose, ear deformities, e.g. nodules education. Health education aims at helping people develop
on the ear and elongated lobules attitudes and behaviour by their own actions and efforts and
Hands Claw hand, wrist-drop, ulcers, absorption of seeking professional help when needed. Health education
digits, thumb-web contracture, hollowing of should be directed towards the patient and his family and the
the interosseous spaces and swollen hand. general public, (a) Patient and his family : The main problem
Feet Plantar ulcers, foot-drop, inversion of the foot, in leprosy control is poor patient compliance with the drug
clawing of the toes, absorption of the toes, regimen and high drop-out rates. The patient and his family
collapsed foot, swollen foot and callosities. should be educated about the need for regular treatment,
Other Gynaecomastia and perforation of the palate repeated examination of contacts, self care regarding
deformities prevention of disabilities and protection of children. Health
education thus minimizes hurdles in implementing the
Source : (21, 23)
leprosy control programme, (b) General public : There is a
The measures to prevent disabilities include actions to growing realization that technological advances alone cannot
take care of the dry, denervated skin of palms and soles, solve the leprosy problem, unless we succeed in involving
heal the wounds, ulcers and skin cracks in palms and soles, the people in the control programme. Health education aims

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prevent injuries to hands and feet by using protective gloves at ensuring community participation. The public should be
and footwear, prevent joint stiffness in cases of paralytic made aware that leprosy is not a hereditary disease; it is a
deformities, protect the eyes, and assess periodically the bacterial disease like tuberculosis; it is curable; not all leprosy
commonly damaged nerves for loss of nerve function and its patients are infectious; regular and adequate treatment is
progression, using simple tests that can be carried out in the essential to obtain cure and prevent disabilities, and that the
field. patient needs sympathy and social support. A nationwide
Improvement of disabilities is achieved through the use of mass education is needed to educate people on the true facts
prostheses and orthopaedic devices, including corrective about leprosy and remove superstitions and wrong beliefs
splints, as well as by corrective surgery. All these measures, and the social stigma associated with leprosy (32).
however, require special expertise and facilities.
2. SOCIAL SUPPORT
VIII. Rehabilitation Chemotherapy alone is not likely to solve the whole
The WHO Expert Committee on Leprosy in its Second problem of leprosy. The economic and social problems of
Report (43) defined rehabilitation as the patient and his family should be identified and met. This
“the physical and mental restoration, as far as possible, of all may include social assistance and social support. This may
treated patients to normal activity, so that they may be able take various forms depending upon the local situation,
to resume their place in the home, society and industry”. e.g., assistance to the patient to travel to and from the clinic;
Rehabilitation is, therefore, an integral part of leprosy help to the needy families in terms of foodgrains, clothes,
control. It must begin as soon as the disease is diagnosed. care of children and their education, and job placement;
The cheapest and surest rehabilitation is to prevent physical programmes such as slum improvement, etc. Such care
deformities and social and vocational disruption by early should be provided through voluntary agencies and
diagnosis and adequate treatment. The measures that are Departments of Social Welfare.
taken in this direction are known as “preventive
rehabilitation”. The approach to rehabilitation should, 3. PROGRAMME MANAGEMENT
therefore, begin with preventing dehabilitation. We should Leprosy control is a long-term activity. Therefore
never allow dehabilitation to take place and afterwards take planning and programme management are essential
up the uphill task of rehabilitation (44). ingredients. It is generally assumed that with existing tools,
we can achieve rapid control of leprosy, provided the
Community-based rehabilitation defined by WHO and “operational performance” is stepped up to the maximum
major NGOs is as follows (41) : level required. This is the responsibility of programme
“Community-based rehabilitation is a strategy within managers. These issues are discussed under evaluation (see
general community development for the rehabilitation, operational indicators and epidemiological indicators
equalization of opportunities and social inclusion of all below). Among the resources that are needed are adequate
people with disabilities. Community-based rehabilitation is infrastructure, trained health personnel, adequate supply of
implemented through the combined efforts of the people drugs and vehicles, and financial allocation. The National
with disabilities themselves, their families, organizations and Leprosy Eradication Programme incorporates all these
communities, and the relevant governmental and non­ elements (see chapter 7).

by R△J
 LEPROSY 37
4. EVALUATION No. of new leprosy cases
An important aspect of leprosy control is to assess the detected in one year
ANCDR = x 100,000
impact of the control operations on the endemicity of the Total population of
disease, and to compare results between different times and the area (as on 31st March)
places. Indicators are required for such an evaluation. It is (2) Rate of new cases with Grade-2 disabilities
important that these indicators can be easily used and satisfy per 10,00,000 population per year
the criteria of repeatability and validity. Ideally they should
be conceived and treated as signals for action by Definition : It is the rate at which new cases with disability
programme managers (6). There are two main types of grade 2 are detected in the defined geographical population
indicators in leprosy control. (area) in a given year.
Total no. of new cases
I. Epidemiological indicators
RNCWG2D = detec_ted_with Gr II disability x 10 00 00Q
These are required to evaluate the effectiveness of the Total population of
programme, that is to assess the impact of the action taken with the area (as on 31st March)
regard to the problem reduction. These indices are :
(a) INCIDENCE : Incidence rates are often calculated (3) Treatment completion rate
separately for different subgroups of population, e.g., age, sex, Definition : It is the rate of patients who complete their
frequency of household contact. It is the most sensitive index of treatment on time as a proxy for cure rate. Cohort analysis
transmission of the disease. It is the only index for measuring of PB and MB cases are done separately.
the effectiveness of the measures taken, i.e., reduction of
transmission. Thus they are useful in monitoring the success of Number of new PB cases who
a control programme, (b) PREVALENCE : This provides a _ completed MDT in 9 months
x 100
measure of the “case load” and is useful in the planning of the Number of new PB cases who
Treatment services. The continued reduction in the prevalence started MDT in a year
could also give information about the downward trend of the
disease. It is often useful to calculate prevalence rates for Number of new MB cases who
different subgroups, e.g., age sex, geographic area. The fact kxo completed MDT in 18 months
MB TCR =--------- —------------ ---------------------- x 100

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that leprosy is not uniformly distributed should be borne in Number of new MB cases who
mind when these statistics are interpreted (6). started MDT in a year
A. Main or core indicators for monitoring 4. Prevalence rate (PR)
progress (41) Definition : It is the total number of leprosy cases on
(1) The number and rate of new cases detected per record/under treatment per 10,000 population at a given
100,000 population per year. point of time in an area.
(2) Rate of new cases with grade-2 disabilities per PR _ Total number of leprosy cases on record x qqq
100,000 population per year. Total population of the area
(3) Treatment completion/cure rate. (as on 31st March)
(4) Prevalence rate
(A case of leprosy is a person with clinical signs of
B. Additional epidemiological indicators (12) leprosy, who requires MDT)
- Proportion of grade II disabilities among new cases 5. Proportion of Grade II disability among new cases
- Proportion of females among new cases (PG2DANC)
- Proportion of MB among new cases Definition : It is the proportion (%) of new leprosy patients
- Proportion of child (0-14 years) among new cases with grade II disability among total new cases detected.
- Child rate per 1,00,000 population No. of Grade II disabled cases
- Scheduled caste new case detection rate detected in a year ------------
- Scheduled tribe new case detection rate PG2DANC = --------------~ x 1Q0
Total new cases detected in a year
C. Quality of service indicators (12)
6. Proportion of female among new cases (PFANC)
- Patient month blister calendar pack stock
Definition : It is the proportion (%) of new female
- Absolute number of patients made RFT
patients among total newly detected cases.
- Number of relapse reported
- Proportion of cases who developed new or additional Number of new female patients
PFANC = —-------------------------------------------------- x 10Q
disability after starting MDT Total no. of newly detected cases
- Proportion of treatment defaulters 7. Proportion of Multi-bacillary (MB) among new cases
- Proportion of new cases correctly diagnosed (PMBANC)
Definitions Definition : It is the proportion (%) of new patients
Indicators and formula to be used for their calculation are diagnosed as MB among newly detected cases.
indicated below : PMBANC = --------- viNumber
new of new MB cases ------------ x 10Q

(1) Annual new case detection rate (ANCDR) Total no. of newly detected cases
Definition : It is the rate at which new cases (never 8. Proportion of child among new cases (PCANC)
treated before) are detected in a defined geographical area Definition : proportion (%) of new leprosy patients upto
(block, district) in a year (April-March). 14 years of age among newly detected patients.
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378 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

A wTZ_ Number of ychild leprosy cases detected . headquarters of this organization later moved to Purulia in West
PCANC =------------------------ -------------------- x 100 Bengal. Since then, many voluntary organizations^now about
Total no. of newly detected leprosy cases
150) hav-&.sjprung_gpjn the cause of leprosy. Important among
9. Child rate (CR) per 100,000 population these are the Hind Kusht Nivaran Sangh (formerly the British
Definition : The rate of new child leprosy cases (0-14 yrs Empire Leprosy Relief Association); Gandhi Memorial Leprosy
of age) detected among the population of the area in a year. Foundation, Sevagram, Wardha; the German Leprosy Relief
No. of new child cases (0-14 yrs) Association; the Damien Foundation; the Danish Save the
detected in a year---------- * 100000 Child Fund; and the more-recent JALMA which was taken over
CR = by the ICMR in 1975. A federation body, “National Leprosy
Population of the area Organization” came into being in 1965 to provide a common
(as on 31st March) platform to discuss their problems and share their experiences.
10. Scheduled caste (SC) new cases detection rate The campaign against leprosy in India is accomplished through
Definition : Total number of new cases detected among an official programme, the National Leprosy Control
the SC population in a given time in an area. Programme which was initiated in the middle or 1954. In 1983,
it was converted into an eradication programme.
Total number of SC cases
An account of the National Leprosy Eradication
newly detected
SCNCDR = ---------------------------------------------- x 10,000 Programme is given in chapter 7.
Total SC population in an area
11. Scheduled tribe (ST) new cases detection rate References
Definition : Total number of new ST cases detected 1. WHO (2001), Weekly Epidemiolgical Record, No. 20, 18 May, 2001.
among the ST population in given time in an area. 2. WHO (2000), Weekly Epidemiological Record, No. 28 14th July, 2000.
3. WHO (2021), Weekly Epidemiological Record, No. 36, 10th Sep.,
Total number of ST cases 2021.
newly detected 4. Govt, of India (2020), Annual Report 2019-20, Ministry of Health and
STNCDR = - x 10,000 Family Welfare, New Delhi.
Total ST population in an area 4A. Govt, of India (2022), Annual Report2021-22, Ministry of Health and
12. Patients month blister calendar pack (BCP) stock Family Welfare, New Delhi.
5. Dharmendra (1985), Leprosy Vol III, Samant and Company, Bombay.

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(PMBCP) 6. WHO (1988). Techn. Rep. Ser., No. 768.
Definition : Stock of BCPs in months, according to the 7. Job, C.K. et al (1975). Leprosy : Diagnosis and Management, Hind
number of patients expected to be treated in the next quarter. Kusht Nivaran Sangh, New Delhi.
8. Periaswamy, V. (1984). Ind. J. Lepr, 56, No.l (suppl).
Number of blister packs of each
9. WHO (1980). A Guide to Leprosy Control.
PMBCP = category [PB(A/C), MB(A/C)] 10. Last, J.M. ed (1980). Maxcy-Rosenau : Public Health and Preventive
No. of cases under treatment in each Medicine, 11th ed., Appleton Century Crofts.
category [PB(A/C), MB(A/C)] 11. Prabhakar, M.C. et al (1984). Ind. J. Lepr, 56 No.l (Suppl).
12. NLEP (2019), Training Manual for Medical Officers, 2019.
13. Absolute number of patients made RFT 13. Van Braket, W.H. et al. (1992). Leprosy review, 63:231 - 245.
Definition : Number of patients released from treatment 14. WHO (2009), Transmission of Leprosy.
during the year. The number should include both the new 15. Noordeen, S.K. (1980). In : A Manual of Leprosy, R.H. Thangaraj (ed)
and the other cases treated in a year. The Leprosy Mission, New Delhi.
16. Desikan, K.V. (1985). Ann. Natl. Acad. Med. Sci, India, 21 (4) 207, The
14. Number of relapses reported Times of India, New Delhi 30 Jan. 1991.
17. Job, C.K. (1987). Ind. J. Lepr., 59 (1) 1-8.
Definition : No. of relapse cases recorded in (and 18. International Leprosy Congress, Madrid (1953). Int. J. Lepr., 21: 504.
reported by) the PHC, District Hospitals, Medical colleges 19. Ridley, D.S. and Jopling, W.H. (1966). Int. J. Lepr., 34, 255.
and other institutions in the district during the given time. 20. Chacko, C. J. G. (1980). In : A Manual of Leprosy, R.H. Thangaraj (ed).
The Leprosy Mission, New Delhi.
15. Proportion of cases with new disability after 21. NLEP (2012). Disability Prevention & Medical Rehabilitation,
starting MDT (PCWNDASMDT) Guidelines for primary, secondary and tertiary level care, June, 2012
22. WHO (1998), Tech. Rep. Ser. No. 874.
Definition : Proportion (%) of cases who developed new
23. Yawalkar, S.l. (1994). Leprosy for medical practitioners and
or additional disability after starting MDT (new disability paramedical workers, Sixth Edition, CIBA-GE1GY Ltd.
includes new nerve damage or new secondary impairment). 24. Bryceson, A. and Roy, E.P. (1979). Leprosy, 2nd ed., Churchill
No. of cases developed Livingstone.
new or additional disability 25. Van Brakel, W.H. et al. (1992). Leprosy review, 63:231-245.
PCWNDASMDT = during treatment 26. Bharadwaj, V.P. (1985). Ann. Natl. Acad. Med. Sci, 21 (3) 128.
x 1Q0
27. Noussitou, F.M. et al (1976). Leprosy in Children WHO.
No. of cases put under
28. Ramu, G. etal (1980). Lepr India, 52 (3)390.
MDT during the year
29. Bharadwaj, V.P et al (1981). Lepr India, 53 : 518.
16. Proportion of new cases correctly 30. Sinha, S. et al (1985). Ind. J. Lepr., 53 : 33-38.
diagnosed (PNCCD) 31. Dharmendra (1982). Lepr India, 54 : 193.
No. of new cases correctly diagnosed 32. Govt, of India (1982). Report of the Working Group on the Eradication
PNCCD = xlOO of Leprosy, Ministry of Health and Family Welfare, New Delhi.
No. of cases validated (DNT team) 33. WHO (1982). Techn. Rep. Ser., No.675.
Anti-leprosy activities in India 34. WHO and NLEP India (2000), Guide to Eliminate Leprosy as a Public
Health Problem.
The history of anti-leprosy work in India goes back to 1874 35. Katochi, K. etal (1985). Ind. J. Lepr., 57 (3) 499.
when the Mission to Lepers (now Leprosy Mission) was 36. WHO (2003), The Final Push strategy to Eliminate Leprosy as a Public
founded by Baily at Chamba, in the Himachal Pradesh. The Health Problem, Questions and Answers, 2nd Ed. 2003.
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 SEXUALLY TRANSMITTED DISEASES

37. Ramu, G. (1985). Ind. J. Lepr., 57 (3) 465. Extent of the problem
38. Ganpati, R., Leprosy - A Glimpse at the Changing Scenario (1996),
Published*by Acworth Leprosy Hospital Society for Research,
Rehabilitation and Education in Leprosy and Bombay Leprosy Project.
WORLD
39. Indian Journal of Leprosy, Oct-Dec. 2003, Vol 75 (4). The true incidence of STDs will never be known not only
40. Govt, of India (2007), Operational Guidelines (Secondary Level), because of inadequate reporting but because of the secrecy
Disability Prevention and Medical Rehabilitation, 2007, National that surrounds them. Most of them are not even notifiable.
Leprosy Eradication Programme, Central Leprosy Division, Ministry
of Health and Family Welfare, New Delhi. All available data, however, indicate a very high prevalence
41. WHO (2009), Enhanced Global Strategy for Further Reducing the of STD .
Disease Burden due to Leprosy (Plan period 2011-2015). STDs have a profound impact on sexual and reproductive
42. Govt, of India (2007), Operational Guidelines (Primay Level), health worldwide, and rank among the top 5 disease
Disability Prevention and Medical Rehabilitation, 2007, National
Leprosy Eradication Programme, Central Leprosy Division, Ministry categories for which adults seek health care.
of Health and Family Welfare, New Delhi. More than 1 million STIs are acquired every day.
43. WHO (1960). Techn. Rep. Ser., No.189. Each year, there are an estimated 374 million new infections
44. Bhowmick, A. (1987). Ind. J. Lepr., 59 (1) 92. with 1 of 4 STIs. During 2020, there were about chlamydia
(129 million), gonorrhoea (82 million), syphilis (7.1 million)
SEXUALLY TRANSMITTED DISEASES and trichomoniasis (156 million). More than 500 million
people are living with genital HSV (herpes) infections. At
The sexually transmitted diseases (STD) are a group of
any point in time, more than 300 million women have an
communicable diseases that are transmitted predominantly
HPV (Human Papilloma Virus) infection, one of the most
by sexual contact and caused by a wide range of bacterial,
common STIs. An estimated 296 million people are living
viral, protozoal and fungal agents and ectoparasites.
with chronic hapatitis B globally (3).
During the past few decades, STDs have undergone a
dramatic transformation (1). First, the change in name from STIs can have serious consequences beyond the
venereal diseases (V.D.) to sexually transmitted diseases immediate impact of the infection itself. STIs like herpes and
(STD) indicates this transformation. The list of pathogens syphilis can increase the risk of HIV acquisition three-fold or
which are sexually transmissible has expanded from the more. Mother-to-child transmission of STIs can result in
5 “classical” venereal diseases (syphilis, gonorrhoea, stillbirth, neonatal death, low-birth-weight and prematurity,

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chancroid, lymphogranuloma venereum and donovanosis) sepsis, pneumonia, neonatal conjunctivitis, and congenital
to include more than 20 agents, as shown in Table 1 (2). deformities. Over 900,000 pregnant women were infected
Secondly, attention is now given not only to specific with syphilis resulting in approximately 350,000 adverse
diseases, but also to clinical syndromes associated with STDs birth outcomes including stillbirth in 2012. HPV infection
as shown in Table 3 (1). Most of the recently recognized causes about 528,000 cases of cervical cancer and 266,000
STDs are now referred to as second generation STDs. cervical cancer deaths each year. STIs such as gonorrhoea
AIDS, the most recently recognized, is a totally new disease. and Chlamydia are major causes of pelvic inflammatory
disease (PID) and infertility in women (4).
TABLE 1
Classification of sexually transmitted disease agents INDIA
A. Bacterial agents Sexually transmitted diseases are becoming a major
Neisseria gonorrhoeae public health problem in India.
Chlamydia trachomatis
Treponema pallidum (a) Syphilis : Serological surveys continue to be the best
Haemophilus ducreyi source of information on the prevalence of syphilis. During
Mycoplasma hominis 2020, about 17,787 cases of syphilis (6,088 males
Ureaplasma urealyticum and 11,699 females) were reported in the country with
Calymmatobacterium granulomatis 40 death (5).
Shigella spp.
Campylobacter spp. (b) Gonorrhoea : Information on the morbidity of
Group B streptococcus gonorrhoea is notoriously lacking as most cases are not
Bacterial vaginosis-associated organisms reported. The general impression is that gonorrhoea is more
B. Viral agents
widely prevalent than syphilis. During 2020, about 27,582
Human (alpha) herpesvirus 1 or 2 (herpes simplex virus) gonorrhoea cases (8,669 males and 18,903 females) were
Human (beta) herpesvirus 5 (formerly cytomegalovirus) reported in the country with 5 deaths (5).
Hepatitis virus B (c) Chancroid : Chancroid or soft sore is reported to be
Human papilloma viruses fairly widely prevalent in India.
Molluscum contagiosum virus
Human immunodeficiency virus (d) LGV : It is reported to be more prevalent in the
southern states of Tamil Nadu, Andhra Pradesh,
C. Protozoal agents
Maharashtra and Karnataka than in the northern states.
Entamoeba histolytica
Giardia lamblia (e) Donovanosis : Donovanosis or granuloma inguinale is
Trichomonas vaginalis endemic in Tamil Nadu, Andhra Pradesh, Orissa, Karnataka
D. Fungal agents and Maharashtra. A greater prevalence along the coastal
Candida albicans areas has been reported.
E. Ectoparasites (f) Other STDs : Information on the other STDs is not
Ph th ir us pubis readily available, as there is no reporting system for these
Sarcoptes scabiei diseases.

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 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Epidemiological determinants from prostitutes, whereas in many developed countries, the

professional prostitute has largely been replaced by the
Agent factors “good-time girl”. The male component of prostitution - the
Over 20 pathogens have been found to be spread by prostituant is equally important. Prostitution supplies a
sexual contact. A classification of these agents and the demand; if there were no prostituants, there would be no
diseases caused by them are as shown in Table 2. prostitutes, (b) Broken homes : Social studies indicate the
promiscuous women are usually drawn from broken homes,
TABLE 2 e.g., homes which are broken either due to death of one or
Important sexually transmitted pathogens both parents or their separation. The atmosphere in such
and the diseases caused by them homes is unhappy, and children reared in such an
atmosphere are likely to go astray in search of other avenues
Pathogen Disease or syndrome of happiness, (c) Sexual disharmony : Married people with
strained relations, divorced and separated persons are often
Neisseria gonorrhoeae Gonorrhoea, urethritis, cervicitis, victims of STDs, (d) Easy money : In most of the developing
epididymitis, salpingitis. PID,
neonatal conjunctivitis world, prostitution is simply a reflection of poverty. It
provides an occupation for earning easy money. It is
Treponema pallidum Syphilis
fostered by lack of female employment and the prospect of a
Haemophilus ducreyi Chancroid financial return impossible to achieve by other means (7).
Chlamydia trachomatis LGV, urethritis, cervicitis, proctitis, (e) Emotional immaturity : This has been often stressed as a
epididymitis, infant pneumonia, social factor in acquiring STDs, (f) Urbanization and
Reiter's syndrome, PID. neonatal
industrialization : These are conductive to the type of
conjunctivitis
lifestyle that contributes to high levels of infection, since
Calymmatobacterium Donovanosis (granuloma
long working hours, relative isolation from the family and
granulomatis inguinale)
geographical and social mobility foster casual sexual
Herpes simplex virus Genital herpes relationships, (g) Social disruption : Caused by disasters,
Hepatitis B virus Acute and chronic hepatitis wars and civil unrest have always caused an increase in the
Human papillomaviruses Genital and ana! warts spread of STDs, (h) International travel : Travellers can

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Human immuno­ AIDS import as well as export infection and their important role in
deficiency virus (HIV) the transmission of STD is exemplified by the rapid spread
Molluscum contagiosum Genital molluscum contagiosum throughout the world of resistant strains of N. gonorrhoea
Candida albicans Vaginitis and AIDS (2). (i) Changing behavioural patterns : In modern
society, the value traditionally set on chastity is in conflict
Trichomonas vaginalis Vaginitis
with the more recent ideas of independence, freedom from
Source : (2, 6) supervision, and equal rights for both sexes. There has been
a relaxation of moral and cultural values in present-day
Host factors society. The tendency to break away from traditional ways
of life is particularly marked among young people, (j) Social
(a) Age : For most notifiable STDs, the highest rates of
stigma : The social stigma attached to STDs accounts for the
incidence are observed in 20-24 year-olds, followed by the
25-29 and 15-19 years age groups. The most serious non-detection of cases, not disclosing the sources of
contact, dropping out before treatment is complete, going to
morbidity is observed during foetal development and in
quacks for treatment, and self-treatment, (k) Alcoholism :
the neonate (2). (b) Sex : For most STDs, the overall
morbidity rate is higher for men than for women, but the The effect of alcohol seems to be more indirect than direct.
morbidity caused by infection is generally much more severe Alcohol may encourage prostitution and conversely,
in women, as for example, pelvic inflammatory disease. prostitution may boost the sale of alcohol.
(c) Marital status : The frequency of STD infection is higher
among single, divorced and separated persons than among Clinical spectrum (8)
married couples, (d) Socio-economic status : Individuals GONOCOCCAL INFECTION : Gonococcal infection
from the lowest socio-economic groups have the highest causes inflammation of the genital tract involving the urethra
morbidity rate. in men and women, the cervix and rectum in women, and
the rectum in men who have sex with men. Other sites are
Demographic factors the throat (pharyngitis) and the eyes. The possible
Certain demographic factors will undoubtedly contribute complications in women include pelvic inflammatory disease
to increase in STDs in the developing countries. These (PID). Long-term sequelae of PID are increased risk of
include population explosion and marked increase in the ectopic pregnancy, infertility and chronic pelvic pain. In
number of young people, the group at high risk for STD in men, complications include inflammation of the epididymis.
the population; rural to urban migration; increasing Long term consequences are sub-fertility and possibly
educational opportunities for women delaying their urethral strictures. Serious consequences in infants include
marriage and increasing STD risks. eye infection which can lead to blindness if not treated
promptly. The antibiotics of choice are ciprofloxacin,
Social factors ceftriaxone, cefixime or spectinomycin.
Numerous social and behavioural factors are involved in SYPHILIS : Syphilis causes ulceration of the uro-genital
the spread of STDs. These include : (a) Prostitution : This is tract, mouth or rectum. Other signs of this infection,
a major factor in the spread of STDs. The prostitute acts as a occurring in later stages, range from skin eruptions to
reservoir of infection. In Asia, most STDs are contracted complications of the cardiovascular and nervous system.

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 SEXUALLY TRANSMITTED DISEASES

Congenital syphilis is an important cause of stillbirth. The There is no cure for HSV-2 infection. However, oral antiviral
antibiotics used to treat syphilis are penicillin, doxycycline medications such as acyclovir, valacyclovir and famciclovir
and erythromycin. are all effective in reducing the severity and duration of first-
CHLAMYDIAL INFECTION : A high percentage of episode genital herpes. Topical creams are less effective.
individuals have no obvious clinical manifestations of this Episodic treatment has a limited role in reducing the
infection. If symptoms occur they are similar to those caused duration of lesions as they tend to last less than a week.
by gonorrhoea. Complications, which are similar to those of HUMAN PAPILLOMA VIRUS : Human papilloma virus
gonorrhoea, can result in steriltiy in women or vertical (HPV) causes ano-genital warts, which vary from the
transmission during childbirth, leading to conjunctivitis or common soft, flesh-coloured protuberances which may
eye inflammation in the newborn. In men it can cause become exuberant (cauliflower like) to papular flat warts on
urethritis with possible epididymitis. The antibiotics used are drier areas (eg. shaft of penis), which resemble those seen
doxycycline or azithromycin. The alternatives are on other parts of the body. They can be seen anywhere in
amoxycillin, ofloxacin, erythromycin or tetracycline. the genitalia including in the perianal region, even in those
TRICHOMONIASIS : This parasitic infection leads to denying anal sexual intercourse. The other commonly
vaginitis and vaginal discharge in women. Usually, there are recognized manifestation of genital HPV infection is cervical
no symptoms. In most men there are no symptoms but it cancer, caused by some sub-types of HPV. Treatment is
may cause urethritis. There is increasing evidence that generally reserved for large lesions because sub-clinical
T. Vaginalis may cause adverse outcomes in pregnancy, e.g. infection tend to resolve on their own. For any viral infection
low birth weight and premature rupture of the membranes. the mainstay of control is prevention, especially in young
The treatment option is metronidazole or tinidazole. sexually active individuals. Regular examination of the
cervix and cervical cytology using Papanicolaou staining
CHANCROID : After infection a small papule develops at method is recommended for female patients and female
the site of inoculation, normally within 2-3 days. The lesion contacts in order to detect progression of lesions to cervical
then erodes into a deep ulcer that is extremely painful. In cancer. Detection programmes based on cervical cytology
about 25 per cent of patients there is a painful swelling of screening and colposcopy services have been successful in
one or the other inguinal lymph nodes (bubo). The curbing the incidence of, and mortality from cervical cancers
antibiotics used are ciprofloxacin, erythromycin, ciftriaxone in industrialized countries, but are expensive to run in

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and azithromycin. developing countries.
LYMPHOGRANULOMA VENEREUM : It commonly
presents with swelling of lymph nodes in the groin. Although Syndromic approach to STD
initially there is a small, painless ulcer of the genitalia 3-30 Many different agents cause sexually transmitted
days after exposure it may pass unrecognized and resolve diseases. However, some of these agents give rise to similar
spontaneously. Untreated, the disease may cause extensive or overlapping clinical manifestations. Common syndromes
lymphatic damage resulting in elephantiasis of the genitalia. and sequelae are as shown in Table 3
The antibiotics used are doxycycline, erythromycin and
tetracycline. Benefit in late cases, e.g. with rectal stricture is TABLE 3
slight. Surgical operation may be of benefit in cases with
Common syndromes and sequelae for which sexual
extensive elephantiasis or deformity.
transmission is of epidemiological importance
DONOVANOSIS : Synonyms are granuloma inguinale,
granuloma venereum. The first manifestation, appearing Male urethritis
after a 3-40 days incubation period, is usually a small Lower genital syndromes in women : vaginitis! cervicitis/urethritis
papule which ruptures to form a granulomatous lesion that Genital ulceration
is characteristically pain free and bleeds readily on contact,
Proctitis/colitis
often elevated above the level of the surrounding skin.
Antibiotics used are azithromycin and doxycycline, or Salpingitis
aiterantively erythromycin, tetracycline, trimethoprim­ Epididymitis/orchitis
sulfamethoxazole . Infertility/ectopic pregnancy
GENITAL HERPES : Herpes simplex virus type 2 (HSV-2) Postnatal and perinatal morbidity
is the primary cause of genital herpes. Classical genital Hepatitis!hepatic carcinoma
herpes can be recognized by the presence of typical papular Genital carcinoma
lesions that progress to multiple blisters and ulcers. Acquired Immuno Deficiency Syndrome (AIDS)
However, the features can be variable in many people and
the appearance can easily be confused with other genital Source : (1)
infections. First episode of disease manifestation are
frequently associated with a prolonged course of ulceration, The traditional method of diagnosing STD is by
lasting up to three to four weeks. Antiviral treatment of these laboratory tests. However, these are often not available or
episodes can be. very effective in. shortening the duration are expensive. Since 1990 WHO has recommended
and alleviating pain. HSV-2 infection is life-long and syndromic management of STDs in patients presenting with
recurrent ulcerative episodes occur. The median recurrence consistently recognized signs and symptoms of STD. The
rate after a symptomatic first episode of genital herpes is syndromic approach is a scientifically derived approach and
four to five episodes per year. Asymptomatic or subclinical offers accessible and immediate treatment, that is effective
infection does occur, as do subclinical recurrences, and efficient, management of STD using flowcharts (as
accompanied by viral shedding without a visible ulcer. These shown in Fig. 1, 2, 3, 4, 5 and 6) is more cost-effective than
subclinical episodes can be infectious to sexual partners. diagnosis based on laboratory tests (9).
by R△J
3S2 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

1. Syndromic management of urethral discharge in males

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(A) Notification and treatment of female partners of men with urethritis are of the highest priority as one of the best ways of
identifying women at high risk of having asymptomatic gonococcal and chlamydial infections.
(B) Treatment:
As dual infection is common, the treatment for urethral discharge should adequately cover therapy for both, gonorrhea and chlamydial
infections.
Recommended regimen for uncomplicated gonorrhea + chlamydia.
Uncomplicated infections indicate that the disease is limited to the anogenital region (anterior urethritis and proctitis).
- Tab. Cefixime 400 mg orally, single dose Plus Tab Azithromycin 1 gram orally single dose, under supervision.
- Advise the patient to return after 7 days of start of therapy.
When symptoms persist or recur after adequate treatment for gonorrhea and chlamydia in the index patient and partner(s), they should be
treated for Trichomonas vaginalis.
If discharge or only dysuria persists after 7 days - Tab. Secnidazole 2 gm orally, single dose (to treat for T. vaginalis).
If the symptoms still persists - Refer to higher centre as early as possible.
If individuals are allergic to Azithromycin, give Erythromycin 500 mg four times a day for 7 days.
(C) Syndrome specific guidelines for partner management:
Treat all recent partners; Treat female partners (for gonorrhea and chlamydia) on same lines after ruling out pregnancy and history of
allergies; advise sexual abstinence during the course of treatment; provide condoms, educate about correct and consistent use; refer for
voluntary counselling and testing for HIV, syphilis and Hepatitis B, and schedule return visit after 7 days.
(D) Management of pregnant partner :
Pregnant partners of male clients with urethral discharge should be examined by doing as per speculum as well as per vaginal examination
and should be treated for gonococcal as well as chlamydial infections.
- Cephalosporins to cover gonococcal infection are safe and effective in pregnancy.
- Tab. Cefixime 400 mg orally, single dose OR Ceftriaxone 125 mg by intramuscular injection.
+
- Tab. Erythromycin 500 mg orally four times a day for seven days OR Cap Amoxicillin 500 mg orally, three times a day for seven days
to cover chlamydial infection.
- Quinolones (like ofloxacin, ciprofloxacin), doxycycline are contraindicated in pregnant women.
(E) Follow up after seven days to see reports of tests done for HIV, syphilis and Hepatitis B; if symptoms persist, to assess whether it is due to
treatment failure or re-infection; and for prompt referral if required.

FIG. 1
Syndromic management of urethral discharge (in the absence of laboratory support)
Source : (9)

by R△J
 SEXUALLY TRANSMITTED DISEASES
383
2. Syndromic management of vaginal discharge

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FIG. 2
Syndromic management of vaginal discharge
Source : (9)

by R△J
334 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

3. Management of lower abdominal pain in females

Causative organisms:
Neisseria gonorrhoeae; Chlamydia trachomatis; and
Mycoplasma, Gardnerella, Anaerobic bacteria
(Bacteroides specially gram positive cocci).
Differential diagnosis . ectopic pregnancy, twisted
ovarian cyst, ovarian tumor, appendicitis, and
abdominal tuberculosis.

_________________________________________________________________________________________________ i_______________
Syndrome specific guidelines for partner
Treatment (out patient treatment): management:
In mild or moderate PID (in the absence of tubo ovarian abscess), out patient - Treat all partners in past 2 months.
treatment can be given. Therapy is required to cover Neisseria gonorrhoeae, - Treat male partners for urethral discharge

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Chlamydia trachomatis and anaerobes (gonorrhea and chlamydia).
- Tab. Cefixime 400 mg orally twice daily for 7 days + Tab. Metronidazole - Advise sexual abstinence during the course of
400 mg orally, twice daily for 14 days. treatment.
+ - Provide condoms, educate on correct and
- Doxycycline, 100 mg orally, twice a day for 2 weeks consistent use.
(to treat chlamydial infection). Refer for voluntary counselling and testing for
- Tab. Ibuprofen 400 mg orally, three times a day for 3-5 days HIV, syphilis and Hepatitis B.
- Tab. Ranitidine 150 mg orally, twice daily to prevent gastritis. - Inform about the complications if left untreated
- Remove intra uterine device, if present, under antibiotic cover of 24-48 hours. and sequelae.
- Advise abstinence during the course of treatment and educate on correct - Schedule return visit after 3 days, 7 days and
and consistent use of condoms. 14 days to ensure compliance.
- Observe for 3 days. If no improvement (i.e absence of fever, reduction in
abdominal tenderness, reduction in cervical movement, adnexal and
uterine tenderness) or if symptoms worsen, refer for In patient treatment. Management of pregnant women:
Caution : PID can be a serious condition. Refer the patient to the hospital if Though PID is rare in pregnancy,
she does not respond to treatment within 3 days and even earlier - Any pregnant woman suspected to have PID
if her condition worsens. should be referred to district hospital for
hospitalization and treated with a parenteral
regimen which would be safe in pregnancy
- Doxycycline is contraindicated in pregnancy.
- Note : Metronidazole is generally not
recommended during the first three months of
pregnancy. However, it should not be withheld
for a severly acute PID, which represents an
emergency.

Hospitalization of clients with acute PID should be seriously considered when:

- The diagnosis is uncertain.
- Surgical emergencies e.g. appendicitis or ectopic pregnancy can not be excluded.
- A pelvic abscess is suspected.
Severe illness precludes management on an out patient basis.
- The woman is pregnant.
- The patient is unable to follow or tolerate an out patient regimen.
- The patient has failed to respond to out patient therapy
Note : All patients requiring hospitalization should be referred to the district hospital.

FIG. 3
Management of lower abdominal pain in females
Source : (9)

by R△J
 SEXUALLY TRANSMITTED DISEASES 385
4. Management of genital ulcers

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t
Management of pregnant women:
Syndrome specific guidelines for - Quinolones (like ofloxacin, ciprofloxacin), doxycycline, sulfonamides are contraindicated in
partner management: pregnant women.
Treat all partners who are in Pregnant women who test positive for RPR should be considered infected unless adequate
contact with patient in treatment is documented in the medical records and sequential serologic antibody titers have
last 3 months. declined.
- Partners should be treated for - Inj Benzathine penicillin 2.4 million IU IM after test dose (with emergency tray ready).
syphilis and chancroid. A second dose of benzathine penicillin 2.4 million units IM should be administered 1 week
- Advise sexual abstinence after the initial dose for women who have primary, secondary, or early latent syphilis.
during the course of treatment. - Pregnant women who are allergic to penicillin should be treated with erythromycin and the
Provide condoms, educate about neonate should be treated for syphilis after delivery.
correct and consistent use - Tab Erythromycin 500 mg Orally four times a day for 15 days
- Refer for voluntary counselling - (Note : Erthromycin estolate is contraindicated in pregnancy because of drug related
and testing for HIV, Syphilis hepatotoxicity. Only Erythromycin base or Erythromycin ethyl succinate should be used in
and Hepatitis B. pregnancy).
- Schedule return visit All pregnant women should be asked history of genital herpes and examined carefully for
after 7 days. herpetic lesions.
Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally.
Women with genital herpetic lesions at the onset of labour should be delivered by caesarean
section to prevent neonatal herpes.
- Acyclovir may be administered orally to pregnant women with first episode genital herpes or
severe recurrent herpes.

FIG. 4
Management of genital ulcers
Source : (9)

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

5. Management of scrotal swelling

Differential diagnosis (non RTIs/STIs)

Infections causing scrotal swelling .
Causative Organisms
tuberculosis, filariasis, coliforms, pseudomonas,
Neisseria gonorrhoeae
mumps virus infection.
Chlamydia trachomatis.
Non infectious causes :
trauma, hernia, hydrocele, testicular torsion,
and testicular tumors.

Examination Laboratory Investigations

Look for (If available)
- Scrotal swelling - Gram’s stain examination of the
History of
urethral smear will show gram­
- Swelling and pain in scrotal region. - Redness and edema of the
negative intracellular diplococci
overlying skin.
- Pain or burning while passing urine. in case of complicated
- Systemic symptoms like malaise, ►- Tenderness of the epididymis ► gonococcal infection
and vas deferens.
fever. - In non-gonococcal urethritis more
- Associated urethral discharge/genital than 5 neutrophils per oil
- Sexual exposure of either partner
ulcer/inguinal lymph nodes and immersion field in the urethral
to high risk practices including
if present refer to the respective flowchart. smear or more than 10 neutrophils
oro-genital sex.
- A transillumination test to rule out per high power field in the
hydrocele should be done. sediment of the first void urine
are observed.

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Treatment
- Treat for both gonococcal and chlamydial infections
Tab Cefixime 400 mg orally twice daily for 7 days, Plus
Cap. Doxycycline 100 mg orally, twice daily for 14 days and refer to higher
centre as early as possible since complicated gonococcal infection needs
parenteral and longer duration of treatment.
- Supportive therapy to reduce pain
(bed rest, scrotal elevation with T-bandage and analgesics)
Note '
If quick and effective therapy is not given, damage and scarring of
testicular tissues may result, causing sub-fertility.

Syndrome specific guidelines for Management protocol in case the

partner management. partner is pregnant
Partner needs to be treated - Depending on the clinical findings
depending on the clinical findings in the pregnant partner (whether
vaginal discharge or endocervical
discharge or PID is present) the
drug regimens should be used.
- Doxycycline is contraindicated in
pregnancy.
- Erythromycin base/Amoxicillin can
be used in pregnancy.
(Erythromycin estolate is
contraindicated in pregnancy due to
hepatotoxicity.
Erythromycin base or erythromycin
ethyl succinate should be given).

FIG. 5
Syndromic management of scrotal swelling
Source : (9)

by R△J
 SEXUALLY TRANSMITTED DISEASES
387
6. Management of inguinal bubo

Causative organisms
Chlamydia trachomatis serovars LI, L2, L3,
causative agent of lympho granuloma
venerum (LGV).
- Haemophilus ducreyi causative agent of
chancroid

Differential diagnosis
- Mycobacterium tuberculosis, filarisis.
- Any acute infection of skin of pubic area, genitals, buttocks,
anus and lower limbs can also cause inguinal swelling.
If malignancy or tuberculosis is suspected refer to higher
centre for biopsy

Examination
History Look for
- Localized enlargement of lymph nodes in
- Swelling in inguinal region which may be painful. groin which may be tender and fluctuant. Laboratory
- Preceding history of genital ulcer or discharge. - Inflammation of skin over the swelling. Investigations
- Sexual exposure of either partner to high risk - Presence of multiple sinuses. Diagnosis is on
practices including oro-genital sex. clinical grounds.
- Edema of genitals and lower limbs
- Systemic symptoms like malaise, fever.
- Presence of genital ulcer or urethral
discharge, and if present refer to

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respective flowchart.

Treatment
- Start Cap. Doxycycline 100 mg orally twice daily for 21 days (to cover LGV)
Plus
- Tab Azithromycin lg orally single dose OR
- Tab. Ciprofloxacin 500 mg orally, twice a day for three days to cover chancroid.
- Refer to higher centre as early as possible
Note :
- A bubo should never be incised and drained at the primary health centre, even if it is fluctuant,
as there is a high risk of a fistula formation and chronicity. If bubo becomes fluctuant always
refer for aspiration to higher centre.
- In severe cases with vulval edema in females, surgical intervention may be required for which
they should be referred to higher centre.

v_________________________
Syndrome specific guidelines for partner
management
Management of Pregnant partner
- Treat all partners who are in contact with
patient in last 3 months. - Quinolones (like ofloxacin, ciprofloxacin),
doxycycline, sulfonamides are contraindicated
- Partners should be treated for in pregnant women.
chancroid and LGV.
- Pregnant and lactating women should be treated
- Tab Azithromycin 1 g orally single with the erythromycin regimen, and consideration
dose to cover chancroid should be given to the addition of a parenteral
+ amino glycoside (e.g., gentamicin)
Cap Doxycycline 100 mg orally, twice daily Tab. Erythromycin base, 500 mg orally,
for 21 days to cover LGV 4 times daily for 21 days and refer to higher centre.
- Advise sexual abstinence during (Erythromycin estolate is contraindicated in
the course of treatment. pregnancy due to hepatotoxicity. Erythromycin
- Provide condoms, educate on base or erythromycin ethyl succinate should be given)
correct and consistent use.
- Refer for voluntary counselling and testing
for HIV, syphilis and Hepatitis B.
- Schedule return visit after
7 days and 21 days.

FIG. 6
Syndrome management of inguinal bubo
Source : (9)

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Control of STDs by specially trained staff. The key to success in contact tracing
is the patient himself who must disclose all sex contacts
The aim of the control programme for STDs is the
voluntarily. In some parts of USA, contacts are sought as
prevention of ill-health resulting from the above conditions
through various interventions. These interventions may quickly as possible using telephone, telegram and other rapid
have a primary prevention focus (the prevention of means of communication. The contacts are then persuaded
infection), a secondary prevention focus (minimizing the to attend a STD clinic for examination and treatment. Where
adverse health effects of infection), or usually a combination prevalence is low, contact tracing is relatively expensive.
of the two. The control of STD may be considered under the (c) CLUSTER TESTING : Here the patients are asked to
following heads (10). name other persons of either sex who move in the same
1. Initial planning socio-sexual environment. These persons are then screened
(e.g., blood testing). This technique has been shown almost
2. Intervention strategies to double the number of cases found (12).
3. Support components
4. Monitoring and evaluation 2. Case holding and treatment
Adequate treatment of patients and their contacts is the
INITIAL PLANNING mainstay of STD control. There is a tendency on the part of
patients suffering from STDs to disappear or drop out before
Control programmes have to be designed to meet the treatment is complete. Therefore every effort should be
unique needs of each country and to be in line with that made to ensure complete and adequate treatment. A recent
country’s health care system, its resources and priorities. WHO Expert Committee (2) drew up a list of recommended
This requires initial planning which comprises the following regimens for treating STDs. Not less than the recommended
steps : (1) PROBLEM DEFINITION : The disease problem dosages should be used.
must be defined in terms of prevalence, psychosocial
consequences and other health effects - by geographic areas 3. Epidemiological treatment
and population groups, with the aid of sero-epidemiological
What is known as epidemiological treatment or more
surveys and population surveys. This is an important first
appropriately contact treatment has become a keystone
step, since such information is usually inadequate or non­
of the control campaigns (11). It consists of the
existent in most cases. (2) ESTABLISHING PRIORITIES :
administration of full therapeutic dose of treatment to
Rational planning requires establishment of priorities. This

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persons recently exposed to STD while awaiting the results
will depend upon health problem considerations (e.g.,
of laboratory tests (13). Epidemiological treatment should
magnitude, consequences) and feasibility of control (e.g.,
not be an end in itself. Its effects are not lasting unless it is
availability of adequate resources, social and political
combined with a venereological examination and the tracing
commitment). Priority groups may be categorized on the
of contacts revealed by that examination.
basis of age, sex, place of residence, occupation, drug
addiction, etc. (3) SETTING OBJECTIVES : Priorities must 4. Personal prophylaxis
be converted into discrete, achievable and measurable
(i) Contraceptives: Mechanical barriers (e.g., condoms and
objectives. That is, to reduce the magnitude of the problem,
the diaphragms) can be recommended for personal
in a given population and a stated time. To be most useful,
prophylaxis against STDs. These barrier methods, especially
objectives should be unambiguous and quantifiable. Broad
when used with spermicides, will minimize the risk of
coverage of the population is crucial for effective STD
acquiring STD infections. However, their use is limited by lack
control. (4) CONSIDERING STRATEGIES : A variety of
intervention strategies are available. Planners must define of motivation, acceptability and convenience. The
effectiveness of most of the prophylactic techniques available
the mixture of strategies that appears to be most appropriate
is poorly documented since few controlled studies have been
to the setting. (The reader is referred to chapter 23 for a
broad discussion of the planning cycle). carried out (2). The exposed parts should be washed with soap
and water as soon after contact as possible, (ii) Vaccines : The
development of a vaccine for hepatitis B has raised hopes that
INTERVENTION STRATEGIES vaccines will be found for other STDs.
1. Case detection 5. Health education
Case detection is an essential part of any control Health education is an integral part of STD control
programme. The usual methods of early detection in a programmes. The principal aim of educational intervention
STD control programme are : is to help individuals alter their behaviour in an effort to
(■a) SCREENING : Screening is the testing of apparently avoid STDs, that is, to minimize disease acquisition and
healthy volunteers from the general population for the early transmission. The target groups may include the general
detection of disease. High priority is given to screening of public, patients, priority groups, community leaders, etc.
special groups, viz. pregnant women, blood donors, The primary health care of WHO also. underlines the
industrial workers, army, police, refugees, prostitutes, importance of health education.
convicts, restaurant and hotel staff etc. The availability of an
appropriate test is critical for screening purposes. The SUPPORT COMPONENTS .
sensitivity, specificity, and the predictive value of a test are
important considerations (see Chapter 4). 1. STD clinic
(b) CONTACT TRACING : Contact tracing is the term used The starting point for . the control of STDs is the
for the technique by which the sexual partners of diagnosed establishment of STD clinics where all consultation,
patients are identified, located, investigated, and treated investigations and treatment, contact tracing and all other
(11). This is one of the best methods of controlling the spread relevant services are available. An ideal service is one that is
of infection. Patients are interviewed for their sexual contacts free, easily accessible to patients and available for long

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 SEXUALLY TRANSMITTED DISEASES 389
hours each day. There should be suitable arrangements for 5. Legislation
treating female patients separately. Since the patients desire
Many countries are still far away in enacting suitable
anonymity, the STD clinic should try to maintain it.
legislation for the control of STDs (14). Although legislations
Because of the stigma attached to the STD clinics, many and regulations cannot wipe out STDs, they are nonetheless
patients seek alternative sources of medical care, including needed, particularly to establish responsibilities and define
self-medication. It is now considered that the key to the standards. The purpose of legislation should be to encourage
success of a STD control programme is the integration of its patients to seek early treatment and name their sexual
essential elements into the primary health care services. contacts, to screen high risk groups, to improve notification by
However, it is essential to have in each administrative general practitioners, health education of the public, etc. The
unit one specialized centre, which should provide the Immoral Traffic (Prevention) Act, 1986 (which replaced the
necessary clinical, and laboratory expertise and coordinate earlier Suppression of the Immoral Traffic Act, 1956) covers all
control activities at all levels of the health care system. The persons, whether male or female, who are exploited sexually
centre should be housed adjacent to other medical facilities for commercial purposes. It makes punishment for the
and training centres. offences under the Act more stringent than the previous Act.

2. Laboratory services 6. Social welfare measures

Adequate laboratory facilities and trained staff are STDs are social problems with medical aspects. It implies
essential for proper patient management. It provides a basis there should be “social therapy” which would prevent or
for correct aetiological diagnosis and treatment decisions; control the conditions leading to promiscuity and STDs. The
for contact tracing; surveillance of morbidity and detection various social measures include : rehabilitation of prostitutes;
of antimicrobial resistance. The diagnostic tests that should provision of recreation facilities in the community; provision
be available for the important sexually transmitted of decent living conditions; marriage counselling; prohibiting
pathogens are given in a WHO report (10). the sale of sexually stimulating literature, pornographic
books and photographs, etc.
3. Primary health care
The current trend is to integrate STD control activities MONITORING AND EVALUATION
into primary health care system. This will imply inclusion of

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A critical aspect of effective management is the monitoring
primary health care workers (e.g., ASHA, multipurpose of disease trends and evaluating programme activities.
workers) in the STD “health team”. Then only it will be Evaluation will show if the activities have been performed in
possible to provide effective treatment to the greatest a satisfactory way. Ongoing evaluation of disease trends
number of cases in the community. Such management limits provides a more direct measure of programme effectiveness
further disease transmission. Primary health care which is and may be used to determine the appropriateness of the
based on the principles of universal coverage, community selected intervention strategies for a particular setting (10).
participation, equity and intersectoral coordination is ideally
suited to control STD in the community. Global health sector strategy on HIV, hepatitis
and sexually transmitted infections, 2022-2030
4. Information system
With this framework, WHO
The basis of an effective control programme of any
communicable disease is the existence of an information 1. develops global targets, norms and standards for STI
system. It is a prerequisite for effective programme planning, prevention, testing and treatment;
coordination, monitoring and evaluation. Three types of 2. supports the estimation and economic burden of STIs
data requirement are relevant in the control of STDs: these and the strengthening of STI surveillance;
are clinical notification, laboratory notification, and sentinel 3. globally monitors anti microbial resistance (AMR) to
and adhoc surveillance. gonorrhoea; and
National notification system, at best, includes only the 4. leads the setting of the global research agenda on STIs,
“classical” venereal diseases, where existing, reporting including the development of diagnostic tests, vaccines
systems suffer from undernotification, inaccurate diagnosis and additional drugs for gonorrhoea and syphilis (3).
and concealment of cases owing to social stigma. Without a
National STD Control Programme
notification system, it is not possible to assess the magnitude
of the problem, to allocate resources and to evaluate the See chapter 7 for details.
impact of control measures. There is an urgent need to
develop an effective and detailed reporting system of STDs References
in countries where it does not exist. Sentinel surveillance 1. Brown, S.T. et al {1985). Int. J. Epidemiology, 14 (4) 505.
systems and/or adhoc surveys can be used to supplement 2. WHO (1986). Techn. Rep. Ser., No. 736.
the routine reporting system. Population-based sample 3. WHO (2022), Fact Sheet on STIs, 22nd Aug. 2022.
surveys may also be used to identify the true distribution of 4. WHO (2017), Prevention, Diagnosis and Treatment of Sexually
Transmitted Infections, 27th Dec. 2017.
disease in a particular setting. Such surveys are very
5. Govt, of India (2021), National Health Profile 2021, Ministry of Health
expensive and are generally of limited use for sexually and Family Welfare, New Delhi.
transmitted disease programmes (10). 6. WHO (1981). Techn. Rep. Ser., No. 660.
The information system should be built around a small 7. Willcox, R.R. (1976). Sexually Transmitted Diseases, R.D. Catterall
number of questions : How many cases were interviewed ? and C.S. Nicol (eds). Academic Press.
How many villages were visited ? How many cultures were 8. WHO Fact Sheet, 2006, on STD.
9. Govt, of India (2007), National Guidelines on Prevention,
examined? The system should provide information on Management and Control of Reproductive Tract Infections including
activities, resource utilization and task accomplishment of Sexually Transmitted Infections, NACO, Ministry of Health and Family
programme personnel (10). Welfare, New Delhi.
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

10. WHO (1985). Control of Sexually Transmitted Diseases, WHO, nasopharynx and bones (5). A single injection of benzathine
Geneva. penicillin G is the treatment of choice. For patients under
11. WHO (1982). Techn. Rep. Ser., No. 674. 10 years the dose is 0.6 mega units, and for patients age
12. WHO (1963). Techn. Rep. Ser., No. 262. 10 years and over, the dose is 1.2 mega units (3).
13. WHO (1978). Techn. Rep. Ser., No. 616.
14. WHO (1975). VD Control: A Suruey of Recent Legislation, Geneva. YAWS
Yaws is a chronic contagious non-venereal disease caused
ENDEMIC TREPONEMATOSIS__________ by T. pertenue, usually beginning in early childhood. It
Endemic treponematoses (pinta, endemic syphilis (Bejel, resembles syphilis in its clinical course and is characterized by
yaws) continue to be public health problems in some a primary skin lesion (mother yaw) followed by a generalized
tropical countries. Of these, yaws and endemic syphilis still eruption and a late stage of destructive lesions of the skin and
constitute a considerable health hazard to the child bone. Yaws is also known as pian, bubas or framboesia.
population in medically under-served areas, particularly in
West and Central Africa and, the Americas (1). These Geographic distribution
diseases are caused by agents which are microscopically The disease is found primarily in poor communities in
indistinguishable. Typically these diseases have a patchy warm, humid and tropical forest areas of Africa, Asia, Latin
distribution in population groups away from the network of America and the Pacific. The majority of affected
health centres (1). They are usually contracted in childhood, populations live at the “end of the road” and therefore have
non-venereally. Intrauterine transmission is absent. The late limited access to basic social amenities and health care.
cardiac and cerebral manifestations of venereal syphilis A review of historic documents from the 1950s shows that
which are particularly severe in that disease, do not occur in at least 88 countries and territories within the tropical belt
these infections (excepting scanty or mild lesions in endemic 20 degrees north and south of the equator were endemic for
syphilis). In most countries, the prevalence of these diseases yaws. Only 13 countries are known to be currently endemic
was reduced to low levels, and in some areas their for yaws. However, these countries need support to
transmission was interrupted due to mass-treatment implement the WHO “Yaws Eradication Strategy” (the
campaigns. However, complacency after successful mass Morges Strategy). Recent estimates indicate that about
campaigns and the premature discontinuation of 89 million people live in the 13 countries endemic for yaws.
surveillance activities have led to resurgence of these

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infections in a number of countries (1). Ecuador and India have reported no cases of yaws since
2003. A WHO International Verification Team (IVT) visited
PINTA India in October 2015 to assess the status of interruption of
transmission. Based on the report of the IVT and endorsed
A chronic infectious disease caused by T. carateum. by the WHO NTD Strategic and Technical Advisory Group
Reports suggest that pinta has virtually disappeared from (STAG); WHO declared India free of yaws in May 2016 (6).
countries of Latin America (1,2). The disease is now restricted
to the Philippines and some areas of the Pacific. The disease is Epidemiological determinants
essentially one of childhood, often beginning after the age of
10 to 15 years. Transmission is non-venereal, by direct contact Agent factors
with infectious lesions. After an incubation period of 7 to 21 (a) AGENT : Yaws is caused by T. pertenue which closely
days, an initial papular lesion appears on the hands and legs, resembles T. pallidum culturally and morphologically. It
followed by a maculo-papular, erythematous rash (pintides) measures 20|i in length with 8 to 12 rigid spirals. The agent
lasting for years. A late stage is characterized by depigmented, occurs in the epidermis of the lesions, lymph glands, spleen
leukodermic patches which may be permanent. Individuals and bone marrow. The organism rapidly dies outside the
with late pinta are resistant to infection with T. pallidum. In the tissues, (b) RESERVOIR OF INFECTION : Man is the only
treatment of pinta, the antibiotic of choice is benzathine known reservoir of yaws. He is an infected person. Clinical
penicillin G (BPG) which has replaced PAM. The dose for lesions may relapse 2 to 3 times or more during the first 5 years
patients under 10 years is 0.6 mega units, and for those of infection, and serve as source for new infections (1). Most
10 years and over 1.2 mega units (3). latent cases are found in clusters centred around an infectious
case. There are frequent relapses in latent cases within the first
ENDEMIC SYPHILIS 3 to 5 years of infection. The source of infection is usually
Endemic syphilis (Bejel is a local name for this disease in the skin lesions and the exudates from early lesions,
Syria) occurs in the arid areas of Syria, Saudi Arabia, Iraq, (c) COMMUNICABILITY : Variable, and may extend over
Iran, Yugoslavia, northern and southern Africa and Australia. several years intermittently as moist lesions break out.
It does not occur in the Americas. The causative agent is Treponema are usually not found in late lesions.
difficult to differentiate from T. pallidum. The claim that it is
the same microorganism has yet to be substantiated (4). It is Host factors
transmitted non-venereally by direct or indirect contact - (a) AGE : Yaws is primarily a disease of childhood and
among children and adolescents through their play or by adolescence. Over 75 per cent of cases occur before the age of
drinking vessels and common eating and other household 15 years, but the disease can occur at any age (9).
utensils under primitive, crowded and substandard (b) SEX: Generally, the prevalence among males is greater than
conditions of living. It is thought that poor hygiene rather among females, (c) IMMUNITY : Man has no natural immunity.
than climatic conditions is a major factor in the continued Acquired resistance develops slowly and may take months or
transmission of Bejel. It is thought that 25 per cent of years to develop fully unless suppressed by treatment. There is
children acquire the infection before the age of 10 years. The considerable experimental and epidemiological evidence (3)
figure is increased to 60 per cent before the age of 16 years that yaws provides partial immunity to venereal syphilis. The
(4). Endemic syphilis produces highly infectious skin lesions. near eradication of yaws in Haiti has been followed by a high
Late manifestations include gumatous lesions of the skin, prevalence of venereal syphilis.
by R△J
 ENDEMIC TREPONEMATOSIS 391
Environmental factors likely contacts in the community will interrupt transmission
in the community (9).
(a) CLIMATE : Yaws is endemic in warm and humid
regions. High humidity for at least 6 months of the year and Benzathine penicillin G is the penicillin of choice. It has
an average rainfall of at least 40 inches are considered now replaced PAM (3). The dose of BPG is 1.2 million units
favourable for the transmission of yaws, (b) SOCIAL for all cases and contacts, and half that dose (0.6 million
FACTORS : Social factors are even more important than units) for children under 10 years of age. Azithromycin is
biological factors in the perpetuation of yaws in the endemic given as a single oral dose at 30 mg/kg body weight
areas. Yaws is mostly endemic among the tribal people, (maximum 2 gm).
whose ways of living favour its transmission. Scanty clothing, The WHO (3) has recommended three treatment policies :
poor personal cleanliness, overcrowding, bad housing, low (a) TOTAL MASS TREATMENT : In areas where yaws is
standard of living and the absence of soap are important hyperendemic (i.e., more than 10 per cent prevalence of
socio-economic factors in the epidemiology of yaws. Yaws is clinically active yaws), a great part of the population is at
a crippling disease; lesions on palms and soles may disable a risk. The entire population including the cases should be
person for long periods making him dependant on others. given penicillin in the doses mentioned above.
Mode of transmission (b) JUVENILE MASS TREATMENT : In meso-endemic
communities (5 to 10 per cent prevalence), treatment is
Yaws is transmitted non-venereally by : (a) DIRECT given to all cases and to all children under 15 years of age
CONTACT : That is, by contact with secretions from and other obvious contacts of infectious cases.
infectious lesions, (b) FOMITES : Yaws may also be (c) SELECTIVE MASS TREATMENT : In hypo-endemic or
transmitted by indirect contact. The organism may remain areas of low prevalence (less than 5 per cent) treatment is
alive on fomites or on the earthen floor in hot and humid confined to cases, their household, and other obvious
conditions long enough to cause infection, and (c) VECTOR : contacts of infectious cases.
There is some evidence that small flies and other insects
feeding on the lesion may possibly convey the infection 3. Resurvey and treatment
mechanically for brief periods.
It is unlikely that a single round of survey and treatment
Transplacental, congenital transmission does not occur. will cover the entire population. In order to interrupt
transmission, it is necessary to find out and treat the missed

telegram-@Cherry_2412
Incubation period
cases and new cases. Resurveys should be undertaken every
9-90 days (average 21 days). 6 to 12 months. Several such follow-ups may be needed
Clinical features before eradication is achieved.
(a) EARLY YAWS : The primary lesion or “mother yaw” 4. Surveillance
appears at the site of inoculation after an incubation period
With the decline of yaws to very low levels, emphasis has
of 3 to 5 weeks. The lesion is extra-genital and is seen on
shifted to “Surveillance and containment” - a technique
exposed parts of the body such as legs, arms, buttocks or
which has proved highly successful in the eradication of
face. The local lymph glands are enlarged and the blood
smallpox. The surveillance and containment measures
becomes positive for STS. Within the next 3 to 6 weeks, a
would be concentrated on affected villages, households and
generalized eruption appears consisting of large, yellow,
other contacts of known yaws cases. The measures comprise
crusted, granulomatous eruptions often resembling
epidemiological investigation of cases to identify probable
condylomata lata in secondary syphilis. During the next
5 years skin, mucous membrane, periosteal and bone lesions source(s) of infection and contacts of each known case so as
may develop, subside and relapse at irregular intervals. The to discover previously unknown cases and prevent new
early lesions are highly infectious. cases; treatment of cases; prophylactic treatment of contacts
with BPG; and, monthly follow-up of households with
(b) LATE YAWS : By the end of 5 years, destructive and confirmed cases for at least 3 to 4 months after treatment of
often deforming lesions of the skin, bone and periosteum the last active case to assure interruption of transmission.
appear. The lesions of sole and palms are called “crab
yaws”. The destructive lesions of soft palate, hard palate, 5. Environmental Improvement
and nose are called “Gangosa”. Swelling by the side of the In a disease like yaws, an attack on social and economic
nose due to osteo-periostitis of the superior maxillary bone conditions of life is as important as an attack on the
is called “Goundu”. biological cause. Recrudescence of the disease is apt to
occur unless environmental improvement is promoted, e.g.,
CONTROL OF YAWS improvement of personal and domestic hygiene, adequate
water supply, liberal use of soap, better housing conditions
The control of yaws is based on the following principles :
and improvement of the quality of life.
1. Survey 6. Renewed eradication efforts (9)
A clinical survey of all the families in endemic areas is
The WHO roadmap for neglected tropical diseases
made. The survey should cover not less than 95 per cent of
(NTDs) have set 2020 target for the eradication of yaws
the total population. During the survey, persons suffering
from the remaining countries.
from yaws and their contacts are listed.
Since January 2012, when the WHO roadmap for NTDs
2. Treatment were set and an article in the Lancet on the efficacy of a
Treatment is based on the following observations : single-dose azithromycin in the treatment of yaws was
(a) treatment with a single dose of Azithromycin oral or a published, WHO has taken steps to move the renewed
single injection of long-acting penicillin will cure infection. eradication efforts by developing a new eradication strategy
(b) the simultaneous treatment of all clinical cases and their based on single dose treatment with azithromycin. These are:
by R△J
392 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

a. Total community treatment (TCT) - treatment of the Europe and Central Asia, where the numbers of people
endemic community, irrespective of the number of active acquiring HIV infection and dying from HIV-related causes
clinical cases; continue to increase. The global HIV epidemic during 2019
b. Total targeted treatment (TTT) - treatment of all active is summarized in Table 1.
clinical cases and their contacts (household, school, WHO and UNAIDS has defined different types of HIV
playmates). epidemics. They are as follows (3) :
As a first step in implemeting the new eradication
strategy, 7 countries were selected for the initial pilot Low-level HIV epidemics
treatment campaigns. In 2012 it was implemented in Betou Although HIV may have existed for many years, it has
and Enyelle districts of Congo. In 2013, implementation was never spread to substantial levels in any sub-population.
carried out in Ghana, Papua New Guinea and Vanuatu, Recorded infection is largely confined to individuals with
achieving a coverage of more than 90 per cent. In 2014, higher risk behaviour e.g. sex workers, drug injectors, men
Cameroon, Indonesia, and Solomon Islands are to having sex with other men. Numerical proxy : HIV
implement mass treatment activities (9). prevalence has not consistently exceeded 5% in any defined
sub-population.
7. Evaluation
To determine whether or not yaws has really been Concentrated HIV epidemics
brought under control, serological studies are needed. HIV has spread rapidly in a defined sub-population, but
Ideally if no yaws antibodies were found among children is not well-established in the general population. This
born since the yaws mass campaign was completed, it would epidemic state suggests active networks of risk within the
mean that the campaign had been totally successful. The sub-population. The future course of the epidemic is
actual sample of the population to be tested may be as low determined by the frequency and nature of links between
as 1 or 2 per cent. highly infected sub-populations and the general population.
Numerical proxy : HIV prevalence is consistently over 5% in
References at least one defined sub-population but is below 1% in
1. WHO (1981). Wkly. Epi. Rec., 56 : 241-248. pregnant women in urban areas.
2. WHO (1982). The Work of WHO, 1980-81.

telegram-@Cherry_2412
3. WHO (1982). Techn. Rep. Ser., 674. Generalized HIV epidemics
4. Wasley, G.D. (1980). Middle East Health, 4 (7) 33.
5. Chulay, J.D. (1979). Principles and Practice of Infectious Diseases, In generalized epidemics, HIV is firmly established in the
Mandell, G.L. et al (eds), John Wiley, New York. general population. Although sub-populations at high risk
6. WHO (2016), Yaws Fact sheet, June 2016. may contribute disproportionately to the spread of HIV,
7. WHO (1968). The Second Ten Years of the WHO, 1958-1967. sexual networking in the general population is sufficient to
8. Hopkins, D.R. (1976). Am. J. Trop. Med& Hyg., 25 : 860. sustain an epidemic independent of sub-populations at
9. WHO (2014), Fact Sheet, No. 316, Feb. 2, 2014. higher risk of infection. Numerical proxy : HIV prevalence
consistently over 1% in pregnant women.
AIDS On the verge of fourth decade of the AIDS epidemic, the
world has turned the corner - it has halted and begun to
AIDS, the acquired immuno-deficiency syndrome reverse the spread of HIV. The question remains how quickly
(sometimes called “slim disease”) is a fatal illness caused by the response can chart a new course towards vision zero
a retrovirus known as the human immuno-deficiency virus discrimination, zero new HIV infection and zero
(HIV) which breaks down the body’s immune system, AIDS-related deaths through universal access to effective
leaving the victim vulnerable to a host of life-threatening HIV - prevention, treatment, care and support.
opportunistic infections, neurological disorders, or unusual HIV incidence (the number of new HIV infections in a
malignancies (1). Among the special features of HIV population per year) is the key parameter that prevention
infection are that once infected, it is probable that a person efforts aim to reduce, since newly infected persons
will be infected for life. Strictly speaking, the term AIDS contribute to the total number of persons living with HIV;
refers only to the last stage of the HIV infection. AIDS can be they will progress to disease and death over time; and are a
called our modern pandemic, affecting both industrialized potential source of further transmission. Since 1997, the
and developing countries. year in which annual new infections peaked to 3.2 million
cases globally, the number of new infections has fallen to 1.5
Problem statement million in 2021. This reduction in HIV incidence reflects
natural trend of epidemic, as well as the result of prevention
WORLD programmes resulting in behavioural changes in different
Recognized as an emerging disease only in the early contexts, like changes in sexual behavior; programmes
1980s, AIDS has rapidly established itself throughout the targeting key populations such as harm-reducing
world, and is likely to endure and persist well into the 21st programmes for people who inject drugs; maximizing the
century. AIDS has evolved from a mysterious illness to a prevention benefits of ARVs, including for the prevention of
global pandemic which has infected tens of millions people. mother-to-child transmission of HIV; and voluntary medical
Promising development have been seen in recent years in male circumcision in high HIV-prevalence settings (4).
global efforts to address the AIDS epidemic, including Women represent about half of all people living with
increased access to effective treatment and prevention HIV worldwide, and more than half (about 63 per cent) in
programmes. However, the number of people living with sub-Saharan Africa. HIV is the leading cause of death among
HIV continues to grow, as does the number of deaths due to women in reproductive age. Gender inequalities, differential
AIDS. Of particular concern are trends affecting Eastern access to services and sexual violence increase women’s
by R△J
 AIDS

TABLE 1
Global HIV statistics (2021)

Global HIV - 38.4 million (33.9 million-43.8 million) people globally were living with HIV in 2021.
statistics (2) 1.5 million (1.1 million-2.0 million) people became newly infected with HIV in 2021.
- 6,50,000 (5,10,000-8,60,000) people died from AIDS-related illnesses in 2021.
- 28.7 million people were accessing antiretroviral therapy in 2021.
- 84.2 million (64.0 million-113.0 million) people have become infected with HIV since the start of the epidemic.
- 40.1 million (33.6 million-48.6million) people have died from AIDS-related illnesses since the start of the epidemic.

People living - In 2021, there were 38.4 million (33.9 million-43.8 million) people living with HIV
with HIV • 36.7 million (32.3 million-41.9 million) adults (15 years or older) .
• 1.7 million (1.3 million-2.1 million) children (0-14 years).
• 54% of all people living with HIV were women and girls.
- 85% (75-97%) of all people living with HIV knew their HIV status in 2021
About 5.9 million people did not know that they were living with HIV in 2021.

People living with - As of the end of December 2021, 28.7 million people were accessing antiretroviral therapy,
HIV accessing up from 7.8 million in 2010.
antiretroviral' - In 2021, 75% (66-85%) of all people living with HIV were accessing treatment.
therapy • 76% (67-87%) of adults aged 15 years and older living with HIV had access to treatment, as did 52% (42-65%)
of children aged 0-14 years.
• 80% (72-91%) of female adults aged 15 years and older had access to treatment; however, just 70% (61-82%)
of male adults aged 15 years and older had access.
- 81% (63-97%) of pregnant women living with HIV had access to antiretroviral medicines to prevent transmission
of HIV to their child in 2021.

New HIV - New HIV infections have been reduced by 54% since the peak in 1996.
infections • In 2021, around 1.5 million (1.1 million-2.0 million) people were newly infected with HIV,
compared to 3.2 million (2.4 million-4.3 million) people in 1996.
• Women and girls accounted for 49% of all new infections in 2021.
Since 2010, new HIV infections have declined by 32%, from 2.2 million (1.7 million-2.9 million)
to 1.5 million (1.1 million-2.0 million) in 2021.

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• Since 2010, new HIV infections among children have declined by 52%, from 3,20,000 (2,20,000-4,80,000)
in 2010 to 1,60,000 (1,10,000-2,30,000) in 2021.

AIDS-related - AIDS-related deaths have been reduced by 68% since the peak in 2004 and by 52% since 2010.
deaths • In 2021, around 6,50,000 (5,10,000-8,60,000) people died from AIDS-related illnesses worldwide, compared to
2.0 million (1.6 million-2.7 million) people in 2004 and 1.4 million (1.1 million-1.8 million) people in 2010.
- AIDS-related mortality has declined by 57% among women and girls and by 47% among men and boys since 2010.

Key populations - In 2021, key populations (sex workers and their clients, gay men and other men who have sex with men, people
who inject drugs, transgender people) and their sexual partners accounted for 70% of HIV infections globally :
- 94% of new HIV infections outside of sub-Saharan Africa.
- 51% of new HIV infections in sub-Saharan Africa.
- The risk of acquiring HIV is :
- 35 times higher among people who inject drugs than adults who do not inject drugs.
- 30 times higher for female sex workers than adult women.
- 28 times higher among gay men and other men who have sex with men than adult men
- 14 times higher for transgender women than adult women.

Women - Every week, around 4,900 young women aged 15-24 years become infected with HIV
- In sub-Saharan Africa, six in seven new HIV infections among adolescents aged 15-19 years are among girls. Girls
and young women aged 15-24 years are twice as likely to be living with HIV than young men.
- In sub-Saharan Africa, women and girls accounted for 63% of all new HIV infections in 2021

95-95-95 - In 2021, 85% (75-97%) of people living with HIV knew their HIV status.
- Among people who knew their status, 88% (78— >98%) were accessing treatment.
- And among people accessing treatment, 92% (81—>98%) were virally suppressed.
Of all people living with HIV, 85% (75-97%) knew their status, 75% (66-85%) were accessing treatment and
68% (60-78%) were virally suppressed in 2021.
Source : (2)

vulnerability to HIV, and women, especially younger women, reduction in new infection between 2010 and 2020,
are biologically more susceptible to HIV (5). achieving zero discrimination and reducing annual HIV-
The UNAIDS 2016-2021 strategy is a bold call to action related deaths to less than 500,000 by 2020 globally (6).
to get on the “Fast-Track” and reach people being left Only when above targets are met, the next set of goals
behind. The strategy focuses on the unfinished agenda. It is will be 95-95-95 for treatment, i.e., 95 per cent of people
a call to reach the 90-90-90 treatment targets, to close the living with HIV knowing their HIV status; 95 per cent of
testing gap and to protect the health of the people living with people who know their status on treatment; and 95 per cent
HIV. It calls for 90 per cent of the people with HIV being of people on treatment with suppressed viral loads. Reduce
aware of their infection, 90 per cent of people aware that the annual number of new HIV infection among adults to
they have HIV initiating ART and 90 per cent of those 200,000 and achieving zero discrimination (7).
receiving ART having undetectable levels of HIV in their The Sustainable Development Goal target is to end the
blood by 2020. Milestone targets also include a 75 per cent AIDS epidemic by 2030. UNAIDS has led the development of

by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

a global strategy, “Fast Track : Ending the AIDS Epidemic by TABLE 2

2030”, while more detailed, sectoral strategy such as the HIV estimates, summary for the year 2021 (India)
WHO sector strategy on HIV 2016-2021 are under
Indicators Value
development. The main areas of focus post-2015 include (4) :
1. A focus on population left behind by the HIV response, Adult (15-49 years) Total 0.21 (0.17-0.25)
Prevalence Male 0.22 (0.18-0.28)
such as adolescent girls, key population (sex workers, (in %) Female 0.19 (0.15-0.23)
men who have sex with men, people who inject drugs and
transgender people), migrants and children; Number of Total 24.01 (19.92-29.07)
people living Adult (15+ years) 23.31 (19.38-28.19)
2. A focus on locations where the greatest HIV transmission with HIV Women (15+ years) 10.50 (8.73-12.69)
is occurring and with the greatest HIV burden, and the (in lakh) Children (< 15 years) 0.70 (0.54-0.89)
use of data to support the impact of programmes; Young people (15-24) 1.70(1.30-2 26)
3. An integrated HIV response that expands the HIV incidence per Total 0.05 (0.03-0.08)
contribution towards universal health care, including 1000 uninfected Male 0.05 (0.03-0.09)
health workforce, procurement systems, injection and population Female 0.04 (0.02-0.07)
blood safety, and treatment of coinfections; and
New HIV Total 62.97 (36.72-104.06)
4. Sustainable programmes with transitioning to domestic Infections Adults (15+ years) 57.97 (33.49-96.53)
funding of essential HIV services. (in thousand) Women (15+ years) 24.55 (14.27-40.69)
The interaction of HIV/AIDS with other infectious Young people (15-24) 15.08 (8.60-25.17)
diseases is an increasing public health concern. Decline in Total 46.25
Tuberculosis, bacterial infection and malaria have been new HIV Adults (15+ years) 44.48
identified as the leading cause of HIV-related morbidity in infections since Female (15+ years) 43 75
Sub-Saharan Africa. HIV infection increases the incidence 2010 (%) Children (< 15 years) 60.82
and severity of clinical malaria in adults (8). AIDS-related Total 41.97 (26.50-67.45)
deaths Adults (15+ years) 39.46 (25.14-63.26)
The national HIV strategic plans in most SEAR countries (in thousand) Women (15+ years) 11.26 (5.79-20.46)
accord priority to prevention, care and treatment Children (< 15 years) 2 51 (1.13-4.39)
interventions to high-risk populations; however coverage of Young people (15-24) 1.12 (0.64-1.95)
a comprehensive package of HIV interventions for sex

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AIDS-related deaths Total 3.08 (1.94-4.95)
workers, men having sex with men, transgender persons and per 100,000 Male 4.21 (2.77-6.41)
injecting drug users remains low in all countries. population Female 1.88 (0.97-3.40)

INDIA Decline in Total 76.54

AIDS related Adults (15+ years) 76.44
Now into its fifth decade, India’s epidemic is marked by deaths since Female (15+ years) 82.74
heterogeneity - not a single epidemic but made up of a number 2010 (%) Children (<15 years) 77.92
of distinct epidemics, in some places within the same state. PMTCT need Total 20 61 (16.38-26.36)
Latest 2021 HIV estimates for India are as shown in Final MTCT Total 24.25 (18.50-29.50)
Table 2. The HIV prevalence trend has been declining since rate ofH!V(%)
the epidemic’s peak in the year 2000.
Source : (9)
At the national level, estimated adult HIV prevalence
(15-49 years) is the highest in the north-east region states excluding Puducherry, Arunachal Pradesh, Meghalaya, and
followed by southern states. AIDS related deaths (ARQ) are Tripura. The highest decline in ARD is estimated in
estimated at 41.97 thousand in 2021. A decline of 76.5 per Chandigarh, Telangana, and West Bengal. Fig. 1 and Fig. 2
cent in ARD has been estimated at national level from 2010 shows estimated prevalence percentage state-wise and ARD
to 2021. The declining trend is noted in all states/UTs state-wise respectively (9)

&

T3
<

FIG. 1
State/UT wise adult HIV prevalence (%), 2021
Source : (9)

by R△J
 AIDS 39 1

10.00 -
9.00 —
-o 8.00 -
c 7.00 -
(0
co
2 6.00 —
O
x:
-+-1 5.00 —
.£ 4.00 -
3.00 -
< 2.00
1.00

State/UT wise Estimated Annual AIDS related deaths (in thousand), 2021

Key population affected in India People who inject drugs and HIV : Prevalence of HIV
among injecting drug users (IDU) is high and major route of
The HIV epidemic in India is driven by sexual transmission,
HIV transmission in India’s north-eastern states. In 2016,
which accounts for 86 per cent of new infections in 2017.
1.7 million people in India were estimated to be injecting
It is followed by parent-to-child, injecting drug users,
drug users. In 2017, 6.3 per cent of people who inject drugs
homosexuals and blood and blood products use etc.
were thought to be living with HIV, of whom half were aware

telegram-@Cherry_2412
According to HIV sentinel surveillance during 2019, the of their status. Prevalence varies with states e.g., 12.1 per
overall HIV prevalence among ANC clinic attendees cent in Manipur, 10 per cent in Mizoram and 3.2 per cent in
(considered as proxy for prevalence among general Nagaland. A 2018 study analyzed unsafe injecting and
population) continues to be low at 0.24 per cent, with an sexual risk behaviours among about 20,000 Indian men who
overall declining trend at national level. India continues to injected drugs. Results suggest that beginning drug use at age
portray a concentrated epidemic. HIV prevalence among 25 years or below, engagement in drug use for longer time,
different risk groups is as shown in Fig. 3. injecting three times or more per day, sharing needles and
Sex workers and HIV (FSW) : In 2017, an estimated syringes, and sufferers of sexually transmitted diseases were
1.6 per cent of female sex workers in India were living with all linked to an increased likelihood of HIV infection (10).
HIV, although this figure varies between states. For example, HIV prevention efforts in the north-east of the country
prevalence among FSW is estimated at 7.4 per cent in have been effective in reducing the number of new
Maharashtra and 6.3 per cent in Andhra Pradesh. Stigma and infections. However, there is evidence that the number of
discrimination against sex workers restrict their access to people who inject drugs is growing. In addition, evidence of
healthcare. NACO reported reaching 77.4 per cent of sex higher HIV prevalence among sub-populations of people
workers with HIV prevention activities in the year 2015. In the who inject drugs is also emerging. For instance, a 2015
year 2017, around 67 per cent of HIV positive sex workers study found prevalence to be more than three times higher
were aware of their status and 91 per cent of sex workers (HIV among women who inject drugs than men (10).
positive and negative) reported using condom (10)
Hijras/transgender people and HIV : HIV prevalence
among transgender people in India was estimated to be
ANC (2019)-I 0.24
3.1% in 2017, the second highest prevalence among all key
Migrants (2017) - 0.51 populations in the country. Around 68% of HIV positive
FSW (2017)-— 1.56 transgender people are aware of their status. In 2017, NACO
reported around 45 per cent of transgender people and
hijras were receiving targetted interventions (10).
Migrant workers and HIV: Research worldwide has linked
migration to increase in HIV transmission. There are an
estimated 7.2 million migrant workers in India, of whom 0.2%
are living with HIV. NACO categorizes groups of migrants as
‘bridge populations’, as they form links between urban and
rural areas, and between groups that are at high-and low-risk
12 of HIV transmission. HIV testing among these groups remains
low, standing at 11.32% in 2016. Despite being an important
driver of the HIV epidemic in India, data on migrant sexual
FIG. 3 behaviour is limited. In 2014, UNAIDS reported that 75% of
HIV prevalence for ANC attendees and among women testing positive in India have a husband who is a
different high risk groups, India, (2017-2019) migrant labourer. A 2017 study found that HIV prevalence
Source : (11) among the wives of migrant workers in rural northern India

by R△J J
396 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

was higher than among women in the general population at Africa, the picture is very different; the sex ratio is equal.
0.59%. Only 15.5% of those questioned had heard of HIV. Certain sexual practices increase the risk of infection more
Truck drivers and HIV: A number of studies have reported than_others, e.g., multiple sexual partners, anal intercourse,
high vulnerability of truckers to HIV transmission in India. and male homosexuality. Higher rate of HIV infection is
NACO estimated that 0.2% of truck drivers were living with found in prostitutes.
HIV in 2017-18. NACO also categorizes truck drivers as a (c) HIGH-RISK GROUPS : Male homosexuals and
bridge population because they often have unprotected sex bisexuals, heterosexual partners (including prostitutes),
with high-risk groups such as female sex workers as well as their intravenous drug abusers, transfusion recipients of blood
regular sex partners, which increases the risk of transmitting and blood products, haemophiliacs and clients of STD.
HIV into the general population. A 2015 study found 49% of
truckers in central India reported paying for sex, of whom Immunology
21.5% had a sexually transmitted infection. HIV testing among The immune system disorders associated with HIV
truck drivers remains low, standing at 21.74% in 2016 (10). infection/AIDS are considered to occur primarily from the
Impoverished, unemployed, under employed, mobile and gradual depletion in a specialised group of white blood cells
migrant youth, and street children are particularly (lymphocytes) called T-helper or T-4 cells..The fulLname of
vulnerable to HIV, as they are less likely to have information T-helper cell is CD4 + T lymphocyte and is also commonly
about HIV or access to preventive measures, and they may known as CD4^+ cell. These cells play a key role in
face repeated risks of HIV infection. regulating the immune response.5^
HIV selectively infects T-helper cells apart from several
EPIDEMIOLOGICAL FEATURES other cells in the immune system such as B-cells, microphages
and nerve cells. When the virus reproduces, the infected_T-
1. Agent factors helper cells are destroyed. Consequently people with AIDS tend
(a) ( AGENT : When the virus was first identified it was to have low overall white blood cell count (14). Whereas healthy
called “lymphadenopathy-associated virus, (LAV)” by the individuals havejwice as many “helper” cells as “suppressor”
French scientists. Researchers in USA called it “human cells, in the AIDS patients the ratio is reversed. A decreased ratio
T-cell lymphotropic virus III (HTLV-III)”. In May 1986, the of T-helper to T-suppressor cells may be an indirect indicator
International Committee on the Taxonomy_gave it a new of reduced cellular immunity. One of the most striking features
oL the immune system of patients with AIDS is profound

telegram-@Cherry_2412
name : human immunodeficiency virus (HIV).
lymphopenia, with a total lymphocyte count often below 500/
The virus is 1/10,000th of a millimetre in diametre. It is a
cu. mm. It is the alteration in T-cell function that is responsible
protein capsule containing two short strands of genetic
for the development of neoplasms, the development of
material (RNA) and enzymes. The virus replicates in actively
opportunistic infections, or the inability to mount a delayed-
dividing T4 lymphocytes and like_ other retroviruses can
type hypersensitivity response. The lack of an obvious
remain in lymphoid cells in a latent state that can be activated.
immunological response by the host to the virus is one of the
<The virus has the unique ability to destroy human T4 helper
problems confronting scientists (15). That is, those with
cells, ajubset of the human T-lymphocytes. The virus is able
antibodies to HIV, usually will have too few of HIV antibodies,
to spread throughout the body. It can pass through the blood­
and these antibodies are also ineffective against the virus.
brain barrier and can then destroy some brain cells. This may
accounTTor certain of the neurological and psychomotor Mode of transmission
abnormalities, observed in AIDS_patients. HIV mutates
rapidly, new strains are continually developing. There are two The causative virus is transmitted from person-to-person,
types of HIV - HIV 1 and HIV 2, which exceeds 50 per cent. most frequently through sexual activity. The basic modes of
transmission are :
CThe virus is easily killed by heat. It is readily inactivated
by ether, acetone, ethanol (20 per cent) aricTZbeta- (a) Sexual transmission
propiolactone (1:400 dilution), but is relatively resistant to
ionizing radiation and ultraviolet light (12). AIDS is first and foremost a sexually transmitted disease.
Any vaginal, anal or oral sex can spread AIDS. Every single
(b) 'RESERVOIR OF INFECTION : These are cases and act of unprotected intercourse with an HIV-infected person
carriers. "Once a person is infected, the virus remains in the exposes the uninfected partner to the risk of infection. The
body life-long. The risk of developing AIDS increases with size of the risk is affected by a number of factors, including
time? STnce~HlV infection can take years to manifest itself, the presence of STD, the sex and age of the uninfected
the symptomless carrier can infect other people for years. partner, the type of sexual act, the stage of illness of the
(c) SOURCE OF INFECTION : The virus has been found infected partner, and the virulence of the HIV strain
in greatest concentration in blood, semen and CSF. Lower involved. A European study of heterosexual couples in
concentrations have been detected in tears, saliva, breast which only one partner was infected at the start, suggests
milk, urine, and cervical and vaginal secretions. HIV has that chances of transmission of HIV infection from male to
also been isolated in brain tissue, lymph nodes, bone female is twice as likely as from female to male (16).
marrow cells and skin_f 13). Generally, women are more vulnerable to HIV infection
because a larger surface is exposed, and semen contains
2. Host factors higher concentration of HIV than vaginal or cervical fluids.
(a) AGE : Most cases have occurred among sexually Anal intercourse carries a higher risk of transmission than
active persons agedJ? 0-49 years. This group represents the vaginal intercourse because it is more likely to injure tissues
most productive members of the society, and those of the receptive-partner. For all forms of sex, the risk of
responsible for child-bearing and child-rearing. transmission is greater where there are abrasions of the skin
(b) SEX : In North America, Europe and Australia, about or mucous membrane. For vaginal sex the risk is greater
51 per cent of cases are homosexual or bisexual men. In when woman is menstruating.

by R△J
 AIDS 397
Exposed adolescent girls and women above 45 years of Transmission of HIV from mother to child can be
age are more prone to get HIV infection. In teenagers the prevented almost entirely by anti-retroviral drug
cervix is thought to be less efficient barrier to HIV than in prophylaxis, elective caesarean section before onset of
mature genital tract of adult women. The thinning of mucosa labour and rupture of membranes, and by refraining from
at menopause is believed to lessen the protective effect. The breast-feeding. However, in economically poor countries,
production of mucus in the genital tract of adolescent girls elective caesarean section is not a safe option. A substantial
and in postmenopausal women is not as prolific as in efficacy of triple combination of drugs has been shown in
women between these life stages and this may also enhance industrialized countries, where the rate of transmission is
their susceptibility to HIV infection. now below 2 per cent in the absence of breast-feeding (8).
An STD in either the HIV-negative or the HIV-positive There is no evidence that HIV is transmitted through
partner facilitates the transmission of HIV. The risk of mosquitoes or any other insect, casual social contact with
transmission is 8-10 times higher. If an STD, such as infected persons including within households, or by food or
syphilis, chancroid or herpes, causes ulceration in the genital water. There is no evidence of spread to health care workers
or perineal region of the uninfected partner, it becomes far in their professional contact with people with AIDS (17).
easier for HIV to pass into his or her tissues. An STD causes
inflammation. T-cells and monocytes/macrophages, get Incubation period
concentrated in the genitaL area. In a person _ already While the natural history of HIV infection is not yet fully
infected with HIV,^some of these key cells of the immune known, current data suggest that the incubation period is
system will be carrying the virus - which magnifies the risk uncertain, (from a few months to 10 years or even more) from
of transmission to the uninfected partner. HIV infection to the development of AIDS. The virus can lie
As for HIV-infected people, they are more infectious to silent in the body for many years. The percentage of people
others in the very early stages, before antibody production infected with HIV, who will develop clinical disease remains
i.e. during the “window .period”, and when the infection is uncertain - possibly 10-30 per cent will develop AIDS, and
well advanced, because levels of virus in the blood at that another 25-30 per cent will develop AIDS-related complex.
time is higher than at other times. However, it is estimated that 75 per cent of those infected
with HIV will develop AIDS by the end of ten years (18).
(b) Blood contact
Clinical manifestations

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AIDS is also transmitted by contaminated blood -
transfusion of whole blood cells, platelets and factors VIII and The clinical features of HIV infection have been classified
IX derived from human plasma. There is no evidence that into four broad categories (15) :
transmission ever occurred through blood products such as I. Initial infection with the virus and development of
albumin, immunoglobulins or hepatitis vaccines that meet antibodies
WHO requirements (12). Contaminated blood is highly
II. Asymptomatic carrier state
infective when introduced in large quantities directly into the
blood stream. The risk of contracting HIV infection from III. AIDS-related complex (ARC)
transfusion of a unit of infected blood is estimated to be over 95 IV. AIDS.
per cent. Since the likelihood of HIV transmission through
blood depends on the “dose” of virus injected, the risk of (I) INITIAL INFECTION
getting infected through a contaminated needle, syringe or any Except for a generally mild illness (fever, sore throat and
other skin-piercing instrument is very much lower than with rash) which about 70 per cent of people experience a few
transfusion. Nevertheless, among drug users who inject heroin, weeks after initial infection with the virus, most HIV -
cocaine or other drugs, this route of transmission is significant infected people have no symptoms for the first five years or
because exposure is repeated so often, in some cases, several so. They look healthy and feel well although right from the
times a day. As a result, needle-sharing by drug users is a major start they can transmit the virus to others. Once infected,
cause of AIDS in many countries, both developed and people are infected for life. Scientists have not found as yet,
developing, and in some it is the predominant cause. Any skin a way of curing them, or making them uninfectious to others.
piercing (including injections, ear-piercing, tattooing,
HIV antibodies usually take between 2 to 12 weeks to
accupuncture or scarification) can transmit the virus, if the
instruments used have not been sterilized and have previously appear in the blood-stream, though they have been known
been used on an infected person. It may be mentioned that to take longer. The period before antibodies are produced is
transfusion of blood and blood products has played a minor the “window period” during which, although the person is
role in the spread of AIDS in the developed countries. particularly infectious because of the high concentration of
virus in the blood, he will test negative on the standard
(c) Maternal-foetal transmission : mother-to antibody blood test. Though the body’s immune system
child transmission reacts to the invasion of HIV by producing antibodies, these
HIV may pass from an infected mother to her foetus, do not inactivate the virus in the usual way.
through the placenta or to her infant during delivery or by
(II) ASYMPTOMATIC CARRIER STATE
breast-feeding. In the absence of any intervention, rates of
this form of transmission can vary from 20-25 per cent. Infected people have antibodies, but no overt signs of
Transmission during the peripartum period accounts for one- disease, except persistent generalized lymphadenopathy. It
third to two-thirds of overall numbers infected, depending on is not clear how long the asymptomatic carrier state lasts.
whether breast-feeding transmission occurs or not, and this
period has, therefore, become a focus of prevention efforts. (III) AIDS-RELATED COMPLEX
The risk of infection is higher if the mother is newly infected, A person with ARC has illnesses caused by damage to the
or if she has already developed AIDS. HIV infected infants immune system, but without the opportunistic infections
and children progress rapidly to AIDS. (Fig. 4) and cancers associated with AIDS, they may exhibit
by R△J
398 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

people. As a consequence, AIDS is reviving an old problem

in developed countries e.g. in the USA, where there was
___.1____
Bacterial infections sudden increase in tuberculosis cases. The situation in
Tuberculosis developing countries is still worst.
Herpes simplex The emergence of drug resistance makes it essential that
Herpes zoster
Vaginal candidiasis antibiotic sensitivity be performed on all positive cultures.
Hairy leukoplakia Drug therapy should be individualized. Patients with multi
Kaposi’s sarcoma drug resistance should receive atleast three drugs to which
their organism is sensitive (19).
Pneumocystosis
Toxoplasmosis A-
PERSISTENT GENERALIZED LYMPHADENOPATHY.
Cryptococcosis Lymph nodes are larger than one centimetre in diameter, in
Coccidioidomycosis two or more sites other than the groin area for a period of at
Cryptosporidiosis least three months.
Disseminated MAC KAPOSI SARCOMA. A tumour featuring reddish brown
infection
Histoplasmosis
or purplish plaques or nodules on the skin and mucous
CMV retinitis membranes. Endemic in Africa prior to HIV, it used to affect
CNSjymphoma mainly older men. With HIV infection it affects a wider age
range and both sexes, and is characterized by lesions in the
FIG. 4 mouth or gut; or lesions are generalized (in two or more
Relationship of CD4 count to development of opportunistic infection places) or rapidly progressive or invasive.
Source : (19) OROPHARYNGEAL CANDIDIASIS. Caused by a
one or more of the following clinical signs; unexplained common yeast fungus, oral thrush presents with soreness
diarrhoea lasting longer than a month, fatigue, malaise, loss of and redness, with white plaques on the tongue, and in the
more than 10 per cent body weight, fever, night sweats, or mouth and throat; and sometimes a white fibrous layer
other milder opportunistic infections such as oral thrush, covering the tonsils and back of the mouth. Infection of the
generalized lymphadenopathy or enlarged spleen. Patients oesophagus presents with pain behind the breastbone.

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from high-risk groups who have two or more of these CYTOMEGALOVIRUS RETINITIS. Inflammation of the
manifestations (typically including generalised eye retina which may lead to blindness.
lymphadenopathy), and who have a decreased number of
T-helper lymphocytes are considered to have AIDS-related PNEUMOCYSTOSIS CARINII PNEUMONIA. Symptoms
complex (1). Some patients with AIDS-related complex, can include a dry, non-productive cough; inability to take a
subsequently develop AIDS. full breath and occasional pain on breathing; and weight loss
and fever.
(IV) AIDS
TOXOPLASMA ENCEPHALITIS. Protozoal infection in
AIDS is the end-stage of HIV infection. A number of the central nervous system, presenting with focal
opportunist infections commonly occur at this stage (Fig. 2), neurological signs such as mild hemiplegia or stroke,
and/or cancers that occur in people with otherwise resulting from damage to part of the brain, seizures or
unexplained defects in immunity. Death is due to uncontrolled altered mental status.
or unbeatable infection. Tuberculosis and Kaposi sarcoma are
usually seen relatively early. Serious fungal infections such as HAIRY LEUKOPLAKIA. White patches on the sides of the
Candida oesophagitis, Cryptococcus meningitis and tongue, in vertical folds resembling corrugations.
penicillosis, and parasitic infections such as Pneumocystis CRYPTOCOCCAL MENINGITIS. A fungal infection in
carinni pneumonia or Toxoplasma gondii encephalitis tend to the central nervous system which usually presents with fever,
occur, when T-helper cell count has dropped to around 100. headache, vomiting and neck stiffness.
People whose counts are below 50 have the late opportunistic
HERPES-ZOSTER OR SHINGLES. Viral inflammation of
infections such as cytomegaloviral retinitis.
the central nervous system, presenting with localised pain
Many people with AIDS are affected by a wasting and burning sensations, followed by vesicle eruption (skin
syndrome that is known, ..especially in Africa, as “slim blistering) and ulceration.
disease”. It involves chronic diarrhoea and severe weight
loss. Another condition, seen worldwide, is AIDS SEVERE PRURIGO OR PRURITIC DERMATITIS.
encephalopathy or AIDS dementia, which is caused by HIV Chronic skin inflammation in the form of a very itchy rash of
crossing “blood-brain barrier”. In its late stages, AIDS small flat spots developing into blisters.
encephalopathy resembles senile dementia or Alzheimer’s SEVERE OR RECURRENT SKIN INFECTIONS. Warts;
disease. AIDS dementia appears to result not from dermatophytosis or ringworm; and folliculitis (inflammation
opportunistic infection, but from the action of the virus itself. of hair follicles)
TUBERCULOSIS. An alarming factor in the AIDS
epidemic is the increasing link between HIV infection and DIAGNOSIS OF AIDS
tuberculosis. In countries where tuberculosis is endemic,
many people are infected in childhood. When the immune CLINICAL
system breaks down, as in HIV infection, tuberculosis
becomes active and the person becomes contagious to I. WHO case definition for AIDS surveillance
others. Studies in Rwanda, the USA, Zaire and Zambia For the purposes of AIDS surveillance an adult or
found that HIV-positive individuals were 30-50 times more adolescent (> 12 years of age) is considered to have AIDS if at
likely to develop active tuberculosis than HIV-negative least 2 of the following major signs are present in combination
by R△J
 !
AIDS

with at least 1 of the minor signs listed below, and if these signs Major signs
are not known to be due to a condition unrelated to HIV • weight loss or abnormally slow growth
infection (20). • chronic diarrhoea for more than 1 month
• prolonged fever for more than 1 month.
Major signs
• weight loss > 10% of body weight Minor signs
• chronic diarrhoea for more than 1 month • generalized lymph node enlargement
• prolonged fever for more than 1 month (intermittent • oropharyngeal candidiasis
or constant). • recurrent common infections, e.g. ear infection,
Minor signs pharyngitis
• persistent cough for more than 1 month3’b • persistent cough
• generalized pruritic dermatitis • generalized rash
• history of herpes zosterb Confirmed HIV infection in the mother counts as a minor
• oropharyngeal candidiasis criterion.
• chronic progressive or disseminated herpes simplex The definition for children is not very specific,
infection particularly in poor regions where childhood malnutrition
• generalized lymphadenopathy. and TB are common. Further, many children present with
The presence of either generalized Kaposi sarcoma or acute HIV-related illness such as pneumocystis carinii
cryptococcal meningitis is sufficient for the diagnosis of pneumonia without any clinical evidence of AIDS.
AIDS for surveillance purposes.
II. Expanded WHO case definition for AIDS
a. For patients with tuberculosis, persistent cough for more surveillance
than 1 month should not be considered as a minor sign
b. Indicates changes from the 1985 provisional WHO For the purposes of AIDS surveillance an adult or
clinical case definition for AIDS (“Bangui definition”) adolescent (>12 years of age) is considered to have AIDS if
a test for HIV antibody gives a positive result, and one or
The clinical definition is relatively specific (if used more of the following conditions are present:

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correctly), meaning that the vast majority of people
• > 10% body weight loss or cachexia, with diarrhoea or
diagnosed as having AIDS will have been correctly assessed.
fever, or both, intermittent or constant, for at least
However, studies show that the definition is relatively
1 month, not known to be due to a condition
insensitive, meaning that only half the patients who have
unrelated to HIV infection
severe illness related to HIV infection are included. This is
because not all HIV-related opportunistic diseases are in the • cryptococcal meningitis
AIDS definition. Tuberculosis is widely recognized as the • pulmonary or extra-pulmonary tuberculosis
commonest opportunistic disease associated with HIV in • Kaposi sarcoma
Africa. But because TB causes wasting, cough and fever in • neurological impairment that is sufficient to prevent
most patients, the AIDS clinical case definition cannot independent daily activities, not known to be due to a
reliably distinguish between HIV-positive and HIV-negative condition unrelated to HIV infection (for example,
TB patients. trauma or cerebrovascular accident)
The clinical case definition was developed to enable • candidiasis of the oesophagus (which may be
reporting of the number of people with AIDS for the presumptively diagnosed based on the presence of
purposes of public health surveillance, rather than for oral candidiasis accompanied by dysphagia)
patient care. However, for the purpose of individual case • clinically diagnosed life-threatening or recurrent
management, it is useful to be able to diagnose whether episodes of pneumonia, with or without aetiological
illnesses may be related to HIV infection (symptomatic HIV confirmation
infection) because : • invasive cervical cancer.
• clinical manifestations can be a reliable indicator of Major features of this expanded surveillance case
underlying HIV infection; definition are that it requires an HIV serological test, and
• over-use of HIV testing is avoided, testing is used to includes a broader spectrum of clinical manifestations of
confirm suspected HIV infection, rather than as a HIV such as tuberculosis, neurological impairment,
diagnostic tool in the first instance; pneumonia, and invasive cervical cancer. The expanded
• a patient with suspected HIV infection can be definition is simple to use and has a higher specificity (20).
counselled about having an HIV test, the implications
for them and their sexual partners, self-care and CLINICAL STAGING
nutrition;
WHO clinical staging system for HIV infection
• many HIV-related illnesses can be treated, improving
the patient’s quality of life; and HIV-related disease (21)
• certain drugs (such as thiacetazone) cause severe side WHO has developed a clinical staging system (originally
effects in people with HIV infection, and should not be for prognosis), based on clinical criteria. The definition of
prescribed for them. symptoms, signs and diseases is according to clinical
judgement. Clinical condition or performance score,
Children (21) whichever is the higher, determines whether a patient is at
The case definition for AIDS is fulfilled if at least 2 major clinical stage 1, 2, 3, or 4 as shown in Table 3. Clinical stage
signs and 2 minor signs are present (if there is no other is important as a criterion for starting antiretroviral (ARV)
known cause of immunosuppression). therapy.
by R△J
400 j EPIDEMIOLOGY OF COMMUNICABLE DISEASES
TABLE 3 Children
WHO clinical staging of HIV disease
WHO clinical staging system for HIV infection and related disease
in adults and adolescents in children
Clinical stage 1 Stage 1 : Asymptomatic
Asymptomatic - Persistent generalized lymphadenopathy
Persistent generalized lymphadenopathy Stage 2 : - Unexplained chronic diarrhoea
Clinical stage 2 - Severe persistent or recurrent candidiasis outside
Moderate unexplained weight loss (under 10% of presumed or the neonatal period
measured body weight) - Weight loss or failure to thrive
Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis - Persistent fever
media, pharyngitis) - Recurrent severe bacterial infections
Herpes zoster Stage 3 : ~ AIDS-defining opportunistic infections
Angular cheilitis - Severe failure to thrive
Recurrent oral ulcerations
- Progressive encephalopathy
Papular pruritic eruptions
- Malignancy
Seborrheic dermatitis
Fungal nail infections - Recurrent septicaemia or meningitis.

Clinical stage 3 Source : (21)

Unexplained severe weight loss (over 10% of presumed or
measured body weight) LABORATORY DIAGNOSIS
Unexplained chronic diarrhoea for longer than 1 month
Unexplained persistent fever (intermittent or constant for SCREENING TESTS : As antibodies to HIV are far easier
longer than 1 month) to detect than the virus itself, their presence or absence in
Persistent oral candidiasis blood-stream is the basis for the most widely used test of
Oral hairy leukoplakia HIV infection. A person whose blood contains HIV
Pulmonary tuberculosis antibodies is said to be HIV-positive, or seropositive,
Severe bacterial infections (e.g. pneumonia, empyema, meaning that he or she is infected with HIV. There is now a
meningitis, pyomyositis, bone or joint infection, wide range of screening tests based on detection of HIV-

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bacteraemia, severe pelvic inflammatory disease)
Acute necrotizing ulcerative stomatitis, gingivitis or antibodies. To be reliable, a screening test must be
periodontitis sensitive enough to identify all “true positives”, while
Unexplained anaemia (below 8 g/dl), neutropenia being specific enough to record few “false positives”. The
(below 0.5 x 109/l) and/or chronic thrombocytopenia ideal test needs both the attributes.
(below 50 x 109/l)
At present, to ensure accuracy, two different tests are
Clinical stage 4 commonly applied. At first a sensitive test is used to detect
HIV wasting syndrome3 the HIV-antibodies, while a second confirmatory test is
Pneumocystis jiroveci pneumonia used to weed out any false positive results. The first kind of
Recurrent severe bacterial pneumonia test is normally the ELISA. The confirmatory test, usually a
Chronic herpes simplex infection (orolabial, genital or anorectal Western Blot is a highly specific test; it is based on
of more than 1 month's duration or visceral at any site
Oesophageal candidiasis (or candidiasis of trachea, bronchi detecting specific antibody to viral core protein (p24) and
or lungs) envelop glycoprotein (gp 41). This is a more difficult test to
Extrapulmonary tuberculosis perform and requires trained and experienced laboratory
Kaposi sarcoma workers to interpret the test.
Cytomegalovirus disease (retinitis or infection of other organs, VIRUS ISOLATION : A test for the virus itself would
excluding liver, spleen and lymph nodes)
eliminate the painful uncertainty of AIDS infection. HIV can
Central nervous system toxoplasmosis
HIV encephalopathy15 be recovered from cultured lymphocytes (22). This type of
Extrapulmonary cryptococcosis including meningitis testing is very expensive and requires extensive laboratory
Disseminated non-tuberculous mycobacteria infection support.
Progressive multifocal leukoencephalopathy The current trend in HIV-antibody tests is towards simple,
Chronic cryptosporidiosis cheap, reliable kits whose results can be read on the spot
Chronic isosporiasis without much waiting and without the need for laboratory
Disseminated mycosis (histoplasmosis, coccidiomycosis) backup. HIV self testing kits are available in the market.
Recurrent septicaemia (including nontyphoidal Salmonella)
Lymphoma (cerebral or B cell non-Hodgkin) Non-specific laboratory findings with HIV infection may
Invasive cervical carcinoma include anaemia, leukopenia (particularly lymphocytopenia)
Atypical disseminated leishmaniasis and thrombocytopenia in any combination, polyclonal
Symptomatic HIV-associated nephropathy or HIV-associated hypergammaglobulinaemia. Cutaneous energy is frequent
cardiomyopathy early in the course, and becomes universal as the disease
a HIV wasting syndrome : weight loss > 10% of body weight, plus progresses (19).
either unexplained diarrhoea for more than one month or chronic
weakness, and unexplained fever for more than one month. Several laboratory markers are available to provide
b HIV encephalopathy : clinical findings of disabling mental or prognostic information and guide therapy decisions. The
motor dysfunction, interfering with activities of daily living, most widely used marker is the absolute CD4 lymphocyte
progressing over weeks and months, in the absence of a count. As the count decreases, the risk of opportunistic
concurrent illness or condition other than HIV infection which infection increases. People with healthy immune system
could explain the findings. usually have more than 950 CD4 cells/pL of blood. The
Source : (22, 23) number falls over the course of HIV infection. People with
by R△J
 AIDS 401
AIDS usually have CD4 cell count below 200 (USA makes Control of AIDS
CD cell count below 200 in an HIV-infected person a
There are four basic approaches to the control of AIDS :
definition of AIDS). The trend of the count is much more
important than any single reading. The frequency of
performance of counts depends on the patient’s health
1. Prevention
system. Some studies suggest that the percentage of CD4 (a) EDUCATION
lymphocytes is more reliable indicator of prognosis than the
absolute count because the percentage does not depend on Until a vaccine or cure for AIDS is found, the only means
calculating a manual differential. Risk of progression to at present available is health education to enable people to
AIDS is high with percentage of CD4 lymphocyte less make life-saving choices (e.g., avoiding indiscriminate sex,
than 20 (19). using condoms). There is, however, no guarantee that the
use of condoms will give full protection. One should also
The laboratory tests and their significance are as
avoid the use of shared razors and toothbrushes.
summarized in Table 4.
Intravenous drug users should be informed that the sharing
TABLE 4 of needles and syringes involves special risk. Women
suffering from AIDS or who are at high risk of infection
Laboratory findings with HIV infection
should avoid becoming pregnant, since infection can be
Test Significance transmitted to the unborn or newborn. Educational material
and guidelines for prevention should be made widely
HIV enzyme-linked Screening test for HIV infection. available. All mass media channels should be involved in
immunosorbent Sensitivity > 99.9%; to avoid false-positive educating the people on AIDS, its nature, transmission and
assay (ELISA) results, repeatedly reactive results must be
confirmed with Western blot. prevention; this includes international travellers.

Western blot Confirmatory test for HIV. Specificity when (b) COMBINATION HIV PREVENTION (24)
combined with ELISA >99 99%.
Indeterminate results with early HIV Combination prevention programmes use a mix of
infection, HIV-2 infection, autoimmune biomedical, behavioural and structural interventions to meet
disease, pregnancy and recent tetanus the current HIV prevention needs of particular individuals

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toxoid administration. and communities so as to have the greatest possible impact
on reducing new infections.
CBC Anaemia, neutropenia, and
thrombocytopenia common with advanced ARV drugs play a key role in HIV prevention. People
HIV infection. taking ART who achieve optimal viral suppression are
Absolute CD4 Most widely used predictor of HIV extremely unlikely to pass HIV to sexual partners. ARV drugs
lymphocyte count progression. Risk of progression to an AIDS taken by people without HIV as PrEP or PEP are highly
opportunistic infection or malignancy is effective in preventing HIV acquisition.
high with CD4 < 200 cells/jiL. Other biomedical interventions that reduce HIV risk
CD4 lymphocyte Percentage may be more reliable than the practices and/or the probability of HIV transmission per
percentage CD4 count. Risk of progression to an AIDS contact event include the following:
opportunistic infection or malignancy is - Male and female condoms and condom compatible
high with percentage < 14%.
lubricant : male condoms are estimated to reduce
HIV viral load tests These tests measure the amount of actively heterosexual transmission by at least 80% and to offer
replicating HIV virus. Correlates with 64% protection in anal sex among men who have sex
disease progression and response to with men, if used consistently and correctly. Fewer data
antiretroviral drugs. are available for the efficacy of female condoms, but
P2 - Microglobulin Cell surface protein indicative of evidence suggests they can have a similar prevention
macrophage - monocyte stimulation. effect.
Levels >3.5 mg/dL associated with rapid - Needle and syringe programmes are highly associated
progression of disease. Not useful with
intravenous drug users. with a reduction in HIV transmission through injecting
drug use.
p24 antigen Indicates active HIV replication. Tends to be - Opioid substitution therapy with methadone or
positive prior to seroconversion and with
advanced disease. buprenorphine is the most effective form of treatment for
opioid dependence and has the’ additional benefit of
Source : (19) effectively reducing HIV risk behaviour and transmission
The WHO has pointed out the danger of compulsory through injecting drug use. Opioid substitution
testing programmes in their tendency to social rejection of therapy also provides adherence support to people on
HIV-carrier and the resulting social and psychological ART.
consequences. Diagnostic testing may be useful in gauging - Voluntary medical male circumcision (VMMC) : three
the magnitude and course of the epidemic. It is a gateway to randomized clinical trials in Africa demonstrated an
HIV prevention, treatment, care and other support services, approximately 60% reduction in the risk of female-to­
including pre-test information and post-test counselling. The male sexual transmission. For high-burden settings, joint
WHO five C’s - consent, confidentiality, counselling, correct programme of WHO and United Nations on HIV/AIDS
test results and connection to care and treatment - are (UNAIDS) recommended the inclusion of VMMC as an
principles that apply to all models of HIV testing services additional important strategy for prevention of
and in all circumstances. heterosexually acquired HIV infection in men.
by R△J
402 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

(c) PREVENTION OF BLOOD-BORNE HIV HIV care and management recommendations

TRANSMISSION (NACO 2021) (23)
People in high-risk groups should be urged to refrain
from donating blood, body organs, sperm or other tissues.
Antiretroviral therapy (ART) in adults and
All blood should be screened for HIV 1 & HIV 2 before adolescents
transfusion. Transmission of infection to haemophiliacs can There has been a rapid decline in HIV-related mortality
be reduced by introducing heat treatment of factors VIII and morbidity due to the wider availability of affordable,
and IX. Strict sterilization practices should be ensured in more efficacious and less toxic ARVs over the last two
hospitals and clinics. Pre-sterilized disposable syringes and decades. ART consists of the use of a combination of at least
needles should be used as far as possible. One should avoid three ARV drugs from different classes to inhibit the
injections unless they are absolutely necessary. replication of HIV and reduce viraemia to undetectable
levels. Continued suppression of viral replication leads to
2. Antiretroviral treatment the restoration of immune response, reflected by an increase
in the CD4 count. Increase in CD4 count leads to slowing of
At present there is no vaccine or cure for treatment of
the disease progression, reduced frequency of OIs,
HIV infection/AIDS. However, the development of drugs
improvement in the quality of life and increased longevity.
that suppress the HIV infection itself rather than its
Successes achieved by ART have now transformed the
complications has been important development. These
perception about HIV infection from being a ‘virtual death
antiviral chemotherapy have proved to be useful in
sentence’ to a ‘chronic manageable illness’. ART was earlier
prolonging the life of severely ill patients.
known as Highly Active ART (HAART) and as combination
The availability of agents in combination suppress HIV ART (cART).
replication. It has a profound impact on the natural history Since 2016, WHO recommended that all people living
of HIV infection. Patients who achieve excellent suppression with HIV be provided with lifelong ART, including children,
of HIV generally have stabilization or improvement of their adolescents and adults, pregnant and breast-feeding
clinical course which results from partial immunologic women, regardless of clinical status or CD4 cell count. The
reconstitution and a subsequent decrease in complications current HIV treatment guidelines include new ARV options
of immunosuppression. Concept about the timing of such

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with better tolerability, higher efficacy, and lower rates of
therapy have changed considerably. treatment discontinuation when compared with previous
recommended medicines.
Classification of drugs used for ART (19)
The goals of ART are as follows (23) :
The drugs used for ART are classified as :
Clinical goals Increased survival and improvement in
Nucleoside reverse transcriptase inhibitors (NRTIs) quality of life
Abacavir (ABC) Virological goals Greatest possible sustained reduction in
Didanosine (ddl) viral load
Emtricitabine (FTC) Immunological goals Immune reconstitution, that is, both
Lamivudine (3TC) quantitative and qualitative
Stavudine (d4T) Therapeutic goals Rational sequencing of drugs in a manner
Zidovudine (AZT) that achieves clinical, virological and
immunological goals while maintaining
Nucleotide reverse transcriptase inhibitors (NtRTIs) future treatment options, limiting drug
toxicity and facilitating adherence
Tenofovir (TDF)
Preventive goals Reduction of HIV transmission by
Non-nucleoside reverese transcriptase inhibitors (NNRTIs) suppression of viral load
Efavirenz (EFV)
Etravirine (ETV)
Rapid ART initiation for newly diagnosed
Nevirapine (NVP) PLHIV at ART centre
The introduction of the ’Treat AH' recommendation
Protease inhibitors (Pls) supports the rapid initiation of ART, including the offer of
Atazanavir 4- ritonavir (ATV/r) same-day initiation where there is no clinical
Darunavir + ritonavir (DRV)r) contraindication. Rapid ART initiation is defined as "ART
Fos-amprenavir 4- ritonavir (FPV/r) initiation within seven days from the day of HIV diagnosis".
Indinavir 4- ritonavir (IDV/r) Following a confirmed HIV diagnosis and clinical
Lopinavir/ritonavir (LPV/r) assessment, same-day /rapid ART initiation should be
Saquinavir 4- ritonavir (SQV/r) offered to all PLHIV adequately prepared and ready for
initiation. However, if an active 01 is present, ART initiation
Integrase strand transfer inhibitors (INSTIs) may be deferred as required.
Raltegravir (RAL) PLHIV should be assessed for readiness for ART initiation
using the algorithm provided in Fig. 5 (with concurrent
Dolutegravir (DTG)
sample collection for CD4 testing and baseline
Fusion inhibitors investigation). This algorithm focusses on clinical screening
of PLHIV for potential presence of common Ols/advanced
Enfuvirtide (T-20, Fuzeon) HIV disease/comorbid conditions.
by R△J
 AIDS 403
Symptoms screening Yes, for
Cough/fever/weight loss/night sweats/ persistent/other serious any symptoms
symptoms

No

Yes, for
any symptoms Appropriate diagnosis,
management/
Expert consultation/
Referral, if required

Day 1

Yes, for any

comorbid
condition

Readiness assessment
• Preparedness counselling
• For PLHIV with psychosocial concerns or comorbid substance

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use, involve relevant persons like family members, relatives,
peers, counsellors, etc. for enhanced counselling and support

________________ i______________
Day 1 Initiate ART- Preferably same day (if patient is ready)
preferably • ART to be dispensed for one month
• Concurrently send samples for CD4 count and other baseline
investigations as per NACO guidelines ART initiation
as soon as
appropriate action
Follow up has been taken
(as per NACO
• Review test result: If test reports are not normal, PLHIV to be guidelines),
called back to ART centre (as soon as possible, within 2 weeks of depending on the
Within ART initiation) reason for deferral
3-5 days • ART counsellor to call all patients & ask about general wellbeing (opportunistic
preferably of patients within 2 weeks of ART initiation infection,
• Medical officer should do appropriate management of comorbidity,
Advanced Disease, adjustments in ART regimen, 01 prophylaxis, etc.)
co-morbidity management, etc. j
FIG. 5
Rapid ART initiation algorithm in PLHIV
Source : (23)

Antiretroviral Therapy Regimens (23) The first-line ART essentially comprises of a NRTI
Fixed-dose combinations (FDCs) of ARVs are preferred backbone, preferably Non-Thymidine (Tenofovir plus
Lamivudine) and one INSTI, preferably DTG. Based on the
because they are easy to prescribe and easy for patients to
evidence supporting better efficacy and fewer side effects,
take, thereby facilitating improved and desirable treatment
the preferred first-line ART regimen for all PLHIV with age
adherence. This is essential for PLHIV as the treatment is
life-long and we need to minimize the chance of developing >10 years and weight > 30kg is as follows :
drug-resistant mutants in their body and the resultant Tenofovir (TDF 300 mg) + Lamivudine (3TC 300 mg) +
treatment failure. Further, FDCs have distinct advantages in Dolutegravir (DTG 50 mg) regimen (TLD) as FDC in a single
drug procurement and distribution, essentially the drug pill once a day (at a fixed time every day as per patient’s
stock management itself. National experience has shown convenience).
that regimens with FDCs are more acceptable, well tolerated This regimen has the advantage of harmonization in the
and adequately complied with. treatment of all adults, adolescents, pregnant women
The basic principle for first-line ART for treatment-naive including those with HIV-1, HIV-2, HIV-1 & 2, women
adult and adolescent patients is to use a triple drug exposed to single dose nevirapine in the past and those co­
combination from two different classes of ARVs. infected with TB or Hepatitis.
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

It is a simple, potent and well-tolerated regimen that TABLE 6

offers the advantage of a decentralized service delivery and Monitoring and follow-up schedule for patients on ART
monitoring. It also simplifies the supply chain and minimizes
monitoring requirements. Monitoring Tool When to Monitor
In cases where the preferred first-line ARV regimen of
TDF+3TC4-DTG cannot be used, the alternative regimens Body weight Every visit
are mentioned in Table 5. Height / length in children

Treatment adherence Every visit

General Guidance
- A single pill of TLD should be taken preferably at Clinical monitoring and T-staging Every visit
bedtime, and instances where additional dose of DTG is 4-symptom TB screening Every visit
indicated should be taken preferably in the morning.
- Patients with severe Diabetes and Hypertension should Screening for common NCD; Every 6 months or
be monitored more closely for TDF toxicity. Hypertension, symptom directed
Diabetes mellitus
- Patients starting on DTG should be monitored for blood
glucose (six monthly) and weight gain (on monthly Laboratory evaluation based Every 6 months or
visits). Appropriate physical activity should be advised to on ART regimen symptom directed
prevent weight gain.
CD4 Count CD4 must be done every
6 months*
Monitoring of Patients on ART
Follow-up and monitoring are essential in patients Viral load At 6 months, 12 months and
initiated on ART to track clinical progress, monitor well­ then every 12 months** ***
being and to identify adverse drug reactions and toxicities. *CD4 Count :
ART monitoring includes clinical monitoring and laboratory 1. As routine virological monitoring is available, CD4 testing
monitoring. Clinical monitoring includes monitoring of should be done every 6 months and can be discontinued in
adherence to ART as well. The client should be monitored PLHIV (except those with HIV-2 infection) when CD4 count
every month for clinical progress, side effects of the ARVs reaches greater than 350 cells/mm3 and viral load is less than

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and treatment adherence. Clinical and laboratory 1000 copies/ml (when both tests are conducted at the same
time).
evaluations are carried out at specified intervals for patients
2. CD4 monitoring should be restarted for any patient if
on ART Table 6 summarizes the monitoring tools (23).
a. the patient has been switched due to treatment failure, that
is, virologic failure (Plasma Viral Load > 1000 copies/ml); or
Paediatric first-line ART regimens (23) b. when deemed necessary for clinical management by the
clinician at any point in time.
ART initiation ** For patients on second/third-line ART, Plasma Viral Load testing
The choice of drugs depends on the child’s age and body to be done every 6 months.
weight. Abacavir (ABC) is the preferred NRTI for initiation
in children less than 10 years of age and body weight of less preferred third drug in all children less than 6 years of age
than 30 kg. For all children above 10 years and above 30 kg and less than 20 kg body weight till the availability of
body weight, Tenofovir (TDF) is the preferred drug for Dolutegravir under the national programme. For children
initiation. This is the simplest, most potent and least toxic older than 6 years of age and of more than 20 kg body
regimen. Lopinavir/ritonavir is recommended as the weight DTG is recommended as the preferred third drug.

TABLE 5
Alternate first-line ART in adults and adolescents
Condition Alternate First-line Regimen
PLHIV with body weight <30 kg ABC 600 mg 4- Lamivudine 300 mg, one tablet 4- DTG (50 mg) once daily in the morning or
any fixed time every day as per patient’s convenience
All patients with high (above ULN ABC 600 mg OD, Lamivudine (as per creatinine clearance**) and DTG 50 mg once daily
for laboratory) serum creatinine values in the morning or any fixed time every day as per patient’s convenience
(Calculate Creatinine clearance)
PLHIV on Rifampicin-containing Tenofovir (300 mg) 4- Lamivudine (300 mg) 4- Dolutegravir (50 mg) - FDC one tablet once
ATT regimen daily (in the morning or any fixed time every day as per patient’s convenience)
4-
Additional dose of DTG 50 mg to be provided (12 hours after taking their regular dose)
until 2 weeks after completion of ATT
Women of childbearing potential Tenofovir (300 mg) 4- Lamivudine (300 mg) 4- Efavirenz (600 mg)
who do not wish to take DTG-based ART If Efavirenz is contraindicated (HIV-2/HlV-l&2/prior NNRTI exposure) then Tenofovir (300 mg)
after adequate and optimal counselling*** + Lamivudine (300 mg) 4- [Lopinavir (200 mg) 4- ritonavir (50 mg) twice daily]
* For all patients with high serum creatinine values (above ULN for laboratory), calculate creatinine clearance.
** Lamivudine, along with Abacavir, may be used in full dose if creatinine clearance is more than 30 ml per minute,
with patient being closely monitored.
*** Women of childbearing potential receive full information and medical guidance that is appropriate to their situation and are
supported in making an informed decision.
Source : (23)
by R△J
 AIDS

First-line ART regimens for infants and children with acceptable alternative to raltegravir in patients who intend
HIV-1 and HIV-2 infection are as follows : to become pregnant and those who initiate therapy during
the first trimester. However, patients should be advised of
Particulars Recommended Regimen
the small risk for teratogenicity when administered in the
1. Age less than 6 years and Abacavir + Lamivudine + first trimester. There is no known elevated risk beyond the
body weight less than 20 kg Lopinavir/ritonavir (AL+LPV/r) first trimester of pregnancy. Non-pregnant individuals of
2. Age between 6 and 10 years Abacavir + Lamivudine + childbearing potential should be counseled about the need
and body weight between Dolutegravir (ALD) for birth control while completing a PEP regimen.
20 kg and 30 kg
3. Age more than 10 years and Tenofovir + Lamivudine + Use of co-trimoxazole prophylaxis for
body weight more than 30 kg Dolutegravir (TLD) HIV-related infections (24)
Important considerations for ART regimens for infants Co-trimoxazole is a fixed dose combination of two
and children include the availability of suitable paediatric antimicrobial drugs (sulfamethoxazole and trimethoprim) that
drug formulations that can be taken in appropriate doses; covers a variety of bacterial, fungal and protozoan infections.
simplicity of dose schedule; and the taste and palatability. The therapy is feasible, well tolerated and inexpensive
All these are potential factors for better treatment adherence intervention for people living with HIV to reduce HIV-related
in young children. Fixed-dose combinations are increasingly morbidity and mortality. The WHO recommendations (2016)
available for younger children (23). for the use of co-trimoxazole is summarized in Table 7.
Occupational HIV postexposure prophylaxis (25) TABLE 7
Use of co-trimoxazole for HIV related infections,
Postexposure prophylaxis (PEP) is recommended for WHO (2016)
healthcare personnel who have an occupational exposure to
blood, tissue, or other body fluids that may contain human Adults (including pregnant women)
immunodeficiency virus (HIV). Types of exposure that might Co-trimoxazole prophylaxis is recommended for severe or advanced
place healthcare personnel at risk for HIV infection include HIV clinical disease (WHO stage 3 or 4) and/or for a CD4 count
any of the following : (1) Percutaneous injury (e.g., a < 350 cells/mm3.
needlestick or cut with a sharp object); and (2) Contact of - In settings where malaria and/or severe bacterial infections are
highly prevalent, co-trimoxazole prophylaxis should be initiated

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mucous membranes or non-intact skin (e.g., exposed skin
that is chapped, abraded, or irritated due to dermatitis) with regardless of CD4 cell count or WHO stage.
blood, tissue, or body fluids that are potentially infectious. Co-trimoxazole prophylaxis may be discontinued in adults
(including pregnant women) with HIV infection who are clinically
The following fluids are considered potentially infectious : stable on antiretroviral therapy, with evidence of immune recovery
(a) Semen and vaginal secretions; (b) Cerebrospinal fluid; and viral suppression.
(c) Synovial fluid; (d) Pleural fluid; (e) Peritoneal fluid; - In settings where malaria and/or severe bacterial infections are
(f) Pericardial fluid; and (g) Amniotic fluid. highly prevalent, co-trimoxazole prophylaxis should be
continued regardless of CD4 cell count or WHO clinical stage.
The following are not considered potentially infectious
unless they are visibly bloody : (a) Faeces; (b) Nasal Infants, children and adolescents
secretions; (c) Saliva; (d) Sputum; (e) Sweat; (f) Tears; (g) Co-trimoxazole prophylaxis is recommended for infants, children,
Urine; and (h) Vomitus. and adolescents with HIV, irrespective of clinical and immune
conditions Priority should be given to all children younger than
Treatment recommendations 5 years old regardless of CD4 cell count or clinical stage and to
HIV PEP should be initiated as soon as possible after the children with severe or advanced HIV clinical disease (WHO clinical
exposure, preferably within hours. Do not delay stage 3 or 4) and/or those with CD4 < 350 cells/mm3.
administration of PEP while awaiting HIV test results of the In settings with a high prevalence of malaria and/or severe
source patient. The rationale behind this practice includes the bacterial infections, co-trimoxazole prophylaxis should be
continued until adulthood irrespective of antiretroviral therapy
following : (a) Animal studies demonstrate that PEP is likely provision.
to be less effective when started more than 72 hours after - In settings with low prevalence for both malaria and bacterial
exposure; (b) In the abscence of PEP, HIV replication occurs infections, co-trimoxazole prophylaxis may be discontinued for
within 48 to 72 hours in regional lymph nodes close to the site children 5 years of age and older who are clinically stable and/or
of exposure, followed by viremia within 72 to 120 hours of virally suppressed on antiretroviral therapy for at least 6 months
virus inoculation; (c) If PEP initiation is delayed, the benefits and CD4 > 350 cells/mm3.
might not outweigh the risks inherent in taking antiretroviral
HIV-exposed infants
medications; and (d) Initiating therapy after a longer interval
(eg, 1 week) might still be considered for exposures that Co-trimoxazole prophylaxis is recommended for HIV-exposed
represent an extremely high risk for transmission. infants from 4-6 weeks of age and should be continued until HIV
infection has been excluded by an age-appropriate HIV test to
Preferred regimens establish final diagnosis after complete cessation of breast-feeding.
LPV/r is recommended as the preferred third drug for HIV post­
- Raltegravir 400 mg twice daily plus tenofovir disoproxil exposure prophylaxis among children younger than 10 years.
fumarate/emtricitabine (300 mg-200 mg) once daily for An age-appropriate alternative regimen can be identified among
4 weeks. ATV/r, RAL, DRV, EFV and NVP.
- Dolutegravir 50 mg once daily plus tenofovir disoproxial
fumarate/emtricitabine (300 mg-200 mg) once daily for HIV and TB coinfection
4 weeks. Routine co-trimoxazole prophylaxis should be administered to all
Lamivudine may be substituted for tenofovir disoproxial HIV-infected people with active TB disease regardless of CD4 cell
fumarate/emtricitabine in either regimen. counts.

Since August 2019, dolutegravir has been considered an Source : (24)

by R△J
40b EPIDEMIOLOGY OF COMMUNICABLE DISEASES

HIV and Tuberculosis 3. WHO (2008), Priority Interventions, HIV/AIDS Prevention Treatment
and Care in the Health Sector, August 2008, WHO HIV/AIDS
Despite being preventable and curable, TB is the leading Department.
cause of HIV-associated mortality. Xpert MTB/RIF should be 4. WHO (2015), From MDGs (Millennium Development Goals) to SDGs
used rather than conventional microscopy, culture and drug (Sustainable Development Goals).
susceptibility testing (DST) as the initial diagnostic test in 5. U.S. Global Health Policy (2012), The Global HIV/AIDS Epidemic,
adults and children suspected of having HIV-associated TB or Fact Sheet, July 2012.
multidrug resistant TB. Isoniazid preventive therapy and ART, 6. WHO (2016), World Health Statistics, 2016.
given together, can reduce the risk of TB among people living 7. UNAIDS (2014), Fast-Track . Ending the AIDS Epidemic by 2030, Nov.
18,2014.
with HIV by upto 97 per cent. For details, refer to page 235. 8. WHO (2004), The World Health Report 2004, Changing History.
9. i NACO/ICMR (2022), India HIV estimates 2021, Fact Sheet, Ministry of
Monitoring the efficacy of ART Health and Family Welfare, New Delhi.
Efficacy is monitored by (20) 10. UNAIDS (2018), Country Fact Sheet, HIV/AIDS in India, 2018.
11. Govt, of India (2022), Annual Report 2021-2022, Ministry of Health
(a) clinical improvement and Family Welfare, New Delhi.
- gain in body weight, 12. WHO (1994), AIDS, Images of the Epidemics.
- decrease in occurrence and severity of HIV-related 13. Population Reports (1986). AIDS : A Public Health Crisis, Sr. L, No.6,
July-Aug 1986. The John Hopkins University, Baltimore, Maryland,
diseases (infections and malignancies), USA.
(b) increase in total lymphocyte count, 14. Internet website :www.naco.nic.in/vsnaco/indiascene/update.
(c) improvement in biological markers of HIV (when 15. WHO (1985). WHO Chronicle 39 (6) 207-211.
available) 16. British Medical Journal, 1992,304:809-813.
- CD4 + T-lymphocyte counts, 17. WHO (1986). Guidelines on AIDS in Europe, WHO, Copenhagen .
- plasma HIV RNA levels. 18. P.N. Sehgal Health For The Millions Aug. 91 P-1, 8, 26.
19. Lawrence M. Tierney et al. (2014), Current Medical Diagnosis and
Treatment, 47th Ed., 2014, A Lange Medical Publication.
3. Specific prophylaxis 20. WHO (1994), Weekly Epidemiological Record, No.37,16 Sept., 1994.
Until more effective antiviral therapy becomes available, 21. WHO (2004), TB / HIV, A Clinical Manual, 2nd Ed., Stop TB
the main aim of existing therapies will be to treat the Department, Department of HIV / AIDS & Department of Child and
manifestations of AIDS. Primary prophylaxis against Adolescent Health and Development.

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P carinii pneumonia should be offered to patients with CD4 22. WHO (2010), Antiretroviral Therapy for HIV infection in Adults and
count below 200 cells/jxL. The regimens available are Adolescents, 2010 Revision, Recommendations for a Public Health
Approach.
trimethoprim - sulfamethoxazole, aerosolized pentamidine 23. Govt, of India (2022), National Guidelines for HIV care and Treatment
and dapsone. Patients who develop P. carinii infection on a 2021, NACO, Ministry of Health and Family Welfare, New Delhi.
particular prophylactic regimen should be switched to the 24. WHO (2016), Consolidated Guidelines on the use of Antiretroviral
other drug or should receive a combination regimen. Drugs for Treating and Preventing HIV Infection, Recommendation for
a Public Health Approach, 2nd Edition, 2016.
M. avium complex occurs in at least one-third of AIDS
25. Medscape (2022), HIV Postexposure prophylaxis occupational, June
patients. Rifabutin has been shown in a randomized trial to 27,2022.
decrease the incidence of disseminated Mavium-
intracellulare in persons with less than 200 CD4 cell/pL.
Clinicians should make certain that patients do not have
EMERGING AND RE-EMERGING
active M. tuberculosis infection before starting Rifabutin. INFECTIOUS DISEASES
Prophylaxis against M. tuberculosis is 300 mg isoniazid daily Today the world stands on the threshold of a new era in
for 9 months to one year. It should be given to all which hundreds of millions of people will be safe from some
HIV-infected patients with positive PPD reactions (defined of the most terrible diseases. Soon poliomyelitis, neonatal
for HIV-infected patients as more than 5 mm in induration). tetanus, guineaworm disease, river blindness, Chagas’
Kaposi’s sarcoma might be treated in some stage with disease will join smallpox as diseases of the past. On the
interferon, chemotherapy or radiation. Cytomegalovirus other hand, the world also stands on the brink of a global
retinitis can be controlled by ganciclovir, cryptococcal crisis in infectious diseases. No country is safe from them and
meningitis with fluconazole. Esophageal candidiasis or no country can afford to ignore their threat any longer. The
recurrent vaginal candidiasis can be treated by fluconazole optimism of a relatively few years ago that many of these
or ketoconazole. Herpes simplex infection and herpes zoster diseases could easily be brought under control has led to a
can be treated with acyclovir or foscamet. tragic complacency among the international community.
4. Primary health care This complacency is now costing millions of lives.(Today the
infectious diseases are not only a health issue; they Tiave
Because of its wide-ranging health implications, AIDS become a social problem with tremendous consequences for
touches all aspects of primary health care, including mother the well-being of the individual and the world we live in.
and child health, family planning and education. It is
important, therefore, that AIDS control programmes are not (3ome infectious diseases once thought to be all but
developed in isolation. Integration into country’s primary conquered, have returned with a vengeancej Others have
health care system is essential. developed stubborn resistance to antibiotic drugs. New and
previously unknown diseases continue to emerge (Table 1).
National AIDS Control Programme Together, these trends amount to a crisis for today and a
Refer to chapter 7 for details. challenge for the future.
The factors responsible for emergence and re-emergence
References of infectious diseases are : (1) unplanned and under-
1. WHO (1986). Techn. Rep. Ser., 736. planned urbanization; (2) overcrowding and rapid
2. UNAIDS (2022), Fact Sheet, Global HIV statistics, 2022. population growth; (3) poor sanitation; (4) inadequate

by R△J
 EMERGING AND RE-EMERGING INFECTIOUS DISEASES

public health infrastructure; (5) resistance to antibiotics; contact with the blood, organs^body secretions or other
(6l"increased exposure of humans fojliseas.e vectors and body fluids of infected animals like chimpanzees, gorillas,
reservoirs of infection in nature; (7) rapid and intense monke s fruit bats etc. 1 iuman to ■ uman transmission is
international travel; and (8) microbial genetic mutation. through blood or body fluids of an infected symptomatic
person or through exposure to objects (such as needles) that
Emerging diseases have been contaminated with infected secretions). It is not
During the past 30 years, at least 30 new dis.eases have transmitted through air. water or food. The illness is
emerged to threaten the health of hundreds of millions of characterized by sudden onset_of fever, intense weakness,
people. For many of these diseases there is no treatment, muscle . ain, headache sore throat, vomiting, diarrhoea,
cure or vaccine and the possibility of preventing or rash, impaired kidney and liver functions and in some cases
controlling them is limited. Both internal and external Heedingx Currently there is no
Emerging infectious diseases are those whose incidence specific treatment for this disease. However, by intensive
in humans has increasgd during the last two decades or supportive care, the mortality can be reduced and spread of
which threaten to increase in the near future^The term also the disease can be prevented by instituting specific infection
control measures. There is no vaccine against ebola (3).
refers to"newly-appearing^infectious diseases, or diseases
that are spreading to new geographical areas - such as The United States has seen the emergence of hantavirus
cholera in South America and yellow fever in Kenya^ pulmonary syndrome, characterized by respiratory failure
The diseases in question involve all the major modes of an : a case fatalit. rate of over 50%. Since it was first
transmission - they are spread either from person to person, recognizedTn 1993, this type of hantavirus infection has been
by insects or animals, or through contaminated water or detected in more than 20 states in that country, and has also
food. The most dramatic example of a new disease is surfaced in Argentina and Brazil. This hantavirus is carried by
rodents, particularly deer mice. ’Other hantaviruses have
COVIIXl? in the year 2O19._ The ongoing COVID-19
pandemic has changed the whole world with virtual global been recognized for many years in Asia, where they cause
lockdown, social distancing and use of mask as the only haemorrhagic fever with renal involvement in humans.
weapon against the uncontrolled spread of the disease kFirst (Epidemics of foodborne and waterborne diseases due to
case of COVID-19 was reported in the month of November, new organisms such as crvptosporidium or new strains of
2019_and on 11th March, 2020, it was declared a pandemic bac eria such as Escherichia coli have hit industrialized
by the WHO. As of 20th Sept., 2022 about 618,141,427 ancT^developing countries alike. The O157:H7 strain of

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cases with 6,533,467 deaths were reported worldwide. E.coli was first reported in 1982 and has since then been
Although, now vaccines are available against COVID-19, the implicated in many serious outbreaks of diarrhoeal illness,
disease is yet to come under control. New strains of the virus sometimes leading to kidney failure. The strain has been
are also now in circulation (1). linked to undercooked hamburger beef and unpasteurized
[Human Monkey pox, in May 2022 multiple cases of milk. A completely new strain oEcholera, 0139, appeared in
monkey pox were reported from several non-endemic south-eastern India in 1992 and has since spread north and
countries. Studies are currently underway to further west to other areas of India, into western China, Thailand
understand the epidemiology, source of infection and and other parts of South-East Asia.
transmission patterns of the disease. (ihe threat of a new global influenza pandemic is
(Tomato fever (tomatoflu), a virus infection has increasing. Major shifts in the make-up of influenza viruses
emerged in India in the state of Kerala in children younger occur every 20 years or so, triggering large epidemics in many
than 5_y_ears of age. It was first Identified in Kollam district parts of the world, and causing many thousands of deaths. The
on May 6, 2022. Till date, this infection has been seen in the next such shift is expected to take place very soon. Epidemic
state of Odisha and Tamil Nadu along with Kerala.KJomato strains of influenza viruses originate from China. The influenza
fever is so called because of the eruptions of.red and painful virus is carried by ducks, chickens and pigs raised in close
blisters throughout the body. In the year 2007 also cases of proximity to one another on farms. QTie exchange of genetic
tomato fever were reported in the state of Kerala. material between these viruses produces new strains; leading
to e idemics of human influenza, each epidemic beiny due to
(AIDS. caused by the human immunodeficiency virus a different strain. Currently avian H5N1 is the strain with
(HIV). The existence of the virus was unknown until 1983. pandemic potential, since it might adapt into a strain that is
About 38.4 million people are living with HIV globally in contagious among humans. Since 1997, 478 cases with 286
2021. 1.5 million cases with 650,000 deaths were reported deaths have been reported to WHO. The first case was from
worldwide in 2021 (2). Hong Kong. Other countries involved are Cambodia,
A new breed of deadly haemorrhagic fevers, of which Indonesia, Thailand and Viet Nam (6). In late 2002, a new
lEbola virus disease (previously known as Ebola disease called SARS was reported from China with rapid
haemorrhagic fever) is the most notorious, has struck in spread to Hong Kong, Singapore, Viet Nam, Taiwan, and
Africa. Ebola appeared for the first time in Zaire and Sudan Toronto. During 2003, 8,422 SARS cases were reported from
in 1976. Since then it has appeared periodically .(Ebola virus 30 countries witK~916 fatalities (7). More recently, pandemic
is a member of Filoviridae family and comprises of 5 distinct due to influenza A (H1N1) 2009 strain is continuing worldwide
species - Zaire ebolavirus; Reston ebolavirus; $udan involving 214 countries, already taking 18,156 lives. (New
ebolavirus: Tai ebolavirus; and Bundibugyo ebplavirus. strains suchasthose of cholera and influenza do not follow the
The recent epidemic smarted in December 2013 in usual pattern of being more common in younger people. They
Guinea and spread to South Africa. By 8th April 2015, affect all age groups. since older people have not acquired
a total of 25,515 cases have been reported with over immunity to them from previous infection.
10,000 deaths. ICase fatality rate _may£ be as high as Table 1 summarizes the aetiological agents and infectious
70 per cent. Ebola has inc r m Lion period o - ays, and diseases in humans and/or animals recognized since 1973.
is not infective during this period. Asymptomatic cases are The year may differ from first appearance and first
also not infective. The virus is transmitted through direct identification of cases.
by R△J
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

TABLE 1
New infectious diseases recognized since 1973

Year Agent Type Disease/Comments

1973 Rotavirus Virus Major cause of infantile diarrhoea worldwide
1975 Parvovirus Bl9 Virus Aplastic crisis in chronic haemolytic anaemia
1976 Cryptosporidium parvum Parasite Acute and chronic diarrhoea
1977 Ebola virus Virus Ebola haemorrhagic fever
1977 Legionella pneumophila Bacterium Legionnaires’ disease
1977 Hantaan virus Virus Haemorrhagic fever with renal syndrome (HRFS)
1977 Campylobacter jejuni Bacterium Enteric pathogen distributed globally
1980 Human T-lymphotropic virus 1 (HTLV-1) Virus T-cell lymphoma-leukaemia
1981 Toxin-producing strains of Staphylococcus aureus Bacterium Toxic shock syndrome
1982 Escherichia coli 0157:H7 Bacterium Haemorrhagic colitis; haemolytic uraemic syndrome
1982 Borrelia burgdorferi Bacterium Lyme disease
1982 HTLV-2 Virus Hairy cell leukaemia
1983 Human immunodeficiency virus (HIV) Virus Acquired immunodeficiency syndrome (AIDS)
1983 Helicobacter pylori Bacterium Peptic ulcer disease
1985 Enterocytozoon bieneusi Parasite Persistent diarrhoea
1986 Cyclospara cayetanensis Parasite Persistent diarrhoea
1986 BSE agent Non-conventional agent Bovine spongiform encephalopathy in cattle
(Mad cow disease)
1988 Human herpes virus 6 (HHV-6) Virus Exanthem subitum
1988 Hepatitis E virus Virus Enterically transmitted non-A, non-B hepatitis
1989 Ehrlichia chaffeensis Bacterium Human ehrlichiosis
1989 Hepatitis C virus Virus Parenterally transmitted non-A, non-B liver hepatitis
1991 Guanarito virus Virus Venezuelan haemorrhagic fever
1991 Encephalitozoon hellem Parasite Conjunctivitis, disseminated disease

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1991 New species of Babesia Parasite Atypical babesiosis
1992 Vibrio cholerae 0139 Bacterium New strain associated with epidemic cholera
1992 Bartonella henselae Bacterium Cat-scratch disease; bacillary angiomatosis
1993 Sin Nambre virus Virus Hantavirus pulmonary syndrome
1993 Encephalitozoon cuniculi Parasite Disseminated disease
1994 Sabia virus Virus Brazilian haemorrhagic fever
1995 Human herpes virus 8 Virus Associated with Kaposi’s sarcoma in AIDS patients
1996 nvCJD Australian bat lyssavirus Virus -
1997 H5N1 Virus Avian flu (Bird flu)
1999 Nipah virus Virus -
2003 Corona virus Virus SARS
2009 H1N1 Virus Pandemic A (H1N1) 2009 influenza
2019 Corona virus Virus COVID-19 (SARS-CoV-2)

Source : (4, 5)

Re-emerging diseases their birthplace, many today go up to 1,000 times further,

travelling the whole world.
The term re-emerging diseases refers to the diseases
which were previously easily controlled_Jxy chemotherapy The practices of modern medicine also contribute. The
an : antibiotics, but now the . have developed antimicrobial spread of viral hepatitis is related in part to techniques such
resistance and are often appearing in epidemic form} as idney dialysis and multiple blood transfusions, as well as
to otherTorms of transmission. Relaxation in immunization
The emergence of drug-resistant strains of practices can quickly result in the resurgence of diseases, as,
microorganisms or parasites is promoted by treatments that for example, the recent spread of diphtheria in the Russian
do not result in cure. The increasing use of antimicrobials Federation and other former republics of the USSR.
worldwide, often in subtherapeutic doses and sometimes in
counterfeit form, indicates that this problem will increase in (jMew animal diseases pose potential foodborne risks to
the foreseeable future. Changes in lifestyle, behaviour human health that are sometimes difficult to evaluate or
(inclu- !ing injecting and non-injecting drug use) and cultural predict. An example that has caused much public concern in
or social values are behind the emergence of some infectious Europe is bovine spongiform encephalopathy, (“mad cow
diseases such as syphilis. Increases in the_number of sexual disease!). Fears have grown that the infectious_agent
partners have been the main factor in the spread of HIV responsible may be passed through the food chain to_cause
infection and other sexually transmitterF diseases. Travel, a variant of the incurable Creutzfeldt-Jakob disease in
including tourism, also plays a role. The spread of syphilis in humans, in which the brain is attacked. The British beef
the 18th and 19th centuries was related to the movement of market has been seriously affected and stringent public
armies. IJoday, the introduction of HIV in many parts of the health safeguards have been introduced—1
world is due to great!, increased human mobility. Studies The reasons for outbreaks of new diseases, or sharp
show that whereas only a few generations ago most people increases in those once believed to be under control, are
in their lifetime travelled no further than 40 kilometres from complex and still not fully understood. The fact is however,
by R△J
 EMERGING AND RE-EMERGING INFECTIOUS DISEASES
------------------------------------------------ ----------------------- ■■
that national health has become an international challenge. arsenal of antimalarial drugs is limited. Most of them act by
An outbreak anywhere must now be seen as a threat to killing parasites when they are multiplying in the blood
virtually'all countries, especially those that serve as major stream of the human host. Unfortunately, due to inadequatp
hubs of international travel. Despite the emergence of new regimens, poor drug supply, and poor quality and misuse of
diseases in the last 30 years, there is still a lack of national drugsTrapid development of drug resistance has occurredTn
and international political will and resources to develop and most areas_of the world. Drug resistance is particularly
support the systems that are necessary to detect them and important in falciparum malaria, the most severe form of the
stop their spread. Without doubt diseases as yet unknown, disease. Resistance to chloroquine, the most commonly used
but with the potential to be the AIDS of tomorrow, lurk in drug,"has been found in all endemic countries except those
the shadows. of Central America and the Caribbean. .^Resistance to
multiple drugsds common in South-East Asia. This serious
Antimicrobial resistance obstacle to malaria control efforts is further complicated by
(^Resistance by disease-causin^organisms to antimicrobial mosquito resistance to insecticides. Many mosquitoes are
drugs and other agents is a major public health problem repbrteJTo be resistant to the three classes of insecticides
worldwide? It is making a growing number of infections available for public health use, and some are becoming
virtually untreatable, both in hospitals and in the general resistant to pyrethroids, widely promoted for bed-net and
community. It is having a deadly impact on the control of curtain impregnation..
diseases such as tuberculosis, malaria, cholera, dysentery (Enterococci contribute to some of the most common
and pneumonia.____ J infections acquired in hospitals, causing intra-abdominal
Antimicrobial resistance is not a new problem, but it has abscesses, endocarditis, and infections of the urinary tract
worsened dramatically in the last decade. During that time, arid soft tissues. In some countries, infections resulting from
the pace of development of new antimicrobials has slowed strains resistant to the main groups of antibiotics, such as the
down while the prevalence of resistance has grown at an beta-lactams and the aminoglycosides, can only be treated
alarming rate. The increase in the number of drug-resistant with vancomycin, an expensive intravenous drug. (JSven
bacteria is no longer matched by a parallel expansion in the resistance to vancomycin has developed in the last 10 years
arsenal of agents used to treat infections. There is strong or so. Staphylococci, which can contribute to skin infections,
evidence that a major cause of the current crisis^ in endocarditis, osteomyelitis, food poisoning and other
antimicrobial resistance is the uncontrolled and serious disorders, have developed resistance to all

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inappropriate use of antibiotic drugs, in both industrialize? antibiotics except vancomycin. Ilf vancomycin-resistant
and developing countries. They are used by too many people strains were to emerge, some of the most prevalent hospital-
to treat tHe wrong kind of infection, in the wrong dosage and acquired infections would become virtually untreatable^
for the wrong period of time. The implications are awesome : (Streptococci have become increasingly resistant to some
drugs that cost tens of millions of dollars to produce, and take antibiotics. They are among the most common disease­
perhaps 10 years to_reach the market^liave only a limited life causing bacteria, responsible for infections of the throat,
span in which they are effective. As resistance spreads, the life middle ear, skin and wounds, and also necrotizing fasciitis
spanks hr in ksl"as Fewer new drugs appear, the gulf widens and gangrene. Pneumococci and Haemophilus influenzae
between infection and control. So farjhe pattern of excessive are the "most common bacteria causing acute respiratory
or inappropriate use and the development of resistance has infections in children, particularly pneumonia. Both of these
been repeated after the introduction _of each new organisms are becoming more and more resistant to drugs.
antimicrobial/The over-use of expensive drugs designed-to Strains of pneumococci, once uniformly susceptible to
cover a range of infectionsis ^particularly serious problem in penicillin, are currently resistant to it in up to 18% of cases
industrialized countries.\Indevelopingcountries, the problem in the United States and, 40% in South Africa. In addition,
is compounded by the ready availability of over-the-counter they are becoming resistant to many other commonly used
drugs. This allows patients to treat themselves, either with the antibiotics, including cotrimoxazole, the drug recommended
wrong medicine, or in quantities that are too small to be by WHO for treatment of pneumonia. iThe most virulent
effective. Sub-standard and counterfeit drugs which lack type of Haemophilus influenzae is today frequently resistant
adequate amounts of active inqredients~furtKef“exacerbate to ampicillin, and strains have been identified that are
the resistance problem. resistant to other drugs, including cotrimoxazole. In brief,
doctors worldwide are losing some of the most useful and
The examples of bacterial resistance are as affordable antibiotics against the two bacteria which are the
follows : major cause of death in children.
Strains of M.tuberculosis resistant to anti-tuberculosis Citeisseria gonorrhoeae, cause of one of the most common
drugs are widespread, although attention has recently sexually transmitted diseases, has acquired such resistance
focused on the alarming outbreaks of tuberculosis caused by to penicillin and tetracyclines in most countries that the use
multidrug-resistant strains in the United States. IDrug of these antibiotics to treat it has become unacceptable and
resistance is the result of poor prescribing practices, or poor this infection now requires the use of much more expensive
patient compliance with treatment. It is low in the few drugs which are often unavailable. \
countries with effective tuberculosis programmes. The most (&higella dysenteriae has been causing outbreaks of
dangerous form of the multidrug-resistant disease occurs severe diarrhoeal disease in central and southern Africa in
when cases become virtually incurable and doctors face recent years, including those in refugee camps, with the
situations similar to those of the pre-antibiotic era. • epidemic strain acquiring increasing resistance to standard
(Malaria presents a double resistance problem : resistance antibiotics, lEpidemic dysentery caused by this strain results
of the Plasmodium parasites, which cause the disease, to in the death of up to 15% of those infected. Salmonella
antimalarial drugs; and resistance of the Anopheles typhi, the bacterium responsible for typhoid fever, has
mosquitoes, the vectors of tTie disease, to insecticides. The developed resistance to antibiotics commonly used in the

by R△J
41 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

past for treatment. (Resistant strains have caused outbreaks

of the disease in India and Pakistan. Without effective HOSPITAL-ACQUIRED INFECTION
antibiotic treatment, typhoid fever kills almost 10% of those Hospital-acquired infection is cross infection of one
infected. In South-East Asia, 50% or more of the strains of patient by another or by doctors, nurses and other hospital
the bacteria may already be resistant to several antibiotics. staff, while in hospital. A high frequency of nosocomial
More than half of the antibiotics produced worldwide are infection is evidence of a poor quality of health service
used in animals, largely in subtherapeutic concentrations delivery. Many factors contribute to the frequency of
which favour the onset of drug resistance. As a result, two nosocomial infections: hospitalized patients are often
important human pathogens of animal origin, E.coli and immunocompromised, they undergo invasive examinations
salmonellae, are today highly resistant to antibiotics in both and treatments, and patient care practices and the hospital
industrialized and developing countries. For instance, in the environment may facilitate the transmission of
United Kingdom, the increase of multidrug-resistant strains microorganisms among patients. The selective pressure of
of Salmonella typhimurium isolated from cattle is paralleled intense antibiotic use promotes antibiotic resistance. While
by increasing resistance among strains of human origin. In progress in the prevention of nosocomial infections has been
Thailand, salmonellae isolated from food animals are also made, changes in medical practice continually present new
highly resistant to the common antibiotics. These bacteria opportunities for development of infection.
cause diarrhoeal disease and can lead to life-threatening Definition of nosocomial infections
complications. Due to the globalization of food supply and
international travel, antimicrobial resistance among animal Nosocomial infections, also called “hospital-acquired
bacteria can affect consumers anywhere in the world. infections”, are infections acquired during hospital care
which are not present or incubating at admission. Infections
Together, these factors have created perhaps the richest occurring more than 48 hours after admission are usually
opportunities ever for the spread of infections, many of considered nosocomial. Definitions to identify nosocomial
which become global problems that make the first line of infections have been developed for specific infection sites
defence - early recognition and adequate and timely (e.g. urinary, pulmonary).
response - essential.
Nosocomial infections may also be considered either
Responding to epidemics endemic or epidemic. Endemic infections are most common.
Epidemic infections occur during outbreaks, defined as an

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The process of response encompasses a multitude of unusual increase above the baseline of a specific infection or
activities including : diagnosis of the disease; investigation to infecting organism.
understand the source of transmission; implementation of
control strategies and programmes; research to develop Changes in health care delivery have resulted in shorter
adequate means to treat the disease and prevent its spread; hospital stays and increased outpatient care. It has been
and the production and distribution of the necessary drugs suggested that the term nosocomial infections should
encompass infections occurring in patients receiving
and vaccines.
treatment in any health care setting. Infections acquired by
The strategy for controlling re-emerging diseases is staff or visitors to the hospital or other health care setting
through available cost-effective interventions such as early may also be considered nosocomial infections.
diagnosis and prompt treatment, vector control measures
Simplified definitions may be helpful for some facilities
and the prevention of epidemics, for malaria; and DOTS- without access to full diagnostic techniques. Table 1
directly observed treatment, short-course - for tuberculosis; provides definitions for common infections that could be
by launching research initiatives for treatment regimens and used for surveys in facilities with limited access to
improved diagnostics, drugs and vaccines; and above all by sophisticated diagnostic techniques.
strengthening epidemiological surveillance and drug­
resistance surveillance mechanisms and procedures with TABLE 1
appropriate laboratory support for early detection, Simplified criteria for surveillance of nosocomial infections
confirmation and communication. Type of nosocomial Simplified criteria
The category of diseases - “new diseases - new infection
problems”- such as Ebola and other viral haemorrhagic
Surgical site infection Any purulent discharge, abscess, or
fevers, is probably the most frightening. The need, therefore, spreading cellulitis at the surgical site
is for expanding research on infectious disease agents, their during the month after the operation.
evolution, the vectors of disease spread and methods of Urinary infection Positive urine culture (1 or 2 species) with
controlling them, and vaccines and drug development. Much at least 105 bacteria/ml, with or without
of this already applies to HIV/AIDS, one of the most serious clinical symptoms.
diseases to emerge in recent decades. Respiratory infection Respiratory symptoms with at least two of
the following signs appearing during
References hospitalization :
- cough
1. Worldometer.info, COVID-19 Corona virus pandemic, 20th Sept.
2022. - purulent sputum
2. UNAIDS (2022), Fact Sheet, Global HIV Statistics, 2022. - new infiltrate on chest radiograph
consistent with infection.
3. WHO (2014), Fact Sheet on Ebola Viral Disease, No. 103, Sept. 2014.
4. WHO (1996), The World Health Report 1996. Vascular catheter Inflammation, lymphangitis or purulent
infection discharge at the insertion site of the
5. WHO (1999), Removing Obstacles to Healthy Development, WHO catheter.
Report on Infectious Diseases.
6. WHO (2005), Weekly Epidemiological Record No. 49/50, 14th Oct., Septicaemia Fever or rigors and at least one positive
2005. blood culture.
7. WHO (2003), World Health Report 2003, Shaping the Future. Source : (1)

by R△J
 HOSPITAL-ACQUIRED INFECTION

According to a French National Prevalence Survey the 3. Recipients

distribtution of sites of nosocomial infection are as shown in
All patients in hospitals are potential recipients of cross
Fig. 1. infection. Some patients are more susceptible than others,
Hospital-acquired infection may be considered from especially those who are severely ill and those under
three angles : corticosteroid therapy. Cross infection is greater in intensive
1. Source care units, urological and geriatric wards and in special baby
care units.
2. Routes of spread; and
3. Recipients. Preventive measures
The main preventive measures are : (a) Isolation :
1. Sources Infectious patients must be isolated. Patients who are
The sources are patients, hospital staff and the susceptible to infection should not be placed in beds next to
environment, (a) PATIENTS : Patients suffering from patients who are a source of infection, (b) Hospital staff :
infectious diseases are potential sources of infection. These Those who are suffering from skin diseases, sore throat,
cases may be certain viral infections (measles, german common cold, ear infection, diarrhoea or dysentery and
measles, influenza, viral hepatitis); Skin infections other infectious ailments should be kept away from work
(discharging wounds, infected skin lesions, eczema, until completely cured. They should be careful about
psoriasis, boils, bed sores); respiratory infections (sore personal hygiene and in regular changes of aprons and
throat, pulmonary tuberculosis, chest infection); and outer clothing, (c) Hand-washing : The most common route
urinary tract infection (B. coli infection). All these are of infection is via the hands. When dealing with patients,
very common sources of hospital acquired infection, hand-washing must be thorough. When hand-washing with
(b) STAFF: The hospital staff (viz doctors, nurses, ward soap and water is not sufficient, a suitable alcohol-based
boys) who come in close contact with patients may often be disinfectant must be employed for hand-washing. In the year
an important source of cross infection. For example, 2009, WHO developed guidelines for hand hygiene known
staphylococcus aureus is commonly carried in the nose or as “Clean Care is Safer Care”. It should be followed to
on the skin. Haemolytic streptococci may be carried in the improve the standards of hand hygiene practices (2).
throat and salmonella in the gut. (c) ENVIRONMENT : The (d) Dust control : Hospital dust contains numerous bacteria

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hospital environment (viz. hospital dust, linen, bed clothes, and viruses. The dust is released during sweeping, dusting
furniture, sinks, basins, door handles and even the air) is and bed making. Suppression of dust by wet dusting and
laden with microorganisms, and is thus an important source vacuum cleaning are important control measures.
of infection. (e) Disinfection : The articles used by the patient as well as
patient’s urine, faeces, sputum should be properly
2. Routes of spread disinfected. Proper sterilization of instruments should be
enforced, (f) Control of droplet infection : Use of face masks,
The common routes of spread of cross infection are : proper bed spacing, prevention of overcrowding and
(a) Direct contact, i.e. the organism may be transferred ensuring adequate lighting and ventilation are important
directly from the hands of a nurse or doctor to a susceptible control measures, (g) Nursing techniques : Barrier nursing
patient; (b) Droplet infection, e.g. droplets released from and task nursing have also been recommended to minimize
nose and throat through coughing or sneezing; (c) Air-borne cross infection, (h) Administrative measures : There should
particles ; (d) Release of hospital dust into the air; be a hospital “Control of Infection Committee” to formulate
(e) Through various hospital procedures, viz, policies regarding admission of infectious cases, isolation
catheterization, intravenous procedures, infected cat gut, facilities, disinfection procedures, and in fact all matters
dressings, sputum cups, bed pans, urinals etc. relating to control of hospital acquired infection.
The four most common nosocomial infections are urinary
tract infections, surgical wound infections, pneumonia, and
Surgical Lower respiratory
site S primary bloodstream infection. Each of these is associated
tract R1
Skin and soft with an invasive medical device or invasive procedure.
tissue SST Specific policies and practices to minimize these infections
Respiratory must be established, reviewed and updated regularly, and
tract (other) compliance monitored, as shown in Table 2.
R2
Bacteraemia Urinary tract Standard (routine) precautions
B U Standard precautions should be applied to the care of all
patients. This includes limiting health care worker contact
ENT/Eye with all secretions or biological fluids; skin lesions, mucous
E/E membranes, and blood or body fluids. Health care workers
Other Sites 0 must wear gloves for each contact which may lead to
contamination, and also gown, mask and eye protection
Catheter site C
where contamination of clothes or the face is anticipated.
Considerations for protective clothing include :
FIG. 1
Sites of the most common nosocomial infections
- gown: should be of washable material, buttoned or tied
at the back and protected, if necessary, by a plastic
Source : (1) apron

by R△J
412 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

TABLE 2
Measures for prevention of infection
Infection Proven effective Proven not effective
Urinary tract infections Limit duration of catheter Systemic antibiotic prophylaxis
Aseptic technique at insertion Bladder irrigation or instillation of normal saline
Maintain closed drainage antiseptic or antibiotic
Antiseptic added to drainage bag
Antimicrobial-coated catheter
Daily antiseptic perineal cleaning.
Surgical site infections Surgical technique Fumigation
Clean operating environment Preoperative shaving
Staff attire
Limiting preoperative hospital stay
Preoperative shower and local skin
preparation of patient
Optimal antibiotic prophylaxis
Aseptic practice in operating room
Surgical wound surveillance.
Pneumonia Ventilator-associated Digestive decontamination for all patients-
Aseptic intubation and suctioning Changes of ventilator circuit every 48 or 72 hours
Limit duration
Non-invasive ventilation
Others
Influenza vaccination for staff
Isolation policy
Sterile water for oxygen and aerosol therapy
Prevention of Legionella and Aspergillus
during renovations.
Vascular device infections All catheters Antimicrobial creams for skin preparation

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Closed system
Limit duration
Local skin preparation
Aseptic technique at insertion
Removal if infection suspected
Central lines
Surgical asepsis for insertion
Limitation of frequency of dressing change
Antibiotic-coated catheter for short term.

- gloves: inexpensive plastic gloves are available and Thus, a programme must be in place to prevent and manage
usually sufficient infections in hospital staff.
- mask : surgical masks made of cloth or paper may be Employee’s health should be reviewed at recruitment,
used to protect from splashes. including immunization history and previous exposure to
communicable diseases (e.g. tuberculosis) and. immune
Standard precautions for all patients are as follows : status. Some previous infections (e.g. varicella-zoster virus
- Wash hands promptly after contact with infective (VZV) may be assessed by serological tests.
material. Immunizations recommended for staff include: hepatitis A
- Use no touch technique wherever possible. and B, yearly influenza, measles, mumps, rubella, tetanus,
- Wear gloves when in contact with blood, body fluids, and diphtheria. Immunization against varicella inay be
secretions, excretions, mucous membranes and considered in specific cases. The Mantoux skin test will
contaminated items. document a previous tuberculosis infection and must be
- Wash hands immediately after removing gloves. obtained as a base-line.
- All sharps should be handled with extreme care. Specific postexposure policies must be developed, and
compliance ensured for: human immunodeficiency virus
- Clean up spills of infective material promptly. (HIV), hepatitis A virus, hepatitis B virus, hepatitis C virus,
- Ensure that patient-care equipment, supplies and linen Neisseria meningitidis, Mycobacterium tuberculosis,
contaminated with infective material is either discarded, varicella-zoster virus, hepatitis E virus, corynebacterium
or disinfected or sterilized between each patient use. diphtheriae, bordetella pertussis, and rabies.
- Ensure appropriate waste handling.
- If no washing machine is available for linen soiled with Reference
infective material, the linen can be boiled. 1. WHO(2002), Prevention of Hospital-Acquired Infections: A practical
guide, 2nd edition, Department of Communicable Disease,
Health care workers are at risk of acquiring infection Surveillance and Response.
through occupational exposure. Hospital employees can 2. WHO (2009), WHO Guidelines on Hand Hygiene in Health Care, First
also transmit infections to patients and other employees. Global Patient Safety Challenge Clean Care is Safer Care.

by R△J
 Epidemiology of
Chronic Non-communicable
Diseases and Conditions
“While there are many diseases, there is, in a sense, only one health"

hronic diseases and conditions have been variously The problem

defined. An EURO symposium in 1957 (1) gave the Chronic non-communicable diseases are assuming
following definition :
increasing importance among the adult population in both
“An impairment of bodily structure and/or function that developed and developing countries. Cardiovascular
necessitates a modification of the patient’s normal life, diseases and cancer are at present the leading causes of
and has persisted over an extended period of time”. death in developed countries. The prevalence of chronic
Another EURO symposium in 1965 (2) observed: disease is showing an upward trend in most countries, and
for several reasons this trend is likely to increase. For one

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“Upto now no widely acceptable definition (of acute
reason, life expectancy is increasing in most countries and a
or chronic patients) has been found. Some authors
greater number of people are living to older ages, and are at
maintain that an acute illness usually consists of a
simple episode of fairly short duration from which the greater risk to chronic diseases of various kinds. For another,
patient returns to normal activity, whereas a chronic the life-styles and behavioural patterns of people are
illness is one of long duration in which the patient is changing rapidly, these being favourable to the onset of
permanently incapacitated to a more or less marked chronic diseases. Modern medical care is now enabling
degree. There is also the view that progress in the many with chronic diseases to survive. The impact of
technology of resuscitation and haemobiology has chronic diseases on the lives of people is serious when
blurred the borderline between acute and chronic measured in terms of loss of life, disablement, family
conditions”. hardship and poverty, and economic loss to the country.
Developing countries are now warned to take appropriate
The Commission on Chronic Illness in USA (3) has steps to avoid the “epidemics” of non-communicable
defined “chronic diseases” as “comprising all impairments diseases likely to come with socio-economic and health
or deviations from normal, which have one or more of the developments.
following characteristics :
A total of 55.4 million deaths occurred worldwide during
a. are permanent 2019. Of these, 41 million were due to NCDs, principally
b. leave residual disability cardiovascular diseases, cancer and chronic respiratory
c. are caused by non-reversible pathological alteration diseases. Nearly three quarters of these NCD deaths (31.4
d. require special training of the patient for rehabilitation million about 77 per cent) occurred in low-and middle­
e. may be expected to require a long period of supervision, income countries. The number of NCD deaths has increased
observation or care.” worldwide and in every region since year 2000, when there
In short, there is no international definition of what were 31 million NCD deaths. The leading cause of NCD
duration should be considered long-term (4), although many death in 2019 were: cardiovascular diseases (17.9 million
consider that chronic conditions are generally those, that deaths or 44 per cent of NCD deaths), cancers (9.3 million
have had a duration of at least 3 months (5). A practical or 16 per cent of NCD deaths), respiratory disease, including
definition should be established which will suit the particular asthma and chronic obstructive pulmonary disease (4.1
conditions of the community (4). million or 9 per cent of NCD deaths), and diabetes (2.0
million or 4 per cent of NCD deaths) (6). In 2016, the age
Non-communicable diseases (NCDs) include standardized NCD death rate was 539 per 100,000
cardiovascular, renal, nervous and mental diseases, musculo­ population globally. The rate was lowest in high-income
skeletal conditions such as arthritis and allied diseases, countries (397 per 100,000) and highest in low-income
chronic non-specific respiratory diseases (e.g., chronic countries (625 per 100,000) and lower-middle income
bronchitis, emphysema, asthma), permanent results of countries (673 per 100,000) (7). Approximately 17 million
accidents, senility, blindness, cancer, diabetes, obesity and
of the deaths were before the age of 70 years (6).
various other metabolic and degenerative diseases and
chronic results of communicable diseases. Disorders of India is experiencing a rapid health transition with a
unknown cause and progressive course are often labelled rising burden of NCDs causing significant morbidity and
“degenerative”. mortality, both in urban and rural population, with
by R△J
 NON-COMMUNICABLE DISEASES
414
considerable loss in potentially productive years (age 35—64 neonatal disorders is being reduced, it remains high. At the
years) of life. NCDs are estimated to account for about same time, the contribution to health loss of non-
63 per cent of all deaths. India shares more than two-thirds communicable conditions such as heart disease, stroke and
of the total deaths due to NCDs in the SEAR of WHO. Four diabetes is rising. The precise nature of this challenge varies
types of NCDs - cardiovascular diseases, cancer, chronic across the country. While all states have experienced a
respiratory diseases and diabetes make the largest change in disease patterns to some degree,, clear differences
contribution to morbidity and mortality due to NCDs. Four emerge both in terms of the extent of this change and the
behavioural risk factors are responsible for significant rate at which it has occurred (10).
proportions of these diseases - tobacco use, unhealthy diet,
Non-communicable disease risk factors (7)
physical inactivity and harmful use of alcohol. Major
metabolic risk factors are obesity, raised blood pressure, Most epidemiologists accept that a setsrof “risk factors”
raised blood glucose and raised total cholesterol levels (8). are responsible for a major share of adult non-
The probability of dying between ages 30 and 70 years from communicable disease morbidity and premature mortality. A
four major NCDs is 23 per cent (27 per cent in men and large percentage of NCDs are preventable through the
20 per cent in women), which means that a 30 year old changes in these factors. The influences of these risk factors
individual has a one-fourth chance of dying from these and other underlying metabolic/physiological causes, on the
diseases before the age of 70 years (8). Fig. 1 shows the non-communicable disease epidemic include (7) :
proportional mortality in the country. Tobacco: Almost 8 million people die from tobacco use each
Other year, both from direct tobacco use and second-hand smoke.
NCDs 13% About 600,000 deaths are caused by second hand smoke, of
Communicable, Diabetes these 170,000 are children. In 2016, there were 1.1 billion
maternal, 3% smokers worldwide with over 80% every day smokers (11). By
perinatal and 2020, this number will increase to 7.5 million, accounting for
nutritional 10% of all deaths. Smoking is estimated to cause about 71% of
conditions Chronic
respiratory lung cancer, 42% of chronic respiratory disease and nearly
diseases 10% of cardiovascular disease. The highest incidence of
11% smoking among men is in lower-middle-income countries; for

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total population, smoking prevalence is highest among upper­
Injuries Cancers middle-income countries.
11% 9%
Insufficient physical activity : WHO defines physical
activity as any bodily movement produced by skeletal
muscles that requires energy expenditure. Physical activity
CVD refers to all movement including during leisure time, for
27%
transport to get to and from places, or as part of a person’s
FIG. 1
work. Both moderate - and vigorous-intensity physical
Proportional mortality in India (% of total deaths, all ages) 2016 activity improve health. Physical activity has significant
Total deaths 9,569,000 health benefits for heart, body and mind; it contributes to
Source : (9) preventing and managing noncommunicable diseases such
as cardiovascular diseases, cancer and diabetes; it reduces
Epidemiological transition ratio (10) symptoms of depression and anxiety; it enhances thinking,
Epidemiological transition ratio is defined as the ratio of learning, and judgment skills; it ensures healthy growth and
DALYs caused by CMNNDs (Communicable, Maternal, development in young people; it improves overall well-being.
Neonatal and Nutritional Diseases) to those caused by NCDs Globally, 1 in 4 adults do not meet the global recommended
and injuries. A ratio greater than one indicates a higher burden levels of physical activity. Upto 5 million deaths a year could
of CMNNDs than NCDs and injuries, while a ratio less than one be averted if the global population was more active. People
indicates the opposite. The lower the ratio, the greater the who are insufficiently active have a 20 per cent to 30 per cent
contribution of NCDs and injuries to a state’s overall disease increased risk of death compared to people .who are
burden. Most of the states had ratios more than one in 1990, sufficiently active. More than 80 per cent of the world’s
whereas all states had ratios less than one in 2016. This means adolescent population is insufficiently physically active.
that the proportion of DALYs caused by NCDs and injuries has
People living with chronic conditions (hypertension, type
increased heavily across the country since 1990, and in 2016
2 diabetes, HIV and cancer survivors), should do at least
accounted for the majority of premature death and disability
150-300 minutes of moderate-intensity aerobic physical
for all states - a major shift in drivers of health loss.
activity or at least 75-150 minutes of vigorous-intensity
There are wide variations in the epidemiological aerobic physical activity; or an equivalent combination of
transition ratio between individual states, ranging from 0.16 moderate- and vigorous-intensity activity throughout the
in Kerala, which is far along in this progression, to 0.74 in week. They should also do muscle-strengthening activities at
Bihar, where the challenge of the double burden of diseases moderate or greater intensity that involve all major muscle
is more acute. The states with ratio 0.56-0.75 in 2016 were groups on 2 or more days a week, as these provide
considered as having the lowest epidemiological transition additional health benefits. As part of their weekly physical
level (ETL), those with ratio 0.41-0.55 as lower-middle ETL, activity, older adults should do varied multicomponent
those with ratio 0.31-0.40 as higher-middle ETL, and those physical activity that emphasizes functional balance and
with ratio 0.30 or less as highest ETL. strength training at moderate or greater intensity, on 3 or
India’s health system therefore faces a dual challenge. more days a week, to enhance functional capacity and to
Although the absolute burden from diseases such as prevent falls. They may increase moderate-intensity aerobic
diarrhoea, lower respiratory infections, tuberculosis, and physical activity to more than 300 minutes; or do more than
by R△J
 NON-COMMUNICABLE DISEASES
—415
150 minutes of vigorous-intensity aerobic physical activity; Overweight and obesity : At least 2.8 million people die
or an equivalent combination of moderate - and vigorous- each year as a result of being overweight or obese. Risks of
intensity activity throughout the week for additional health heart disease, stroke and diabetes increase steadily with
benefits. They should limit the amount of time spent being increasing body mass index (BMI). Raised BMI also increases
sedentary. Replacing sedentary time with physical activity of the risk of certain cancers. The prevalence of overweight is
any intensity (including light intensity) provides health highest in upper-middle-income countries, but very high
benefits, and to help reduce the detrimental effects of high levels are also reported from some lower-middle income
levels of sedentary behaviour on health, all adults and older countries. In the year 2016, 11% of men and 15% of women
adults should aim to do more than the recommended levels aged 18 years and above were obese. More than 42 million
of moderate - to vigorous-intensity physical activity (12). children under the age of 5 years were overweight in
Harmful use of alcohol : Approximately 3.3 million 2015 (11). Factors driving this rise include poor diet and lack
people die each year from the harmful use of alcohol, of exercise. Many children are growing up in a society which
accounting for about 5.9% of all deaths in the world and promotes high energy intake while encouraging physical
5.1 per cent DALYs were attributable to alcoholism (11). inactivity. Most of these children will become obese adults,
More than half of these deaths occur from NCDs including which makes them more susceptible to develop NCDs (11).
cancers, cardiovascular disease and liver cirrhosis. More­ Raised cholesterol : Raised cholesterol is estimated to
over there is a close relationship between drinking and cause 2.6 million deaths annually; it increases the risk of
violent crime including domestic violence. Alcohol related heart disease and stroke. Raised cholesterol is highest in
harm is determined by three related dimensions : the high-income countries.
volume of alcohol consumed, the pattern of drinking and Cancer-associated infections: At least 2 million cancer cases
quality of alcohol consumed (11). While adult per capita per year, 18% of the global cancer burden, are attributable to a
consumption is highest in high-income countries, it is nearly few specific chronic infections, and this fraction is substantially
as high in the populous upper-middle-income countries. larger in low-income countries. The principal infectious agents
Unhealthy diet : Adequate consumption of fruit and are human papillomavirus, Hepatitis B virus, Hepatitis C virus
vegetables reduces the risk for cardiovascular diseases, and Helicobacter pylori. These infections are largely
stomach cancer and colorectal cancer. Most populations preventable through vaccinations and measures to avoid
consume much higher levels of salt than recommended by transmission, or treatable. For example, transmission of

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WHO for disease prevention; high salt consumption is an Hepatitis C virus has been largely stopped among high-
important determinant of high blood pressure and income populations, but not in many low-resource countries.
cardiovascular risk. 1.8 million deaths from CVD causes have Environmental risk factors : occupational hazards, air and
been attributed to excess salt/sodium intake (6). High water pollution, and possession of destructive weapons in
consumption of saturated fats and trans-fatty acids is linked to case of injuries.
heart disease. Unhealthy diet is rising quickly in lower-resource
settings. Available data suggest that fat intake has been rising Gaps in natural history
rapidly in lower-middle-income countries since the 1980s. Fat There are many gaps in our knowledge about the natural
intake, especially saturated fat and industrially-produced history of chronic diseases. These gaps cause difficulties in
trans-fat intake, can be reduced by : (a) steaming or boiling aetiological investigations and research (14). These are
instead of frying when cooking; (b) replacing butter, lard and
ghee with oils rich in polyunsaturated fats, such as soybean, 1. Absence of a known agent
canola (rapeseed), corn, safflower and sunflower oils;
There is much to learn about the cause of chronic
(c) eating reduced-fat dairy foods and lean meats, or trimming
diseases. Whereas in some chronic diseases the cause is
visible fat from meat; and (d) limiting the consumption of
known (e.g., silica in silicosis, asbestos in mesothelioma), for
baked and fried foods, and pre-packaged snacks and foods
many chronic diseases the causative agent is not known.
(e.g. doughnuts, cakes, pies, cookies, biscuits and wafers) that
The absence of a known agent makes both diagnosis and
contain industrially-produced trans-fats.
specific prevention difficult.
In both adults and children, the intake of free sugars should
be reduced to less than 10 per cent of total energy intake. A 2. Multifactorial causation
reduction to less than 5 per cent of total energy intake would Most chronic diseases are the result of multiple causes -
provide additional health benefits. Sugar intake can be rarely is there a simple one-to-one cause-effect relationship.
reduced by : (a) limiting the consumption of foods and drinks In the absence of a known agent, the term “risk factor(s)” is
containing high amounts of sugars, such as sugary snacks, used to describe certain factors in a person’s background or
candies and sugar-sweetened beverages (i.e. all types of life-style that make, the likelihood of the chronic condition
beverages containing free sugars - these include carbonated or more probable. Further, chronic diseases appear to result
non-carbonated soft drinks, fruit or vegetable juices and from the cumulative effects of multiple risk factors. These
drinks^ liquid and powder concentrates, flavoured water, factors may be both environmental and behavioural, or
energy and sports drinks, ready-to-drink tea, ready-to-drink constitutional. Epidemiology has contributed massively in
coffee and flavoured milk drinks); and (b) eating fresh fruit the identification of risk factors of chronic diseases. Many
and raw vegetables as snacks instead of sugary snacks (13). more are yet to be identified and evaluated.
Raised blood pressure : Raised blood pressure is
3. Long latent period
estimated to cause 9.4 million deaths, about 12.8% of all
deaths. It is a major risk factor for cardiovascular disease. A further obstacle to our understanding of the natural
The prevalence of raised blood pressure is similar across all history of chronic disease is the long latent (or incubation)
income groups. During the year 2015, the global prevalence period between the first exposure to “suspected cause” and
of raised blood pressure in adults 18 year and above was the eventual development of disease (e.g., cervical cancer).
around 22 per cent (11). This makes it difficult to link suspected causes (antecedent

by R△J
41E NON-COMMUNICABLE DISEASES

events) with outcomes, e.g., the possible relation between also recommended. Protection against environmental or
oral contraceptives and the occurrence of cervical cancer. In occupational risk factors for cancer, such as aflatoxin,
an attempt to overcome this problem, a search has been asbestos and contaminants in drinking-water can be
made for precursor lesions in, for example, cancer cervix, included in effective prevention strategies.
oral cancer and gastric cancer. But this is not possible in all Present knowledge indicates that the chronically ill require
chronic diseases. However, it has now become increasingly a wide spectrum of services - case finding through screening
evident that the factors favouring the development of and health examination techniques; application of improved
chronic disease are often present early in life, preceding the methods of diagnosis, treatment and rehabilitation; control of
appearance of chronic disease by many years. Examples food, water and air pollution; reducing accidents; influencing
include hypertension, diabetes, stroke, etc. patterns of human behaviour and life-styles through intensive
education; upgrading standards of institutional care and
4. Indefinite onset
developing and applying better methods of comprehensive
Most chronic diseases are slow in onset and development, medical care including primary health care. Political
and the distinction between diseased and non-diseased approaches are also needed as in the case of smoking control,
states may be difficult to establish (e.g., diabetes and control of alcohol and drug abuse. The approach should be
hypertension). In many chronic diseases (e.g., cancer) the holistic in handling the complex medical and social needs of
underlying pathological processes are well established long the chronically ill and should always be considered in relation
before the disease manifests itself. By the time the patient to the family and community.
seeks medical advice, the damage already caused may be
irreversible or difficult to treat. Integrated approach
Prevention It is now felt that the principles of prevention of CHD can
be applied also to other major non-communicable diseases
The preventive attack on chronic diseases is based on the (NCDs) because of common risk factors. A broader concept
knowledge that they are multifactorial in causation, so their is emerging, that is, to develop an overall integrated
prevention demands a complex mix of interventions. programme for the Prevention and Control of NCDs as
Previously only tertiary prevention seemed possible to part of primary health care systems, simultaneously
prevent or delay the development of further disability or the attacking several risk factors known to be implicated in the
occurrence of premature death. But, now, with the development of non-communicable diseases. Such

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identification of risk factors, health promotion activities concerted preventive action should reduce not only
aimed at primary prevention are being increasingly applied cardiovascular diseases but also other major NCDs, with an
in the control of chronic diseases. Some of the interventions overall improvement in health and length of life (16).
that should be undertaken immediately to produce
The WHO has developed a survey methodology known as
accelerated results in terms of lives saved, disease prevented
“the STEPS Non-communicable Disease Risk Factors Survey”
and heavy cost avoided are as follows (15) :
to help countries establish NCD surveillance system. Some
1. Protecting people from tobacco smoke and banning surveys are conducted at the country level and others at the
smoking in public places, warning about the dangers subnational level. The methodology prescribes three steps -
of tobacco use, enforcing bans on tobacco advertising, questionnaire, physical measurements, and biochemical
promotion and sponsorships and raising taxes on measurements. The core topics covered by most surveys are
tobacco; demographic, health status and health behaviours. These
2. Restricting access to retailed alcohol, enforcing bans provide data on socio-economic risk factors and metabolic,
on alcohol advertising and raising taxes on alcohol; nutritional and lifestyle risk factors. Details may differ from
3. Reduce salt intake and salt content of food; country to country and from year to year (17).
4. Replacing trans-fat in food with polyunsaturated fat; In India, the survey was conducted from April 2003 to
and March 2005 in 6 states and again in 2007 in 7 states.
5. Promoting public awareness about diet and physical
activity, including through mass media. WHO Global Action Plan for the Prevention and
In addition, there are many other cost-effective and low- Control of NCDs (2013-2020)
cost population-wide interventions that can reduce risk The Global Action Plan provides member states with a
factors for NCDs. These include : road map and menu of policy options which, when
1. Nicotine dependence treatment; implemented collectively between 2013 and 2020, will
2. Enforcing drink-driving laws; contribute to progress on 9 global NCD targets including
3. Restrictions on marketing of foods and beverages high that of 25 per cent relative reduction in premature mortality
in salt, fats and sugar; from cardiovascular diseases, cancer, diabetes and chronic
4. Food taxes and subsidies to promote healthy diets; respiratory diseases by 2025. These four diseases make the
5. Healthy nutrition environments in schools; largest contribution to mortality and morbidity due to NCDs.
6. Nutrition information and counselling in health care; It will target four behavioural risk factors - tobacco use,
and unhealthy diet, physical inactivity and harmful use of
7. National physical activity guidelines (school based alcohol. The voluntary global targets are (18) :
physical activity programmes for children and 1. A 25 per cent relative reduction in risk of premature
workplace programmes for physical activity and mortality from cardiovascular diseases, cancer, diabetes
healthy diets). and chronic respiratory disease;
There also are population-wide interventions that focus 2. At least 10 per cent relative reduction in the harmful use
on cancer prevention, like vaccination against Hepatitis B, of alcohol as appropriate within national context;
a major cause of liver cancer. Vaccination against human 3. A 10 per cent relative reduction in prevalence of
papillomavirus (HPV), the main cause of cervical cancer, is insufficient physical activity;
by R△J
 CARDIOVASCULAR DISEASES 417
4. A 10 per cent relative reduction in mean population
intake of salt/sodium; CARDIOVASCULAR DISEASES
5. A 30 per cent relative reduction in prevalence of current Cardiovascular diseases (CVD) comprise of a group of
tobacco use in persons aged 15+ years; diseases of the heart and the vascular system. The major
6. A 25 per cent relative reduction in prevalence of raised conditions are ischaemic heart disease (IHD), hypertension,
blood pressure; cerebrovascular disease (stroke) and congenital heart
7. Halt the rise of diabetes and obesity; disease. Rheumatic heart disease (RHD) continues to be an
8. At least 50 per cent of eligible people receive drug important health problem in many developing countries.
therapy and counselling (including glycaemic control) to
prevent heart attacks and strokes; and Problem statement
9. An 80 per cent availability of the affordable basic
technology and essential medicines including generics,
WORLD
required to treat major NCDs in both public and private CVDs are the number one cause of death globally, more
facilities. people die annually from CVD than any other cause. An
estimated 17.9 million people died from CVD in 2019,
2030 Agenda for Sustainable Development representing 32 per cent of all global deaths. Of these global
The Sustainable Development Goals include a specific deaths, an estimated 7.4 million were due to coronary heart
target for NCDs and several NCD - related targets. Target 3.4 disease and 6.7 million were due to stroke (1). At least
calls for a one third reduction in premature mortality from 82 per cent of the world’s deaths from CVDs occur in low
NCDs by year 2030 and is an extension of the global NCD and middle-income countries, where people do not have the
mortality target. For further details, please refer to chapter 14. benefit of integrated primary health care programmes for
early detection and treatment of risk factors compared to
References people in high-income countries. As a result, many cases in
1. Amsterdam (1956), Report on a Symposium, The Public Health these countries are detected late in the course of the disease
Aspects of Chronic Diseases. EURO 111.1, p. 9 WHO. Copenhagen. and die younger from CVDs and other NCDs, often in their
2. Hogarth, J. (1978) Glossary of Health Care Terminology. WHO, most productive years. The poorest people are affected
Copenhagen. most. At the household level, CVD and other NCDs

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3. Commission on Chronic illness (1956) Chronic illness in the US. Vol II, contribute to poverty due to catastrophic health spending
Care of the long-term patient. Cambridge, Mass, Harvard University
Press. and high out-of-pocket expenditure (2).
4. WHO (1981). Health for All, Sr. No. 4, p. 80. The incidence of CVD is greater in urban areas than in rural
5. Wilson, R.W. and T.F. Drury (1984), Annual Review of Public Health, areas reflecting the acquisition of several risk factors such as
5: 83-106. tobacco consumption, lack of physical activity, unhealthy diet
6. WHO (2022), Fact sheet, Non-communicable diseases, 16th Sept. (today’s fast food habits) and obesity. A peculiar cause of
2022.
concern is the relative early age of CVD deaths in the
7. WHO (2014), Global Status Report on Non-communicable Diseases,
2014. developing countries. Ironically CVDs are now in decline in
8. WHO (2014), Non-communicable Diseases by Country Profile, India. the industrialized countries first associated with them. They
9. WHO (2018), Non-communicable Disease, Country Profiles 2018. seem to have crossed the peak of the epidemic by now. The
10. ICMR (2017), India : Health of the Nation’s States, The India State - decline is largely a result of the success of primary prevention
Level Disease Burden Initiative, Dec. 2017. and to a lesser extent, treatment. The middle and low-income
11. JFMJA (2018), Non-communicable Diseases and the 4 Most Common countries are at the mid-point of the emerging epidemic and
Shared risk factors, March meeting 2018 in Hurghada, Egypt. will face its full impact in the coming years. These countries
12. WHO (2020), Fact sheet, Physical Activity, 26th Nov. 2020. can be benefitted from the strategy of primary prevention.
13. WHO (2020), Fact sheet, Healthy Diet, 29th April 2020.
14. Mausner, J.S. and Kramer, K. (1985), Epidemiology-An Introductory INDIA
Text, Saunders.
15. WHO (2011), Global Status Report on Non-communicable Diseases An estimated 2.59 million people died of CVD in India
2010. during 2016, Table 1 shows the break-up of the cases and
16. WHO (1986), Techn. Rep. Ser., No. 732. crude death rate per 100,000 population as reported to WHO.
17. WHO (2011), STEPS : A Framework for Surveillance of NCD Risk Compared with all other countries, India suffers the
Factors.
18. WHO (2013), Global Action Plan for the Prevention and Control of
highest loss in potentially productive years of life, due to
NCD, 2013-2020. deaths from CVD in people aged 35-64 years. The

TABLE 1
Estimated deaths (000) and crude death rate by cause and sex (2016)

Disease
Number CDR Number CDR Number CDR

CVD 15,04,400 219.2 10,85,700 170.2 2,59,100 195.6

Rheumatic Heart Disease 41,800 6.1 55,300 8.7 97,100 7.3
Hypertension 54,100 7.9 60,500 9.5 1,14.600 8.7
Ischaemic Heart Disease 10,00,800 145.8 6,07,800 95.3 16,08,700 121.5
Stroke 3,72,000 54.2 3,34,200 52.4 7,06,200 53.3

Source : (4, 5)
by R△J
418 NON-COMMUNICABLE DISEASES

prevalence of CVD is reported to be 2-3 times higher in the Symptoms of heart attack and stroke
urban population as compared to the rural population. In one Often, there are no symptoms of the underlying disease
study, the prevalence of IHD among adults (based on clinical of the blood vessels. A heart attack or stroke may be the first
and ECG criteria) was estimated at 96.7 per 1000 population warning of underlying disease. Symptoms of a heart attack
in the urban and 27.1 per 1000 in rural areas (3). include:
The contribution of risk factors to the CVD have - pain or discomfort in the centre of the chest; and
increased massively since last couple of decades. These risk
- pain or discomfort in the arms, the left shoulder, elbows,
factors are summarized in Table 2 (4). jaw, or back.
TABLE 2 In addition, the person may experience difficulty in
Risk factors contributing to CVD, India (2016) breathing or shortness of breath; feeling sick or vomiting;
feeling light-headed or faint; breaking into a cold sweat; and
becoming pale. Women are more likely to have shortness of
breath, nausea, vomiting, and back or jaw pain.
The most common symptom of a stroke is sudden
weakness of the face, arm, or leg, most often on one side of
the body. Other symptoms include sudden onset of:
1. numbness of the face, arm, or leg, especially on one side
of the body;
2. confusion, difficulty in speaking or understanding speech;
3. ’ difficulty in seeing with one or both eyes;
4. difficulty in walking, dizziness, loss of balance or
coordination;
5. severe headache with no known cause; and
6. fainting or unconsciousness.
People experiencing these symptoms should seek medical

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care immediately.
Symptoms of rheumatic heart disease include: shortness of
breath, fatigue, irregular heart beats, chest pain and fainting.
Symptoms of rheumatic fever include: fever, pain and swelling
Source : (4, 5) of the joints, nausea, stomach cramps and vomiting.
Risk factors Interventions to reduce cardiovascular disease
The present mortality rates are the consequence of burden (3)
previous exposure to behavioural risk factors such as
inappropriate nutrition, insufficient physical activity and PRIMARY PREVENTION
increased tobacco consumption. It is called the “lag-time” The cost effective interventions that are feasible to be
effect of risk factors for CVD. Overweight, central obesity, implemented include population-wide interventions and
high blood pressure, dyslipidaemia, diabetes and low individual level interventions, which are recommended to be
cardio-respiratory fitness are among the biological factors used in combination to reduce the CVDs.
contributing principally to increased risk. The example of population- wide intervention are:
It is now well established fact that a persistently high - comprehensive tobacco control policies;
cholesterol level can almost certainly precipitate a cardiac - taxation to reduce the intake of foods that are high in fat,
event such as CHD. Still most people do not have an idea of sugar and salt;
nutritional requirements and a balanced diet. Unhealthy
- building walking and cycle paths to increase physical
dietary practices include a high consumption of saturated fats,
activity;
salt and refined carbohydrates, as well as a low consumption
of vegetables and fruits and these tend to cluster together. - strategies to reduce harmful use of alcohol; and
- providing healthy school meals to children.
Cessation of tobacco use, reduction of salt in the diet,
consuming fruits and vegetables, regular physical activity At the individual level, for prevention of first heart attacks
and avoiding harmful use of alcohol have been shown to and strokes, individual health-care interventions need to be
reduce the risk of cardiovascular disease. In addition, drug targeted to those at high total cardiovascular risk or those
treatment of diabetes, hypertension and high blood lipids with single risk factor level above traditional thresholds, such
may be necessary to reduce cardiovascular risk and prevent as hypertension and hypercholesterolemia. The former
heart attacks and strokes. Health policies that create approach is more cost-effective than the later and has the
conducive environment for making healthy choices potential to substantially reduce cardiovascular events. This
affordable and available are essential for motivating people approach is feasible in primary care in low- resource
to adopt and sustain healthy behaviour. settings, including by non-physician health workers.
There are also a number of underlying determinants of SECONDARY PREVENTION
CVDs or “the causes of the causes”. These are a reflection of
the major forces driving social, economic and cultural For secondary prevention of cardiovascular disease in
change - globalization, urbanization and population ageing. those with established disease, including diabetes, treatment
Other determinants of CVDs include poverty, stress and with the following medications are necessary:
hereditary factors. - aspirin;
by R△J
 CORONARY HEART DISEASE
419
- beta-blockers; accurate incidence of CHD rates are difficult to compute.
- angiotensin-converting enzyme inhibitors; and Mortality rates can be used as a crude indicator of incidence.
- statins. fd) Age-specific death rates : When analysis is planned to
The benefits of these interventions are largely throw light on aetiology, it is essential to study the age­
independent, but when used together with smoking cessation, specific rates. Age-specific death rates suggest a true
nearly 75% of recurrent vascular events may be prevented. increase in incidence.
Currently there are major gaps in the implementation of these (e) Prevalence rate : The prevalence of CHD can be
interventions particularly at the primary health care level. estimated from cross-sectional surveys using ECG for
In addition costly surgical operations are sometimes evidence of infarction and history of prolonged chest pain.
required to treat CVDs. They include: A useful publication to conduct such surveys is “Cardio­
vascular Survey Methods” by Rose and Blackburn (6).
- coronary artery bypass;
- balloon angioplasty (where a small balloon-like device is (f) Case fatality rate : This is defined as the proportion of
threaded through an artery to open the blockage); attacks that are fatal within 28 days of onset. The International
- valve repair and replacement; and Society and Federation of Cardiology has suggested that
- heart transplantation. “sudden deaths” be defined to include deaths “occurring
instantly or within an estimated 24 hours of the onset of acute
References symptoms or signs”. Data collected in many industrialized
1. WHO (2022), Fact Sheet, Cardiovascular Diseases, 11th June, 2022. countries indicate that 25-28 per cent of patients who suffer a
2. WHO (2016), Fact Sheet Cardiovascular Diseases, Sept. 2016. heart attack die suddenly. In about 55 per cent of all cardiac
3. WHO (2002), Health Situation in South East Asia Region 1998-2000, deaths mortality occurs within the first hour (7).
New Delhi. (g) Measurement of risk factor levels : These include
4. WHO (2018), Estimated deaths (000) by cause and sex in WHO measurement of levels of cigarette smoking, blood
Member States, 2016.
pressure, alcohol consumption and serum cholesterol in the
5. WHO (2018), Crude Death Rate per 100,000 population by cause and
sex in WHO Member States, 2016. community (8).
(h) Medical care : Measurement of levels of medical care
CORONARY HEART DISEASE in the community are also pertinent.

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Coronary heart disease (syn : ischaemic heart disease) Epidemicity
has been defined as “impairment of heart function due to “Epidemics” of CHD began at different times in different
inadequate blood flow to the heart compared to its needs, countries. In United States, epidemics began in the early
caused by obstructive changes in the coronary circulation to 1920s (9); in Britain in the 1930s (10); in several European
the heart” (1). It is the cause of 25-30 per cent of deaths in countries, still later. And now the developing countries are
most industrialized countries. The WHO has drawn attention catching up. Countries where the epidemic began earlier are
to the fact that CHD is our modern “epidemic”, i.e., a now showing a decline. For example, in United States,
disease that affects populations, not an unavoidable attribute where the epidemic began in early 1920s, a steady decline
of ageing. CHD may manifest itself in many presentations : was evident by 1968, and a 25 per cent fall in mortality (not
a. angina pectoris of effort morbidity) by 1980 (9). Substantial declines in mortality
b. myocardial infarction have also occurred in Australia, Canada and New Zealand.
c. irregularities of the heart The decline in CHD mortality in US and other countries has
d. cardiac failure been attributed to changes in life-styles and related risk factors
e. sudden death. (e.g., diet and diet-dependent serum cholesterol, cigarette use
Myocardial infarction is specific to CHD; angina pectoris and exercise habits) plus better control of hypertension (11).
and sudden death are not. Rheumatic heart disease and The reasons for the changing trends in CHD are not
cardiomyopathy are potential sources of diagnostic confusion precisely known. The WHO has completed a project known
(2). The natural history of CHD is very variable. Death may as MONICA “(multinational monitoring of trends and
occur in the first episode or after a long history of disease. determinants in cardiovascular diseases)” to elucidate this
issue. Forty-one centres in 26 countries were participating in
Measuring the burden of disease this project, which was planned to continue for a 10 year
The burden of CHD may be estimated in various ways, period ending in 1994 (12).
each illustrating a different aspect of the picture (3). When CHD emerged as the modern epidemic, it was the
(a) Proportional mortality ratio : The simplest measure is disease of the higher social classes in the most affluent
the proportional mortality ratio, i.e., the proportion of all societies. Fifty years later the situation is changing; there is a
deaths currently attributed to it. For example, CHD is held strong inverse relation between social class and CHD in
responsible for about 30 per cent of deaths in men and developed countries (13).
25 per cent of deaths in women in most western countries. To summarize, in many developed countries, CHD still
(b) Loss of life expectancy : CHD cuts short the life poses the largest public health problem. But even in those
expectancy. Calculations have been made (4) for the showing a decline, CHD is still the most frequent single
average gain in life expectation that would follow a complete cause of death among men under 65 (13).
elimination of all cardiovascular deaths if other mortality
rates remain unchanged. The benefit would range for men International variations
from 3.4 years to 9.4 years, and even greater for women. With 7.2 million deaths and 12.8 per cent of total deaths,
(c) CHD incidence rate: This is the sum of fatal and non- CHD is a worldwide disease. Mortality rates vary widely in
fatal attack rates (5). Because of its different manifestations, different parts of the world (Table 1).
by R△J
420 NON-COMMUNICABLE DISEASES

TABLE 1 1. Smoking
Mortality due to CHD, global estimates for 2016 Some people commit suicide by drowning, but many by
smoking. A uniquely human habit, smoking has been
identified as a major CHD risk factor (16, 17) with several
possible mechanisms - carbon monoxide induced
atherogenesis; nicotine stimulation of adrenergic drive
raising both blood pressure and myocardial oxygen demand;
lipid metabolism with fall in “protective” high-density
lipoproteins, etc.
It has been calculated that in countries where smoking has
been a widespread habit, it is responsible for 25 per cent of
CHD deaths under 65 years of age in men (18). Cigarettes
* 16.6 per cent of all deaths. seem to be particularly important in causing sudden death
from CHD especially in men under 50 years of age (18).
Source : (14)
The degree of risk of developing CHD is directly related to
The highest coronary mortality is seen at present in the the number of cigarettes smoked per day (20). Filter
Western Pacific Region followed by European Region. On cigarettes are probably not protective (21). There is evidence
the other hand rates in Americas and Eastern Mediterranean that the influence of smoking is not only independent of, but
countries are much lower. also synergistic with other risk factors such as hypertension
and elevated serum cholesterol (Fig. 1). This means that the
Coronary heart disease in India effects are more than additive (18).
Coronary heart disease is assuming serious dimension in The risk of death from CHD decreases on cessation of
developing countries. There is a considerable increase in smoking. The risk declines quite substantially within one
prevalence of CHD in urban areas in India during the last year of stopping smoking and more gradually thereafter
decade. Although there is increase in prevalence of CHD in until, after 10-20 years, it is the same as that of non-
rural areas also, but it is not that steep because life-style changes smokers (18). For those who have had a myocardial
have affected people in urban areas more than in rural areas. infarction, the risk of a fatal recurrence may be reduced by

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The pooled estimates from studies carried out in 1990s 50 per cent after giving up smoking (18).
upto 2002 shows the prevalent rate of CHD in urban areas
as 6.4 per cent and 2.5 per cent in rural areas. In urban
areas the pooled estimate was 6.1 per cent for males and
6.7 per cent for females. In rural areas the estimate was
2.1 per cent for males and 2.7 per cent for females (15).
According to medical certification of cause of death data,
25.1 per cent of total deaths in urban areas are attributable
to diseases of the circulatory system. Therefore, it was
assumed that mortality rates due to CHD (which forms an
important disease entity and the diseases of circulatory
system) in rural areas are expected to be half of CHD
specific mortality rates in urban areas.
It is estimated that 16,08,700 people died of CHD during
2016, of which 10,00,800 were men and 6,07,800 women.
The crude death rate was 121.5/100,000 population.

Risk factors
(16.0) (17.3) (18.7)(20.0) (21.3) (22.7)(24.0) (25.3) (26.7)
The aetiology of CHD is multifactorial. Apart from the
obvious ones such as increasing age and male sex, studies have SBP mmHg (kPa)
identified several important “risk” factors (i.e., factors that
FIG. 1
make the occurrence of the disease more probable). Some of
the risk factors are modifiable, others immutable (Table 2). The importance of risk-factor combinations, illustrated by the
six-year risk of myocardial infarction at various levels of SBP
Presence of any one of the risk factors places an individual in a
and serum cholesterol in smokers and non-smokers
high-risk category for developing CHD. The greater the
number of risk factors present, the more likely one is to develop The vertical axis gives the probability of myocardial infarction
occuring in the next 6 years per 1000 men with a given SBP.
CHD. The principal risk factors are discussed below:
Curve a : risk in the absence of smoking and elevated serum
TABLE 2 cholesterol.
Risk factors for CHD Curve b : risk in smokers.
Not modifiable Curve c : risk with elevated serum cholesterol.
Modifiable
Curve d : risk with smoking and elevated serum cholesterol.
Age Cigarette smoking
The vertical bars a-d show how the increment in the risk of
Sex High blood pressure myocardial infarction associated with a given SBP elevation
Family history Elevated serum cholesterol depends on the various “constellations” (combinations) of risk
Genetic factors Diabetes factors. The ratios of the length of the bars provide a measure of the
Personality Obesity risk due to a particular risk-factor constellation.
Sedentary habits
Stress Source : (19)

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 CORONARY HEART DISEASE 421
2. Hypertension
The blood pressure is the single most useful test for
identifying individuals at a high risk of developing CHD.
Hypertension accelerates the atherosclerotic process,
especially if hyperiipidaemia is also present and contributes
importantly to CHD. In the past, emphasis was placed on
the importance of diastolic blood pressure. Many
investigators feel that systolic blood pressure is a better
predictor of CHD than is the diastolic. However, both
components are significant risk factors. The risk role of
“mild” hypertension is generally accepted (13).

3. Serum cholesterol
It is nearly three decades since it became clear that
elevation of serum cholesterol was one of the factors which
carried an increased risk for the development of myocardial
infarction. Today, there is a vast body of evidence showing a
triangular relationship between habitual diet, blood
cholesterol-lipoprotein levels and CHD, and that these
The risk of CHD and serum cholesterol levels
relationships are judged to be causal (1). There is no
population, in which CHD is common, that does not also
have a relatively high mean level of cholesterol (i.e. greater When we look at the various types of lipoproteins, it is
than 200 mg/dl in adults). This is illustrated in Fig. 2 (1) the level of low-density lipoprotein (LDL) cholesterol that is
which shows the cultural differences in serum cholesterol most directly associated with CHD (24). While very low-
levels between two countries, Japan and Finland - Japan density lipoprotein (VLDL) has also been shown to be
having the lowest incidence and Finland the highest associated with premature atherosclerosis, it is more strongly
incidence of CHD. associated with peripheral vascular disease (e.g.,
intermittent claudication) than with CHD. High-density

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Fig. 3 shows that the risk of CHD rises steadily with the
serum cholesterol concentration (22). The 14-years lipoprotein (HDL) cholesterol is protective against the
experience of the Seven Countries Study (23) showed that development of CHD - the higher its mean level in a group
serum cholesterol concentration is an important risk factor for of individuals, the lower the incidence of infarction in that
the incidence of CHD at levels perhaps 220 mg/dl or more. group (24). HDL should be more than 40 mg/dl.
This supports the notion of a “threshold level” of cholesterol, To further refine CHD risk prediction based on serum
that is, a certain level beyond which there is an association. lipid levels, a total “cholesterol/HDL ratio” has been
The strength of the dietary-fat hypothesis is that developed. A ratio of less than 3.5 has been recommended
observations in the Seven Countries Study (among others) as a clinical goal for CHD prevention (25).
fitted it well - that is, the Japanese had low fat diets, low With newer techniques, high-density and low-density
serum cholesterol and low incidence of CHD while the East lipoproteins have been further subdivided into sub-fractions.
Fins were at the other extreme (Fig. 2). The weakness of the Recent evidence indicates that levels of plasma
hypothesis is that studies of individuals have not shown such apolipoprotein-A-I (the major HDL protein) and
a relationship. This has been attributed to genetic and apolipoprotein-B (the major LDL protein) are better
dietary intake differences between individuals (1). predictors of CHD than HDL cholesterol or LDL cholesterol
respectively. Therefore, measurement of apolipoproteins
may replace lipoprotein cholesterol determinations in
assessing the risk of CHD (26).

4. Other risk factors

(i) Diabetes : The risk of CHD is 2-3 times higher in
diabetics than in non-diabetics. CHD is responsible for 30 to
50 per cent of deaths in diabetics over the age of 40 years in
industrialized countries (27).
(ii) Genetic factors : A family history of CHD is known to
increase the risk of premature death. Genetic factors are
probably the most important determinants of a given
individual’s TC and LDL levels. However, the importance of
genetic factors in the majority of cases is largely unknown.
(Hi) Physical activity : Sedentary life-style is associated
with a greater risk of the development of early CFfD. There
is evidence that regular physical exercise increases the
concentration of HDL (28) and decreases both body weight
123456789 10 and blood pressure which are beneficial to cardiovascular
mmol/1 health.
FIG. 2 (iv) Hormones : The pronounced difference in the
Cultural differences in serum cholesterol levels mortality rates for CHD between male and female subjects

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422 NON-COMMUNICABLE DISEASES

suggests that the underlying factor may have a hormonal of the reduction in saturated fat may be made up
basis. It has been hypothesized that hyperestrogenemia may by mono and poly-unsaturated fats
be the common underlying factor that leads both to - a reduction of dietary cholesterol to below 100 mg
atherosclerosis and its complications such as CHD, stroke per 1000 kcal per day
and peripheral vascular disease (29). - an increase in complex carbohydrate consumption
(v) Type A personality : Type A behaviour is associated (i.e., vegetables, fruits, whole grains and legumes)
with competitive drive, restlessness, hostility and a sense of - avoidance of alcohol consumption; reduction of
urgency or impatience. Type-A individuals are more salt intake to 5 g daily or less.
coronary prone to CHD than the calmer, more philosophical 2. Smoking : As far as CHD is concerned, present
Type B individuals (30). evidence does not support promotion of the so-called “safer
(vi) Alcohol : High alcohol intake, defined as 75g or cigarette” (13). The goal should be to achieve a smoke-free
more per day is an independent risk factor for CHD, society, and several countries are progressing towards this
hypertension and all cardiovascular diseases (13). The goal.
evidence that moderate alcohol intake leads to a reduction To achieve the goal of a smoke-free society, a
in the risk of CHD is un-substantiated (31). comprehensive health programme would be required which
(vii) Oral contraceptives * : Women using oral includes effective information and education activities,
contraceptives have higher systolic and diastolic blood legislative restrictions, fiscal measures and smoking
pressure. The risk of myocardial infarction in women seems cessation programmes.
to be increased by oral contraceptives, and the risk is 3. Blood pressure : It has been estimated that even a
compounded by cigarette smoking (32). small reduction in the average blood pressure of the whole
(viii) Miscellaneous : The possible role of dietary fibre, population by a mere 2 or 3 mm Hg would produce a large
sucrose and soft water have been debated (5). Dyspnoea on reduction in the incidence of cardiovascular complications
exertion and low vital capacity have also been cited as (34, 35). The goal of the population approach to high blood
possible risk factors. pressure would thus be to reduce mean population blood
pressure levels. This involves a multifactorial approach
PREVENTION OF CHD based on a “prudent diet” (reduced salt intake and
In the 1960s the issue was whether CHD could be avoidance of a high alcohol intake), regular physical activity

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prevented or not. Studies were launched, reported and and weight control. The potential benefits and the safety
debated. The accumulated evidence led to a broad and low cost of this advice would justify its implementation.
consensus of expert opinion that CHD is preventable (13). 4. Physical activity : Regular physical activity should be a
This is best expressed in a report of the WHO Expert part of normal daily life. It is particularly important to
Committee on the Prevention of CHD (1) which encourage children to take up physical activities that they
recommended the following strategies : can continue throughout their lives (1).
a. Population strategy
(i) prevention in whole populations PRIMORDIAL PREVENTION
(ii) primordial prevention in whole populations A novel approach to primary prevention of CHD is
b. High risk strategy primordial prevention (1). It involves preventing the
c. Secondary prevention. emergence and spread of CHD risk factors and life-styles
that have not yet appeared or become endemic. This applies
a. Population strategy to developing countries in particular. These countries should
CHD is primarily a mass disease. The strategy should seek to preserve their traditional eating patterns and life­
therefore be based on mass approach focusing mainly on the styles associated with low levels of CHD risk factors.
control of underlying causes (risk factors) in whole Since the aetiology of CHD is multifactorial the approach
populations, not merely in individuals. This approach is to prevention should be multifactorial aimed at controlling
based on the principle that small changes in risk factor levels or modifying as many risk factors as possible. The aim
in total populations can achieve the biggest reduction in should be to change the community as a whole, not the
mortality (33). That is, the aim should be to shift the whole individual subjects living in it (36).
risk-factor distribution in the direction of “biological
normality” (1). This cannot obviously be done by medical Several well-planned risk factor intervention trials (e.g.,
means alone; it requires the mobilization and involvement of The Multiple Risk Factor Intervention Trial (MRFIT) in the
the whole community to alter its lifestyle practices that are US (37), The Stanford Heart Disease Prevention Programme
associated with CHD. in California (38), and The North Kerelia Project in Finland
(39) have demonstrated that primary prevention can
Specific interventions achieve substantial reduction in the incidence of coronary
The population strategy centres round the following key heart disease. For detailed information, the reader is
areas: referred to references no. 37, 38 and 39.
1. Dietary changes : Dietary modification is the principal b. High risk strategy
preventive strategy in the prevention of CHD. The WHO (i) Identifying risk : High-risk intervention can only start
Expert Committee (1) considered the following dietary once those at high risk have been identified. By means of
changes to be appropriate for high incidence populations : simple tests such as blood pressure and serum cholesterol
- reduction of fat intake to 20-30 per cent of total measurement it is possible to identify individuals at special
energy intake risk (1). Individuals at special risk also include those who
consumption of saturated fats must be limited to smoke, those with a strong family history of CHD, diabetes
less than 10 per cent of total energy intake; some and obesity and young women using oral contraceptives.

by R△J
 CORONARY HEART DISEASE
.423
(ii) Specific advice: Having identified those at high risk, the tolerable limits; (b) patients with left main coronary artery
next step will be to bring them under preventive care and stenosis greater than 50 per cent with or without symptoms;
motivate them to take positive action against all the identified (c) patients with three-vessel disease with left ventricular
risk factors, e.g., an elevated blood pressure should be treated; dysfunction (ejection fraction <50 per cent or previous
the patient should be helped to break the smoking habit transmural infarction); (d) patients with unstable angina who
permanently - nicotine chewing gum can be tried to wean after symptom control by medical therapy continue to
patients from smoking (40); serum cholesterol concentration exhibit ischaemia on exercise testing or monitoring; and
should be reduced in those in whom it is raised, etc. (e) post-myocardial infarction patients with continuing
Several well planned high-risk intervention studies (e.g., angina or severe ischaemia on noninvasive testing.
Oslo Heart Study (41), Lipid Research Clinics Study (42), in CABG can be accomplished with a very low mortality
US have shown that it is feasible to reduce the CHD risk factors. rate (1-3 per cent) in otherwise healthy patients with
From a methodological point of view, however, high-risk preserved cardiac function. However, the mortality rate of
approach suffers from the disadvantage that the intervention this procedure rises to 4-8 per cent in older individuals and
(e.g., treatment) may be effective in reducing the disease in in patients who have had a prior CABG. Increasingly,
a high-risk group, but it may not reduce the disease to the younger individuals with focal lesions of one or more vessels
same extent in the general population which consists of are undergoing coronary angioplasty as the initial
symptomatic, asymptomatic, high-risk, low-risk and healthy revascularization procedure, where coronary artery stenosis
people (43). Further, unfortunately, more than half of the can be effectively dilated by inflation of a balloon under
CHD cases occur in those.who are not apparently at special high pressure. PTCA is also possible but less successful in
risk, and this is one limitation of the high-risk strategy (1). bypass graft stenosis.
Nevertheless, recognition and treatment of high-risk cases The incidents of restenosis appears to be reduced with
do make an important contribution to prevention (1). intracoronary stent placement and may be as low as 15-20
per cent. The number of PTCA and stent procedure now
c. Secondary prevention exceeds that of CABG operations. Several studies have
Secondary prevention must be seen as a continuation of shown PTCA to be superior to medical therapy for symptom
primary prevention. It forms an important part of an overall relief but not in preventing infarction or death. In patients
strategy. The aim of secondary prevention is to prevent the with no or only mild symptoms, aggressive lipid-lowering
recurrence and progression of CHD. Secondary prevention and anti-anginal therapy may be preferable to PTCA.

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is a rapidly expanding field with much research in progress
(e.g., drug trials, coronary surgery, use of pace makers). RISK FACTOR INTERVENTION TRIALS
The principles governing secondary prevention are the Since 1951, one of the best known large prospective
same as those already set out in the above sections, e.g., studies, the Framingham Study, has played a major role in
cessation of smoking, control of hypertension and diabetes, establishing the nature of CHD risk factors and their relative
healthy nutrition, exercise promotion, etc. The most importance (48, 49). The major risk factors of CHD are
promising results to date have come from beta-blockers elevated serum cholesterol, smoking, hypertension and
which appear to reduce the risk of CHD mortality in patients sedentary habits. Accordingly, the four main possibilities of
who have already suffered at least one infarct in the order of intervention in CHD prevention are: reduction of serum
25 per cent. None of the preventive measures discussed cholesterol, the cessation of smoking, control of
earlier lose their importance even after the first attack. For hypertension and promotion of physical activity.
example, cessation of smoking is the most effective single Risk factor trials can be “single factor” trials or “multi­
means of intervention currently available in the management factor” trials. Both the approaches are complementary and
of patients after a heart attack. The risk of fatal infarction or both are needed. Early trials of CHD prevention concentrated
sudden death is reduced by 20-50 per cent. If the patient on one factor (e.g., dietary cholesterol). Later emphasis
does not stop smoking, nothing else is worth doing (44). swung away from unifactorial to multifactorial approach.
Despite advances in treatment, the mortality of an acute The widely reported intervention trials are : (a) The
heart attack is still high among survivors, around 10 per cent Stanford Heart Disease Prevention Programme in California,
in the first year, and 5 per cent yearly thereafter. Delay in (b) The North Kerelia Project in Finland, (c) The Oslo Study,
reaching hospital is still considerable even in big cities in the (d) The Multiple Risk Factor Intervention Trial (MRFIT) in
West and may be as much as 3.5 hours. About 30 per cent of USA, and (e) The Lipid Research Clinics Study. A brief
all deaths occur within 30 minutes of onset. This is one of the account of these trials is given below. For more details the
reasons why coronary care units have failed to make impact reader is referred to the references cited in the text.
on the total coronary mortality in the community (45, 46).
Each strategy - population strategy, high-risk strategy, 1. The Stanford-Three-Community Study (38).
secondary prevention - has its advantages and disadvantages, To determine whether community health education can
but the population strategy has the greatest potential. reduce the risk of cardiovascular disease, a field experiment
was undertaken in 1972 in three northern California towns
Revascularization procedures for patients with populations varying between 12,000 and 15,000. In
with angina pectoris (47) two of these towns intensive mass education campaigns
The indications for coronary artery revascularization i.e. were conducted against cardiovascular risk factors over a
coronary artery bypass grafting (CABG) and percutaneous period of 2 years. The third community served as a control.
transluminal coronary angioplasty (PTCA) in patients with People from each community were interviewed and
angina pectoris are often debated. There is general examined before the campaign began and one and two
agreement that otherwise healthy patients in the following years afterwards to assess knowledge and behaviour related
groups should undergo revascularization, (a) patients with to cardiovascular diseases (e.g., diet and smoking) and also
unacceptable symptoms despite medical therapy to its to measure physiological indicators of risk (e.g., blood

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424 NON-COMMUNICABLE DISEASES

pressure, serum cholesterol, relative weight). In the control to lower serum cholesterol level through dietary means (e.g.,
community, the risk of cardiovascular disease increased over a polyunsaturated fat diet), and to decrease or eliminate
the two years, but in the intervention communities there was smoking. At the end of 5 years, the incidence of myocardial
a substantial and sustained decrease in risk. The net infarction (fatal and nonfatal) was lower by 47 per cent in
difference in estimated total risk between control and the intervention group than in the control group.
intervention samples was 23-28 per cent. With this study, primary prevention of CHD entered the
practical field of preventive medicine in an impressive
2. The North Kerelia Project (36, 39) manner.
North Kerelia is a county in the eastern part of Finland,
where CHD is particularly common. Its 185,000 inhabitants 5. Lipid Research Clinics Study (42)
work mostly in farming and forestry and live in the This double-blind, randomized clinical trial involved
countryside. 3,806 asymptomatic “high-risk” American men aged 35-59
A multiple risk factor intervention trial was started in years with type II hyperlipoproteinaemia. The trial was
1972. The project had two aims : (a) to reduce the high designed to test whether reducing serum cholesterol would
levels of risk factors for cardiovascular disease (e.g., prevent CHD events.
smoking, blood pressure and serum cholesterol), and (b) to The men were randomized into two groups, one receiving
promote the early diagnosis, treatment and rehabilitation of cholestyramine and the other receiving a placebo. Both the
patients with CV disease. A control population was groups were followed for an average of 7.4 years.
established in a neighbouring county which has similar CV The treatment group had an 8.5 per cent and 12.6 per cent
mortality. The main strategy employed was mass community greater reduction in total cholesterol and LDL-cholesterol
action against risk factors and advice on their avoidance. levels respectively than the placebo-treated group. This
Follow-up surveys at 5-years demonstrated a significant difference resulted in a 24 per cent reduction in death from
reduction in all three major risk factors. By 1979, mortality definite CHD and a 19 per cent reduction in non-fatal
began to decline by 24 per cent in men and 51 per cent in myocardial infarction. The findings of this study have resulted
women in North Kerelia, compared with 12 per cent in men in enthusiasm for the drug treatment of those men with
and 26 per cent in women in rest of Finland. A further considerably elevated serum cholesterol levels.
representative sample (8000) was studied in 1982. It
Secondary prevention trials

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exhibited its effect on CHD deaths - more than twice the
reduction achieved in the rest of Finland during the same Secondary prevention trials are aimed at preventing a
period. Thus it took 10 years (Rose’s 10-years incubation subsequent coronary attack or sudden death. A wide range
period) to exhibit its effect on CHD deaths. of clinical trials have been performed with four main groups
of drugs - anti-coagulants, lipid-lowering agents (e.g.,
3. MRFIT (37) clofibrate), anti-thrombotic agents (e.g., aspirin) and beta­
The multiple risk'factor intervention trial (MRFIT) carried blockers. The most promising results to date have come from
out in USA was aimed at high risk adult males aged 35-57 beta blockers.
years. A total of 12,866 men who showed no evidence of In general the above studies and similar others show that
CHD either clinically or on ECG were enrolled for the study. it is feasible through well-planned intervention programmes
Half the group was randomly allocated to an intensive to reduce the risk factors in the populations studied. The
intervention programme, being seen at least every four primary and secondary prevention studies promise at
months to ensure adequate control of risk factors. The other present to be the main contribution of epidemiology to the
half (control group) received a medical examination once conquest of chronic diseases.
yearly, and no specific advice was given to them about the
control of risk factors. The intervention procedures included References
cessation of smoking, controlling blood pressure and altering 1. WHO (1982) . Techn Rep. Ser. No. 678.
diet to reduce hypercholesterolemia. 2. Pedoe, H.T. (1982). In Epidemiology of Diseases, D.L. Miller and
R.T.D. Farmer (eds), Blackwell, Oxford.
Over the 7 year follow-up period, IHD mortality was 3. Rose, G.A. (1973). In : Chronic Diseases, Public Health in Europe No.
reduced by 22 per cent more in the intervention group but 2, Regional Office of WHO, Copenhagen.
this was not statistically significant. This was because the 4. WHO (1972). WHO Statis Rep., 25:430.
control group had also changed their habits and lifestyle to a 5. Oliver, M.F. (1981). Br. Med. Bull., 37 (1) 49.
far greater extent than anticipated by the designers of the 6. Rose, G.A. and Blackburn, H. (1968). Cardiovascular Survey
trial. The trial produced no significant changes at all in Methods, Geneva, WHO.
mortality or risk factors in as much as the control group was 7. WHO (1985). Techn. Rep. Ser. No 726.
not properly chosen. 8. Hetzel, B.S. (1979). In : Measurement of Levels of Health, WHO.
Copenhagen.
4. Oslow diet/smoking Intervention Study (41) 9. Rose, G. (1985) In : Oxford Textbook of Public Health, Vol. 4, p. 133.
10. Hart, J.T. (1983). In : Practising Prevention, British Medical
This study began in 1973. 16,202 Norwegian men aged Association.
40-49 years were screened for coronary risk factors; of these 11. Stamler, J. (1985). N. Eng. J. Med., 312 : 1053.
1,232 healthy normotensive men at high risk (total serum 12. WHO (1983). Bull WHO, 61: 45.
cholesterol 290-379 mg/dl; smoking) of CHD were selected 13. WHO (1985). Primary Prevention of CHD EURO Rep and Studies 98.
for a 5 year randomized trial. The aim of the study was to Copenhagen.
determine whether lowering of serum lipids and cessation of 14. WHO (2018), World Health Estimates by cause and WHO Regions,
2018.
smoking would reduce the incidence of first attack of CHD in
15. ICMR (2004). Assessment of Burden of Hon-Communicable Diseases,
males aged 40-50. Final Report.
The intervention group underwent techniques designed 16. Slone, D. et al (1978). N. Eng. J. Med. 298 : 1273.

by R△J
 HYPERTENSION 425
17. Shaper A.G. et al (1981). Brit. Med. J. 283 : 179. TABLE 1
18. WHO (1979). Tech. Rep. Ser., No. 636. Classification of blood pressure measurements
19. WHO (1996). Tech. Rep. Ser. No. 862, Hypertension control.
20. Bain, C. et al (1978). Lancet, 1 :1087. Systolic Diastolic
Category
21. Wald, N.J. (1976). Lancet, 1 :136. (mm of Hg) (mm of Hg)
22. Kannel, W.B. (1976). Am. J. Cardiol., 37 : 269. Optimal < 120 and <80
23. Keys, A. (1980). Seven Countries : A Multivariate Analysis of Death Normal < 130 and/or < 85
and CHD, Harvard University Press, Cambridge, M.A.
High normal 130-139 and/or 85-89
24. Gordon, T. et al (1977). Am. J. Med., 62 : 707.
Grade 1 Hypertension 140-159 and/or 90-99
25. Superko, H.R. et al (1985). Am. J. Med., 78 : 826.
Grade 2 Hypertension > 160 and/or > 100
26. Schaefer, E.J. (1985). N. Eng. J. Med., 312 : 1300.
27. WHO (1985). Techn. Rep. Ser., 727. Hypertensive crisis >180 and/or > 110
28. Miller, N.E. et al (1979) Lancet, 1:111. Isolated systolic hypertension >140 and <90
29. Phillips, G.B. (1985). Am. J. Med., 78 (3) 363. Source : (2)
30. Jenkins, C.D. et al (1974). N. Eng. J. Med., 290 :1271.
31. WHO (1986). Techn. Rep. Ser., No. 732. When systolic and diastolic blood pressure fall into
32. Mann, J.I. et al (1976). Brit. Med. J., 2 : 445. different categories, the higher category should be selected
33. WHO (2008). The Global Burden of Disease, 2004 update. to classify the individual’s blood pressure. “Isolated systolic
34. WHO (1986). Techn. Rep. Ser., No. 732. hypertension” is defined as a systolic blood pressure of
35. Rose, G. (1981). Brit. Med. J., 282 :1847. 140 mm of Hg or more and a diastolic blood pressure of less
36. Puska, P et al (1979). Brit. Med. J., 2 : 1173. than 90 mm of Hg.
37. Multiple Risk Factor Intervention Trial Research Group (1982). JAMA,
248 : 1465. Organ damage
38. Farquhar, J. etal (1977). Lancet., 1 : 1192.
39. Salonen, J.T. etal (1983). Brit. Med. J., 286 : 1857.
Although the extent of organ damage often correlates
40. Lancet (1985). 1:320.
with the level of blood pressure, it is not always the case. In
41. Hjermann. I. etal (1981). Lancet, 2 : 1303. addition the rate of progression of organ damage varies
42. Lipid Research Clinics Programme (1984). JAMA, 251 : 351. from one individual to another depending on many
43. Glasunov, I. et al (1973). /nt. J. Epi., 2 (2) 137. influences, most of which are incompletely understood.
44. Bradely, N. (1984). In : Medical Annual, D.J.P. Gray (ed). John Wright Therefore, blood pressure and organ impairment should be

telegram-@Cherry_2412
and Sons. evaluated separately, since markedly high pressures may be
45. Rose, G. (1975). Brit. J. PSM, 29:147. seen without organ damage and, conversely, organ damage
46. G. Lamm (1979) In : Measurement of Levels of Health, WHO Reg. may be present with only moderate elevation of blood
Publ. EURO Ser. No. 7. pressure. The presence of signs of organ damage confers an
47. Lawrence M. Tierney, Jr. Stephen J. Mcphee Maxine A. Papadakis increased cardiovascular risk to any level of blood pressure.
(2002), Current Medical Diagnosis and Treatment, 41st Ed., 2002,
Large Publication. Blood pressure measurement
48. Dawber, T.R. (1980). The Framingham Study, Cambridge, M.A.,
Harvard University Press. Despite more than 75 years of experience with the
49. Kannel, W.B. etal (1976). Am. J. Cardiol., 38:46. measurement of blood pressure, discussion continues about
its reliability and wide variability in individual subjects.
Accurate measurements are essential under standardized
HYPERTENSION conditions for valid comparison between persons or groups
over time. Three sources of errors have been identified in the
Hypertension is a chronic condition of concern due to its recording of blood pressure : (a) Observer errors : e.g.,
role in the causation of coronary heart disease, stroke and hearing acuity, interpretation of Korotkow sounds.
other vascular complications. It is the commonest (b) Instrumental errors : e.g., leaking valve, cuffs that do not
cardiovascular disorder, posing a major public health encircle the arm. If the cuff is too small and fails to encircle the
challenge to population in socio-economic and arm properly then too high a reading will be obtained; and
epidemiological transition. It is one of the major risk factors (c) Subject errors : e.g., the circumstances of examination.
for cardiovascular mortality, which accounts for 20-50 per These include the physical environment, the position of the
cent of all deaths. subject, external stimuli such as fear, anxiety, and so on (3).
Definition of hypertension is difficult and, by necessity A few salient points need be mentioned about measuring
arbitrary. Sir George Peckering first fomulated a concept blood pressure. A WHO Study Group (4) recommended the
that blood pressure in a population is distributed sitting position than the supine position for recording blood
continuously as a bell-shaped curve with no real separation pressure. In any clinic a uniform policy should be adopted,
using either the right or left arm consistently. The pressure at
between normotension and hypertension (1). There is also a
which the sounds are first heard (phase I) is taken to indicate
direct relation between cardiovascular risk and blood the systolic pressure. Near the diastolic pressure the sounds
pressure : the higher the blood pressure, the higher the risk first become muffled (phase IV) and then disappear
of both stroke and coronary events (1). As a consequence, (phase V). Most of the studies have used phase V to measure
the dividing line between normal and high blood pressure diastolic blood pressure. The systolic and diastolic pressures
can be defined only in an operational way. should be measured at least three times over a period of at
As intervention trials included only adults aged 18 years least 3 minutes and the lowest reading recorded. For reasons
or older, definition and classification of hypertension refers of comparability, the data should be recorded everywhere in
to adults not taking anti-hypertensive drugs and not actually a uniform way.
ill, and based on the average of two or more readings on two
or more occasions after initial screening. Table 1 shows the Classification
classification of hypertension by blood pressure level. Hypertension is divided into primary (essential) and

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 NON-COMMUNICABLE DISEASES

secondary. Hypertension is classified as “essential” when the overall prevalence of hypertension in adults is around 30-40
causes are generally unknown. Essential hypertension is the per cent, with a global age standardized prevalence of 24
most prevalent form of hypertension accounting for 90 per and 20 per cent in men and women respectively. This high
cent of all cases of hypertension. Hypertension is classified prevalence of hypertension across the world is irrespective of
as “secondary” when some other disease process or income status i.e., in lower, middle and higher income
abnormality is involved in its causation. Prominent among countries. Hypertension becomes progressively more
these are diseases of kidney (chronic glomerulo-nephritis common with advancing age, with a prevalence of >60 per
and chronic pyelonephritis), tumours of the adrenal glands, cent in people aged >60 years. As populations age, they
congenital narrowing of the aorta and toxemias of adopt more sedentary life styles and increase in their body
pregnancy. Altogether, these are estimated to account for weight. It is estimated that the number of people with
about 10 per cent or less of the cases of hypertension. hypertension will increase by 15-20 per cent by year 2025
(2). Elevated blood pressure is a leading cause of premature
Magnitude of the problem death in 2015, accounting to almost 10 million deaths and
Although blood pressure is easily measured, it had taken over 200 million DALYs. Despite advances in diagnosis and
several decades to realise that arterial hypertension is a treatment over the past 30 years, the DALYs have increased
frequent, worldwide health disorder (5). by 40 per cent since 1990. Systolic blood pressure >140
mmHg accounts for most of the mortality and disability
“Rule of halves" burden. The largest number of systolic blood pressure related
Hypertension is an “iceberg” disease. It became evident deaths per year are due to IHD (4.9 million), haemorrhagic
in the early 1970s that only about half of the hypertensive stroke (2 million) and ischaemic stroke (1.5 million) (2).
subjects in the general population of most developed
countries were aware of the condition, only about half of Prevalence in India
those aware of the problem were being treated, and only In India an individual is classified as having hypertension
about half of those treated were considered adequately if that individual has a systolic blood pressure level greater
treated (6). Fig. 1 illustrates this situation (7). If this was the than or equal to 140 mmHg or a diastolic blood pressure
situation in countries with highly developed medical level greater than or equal to 90 mmHg or that individual is
services, in the developing countries, the proportion treated currently taking antihypertensive medication to lower his/
would be far too less. her blood pressure.

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Based on blood pressure measurement during the NFHS-5
21 per cent of women age 15 years and over have hypertension,
including 12 per cent with mildly elevated blood pressure,
4 per cent with moderately elevated blood pressure, and
2 per cent with severely elevated blood pressure. Forty-four
per cent of women have blood pressure within the normal
range. Almost two-fifths (39%) of women are pre-hypertensive.
One per cent of women are currently taking antihypertensive
medicine and have their blood pressure in the normal range.
The prevalence of hypertension is higher among men age
15 years and over than among women age 15 years and
over. Twentyfour per cent of men age 15 years and over
have hypertension, including 16 per cent with mildly
elevated blood pressure, 4 per cent with moderately elevate
blood pressure, and 2 per cent with severely elevated blood
FIG. 1 pressure. Thirty per cent of men have normal blood pressure
Hypertension in the community
and 49 per cent are pre-hypertensive. About one per cent of
The areas of the circles shown in Fig. 1 correspond to the men are currently taking antihypertensive medicine and
actual proportions observed in several population based have their blood pressure in the normal range.
studies and number-wise represent the following : (6). Patterns by background characteristics
1. The whole community 1. For both women and men, the prevalence of hypertension
2. Normotensive subjects increases sharply with age. This increase is for all
3. Hypertensive subjects categories of hypertension, including pre-hypertension,
4. Undiagnosed hypertension for both women and men. About one-fourth of women
5. Diagnosed hypertension and men age 40-49 have hypertension. Even at an earlier
6. Diagnosed but untreated age, one in eight women and more than one in five men
7. Diagnosed and treated age 30-39 have hypertension as seen in Fig. 2.
8. Inadequately treated 2. The prevalence of hypertension is higher among Sikhs
(37% for men and 31% for women), Jains (30% for men
9. Adequately treated
and 25% for women), and Christians (29% for men and
INCIDENCE : The concept of incidence has limited value 26% for women) than the rest of the religions.
in hypertension because of the variability of consecutive 3. There is a consistent and steep increase in the
readings in individuals, ambiguity of what is “normal” blood prevalence of hypertension with increases in the body
pressure and the insidious nature of the condition (8). mass index (BMI) for both women and men. Forty
The global prevalence of hypertension was estimated to percent of obese men and 28 per cent of obese women
be 1.13 billion killing 10 million people every year. The are hypertensive.

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 HYPERTENSION 427
Percentage of women and men age 15 and over
M Women Men

FIG. 2
Prevalence of Hypertension by Age and Sex

4. The prevalence of hypertension among women is highest 1. Non-modifiable risk factors

(35%) in Sikkim. The prevalence of hypertension among (a) AGE: Blood pressure rises with age in both sexes and the
men age 15 and over ranges from 15 per cent in Dadra & rise is greater in those with higher initial blood pressure. Age
Nagar Haveli and Daman & Diu to 42 per cent in Sikkim. probably represents an accumulation of environmental
5. For both women and men, the southern states have a influences and the effects of genetically programmed
higher prevalence of hypertension than the national senescence in body systems (3). Some populations have now

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average. been identified whose mean blood pressure does not rise with
age (10). These communities are for the most part primitive
“Tracking” of blood pressure societies with calorie and often salt intakes at subsistence level.
If blood pressure levels of individuals were followed up (b) SEX : Early in life there is little evidence of a difference
over a period of years from early childhood into adult life, in blood pressure between the sexes. However, at
then those individuals whose pressures were initially high in adolescence, men display a higher average level. This
the distribution, would probably continue in the same difference is most evident in young and middle aged adults.
“track” as adults. In other words, low blood pressure levels Late in life the difference narrows and the pattern may even
tend to remain low, and high levels tend to become higher as be reversed (1). Post-menopausal changes in women may be
individuals grow older (Fig. 3). This phenomenon of the contributory factor for this change. Studies are in progress
persistence of rank order of blood pressure has been to evaluate whether oestrogen supplementation protects
described as “tracking” (9). This knowledge can be applied against the late relative rise of blood pressure in women (1).
in identifying children and adolescents “at risk” of
developing hypertension at a future date. (c) GENETIC FACTORS : There is considerable evidence
that blood pressure levels are determined in part by genetic
Risk factors for hypertension factors, and that the inheritance is polygenic. The evidence
Hypertension is not only one of the major risk factors for is based on twin and family studies. Twin studies have
most forms of cardiovascular disease, but that it is a confirmed the importance of genetic factors in hypertension.
condition with its own risk factors. A WHO Scientific Group The blood pressure values of monozygotic twins are usually
(5) has recently reviewed the risk factors for essential more strongly correlated than those of zygotic twins. In
contrast, no significant correlation has been noted between
hypertension. These may be classified as :
husbands and wives, and between adopted children and
their adoptive parents (5).
Family studies have shown.that the children of two
normotensive parents have 3 per cent possibility of
developing hypertension, whereas this possibility is 45 per
cent in children of two hypertensive parents (11). Blood
pressure levels among first degree adult relatives have also
been noted to be statistically significant (5).
Attempts to find genetic markers that are associated with
hypertension have been largely unsuccessful. The detailed
mechanism of heredity, i.e., how many genes and loci are
involved and their mode of inheritance have not yet been
conclusively elucidated.
(d) ETHNICITY : Population studies have consistently
revealed higher blood pressure levels in black communities
FIG. 3 than other ethnic groups (1). Average difference in blood
Tracking of blood pressure pressure between the two groups vary from slightly less

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428 NON-COMMUNICABLE DISEASES

than 5 mm Hg during the second decade of life to nearly revealed significantly higher noradrenaline levels in
20 mm Hg during the sixth. Black Americans of African hypertensives than in normotensives. This supports the
origin have been demonstrated to have higher blood contention that over-activity of the sympathetic nervous
pressure levels than whites. system has an important part to play in the pathogenesis of
hypertension (9).
2. Modifiable risk factors (i) SOCIO-ECONOMIC STATUS : In countries that are in
(a) OBESITY : Epidemiological observations have post-transitional stage of economic and epidemiological
identified obesity as a risk factor for hypertension (12). The change, consistently higher levels of blood pressure have
greater the weight gain, the greater the risk of high blood been noted in lower socio-economic groups. This inverse
pressure. Data also indicate that when people with high relation has been noted with levels of education, income
blood pressure lose weight, their blood pressure generally and occupation. However, in societies that are transitional
decreases. “Central obesity” indicated by an increased waist or pre-transitional, a higher prevalence of hypertension
to hip ratio, has been positively correlated with high blood have been noted in upper, socio-economic groups.
pressure in several populations. This probably represents the initial stage of the epidemic of
CVD (1).
(b) SALT INTAKE : There is an increasing body of
evidence to the effect that a high salt intake (i.e., 7-8 g per (j) OTHER FACTORS : The commonest present cause of
day) increases blood pressure proportionately. Low sodium secondary hypertension is oral contraception, because of
intake has been found to lower the blood pressure (13). For the oestrogen component in combined preparations. Other
instance, the higher incidence of hypertension is found in factors such as noise, vibration, temperature and humidity
Japan where sodium intake is above 400 mmol/day while require further investigation (5).
primitive societies ingesting less than 60 mmol/day have
virtually no hypertension (14). It has been postulated that PREVENTION OF HYPERTENSION
essential hypertensives have a genetic abnormality of the The low prevalence of hypertension in some communities
kidney which makes salt excretion difficult except at raised indicates that hypertension is potentially preventable (16).
levels of arterial pressure (5). The WHO has recommended the following approaches in
Besides sodium, there are other mineral elements such as the prevention of hypertension :
potassium which are determinants of blood pressure. 1. Primary prevention

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Potassium antagonizes the biological effects of sodium, and
(a) Population strategy
thereby reduces blood pressure. Potassium supplements
have been found to lower blood pressure of mild to (b) High-risk strategy
moderate hypertensives. Other cations such as calcium, 2. Secondary prevention
cadmium and magnesium have also been suggested as of
importance in reducing blood pressure levels. 1. PRIMARY PREVENTION
(c) SATURATED FAT : The evidences suggest that Although control of hypertension can be successfully
saturated fat raises blood pressure as well as serum achieved by medication (secondary prevention) the ultimate
cholesterol (15). For further details refer to chapter 11. goal in general is primary prevention. Primary prevention
has been defined as “all measures to reduce the incidence of
(d) DIETARY FIBRE : Several studies indicate that the disease in a population by reducing the risk of onset” (17).
risk of CHD and hypertension is inversely related to the The earlier the prevention starts the more likely it is to be
consumption of dietary fibre. Most fibres reduce plasma total effective.
and LDL cholesterol (1).
In connection with primary prevention, terms such as
(e) ALCOHOL : High alcohol intake is associated with an “population strategy” and “high-risk strategy” have become
increased risk of high blood pressure. It appears that alcohol established (5, 18). The WHO has recommended these
consumption raises systolic pressure more than the diastolic. approaches in the prevention of hypertension. Both the
But the finding that blood pressure returns to normal with approaches are complementary.
abstinence suggests that alcohol-induced elevations may
not be fixed, and do not necessarily lead to sustained blood a. POPULATION STRATEGY
pressure elevation (3).
The population approach is directed at the whole
(f) HEART RATE : When groups of normotensive and population, irrespective of individual risk levels. The
untreated hypertensive subjects, matched for age and sex, concept of population approach is based on the fact that
are compared, the heart rate of the hypertensive group is even a small reduction in the average blood pressure of a
invariably higher. This may reflect a resetting of sympathetic population would produce a large reduction in the incidence
activity at a higher level. The role of heart variability in of cardiovascular complications such as stroke and
blood pressure needs further research to elucidate whether CHD (16). The goal of the population approach is to shift
the relation is casual or prognostic (1). the community distribution of blood pressure towards lower
(g) PHYSICAL ACTIVITY : Physical activity by reducing levels or “biological normality” (9). This involves a
body weight may have an indirect effect on blood pressure. multifactorial approach, based on the following
(h) ENVIRONMENTAL STRESS : The term hypertension non-pharmacotherapeutic interventions :
itself implies a disorder initiated by tension or stress. Since (a) NUTRITION : Dietary changes are of paramount
stress is nowhere defined, the hypothesis is untestable (3). importance. These comprise : (i) reduction of salt intake to
However, it is an accepted fact that psychosocial factors an average of not more than 5 g per day (ii) moderate fat
operate through mental processes, consciously or intake (iii) the avoidance of a high alcohol intake, and
unconsciously, to produce hypertension. Virtually all studies (iv) restriction of energy intake appropriate to body needs,
on blood pressure and catecholamine levels in young people (b) WEIGHT REDUCTION : The prevention and correction

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 HYPERTENSION

of over weight/obesity (Body Mass Index greater than 25) is mortality from coronary, cerebrovascular and kidney
a prudent way of reducing the risk of hypertension and disease. The control measures comprise:
indirectly CHD; it goes with dietary changes, (c) EXERCISE (i) EARLY CASE DETECTION: Early detection is a major
PROMOTION : The evidence that regular physical activity problem. This is because high blood pressure rarely causes
leads to a fall in body weight, blood lipids and blood symptoms until organ damage has already occurred, and our
pressure goes to suggest that regular physical activity should aim should be to control it before this happens. The only
be encouraged as part of the strategy for risk-factor control, effective method of diagnosis of hypertension is to screen the
(d) BEHAVIOURAL CHANGES : Reduction of stress and population. But screening, that is not linked to follow-up and
smoking, modification of personal life-style, yoga and sustained care, is a fruitless exercise. It is emphasized that
transcendental meditation could be profitable, (e) HEALTH screening should not be initiated if health resources for
EDUCATION : The general public require preventive advice treatment and follow-up are not adequate.
on all risk factors and related health behaviour. The whole In the developed countries, mass screening is not
community must be mobilized and made aware of the considered essential for the adequate control of blood
possibility of primary prevention, and (f) SELF-CARE : An pressure in the population. In Europe, the large majority of
important element in community-based health programmes people have at least one contact in every 2 years with the
is patient participation. The patient is taught self-care, i.e., health service. If blood pressure is measured at each such
to take his own blood pressure and keep a log-book of his contact, the bulk of the problem of detecting those in need
readings. By doing so, the burden on the official health of intervention is solved.
services would be considerably reduced. Log-books can
also be useful for statistical purposes and for the long-term (ii) TREATMENT : In essential hypertension, as in
follow-up of cases (19). diabetes, we cannot treat the cause, because we do not know
what it is. Instead, we try to scale down the high blood
Table 2 shows some of the lifestyle modifications to pressure to acceptable levels. The aim of treatment should be
manage hypertension. to obtain a blood pressure below 140/90 mm Hg, and ideally
a blood pressure of 120/80 mm Hg. Control of hypertension
b. HIGH-RISK STRATEGY has been shown to reduce the incidence of stroke and other
This is also part of primary prevention. The aim of this complications. This is a major reason for identifying and
approach is “to prevent the attainment of levels of blood treating asymptomatic hypertension. Care of hypertensives
should also involve attention to other risk factors such as

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pressure at which the institution of treatment would be
considered” (3). This approach is appropriate if the risk smoking and elevated blood cholesterol levels (16).
factors occur with very low prevalence in the community (3). (iii) PATIENT COMPLIANCE : The treatment of high
Detection of high-risk subjects should be encouraged by blood pressure must normally be life-long and this presents
the optimum use of clinical methods. Since hypertension problems of patient compliance, which is defined as “the
tends to cluster in families, the family history of extent to which patient behaviour (in terms of taking
hypertension and “tracking” of blood pressure from medicines, following diets or executing other lifestyle
childhood may be used to identify individuals at risk. changes) coincides with clinical prescription”. The
compliance rates can be improved through education
2. SECONDARY PREVENTION directed to patients, families and the community.
The goal of secondary prevention is to detect and control Intensive research carried out during the past decade,
high blood pressure in affected individuals. Modern anti­ aiming at control of hypertension at the community level,
hypertensive drug therapy can effectively reduce high blood has already provided valuable results. The studies have
pressure and consequently, the excess risk of morbidity and shown that control of hypertension in a population is

TABLE 2
Lifestyle modifications to manage hypertension

Modification Recommendation Approximate systolic BP

Reduction, Range

Weight reduction Maintain normal body weight (BMI, 18.5-24.9) 5-20 mm Hg/10 kg
weight loss
Adopt DASH Consume a diet rich in fruits, vegetables and low-fat dairy products with a 8-14 mm Hg
eating plan reduced content of saturated fat and total fat
Dietary sodium Reduce dietary sodium intake to no more than 100 mEq/d 2-8 mm Hg
reduction (2.4 g sodium or 6 g sodium chloride)
Physical activity Engage m regular aerobic physical activity such as brisk walking 4-9 mm Hg
(at least 30 minutes per day, most days of the week)
Moderation of alcohol Limit consumption to no more than two drinks per day 2-4 mm Hg
consumption (1 oz or 30 ml ethanol eg, 24 oz beer, 10 oz wine, or 3 oz 80- proof whisky)
in most men, and no more than one drink per day in women and
lighter-weight persons

For overall cardiovascular risk reduction, stop smoking.

The effects of implementing these modifications are dose and time dependent and could be higher for some individuals.
BMI - body mass index calculated as weight in kilograms divided by the square of height in metres;
DASH - Dietary Approaches to Stop Hypertension.
Source : (20)

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 NON-COMMUNICABLE DISEASES
430
feasible, that it can be carried out through the existing system B. Haemorrhagic stroke
of health services in different countries, and that the control a. Spontaneous intracerebral haemorrhage
of blood pressure leads to a reduction of complications of b. Subarachnoid haemorrhage
high blood pressure - namely stroke, heart failure and renal c. Intracranial aneurysm
failure. In some of the projects the incidence of myocardial d. Arteriovenous malformations.
infarction was also reduced. As a result of these findings
some countries have launched nationwide control Problem
programmes in the field of hypertension (21).
Stroke is a worldwide health problem. It makes an
References important contribution to morbidity, mortality and disability
in developed as well as developing countries. Although there
1. WHO (1996). Techn. Rep. Ser., No. 862.
2. European Heart Journal (2018), Guidelines for the management of are substantial differences in frequency from place to place,
arterial hypertension, Vol. 39 issue 33, 25 Aug. 2018. cerebral thrombosis is usually the most frequent form of
3. Hart, J.T. (1980). Hypertension, Library of General Practitioner stroke encountered in clinical studies, followed by
Series, Churchill Livingstone. haemorrhage. Subarachnoid haemorrhage and cerebral
4. WHO (1983). Bull WHO, 61 (1) 53. embolism come next as regards both mortality and
5. WHO (1983). Techn. Rep. Ser., No. 686. morbidity (2). However, stroke from cerebral haemorrhage
6. Strasser, T. (1972). WHO Chronicle, 26 : 451. is more common in Japan than elsewhere (1).
7. WHO (1974). WHO Chronicle, 28 (3) 11.
8. Govt, of India (2022), National Family Health Survey-5 (2019-2021), MORBIDITY AND MORTALITY
Ministry of Health and Family welfare, New Delhi.
9. WHO (1985). Techn. Rep. Ser., No. 715. Cerebrovascular disease remain a leading cause of death
10. Marmot, M.G. (1984). Brit. Med. Bulletin, 40 (4) 380. from NCDs. In 2016 it was estimated that cerebrovascular
11. Bianchi, G. et al (1979). Lancet, 1 :173-177. disease accounted for 5.78 million deaths worldwide,
12. Stamler, R. et al (1978). JAMA, 240 :1607. equivalent to 10.2 per cent of all deaths. Majority of these
13. Beard, T.C. et al (1982). Lancet, 2 : 455. deaths occurred in people living in developing countries and
14. Oliver, M.F. (1981). Br. Med. Bull., 37 (1) 49. 33.72 per cent of the subjects were aged less than 70 years (3).
15. Puska, P etal (1983). Lancet, 1 :1-5. Additionally, cerebrovascular disease is the leading cause of
16. WHO (1986). Techn. Rep. Ser., No. 732. disability in adults and each year millions of stroke survivors

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17. Hogarth, J. (1978). Glossary Health Care Terminology, WHO, have to adopt life with restriction in activities of daily living as
Copenhagen. a consequence of stroke. Many surviving stroke patients will
18. Rose, G. (1981). Brit.Med.J., 1:1847. often depend on other people's continuous support to live (4).
19. WHO (1978). WHO Chronicle, 32 (11) 448.
20. STEPHEN J. McPHEE, MAXINE A. PAPADAKIS (2010). Current In demographically developed countries, the average age
Medical Diagnosis and Treatment, 49th Ed. A Lange Publication. at which stroke occurs is around 73 years reflecting the older
21. WHO (1980). Sixth Report World Health Situation, Part I. age structure of these countries. The probability of a first
stroke or first TIA is around 1.6 per 1000 and 0.42 per 1000
STROKE respectively. In less developed regions, the average age of
stroke is less due to the different population age structure,
The term “stroke” (syn : apoplexy) is applied to acute resulting from higher mortality rates.
severe manifestations of cerebrovascular disease. It causes Stroke patients are at highest risk of death in the first
both physical and mental crippling. WHO defined stroke as weeks after the event, and between 20-50 per cent die
“rapidly developed clinical signs of focal disturbance of within first month depending on type, severity, age, co­
cerebral function; lasting more than 24 hours or leading morbidity and effectiveness of treatment of complications.
to death, with no apparent cause other than vascular Patients who survive may be left with no disability or with
origin” (1). The 24 hours threshold in the definition excludes mild, moderate or severe disability. Considerable
transcient ischaemic attacks (TIA) which is defined to last spontaneous recovery occurs upto about 6 months.
less than 24 hours, and patients with stroke symptoms However, patients with history of stroke are at high risk of a
caused by subdural haemorrhage, tumours, poisoning or subsequent event of around 10 per cent in the first year and
trauma are excluded. 5 per cent year thereafter (4).
The disturbance of cerebral function is caused by three The proportion of patients achieving independence in
morphological abnormalities, i.e., stenosis, occlusion or self-care by one year after a stroke range from around
rupture of the arteries. Dysfunction of the brain (“neurological 60 to 83 per cent. This depends on whether the studies are
deficit”) manifests itself by various neurological signs and community-based or hospital-based, which activity is
symptoms that are related to extent and site of the area considered in estimating independence, and the methods
involved and to the underlying causes. These include coma, used to rate ability (4).
hemiplegia, paraplegia, monoplegia, multiple paralysis,
speech disturbances, nerve paresis, sensory impairment, etc. There is evidence that mortality from stroke has been
Of these hemiplegia constitutes the main somatoneurological declining in many countries for several years. Some of the
disorder in about 90 per cent of patients (2). decline occurred before modern treatment methods became
available, indicating that the decline in stroke was associated
Stroke includes a number of syndromes with differing with social and economic changes.
aetiologies, epidemiology, prognosis and treatment. These
are listed below : INDIA
A. Ischaemic stroke Although the prevalence of stroke appears to be
a. Lacunar infarct comparatively less in India than in developed countries, it is
b. Carotid circulation obstruction likely to increase proportionally with the increase in life
c. Vertebro-basilar obstruction expectancy. The proportion of stroke in the young

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 RHEUMATIC HEART DISEASE 431
population is significantly more in India than in developed In summary, control of stroke that was once considered an
countries; some of the more important causes for this are inevitable accompaniment to ageing is now being
likely to be rheumatic heart disease, ischaemic strokes in approached through primary prevention. It has generated the
peripartum period and arteriopathies as a sequale of CNS hope that stroke can be tackled by community health action.
infections like bacterial and tubercular meningitis etc. (5).
References
In India 0.706 million people died of stroke in 2016 of
which 0.372 million were men and 0.334 million were 1. WHO (1980). Bull WHO, 58 :113-130.
2. WHO (1971). Techn. Rep. Ser., No. 469.
women. The crude death rate of stroke was about 54.2 per
3. WHO (2018). Global Health Estimates, April 2018.
100,000 population (3). More recently, in 2020, 73,349
4. WHO (2011). Related Article to the Global Burden of Cerebrovascular
people were diagnosed as having stroke (7). Disease by Truelse T.
5. ICMR (2004). Assessment of Burden of Non-Communicable Diseases,
1. RISK FACTORS Final Report.
Epidemiological studies have indicated that stroke does 6. Pedoe, H.T. (1982). In : Epidemiology of Diseases, Miller, D.L. and
not occur at random, and there are factors (risk factors) R.D.T. Farmer (eds), Blackwell, Oxford.
which precede stroke by several years. These are : 7. Govt, of India (2021), National Health Profile 2021.
(a) Hypertension: This is considered the main risk factor for
cerebral thrombosis as well as cerebral haemorrhage; RHEUMATIC HEART DISEASE
(b) Other factors: Additional factors contributing to risk are Rheumatic fever (RF) and rheumatic heart disease (RHD)
cardiac abnormalities (i.e., left ventricular hypertrophy, cannot be separated from an epidemiological point of
cardiac dilatation), diabetes, elevated blood lipids, obesity, view (1). Rheumatic fever is a febrile disease affecting
smoking, glucose intolerance, blood clotting and viscosity, connective tissues particularly in the heart and joints
oral contraceptives, etc. The importance of these factors is initiated by infection of the throat by group A £ haemolytic
not clearly defined. Although the risk factors for stroke are streptococci. Although RF is not a communicable disease, it
similar to those for CHD, their relative importance differs (6). results from a communicable disease (streptococcal
pharyngitis). Rheumatic fever often leads to RHD which is a
2. TRANSCIENT ISCHAEMIC ATTACKS (TIA)
crippling disease. The consequences of RHD include :
One phenomenon that has received increasing attention continuing damage to the heart; increasing disabilities;
is the occurrence of TIA in a fair proportion of cases. These repeated hospitalization, and premature death usually by the

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are episodes of focal, reversible, neurological deficit of age of 35 years or even earlier. RHD is one of the most
sudden onset and of less than 24 hours duration. They show readily preventable chronic disease.
a tendency to recurrence. They are due to microemboli, and
are a warning sign of stroke. Problem
HOST FACTORS WORLD
(i) Age : Stroke can occur at any age. Usually incidence The incidence of rheumatic fever and rheumatic heart
rates rise steeply with age. Globally about 47 per cent of all disease has not decreased in developing countries.
stroke deaths occur in persons over 70 years. In India, about Retrospective studies reveal developing countries to have
one-fifth of all strokes occur below the age of 40 (called the highest figures for cardiac involvement and recurrence
“strokes in the young”). This is attributed to our “young rates of rheumatic fever. Worldwide, there are over
population”, and shorter life expectancy. 15 million cases of RHD with 500,000 new cases. During
2008, 230,000 deaths from this disease occurred which is
(ii) Sex : The incidence rates are higher in males than
about 0.4 per cent of total deaths (2).
females at all ages.
RHD is a major cause of morbidity and a major cause of
(Hi) Personal history : The WHO Study showed that
mitral insufficiency and stenosis in the world. Variables that
nearly three-quarters of all registered stroke patients had correlate with the severity of valve disease include the
associated diseases, mostly in the cardiovascular system or number of previous attacks of RF, the length of time between
of diabetes. This supports the view that in most cases stroke the onset of disease and start of therapy, and sex (the disease
is merely an incident in the slowly progressive course of a is more severe in females than in males). Insufficiency from
generalized vascular disease. acute rheumatic valve disease resolves in 60-80 per cent of
Stroke control programme patients who adhere to antibiotic prophylaxis (3).
The aim of a stroke control programme is to apply at In a number of affluent countries (North America,
community level effective measures for the prevention of Western Europe and in Japan) the incidence of RF and the
stroke. The first priority goes to control of arterial hypertension prevalence of and mortality from RHD have fallen during
which is a major cause of stroke. As transcient ischaemic the last two decades, where the disease is now generally
attacks (TIA) may be one of the earliest manifestations of uncommon. Some of this decline occurred before modern
stroke, their early detection and treatment is important for the treatment methods became available, indicating that the fall
prevention of stroke (2). Control of diabetes, elimination of in prevalence and incidence was associated with social and
smoking, and prevention and management of other risk factors economic changes (4).
at the population level are new approaches. Treatment for As a result of the above decline, there has been a
acute stroke is largely the control of complications. Facilities for tendency to minimize the public health importance of RF -
the long-term follow-up of patients are essential. The the assumption being that the disease may subside or even
education and training of health personnel and of the public vanish spontaneously as living standards rise. However,
form an integral part of the programme. For any such even in the most affluent countries, there remain pockets of
programme, reliable knowledge of the extent of the problem in poverty where socio-economic conditions continue to favour
the community concerned is essential (2). the persistence of RF (5).

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432 NON-COMMUNICABLE DISEASES

INDIA the high incidence of “juvenile mitral stenosis” in India (9,

10). The initial attack of RF occurs at a young age,
In India, RHD is prevalent in the range of 5-7 per
progresses to valvular lesions faster and is associated with
thousand in 5-15 years age group and there are about
pulmonary arterial hypertension. The cause of the
1 million RHD cases in India. RHD constitutes 20-30% of
“juvenile” disease in India is not known, (b) SEX : The
hospital admissions due to CVD in India (6). Streptococcal
disease affects both sexes equally but prognosis is worse for
infections are very common especially in children living
females than for males, (c) IMMUNITY : An immunological
in under-privileged conditions, and RF is reported to occur
basis for RF and RHD has been proposed. The most
in 1-3 per cent of those infections (7).
prevalent concept is the toxic-immunological hypothesis.
Jai Vigyan Mission Mode project on Community Control According to this theory, group A streptococcal products
of RF/RHD in India is being carried out with four main have certain toxic products, and components of the
components, viz. to study the epidemiology of streptococcal streptococcus and of host tissues have an .antigenic cross­
sore throats, establish registries for RF and RHD, vaccine relationship, leading to immunological processes that result
development for streptococcal infection and conducting in an attack of RF (11). (d) SOCIO-ECONOMIC STATUS :
advanced studies on pathological aspects of RF and RF is a social disease linked to poverty, overcrowding, poor
RHD (7). housing conditions, inadequate health services, inadequate
expertise of health-care providers and a low level of
Epidemiological factors awareness of the disease in the community. It declines
sharply when the standard of living is improved, but even in
1. AGENT FACTORS the most affluent countries, there are areas where the
(a) AGENT : The onset of RF is usually preceded by a disease still exists, (e) HIGH-RISK GROUPS : The school­
streptococcal sore throat. Of the streptococci, it is the group age children between 5 and 15 years; slum dwellers; and
A streptococcus that has been incriminated as the causative those living in a closed community (e.g., barracks).
agent. It has been suggested that not all strains of group A Table 1 summarizes the effects of environmental factors
streptococci lead to RF; it is believed that there might be on RF and RHD.
some strains with “rheumatogenic potential”. The serotype
that has attracted special emphasis is M type 5 which is Clinical features
frequently associated with RF (8). All group A streptococci (a) FEVER : Fever is present at the onset of acute illness

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are sensitive to penicillin. Unfortunately, the group consists and may be accompanied by profuse sweating. It may last
of a great number of immunologically different types with for about 12 weeks or longer and has a tendency to recur,
little cross immunity, defying all attempts to produce an (b) POLYARTHRITIS: This occurs in 90 per cent of cases.
effective vaccine. Recently the virus (coxsackie B4) has been Large joints like ankles, knees, elbows and wrists are
suggested as a causative factor and streptococcus acting as a involved; uncommonly smaller joints of hands and feet may
conditioning agent. There are many gaps in our knowledge be involved. The pain and swelling come on quickly and
about the causative agent and underlying pathogenic also subside spontaneously within 5-7 days. There is no
mechanisms, (b) CARRIERS : Carriers of group A residual damage to the joint, (c) CARDITIS : Occurs in
streptococcus are frequent, e.g., convalescent, transcient 60-70 per cent of cases. It starts early in the course of RF.
and chronic carriers. In view of the high carrier rate, their Moreover RHD may not be preceded by a clinically apparent
eradication is not even theoretically possible (9). attack of RF. All layers of the heart- pericardium,
myocardium and the heart valves - are involved. The
2. HOST AND ENVIRONMENTAL FACTORS involvement of heart is manifested by tachycardia, cardiac
(a) AGE : RF is typically a disease of childhood and murmurs, cardiac enlargement, pericarditis and heart
adolescence (5-15 years) although it also occured in adults failure. The most common ECG finding is the first degree AV
(20 per cent cases). Mention has already been made about block, (d) NODULES : Nodules below the skin tend to

TABLE 1
Direct and indirect results of enviromental and health-system determinants
on rheumatic fever and rheumatic heart disease

Determinants Effects Impact on RF and RHD burden

Socio-economic and Rapid spread of group A Higher incidence of acute streptococcal-pharyngitis
environmental factors : streptococcal strains. and suppurative complications.
(poverty, undernutrition, Difficulties in accessing health Higher incidence of acute RF.
overcrowding, poor housing). care. Higher rates of recurrent attacks.
Health-system related factors : Inadequate diagnosis and Higher incidence of acute RF and
- shortage of resources for treatment of its recurrence.
health care; streptococcal pharyngitis
- inadequate expertise Misdiagnosis or late diagnosis Patients unaware of the first RF
of health-care providers; of acute RF. episode.
More severe evolution of disease
1 - Low-level awareness of the Inadequate secondary prophylaxis Untimely initiation or lack of
disease in the community and/or non-compliance with secondary prophylaxis.
secondary prophylaxis. Higher rates of recurrent attacks with more
frequent and severe heart valve involvement,
and higher rates of repeated hospital admissions
and expensive surgical interventions.
Source : (12)

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 RHEUMATIC HEART DISEASE __433
appear 4 weeks after the onset of RF. They are small, The diagnosis of RF in the whole population with evidence
painless and non-tender. They last for a variable period of of antecedent group A p-hemolytic streptococcal infection
time and then disappear leaving no residual damage. requires a confirmation of two major criteria or one major
(e) BRAIN INVOLVEMENT: This manifests as abnormal and two minor criteria - the first episode of the disease.
jerky purposeless movements of the arms, legs and the body. Diagnosis of subsequent episodes of the disease requires
It gradually disappears leaving no residual damage. a confirmation of two major criteria or one major and two
(f) SKIN : Various types of skin rash are known to occur. It is minor criteria or three minor criteria.
thus obvious that except carditis all other manifestations of
RF do not cause permanent damage. Echocardiographic examination is currently the main
diagnostic tool used for confirmation, diagnosis and
Diagnosis monitoring of valvular lesions in the course of RF, especially
The 2015 WHO criteria for the diagnosis of RF and RHD in cases of subclinical carditis.
are based on revised Jones criteria (Table 2). Subclinical carditis is one in which physical examination
In the revised 2015 Jones criteria, a low, medium and does not confirm any lesions in auscultation over the heart.
high-risk population was identified. A low risk population is Only echocardiography (Doppler) reveals mitral or aortic
one in which cases of acute RF occur in < 2/100 000 school­ valve pathology.
age children or rheumatic heart disease is diagnosed in < 1/ The echocardiographic criteria developed by AHA in
1000 patients at any age during one year. 2012 are as follows (13) :
The modifications introduced in 2015 in the Jones I. Echocardiographic (Doppler) criteria :
criteria are as follows : • Pathological mitral regurgitation-4 criteria (all must be
1. In the major criteria: met) :
- Low risk population : clinical and/or subclinical 1. Visible at least in 2 projections.
carditis. AHA recommends that all the patients with 2. Regurgitation jet length > 2 cm at least in 1 projection.
suspected RF undergo Doppler echocardiographic 3. Regurgitation peak velocity > 3 m/s.
examination, even if no clinical signs of carditis are 4. Regurgitation pansystolic.
present. In doubtful cases it is recommended that
echocardiography is repeated. • Pathological aortic regurgitation-4 criteria (all must be
met) :

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- Medium and high risk population : also clinical and/or
1. Visible at least in 2 projections.
subclinical carditis and arthritis - monoarthritis or
polyarthritis, possibly also with polyarthralgia. 2. Regurgitation jet length >1 cm at least in 1 projection.
3. Regurgitation peak velocity > 3 m/s.
2. In the minor criteria: 4. Regurgitation pandiastolic.
- Low risk population : the parameters of inflammation
and the level of fever were defined precisely. Prevention
- Medium and high risk population : monoarthralgia, Two preventive approaches are possible :
also with defined parameters of inflammation and the
level of fever. a. PRIMARY PREVENTION
TABLE 2 The aim of primary prevention is to prevent the first
Diagnostic criteria for rheumatic fever attack of RF, by identifying all patients with streptococcal
modified 2015 Jones criteria throat infection and treating them with penicillin. While this
approach is theoretically simple, in practice, it is difficult to
Major criteria achieve and may not be feasible in many developing
Low risk population High risk population countries (4). In order to prevent a single case of RHD,
several thousand cases of streptococcal throat infection must
Carditis (clinical or subclinical) Carditis (clinical or subclinical) be identified and treated. Many infections are inapparent or
Arthritis - only polyarthritis Arthritis - monoarthritis or if apparent are not brought to the attention of the health
polyarthritis
services; even if they are reported, quick and reliable
Chorea Polyarthralgia
laboratory services are needed to confirm the diagnosis.
Erythema marginatum Chorea
Subcutaneous nodules Erythema marginatum A viable approach is to concentrate on “high-risk” groups
Subcutaneous nodules such as school-age children. They should be kept under
surveillance for streptococcal pharyngitis. Ideally a sore throat
Minor criteria should be swabbed and cultured. If streptococci are present,
the child should be put on penicillin. Since facilities for throat
Low risk population High risk population
swab culture are not easily available, it is justified to treat a
Polyarthralgia Monoarthralgia sore throat with penicillin even without having the culture. For
Hyperpyrexia (> 38.5°C) Hyperpyrexia (> 38.0°C) this purpose, a single intramuscular injection of 1.2 million
ESR > 60 mm/h and/or ESR > 30 mm/h and/or units of benzathine benzyl penicillin for adults and 600,000
CRP > 3.0 mg/dl CRP >3.0 mg/dl units for children is adequate, or oral penicillin (Penicillin V or
Prolonged PR interval (after Prolonged PR interval (after Penicillin G) should be given for 10 days. This is the least
taking into account the taking into account the expensive method of giving penicillin for eradication of
differences related to age; if differences related to age; if
streptococci from the throat. For patients with allergy to
there is no carditis as a there is no carditis as a
major criterion) major criterion) penicillin, first generation cephalosporins i.e., cefodroxil or
cefalexin is used. The other drugs used - erythromycin,
ESR - erythrocyte sedimentation rate; CRP - C-reactive protein clarithromycin and azithromycin (13). The MCH and school
Source : (13) health services should be utilized for this purpose.

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434 NON-COMMUNICABLE DISEASES

In short, the impossible logistics of primary prevention

coupled with enormous financial constraints force us to CANCER
concentrate on secondary prevention (10).
Cancer may be regarded as a group of diseases
b. SECONDARY PREVENTION characterized by an (i) abnormal growth of cells (ii) ability to
Secondary prevention (i.e., the prevention of recurrences invade adjacent tissues and even distant organs, and (iii) the
of RF) is a more practicable approach, especially in eventual death of the affected patient if the tumour has
developing countries. It consists in identifying those who progressed beyond that stage when it can be successfully
have had RF and giving them one intramuscular injection of removed. Cancer can occur at any site or tissue of the body
benzathine benzyl penicillin (1.2 million units in adults and and may involve any type of cells.
600,000 units in children) at intervals of 3 weeks (12). This The major categories of cancer are : (a) Carcinomas,
must be continued for at least 5 years or until the child which arise from epithelial cells lining the internal surfaces
reaches 21 years whichever is later. For patients with carditis of the various organs (e.g. mouth, oesophagus, intestines,
(mild mitral regurgitation or healed carditis) the treatment uterus) and from the skin epithelium; (b) Sarcomas, which
should continue for 10 years after the last attack, or at least arise from mesodermal cells constituting the various
until 40 years of age, which ever is longer. More severe connective tissues (e.g. fibrous tissue, fat and bone); and
valvular disease or post-valve surgery cases need life-long (c) Lymphomas, myeloma and leukaemias arising from the
treatment (13). This prevents streptococcal sore throat and cells of bone marrow and immune systems.
therefore recurrence of RF and RHD.
The term “primary tumour” is used to denote cancer in
However, the crucial problem is one of patient the organ of origin, while “secondary tumour” denotes
compliance as penicillin prophylaxis is a long-term affair. cancer that has spread to regional lymph nodes and distant
Studies have shown that secondary prevention is feasible, organs. When cancer cells multiply and reach a critical size,
inexpensive and cost-effective, when implemented through the cancer is clinically evident as a lump or ulcer localized to
primary health care systems (13). the organ of origin in early stages. As the disease advances,
c. NON-MEDICAL MEASURES symptoms and signs of invasion and distant metastases
become clinically evident (1).
Non-medical measures for the prevention/control of RF
are related to improving living conditions, and breaking the Problem statement

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poverty-disease-poverty cycle. Improvements in socio­
economic conditions (particularly better housing) will in the WORLD
long term reduce the incidence of RF. In the year 2020, the global burden of cancer rose to an
Objective evaluation of available data indicates that estimated 19.292 million new cases with 9.958 million
penicillin alone will not lead to effective control. Predictions deaths. The most common cancer diagnosed were cancer
suggest that many of the countries which suffer severe breast followed by cancer lung, prostate, colon and stomach.
economic constraints will not be likely to be able to raise The most common cause of death due to cancer was cancer
their standards of living in the foreseeable future to lung, cancer liver, cancer stomach and cancer breast. The
significantly alter the incidence of this disease (9). summary statistics for the year 2020 is as follows (2) :
d. EVALUATION
Males Females Both sexes
In the evaluation of the programme, the prevalence of Population 3,929,973,836 3,864,824,712 7,794,798,844
RHD in school children from periodic surveys of random
Number of new 10,065,305 9,227,484 19,292,789
samples is probably the best indicator. It is suggested that cancer cases
surveys should be carried out on samples of schools (not Age-standardized 222.0 186.0 201.0
individuals) in the 6-14 years age group at 5-year intervals. incidence rate (World)
The recommended sample size is 20,000 to 30,000 children Risk of developing cancer 22.6 18.6 20.4
depending upon the expected prevalence (14). before the age of
75 years (%)
References Number of 5,528,810 4,429,323 9,958,133
1. WHO (1969). WHO Chronicle, 28:345. cancer deaths
2. WHO (2011). Disease and Injuries, Regional Estimates, Cause Specific Age-standardized 120.8 84.2 100.7
Mortality, Estimates for 2008. mortality rate (World)
3. Medscape (2012). Thomas K Chin, Paediatric Rheumatic Heart Risk of dying from cancer 12.6 8.9 10.7
Disease Ouerview Epidemiology, May 30th, 2012. before the age of 75 years (%)
4. WHO (1986). Techn Rep. Ser. No. 732.
5. Strasser, T. and Rotta J. (1973) WHO Chronicle, 27 (2) 49-54. 5-year prevalent cases 24,828,480 25,721,807 50,550,287
6. Govt, of India (2006). Health Information of India, 2005, Min. of Top 5 most frequent Lung Breast Breast
Health and Family Welfare New Delhi. cancers excluding Prostate Colorectum Lung
7. Govt of India (2004). Annual Report 2003-2004, Ministry of Health non-melanoma Colorectum Lung Colorectum
and Family Welfare, New Delhi. skin cancer Stomach Cervix uteri Prostate
8. Kaplan, E.L. (1985). /nt. J. Epi, 14 (4) 499. (ranked by cases) Liver Thyroid Stomach
9. Strasser, T. (1978). WHO Chronicle, 32 (1) 18-25. The age standardized incidence rate of top 10 cancers by
10. Wahi, P.L. (1984). Ann Acad. Med. Sci. (India) 20 (4) 199-215.
sex, and age standardized incidence and mortality rate of
11. El Kholy, A. et al (1978). Bull WHO, 56:887.
top 10 cancers worldwide are as shown in Fig. 1 and 2.
12. WHO (2004), Tech. Rep. Ser. No. 923.
13. Szczggielska Izabela et.al. (2018), Rheumatic fever-new diagnostic As a consequence of growing and ageing populations, as
criteria, Rheumatologia 2018 : 56 (1) : 37-41. well as changes in the prevalence and distribution of main
14. Strasser, T. et al (1981), Bull WHO, 59 : 285-294. risk factors for cancer, several of which are associated with

by R△J
 CANCER 435

ASR (World) per 100,000

FIG. 1
Age standardized (World) incidence rates by sex, top 10 cancers
Source : (2)

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FIG. 2
Age standardized (World) incidence and mortality rates, top 10 cancers
Source : (2)

socio-economic development, developing countries are prostate and colorectal cancers. This westernization effect is
disproportionately affected by the increasing numbers of a result of reduction in infection-related cancers and
cancers. increase in cancers associated with reproductive, dietary
For both sexes combined, one-half of all cases and and hormonal risk factors (4).
58.3 per cent of cancer deaths are estimated to occur in Asia For any disease, the relationship of incidence to mortality
in 2020, where 59.5 per cent of the global population is an indication of prognosis. Similar incidence and mortality
resides. Europe accounts for 22.8 per cent of the total rates being indicative of an essentially fatal condition. Thus,
cancer cases and 19.6 per cent of the cancer deaths, lung cancer accounts for most deaths from cancer in the
although it represents 9.7 per cent of the global population, world (1.7 million) annually, since it is most invariably
followed by the Americas’ 20.9 per cent of incidence and associated with poor prognosis. On the other hand,
14.2 per cent of mortality worldwide. In contrast to other appropriate intervention is often effective in avoiding fatal
regions, the share of cancer deaths in Asia (58.3 per cent) outcome following diagnosis of breast cancer. Hence this
and Africa (7.2 per cent) are higher than the share of particular cancer, which rank second in terms of incidence,
incidence (49.3 per cent and 5.7 per cent, respectively) is not among the top three causes of death from cancer,
because of the different distribution of cancer types and which are respectively cancers of the lung, stomach, and
higher case fatality rates in these regions (3^. liver.
The “Westernization” trends : As low human-development The most conspicuous feature of the distribution of
index (HDI) countries become more developed through cancers between the sexes is the male predominance of lung
rapid societal and economic changes, they are likely to cancer. Prostate, colorectal, stomach and liver cancer are
become “westernized”. As such, the pattern of cancer also much more common in males. Cancer of breast,
incidence is likely to follow that seen in high HDI settings, colorectum, lung, cervix, uteri and stomach are common in
with likely decline in cancer incidence rate of cervix uteri females (5). For the most part, differences in distribution
and stomach, and increasing incidence rates of breast, between the sexes are attributable to differences in exposure

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436 NON-COMMUNICABLE DISEASES

to causative agents rather than to variation in the Summary statistics 2020, India
susceptibility. For other tumour types, including cancers of
Males Females Both sexes
pancreas and colorectum, there is little difference in the sex
distribution. Generally speaking, the relationship of Population 717,100,976 662,903,415 1,380,004,378
incidence to mortality is not affected by sex. Thus for Number of new 646,030 678,383 1,324,413
example, the prognosis following diagnosis of liver or cancer cases
pancreatic cancer is dismal for both males and Age-standardized 95.7 99.3 97.1
incidence rate
females. Many other tumour types are more responsive to
Risk of developing cancer 10.4 10.5 10.4
therapy, so that cancers of breast, prostate and uterine before the age of
cervix are the cause of death in only a minority of patients 75 years (%)
diagnosed (6). Number of 438,297 413,381 851,678
The burden of cancer is distributed unequally between cancer deaths
developed and developing countries, with particular cancer Age-standardized 65.4 61.0 63.1
mortality rate
types exhibiting different patterns of distribution.
Risk of dying from cancer 7.4 6.7 7.1
before the age of 75 years (%)
INDIA
5-year prevalent case is 1,208,835 1,511,416 2,720,251
In India, the National Cancer Registry Programme of the Top 5 most frequent Lip, oral cavity Breast Breast
ICMR provides data on incidence, mortality and distribution cancers excluding Lung Cervix uteri Lip, oral cavity
of cancer from 28 population-based registries and 5 hospital non-melanoma Stomach Ovary Cervix uteri
based registries. skin cancer Colorectum Lip, oral cavity Lung
(ranked by cases) Oesophagus Colorectum Colorectum
In India, in the year 2020, the number of prevalent cases
(5 years) is about 2,720,251, the number of new cases Source : (7)
1,324,413 and the number of deaths 851,678. The The age standardized incidence rate of top 10 cancers by
summary statistical situation for the year 2020 in the sex, and age standardized mortality rate and incidence rate
country is as follows : per lakh population in India is as shown in Fig. 3 and 4 (7)

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FIG. 3
Age standardized incidence rates by sex, top 10 cancers in India (2020)

ASRper 100,000
FIG. 4
Age standardized incidence and mortality rates, top 10 cancers in India (2020)

by R△J
 CANCER

The five most frequent cancers in men were cancer lip 80 to 90 per cent of all human cancers. The major
and oral cavity, lung, stomach, colorectum and oesophagus, environmental factors identified so far include :
and in women, cancer breast, cervix uteri, ovary, lip, oral (a) TOBACCO : Tobacco in various forms of its usage (e.g.,
cavity and colorectum. Cancer in males were mostly tobacco smoking, chewing) is the major environmental cause of
related. In women, cervical cancer is closely associated with cancers of the lung, larynx, mouth, pharynx, oesophagus,
poor genital hygiene, early consummation of marriage, bladder, pancreas and probably kidney. It has been estimated
multiple pregnancies, and contact with multiple sexual that, in the world as a whole, cigarette smoking is now
partners. It is also reported that breast cancer is responsible for more than one million premature deaths each
proportionately on the increase in a few metropolitan areas year (9). (b) ALCOHOL : Excessive intake of alcoholic
of India. This appears to be related to late marriage, birth of beverages is associated with oesophageal and liver cancer.
the first child at a late age, fewer children, and shorter Some recent studies have suggested that beer consumption
periods of breast-feeding, which are increasingly common may be associated with rectal cancer (10). It is estimated that
practice among the educated urban women (8). alcohol contributed to about 3 per cent of all cancer
Facilities for screening and proper management of cancer deaths (11). (c) DIETARY FACTORS : Dietary factors are also
patients are grossly limited in India. More than two-thirds of related to cancer. Smoked fish is related to stomach cancer,
cancer patients are already in an advanced and incurable dietary fibre to intestinal cancer, beef consumption to bowel
stage at the time of diagnosis. Appropriate strategies are cancer and a high fat diet to breast cancer. A variety of other
being developed, including creating public awareness about dietary factors such as food additives and contaminants have
cancer, tobacco control and application of self or assisted fallen under suspicion as causative agents. (Refer to chapter
screening technique for oral, cervical, and breast cancers. 12 for further details.) (d) OCCUPATIONAL EXPOSURES :
Time trends These include exposure to benzene, arsenic, cadmium,
chromium, vinyl chloride, asbestos, polycyclic hydrocarbons,
Few decades ago, cancer was the sixth leading cause of etc. Many others remain to be identified. The risk of
death in industrialized countries; today, it is the second occupational exposure is considerably increased if the
leading cause of death. There are a number of reasons for this individuals also smoke cigarettes. Occupational exposures
increase, the three main ones being a longer life expectancy, are usually reported to account for 1 to 5 per cent of all
more accurate diagnosis and the rise in cigarette smoking, human cancers (12). (e) VIRUSES : An intensive search for a
especially among males. The overall rates do not reflect the

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viral origin of human cancers revealed that hepatitis B and C
different trends according to the type of cancer. For example, virus is causally related to hepatocellular carcinoma. The
there has been a large increase in lung cancer incidence and relative risk of Kaposi’s sarcoma occurring in patients with
the stomach cancer has shown a declining trend in most HIV infection is so high that it was the first manifestation of
developed countries for reasons not understood.
the AIDS epidemic to be recognized. Non-Hodgkin’s
Cancer patterns lymphoma, a cancer of the lymph nodes and spleen is a late
complication of AIDS. The Epstein-Barr virus (EBV) is
There are wide variations in the distribution of cancer associated with 2 human malignancies, viz. Burkitt’s
throughout the world. That cancer of the stomach is very
lymphoma and nasopharyngeal carcinoma. Cytomegalovirus
common in Japan, and has a low incidence in United States.
(CMV) is a suspected oncogenic agent and classical Kaposi’s
The cervical cancer is high in Columbia and has a low
incidence in Japan. In the South-East Asia Region of WHO, sarcoma is associated with a higher prevalence of antibodies
the great majority are cancers of the oral cavity and uterine to CMV. Human papilloma virus (HPV) is a chief suspect in
cervix. These and other international variations in the cancer cervix. Hodgkin’s disease is also believed to be of viral
pattern of cancer are attributed to multiple factors such as origin. The human T-cell leukaemia virus is associated with
environmental factors, food habits, lifestyle, genetic factors adult T-cell leukaemia/lymphoma in the United States and
or even inadequacy in detection and reporting of cases. southern parts of Japan (6, 13). (f) PARASITES : Parasitic
infections may also increase the risk of cancer, as for
Hospital data clearly indicates that the two organ sites example, schistosomiasis in Middle East producing
most commonly involved are: (i) the uterine cervix in carcinoma of the bladder, (g) CUSTOMS, HABITS AND
women, and (ii) the oropharynx in both sexes. These two
LIFESTYLES : To the above causes must be added customs,
sites represent approximately 50 per cent of all cancer cases.
habits and lifestyles of people which may be associated with
Both these cancers are predominantly environment related
an increased risk for certain cancers. The familiar examples
and have a strong socio-cultural relationship. It is also
are the demonstrated association between smoking and lung
important to note that these two kinds of cancer are easily
accessible for physical examination and amenable to early cancer, tobacco and betel chewing and oral cancer, etc (14).
diagnosis by knowledge already available, i.e., good clinical (h) OTHERS : There are numerous other environmental
examination and exfoliative cytology. The cure rate for these factors such as sunlight, radiation, air and water pollution,
neoplasma is also very high if they are treated surgically at medications (e.g., oestrogen) and pesticides which are
stages I and II. But unfortunately, in most cases, the patients related to cancer.
present themselves to a medical facility when the disease is
far advanced and is not amenable to treatment. This is the 2. GENETIC FACTORS
crux of the problem. Genetic influences have long been suspected. For
example, retinoblastoma occurs in children of the same
Causes of cancer parent. Mongols are more likely to develop cancer
As with other chronic diseases, cancer has a multifactorial (leukaemia) than normal children. However, genetic factors
aetiology. are less conspicuous and more difficult to identify. There is
probably a complex interrelationship between hereditary
1. ENVIRONMENTAL FACTORS susceptibility and environmental carcinogenic stimuli in the
Environmental factors are generally held responsible for causation of a number of cancers.
by R△J
438 NON-COMMUNICABLE DISEASES

Cancer control There is no doubt that the possibilities for primary

Cancer control consists of a series of measures based on prevention are many. Since primary prevention is directed at
present medical knowledge in the fields of prevention, large population groups (e.g., high risk groups, school
detection, diagnosis, treatment, after care and rehabilitation, children, occupational groups, youth clubs), the cost can be
aimed at reducing significantly the number of new cases, high and programmes difficult to conduct. Primary
increasing the number of cures and reducing the invalidism prevention, although a hopeful approach, is still in its early
due to cancer. stages. Major risk factors have been identified for a small
number of cancers only and far more research is needed in
The basic approach to the control of cancer is through that direction.
primary and secondary prevention. It is estimated that at
least one-third of all cancers are preventable (15). 2. SECONDARY PREVENTION
1. PRIMARY PREVENTION Secondary prevention comprises the following measures :
Cancer prevention until recently was mainly concerned i) CANCER REGISTRATION
with the early diagnosis of the disease (secondary Cancer registration is a sine qua non for any cancer
prevention), preferably at a precancerous stage. Advancing control programme. It provides a base for assessing the
knowledge has increased our understanding of causative magnitude of the problem and for planning the necessary
factors of some cancers and it is now possible to control services. Cancer registries are basically of two types :
these factors in the general population as well as in hospital-based and population based, (a) HOSPITAL­
particular occupational groups. They include the following : BASED REGISTRIES: The hospital-based registry includes
(a) CONTROL OF TOBACCO AND ALCOHOL all patients treated by a particular institution, whether in­
CONSUMPTION : Primary prevention offers the greatest patients or out-patients. Registries should collect the
hope for reducing the number of tobacco-induced and uniform minimum set of data recommended in the “WHO
alcohol related cancer deaths. It has been estimated that Handbook for Standardized Cancer Registers” (17). If there
control of tobacco smoking alone would reduce the total is a long-term follow-up of patients, hospital-based registries
burden of cancer by over a million cancers each year (16). can be of considerable value in the evaluation of
(b) PERSONAL HYGIENE: Improvements in personal diagnostic and treatment programmes. Since hospital
hygiene may lead to declines in the incidence of certain types population will always be a selected population, the use of

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of cancer, e.g., cancer cervix, (c) RADIATION: Special efforts these registries for epidemiological purposes is thus limited.
should be made to reduce the amount of radiation (including (b) POPULATION-BASED REGISTRIES : A right step is to
medical radiation) received by each individual to a minimum set up a “hospital-based cancer registry” and extend the
without reducing the benefits, (d) OCCUPATIONAL same to a “population-based cancer registry”. The aim is to
EXPOSURES : The occupational aspects of cancer are cover the complete cancer situation in a given geographic
frequently neglected. Measures to protect workers from area. The optimum size of base population for a population
exposure to industrial carcinogens should be enforced in based cancer registry is in the range of 2-7 million (18). The
industries, (e) IMMUNIZATION : In the case of primary liver data from such registries alone can provide the incidence
cancer, immunization against hepatitis B virus and for rate of cancer and serve as a useful tool for initiating
prevention of cancer cervix immunization against HPV epidemiological enquiries into causes of cancer, surveillance
presents an exciting prospect, (f) FOODS, DRUGS of time trends, and planning and evaluation of operational
AND COSMETICS: These should be tested for carcinogens. activities in all main areas of cancer control.
(g) AIR POLLUTION : Control of air pollution is another
preventive measure, (h) TREATMENT OF PRECANCEROUS ii) EARLY DETECTION OF CASES
LESIONS : Early detection and prompt treatment of Cancer screening is the main weapon for early detection
precancerous lesions such as cervical tears, intestinal of cancer at a pre-invasive (in situ) or pre-malignant stage.
polyposis, warts, chronic gastritis, chronic cervicitis, and Effective screening programmes have been developed for
adenomata is one of the cornerstones of cancer prevention. cervical cancer, breast cancer and oral cancer. Like primary
(i) LEGISLATION : Legislation has also a role in primary prevention, early diagnosis has to be conducted on a large
prevention. For example, legislation to control known scale; however, it may be possible to increase the efficiency
environmental carcinogens (e.g., tobacco, alcohol, air of screening programmes by focussing on high-risk groups.
pollution), (j) CANCER EDUCATION : An important area of Clearly, there is no point in detecting cancer at an early
primary prevention is cancer education. It should be directed stage unless facilities for treatment and after-care are
at “high-risk” groups. The aim of cancer education is to available. Early detection programmes will require
motivate people to seek early diagnosis and early treatment. mobilization of all available resources and development of a
Cancer organizations in many countries remind the public of cancer infrastructure starting at the level of primary health
the early warning signs (“danger signals”) of cancer. These care, ending with complex cancer centres or institutions at
are : the state or national levels.
a. a lump or hard area in the breast
Hi) TREATMENT
b. a change in a wart or mole
c. a persistent change in digestive and bowel habits Treatment facilities should be available to all cancer
patients. Certain forms of cancer are amenable to surgical
d. a persistent cough or hoarseness
removal, while some others respond favourably to radiation
e. excessive loss of blood at the monthly period or loss of or chemotherapy or both. Since most of the known methods
blood outside the usual dates of treatment have complementary effect on the ultimate
f. blood loss from any natural orifice outcome of the patient, multi-modality approach to cancer
g. a swelling or sore that does not get better control has become a standard practice in cancer centres all
h. unexplained loss of weight. over the world. In the developed countries today, cancer
by R△J
 CANCER 439
treatment is geared to high technology. For those who are VIA or VIAM. The test is followed by a single visit approach
beyond the curable stage, the goal must be to provide pain for further investigation and management at district hospital.
relief. A largely neglected problem in cancer care is the The management at district hospital is planned in such a
management of pain. The WHO has developed guidelines way that the treatment based on colposcopy is offered in the
on relief of cancer pain (19). “Freedom from cancer pain” is same visit. Pap smear and biopsy are the investigations that
now considered a right of cancer patients. are done to ensure that there are cytological and
histopathological back-up for the interventions (21).
CANCER SCREENING With its updated guidelines, WHO now encourages
In the light of present knowledge, early detection and countries to use HPV tests for cervical screening, including
prompt treatment of early cancer and precancerous HPV DNA and HPV mRNA tests. HPV-DNA testing detects
conditions provide the best possible protection against high-risk strains of HPV, which cause almost all cervical
cancer for the individual and the community. Now a good cancers; and HPV mRNA detects HPV infections leading to
deal of attention is being paid to screening for early cellular transformation. Unlike tests that rely on visual
detection of cancer. This approach, that is, cancer screening inspection, HPV-testing is an objective test. It has been
may be defined as the “search for unrecognized malignancy shown to be simpler, prevents more pre-cancers and cancer,
by means of rapidly applied tests”. and saves more lives. It is also more cost-effective than
visual inspection techniques or cytology (commonly known
Cancer screening is possible because : (a) in many as ‘pap smears’). Screening should start from 30 years of
instances, malignant disease is preceded for a period of age in the general population of women, with regular
months or years by a premalignant lesion, removal of which screening with a validated HPV test every 5 to 10 years, and
prevents subsequent development of cancer; (b) most from 25 years of age for women living with HIV. Women
cancers begin as localized lesions and if found at this stage a living with HIV also need to be screened more frequently,
high rate of cure is obtainable; and (c) as much as 75 per every 3 to 5 years. Screening must be linked to treatment
cent of all cancers occur in body sites that are accessible. and management of positive screening tests. HPV positive
METHODS OF CANCER SCREENING women may be treated without diagnostic verification in
limited resourced settings. A test to triage the HPV positive
(a) Mass screening by comprehensive cancer detection women (e.g. VIA) is essential for treating HIV positive
examination: A rapid clinical examination, and examination of women (20).

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one or more body sites by the physician is one of the important
approaches for screening for cancer, (b) Mass screening at Intensive information, education and communication
single sites: This comprises examination of single sites such as activities are required to sensitize the community about the
uterine cervix, breast or lung, (c) Selective screening : This significance of the disease and its early detection through
refers to examination of those people thought to be at special screening.
risk, for example, parous women of lower socio-economic
strata upwards of 30 years of age for detection of cancer cervix, 2. Screening for breast cancer
chronic smokers for lung cancer, etc. There is evidence that screening for breast cancer has a
favourable effect on mortality from breast cancer. The basic
1. Screening for cancer cervix techniques for early detection of breast cancer are :
Screening for cervical cancer has become an accepted (a) breast self-examination (BSE) by the patient (b) palpation
clinical practice. The prolonged early phase of cancer in situ by a physician (c) thermography, and (d) mammography.
can be detected by the Pap smear. Current policy suggests All women should be encouraged to perform breast self­
that all women should have a Pap test (cervical smear) at the examination. Breast cancers are more frequently found by
age of 30 years, and then every 3 years thereafter. A women themselves than by a physician during a routine
periodic pelvic examination is also recommended. examination. Although the effectiveness of BSE has not been
Organized population based screening programmes have adequately quantified, it is a useful adjuvant to early case
reduced the incidence and mortality from cervical cancer in detection. In many countries, BSE will probably be the only
many developed countries. feasible approach to wide population coverage for a long
However, screening for cancer cervix using Pap smear time to come. Palpation is unreliable for large fatty breasts.
requires excessive resources in terms of laboratories, Thermography has the advantage that the patient is not
equipments and trained personnels. This has led to search exposed to radiation. Unfortunately, it is not a sensitive tool.
for an alternative screening method that can be more cost- Mammography is most sensitive and specific in detecting
effective. Visual inspection based screening tests such as small tumours that are sometimes missed on palpation. The
visual inspection with 5 per cent acetic acid (VIA), VIA with use of mammography has three potential drawbacks:
magnification (VIAM), and visual inspection post application (i) exposure to radiation. This may amount to a dose of
of Lugol's iodine (VILI) are some of the alternative screening 500 milliroentgen compared to a 30-40 milliroentgen dose
tests, which have been studied for their effectiveness in received in chest X-ray. Therefore, there has been concern
India. Sensitivity of VIA tends to be similar to cytology based about exposure to radiation from repeated mammographies
screening. It is easy to carry out and easy to train and the risk of breast cancer developing as a result
appropriate health workers (21). (ii) mammography requires technical equipment of a
The strategy is to screen women using visual inspection high standard and radiologists with very considerable
after application of freshly prepared 5 per cent acetic acid experience - these two factors limit its more widespread use
solution (5 ml of glacial acetic acid mixed with 95 ml distilled for mass screening purposes, and (iii) biopsy from a
water). Detection of well-defined opaque acetowhite lesions suspicious lesion may end up in a false-positive in as many
close to the squamo-columnar junction, well defined circum- as 5-10 cases for each case of cancer detected.
orificial acetowhite lesion or dense acetowhitening of Although recent evidence points to the superiority of
ulceroproliferative growth on the cervix constiute a positive mammography over clinical examination in terms of sensitivity
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 NON-COMMUNICABLE DISEASES
440
and specificity (22j, medical opinion is against routine of manufactured cigarettes. The indigenous forms of
mammography on the very young. Women under 35 years of smoking are : bidi, chutta (cigar), chilum, hookah (hubble-
age should not have X-rays unless they are symptomatic or a bubble). Tobacco in powdered form is inhaled as snuff.
family history of early onset of breast cancer (23). The most common form of tobacco chewing in India is
3. Screenins for lung cancer the betel quid which usually consists of the betel leaf,
arecanut, lime and tobacco. It is common for the poorer
At present there are only two techniques for screening for people to rub with the thumb flakes of sun-dried tobacco
lung cancer, viz. chest radiograph and sputum cytology. and slaked lime in the palm of their left hand until the
Mass radiography has been suggested for early diagnosis at desired mixture is obtained. The mixture (khaini) is then put
six monthly intervals, but the evidence in support of this is into the mouth in small amounts and at frequent intervals
not convincing. So it is not recommended. It is doubtful during the day and slowly sucked and swallowed after
whether the disease satisfies the criteria of suitability for dilution with saliva.
screening (see chapter 4).
Cancer of the oral cavity is also very prevalent in
Central Asian districts of USSR, where people chew “nass”
EPIDEMIOLOGY OF SELECTED CANCERS or “nasswar” - a mixture of tobacco, ashes, lime and cotton­
1. Oral cancer seed oil.
Another type of cancer common in the eastern coastal
Oral cancer is one of the ten most common cancers in the
regions of Andhra Pradesh state in India is the epidermoid
world. Its high frequency in Central and South East Asian
countries (e.g., India, Bangladesh, Sri Lanka, Thailand, carcinoma of the hard palate. It is associated with the habit
of reverse smoking of cigar (chutta), i.e., smoking with the
Indonesia, Pakistan) has been well documented. It is estimated
burning end inside the mouth (29).
that during the year 2020, about 2,64,211 men and 1,13,502
women were having oral cancer. About 1,77,757 persons
PREVENTION
(1.8 per cent of all cancers) died of oral cancer worldwide.
Oral cancer is a major problem in India. It is estimated a. PRIMARY PREVENTION
that in 2020 it caused 5.4 deaths per 100,000 population Oral cancer is amenable to primary prevention. If the
(total 75,290 deaths), 57,380 cases in men and 22,483 tobacco habits are eliminated from the community, a great

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cases in women. The age standardized incidence rate was deal of reduction in the incidence of oral cancer can be
14.8 per 100,000 population in men and 4.6 per 100,000 achieved. This requires intensive public education and
population in women (7). motivation for changing lifestyles supported by legislative
measures like banning or restricting the sale of tobacco.
EPIDEMIOLOGICAL FEATURES
(a) Tobacco : Approximately 90 per cent of oral cancers in b. SECONDARY PREVENTION
South East Asia are linked to tobacco chewing and tobacco Oral cancers are easily accessible for inspection allowing
smoking. During 1966-1977, a large epidemiological survey early detection. If detected early, possibly at the
was carried out in different parts of the country. In this precancerous stage, they can be treated or cured. The
10-year follow-up study of 30,000 individuals in the three precancerous lesions can be detected for up to 15 years,
districts of Ernakulam (Kerala), Srikakulam (Andhra), and prior to their change to an invasive carcinoma. Leukoplakia
Bhavnagar (Gujarat), the results indicated that (i) oral cancer can be cured by cessation of tobacco use. The main
and precancerous lesions occurred almost solely among treatment modalities that offer hope are surgery and
those who smoked or chewed tobacco, and (ii) oral cancer radiotherapy (30). In developing countries over 50 per cent
was almost always preceded by some type of precancerous of oral cancers are detected only after they have reached an
lesion (24, 25). The case about tobacco is further advanced stage (15).
strengthened by the findings that the cancer almost always The primary health care workers (village health guides,
occurred on the side of the mouth where the tobacco quid and multi-purpose workers) are in a strategic position to
was kept (26), and the risk was 36 times higher than for non- detect oral cancers at an early stage during home visits.
chewers if the quid was kept in the mouth during sleep (27). They can prove to be a vital link and a key instrument in the
(b) Alcohol : Data indicates that oral cancer can also be control of oral cancer in developing countries (31).
caused by high concentrations of alcohol, and that alcohol
appears to have a synergistic effect in tobacco users (26). 2. Cancer of the cervix
(c) Pre-cancerous stage : The natural history of oral cancer Cervical cancer is the fourth most frequent cancer in
shows that often a precancerous stage precedes the women with an estimated 6,04,000 new cases in 2020
development of cancer. The pre-cancerous lesions representing 6.6 per cent of all female cancers (3). During
(leukoplakia, erythroplakia) can be detected for upto 15 years the year about 3,42,000 women died of cervical cancer,
prior to their change to an invasive carcinoma (26). which comes to 3.1 per cent of all deaths due to cancer in
Intervention at this stage may result in regression of the lesion. women (3). Approximately 90 per cent of deaths from
cervical cancer occurred in low and middle income
(d) High-risk groups : These include tobacco chewers and countries. Wide variations in incidence and mortality from
smokers, bidi smokers, people using tobacco in other forms the disease exist between countries. Cases and deaths have
such as betel quid; people who sleep with the tobacco quid declined markedly in the last 40 years in most industrialized
in the mouth (28). countries, partly owing to a reduction in risk factors,
(e) Cultural patterns : In studying the tobacco habits in but mainly as a result of extensive screening programmes.
developing countries, indigenous forms of smoking, as well More limited improvements have been observed in
as chewing, which are characteristic of certain regions have developing countries, where persistently high rates tend to
to be taken into account (9). Tobacco is smoked in the form be the rule (1).

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 CANCER 441
In India, cancer cervix constitutes 9.4 per cent of all linked with sexual intercourse, (d) EARLY MARRIAGE: Early
cancer incidence among women. The age standardized marriage, early coitus, early childbearing and repeated
incidence rate is about 18.0 per 100,000 population. The childbirth have been associated with increasing risk.
estimated deaths were 77,348 in 2020 (7). (e) ORAL CONTRACEPTIVE PILLS : There is renewed
concern about the possible relationship between pill use and
NATURAL HISTORY the development of invasive cervical cancer (34). A recent
(a) The disease: Cancer cervix seems to follow a WHO study finds an increased risk with increased duration
progressive course from epithelial dysplasia to carcinoma in of pill use and with the use of oral contraceptives high in
situ to invasive carcinoma (Fig. 5). There is good evidence oestrogen (35). (f) SOCIO-ECONOMIC CLASS : Cancer
that carcinoma in situ persists for a long time, more than cervix is more common in the lower socio-economic groups
8 years on an average (32). The proportion of cases reflecting probably poor genital hygiene.
progressing to invasive carcinoma from preinvasive stage is
not known - it may average 15 to 20 years or longer. The PREVENTION AND CONTROL
duration of the preinvasive stage is also not known. There is The Global strategy towards eliminating cervical cancer
evidence that some in situ cases will spontaneously regress as a public health problem, adopted by the World Health
without treatment. Once the invasive stage is reached, the Assembly in 2020, recommends a comprehensive approach
disease spreads by direct extension into the lymph nodes to cervical cancer prevention and control. The
and pelvic organs. recommended actions include interventions across the life
course (20).
Normal < > Dysplasia < > Cancer > Invasive Primary Secondary Tertiary
epithelium in situ cancer prevention prevention prevention
Girls 9-14 years From 30 years of age for All women as
FIG. 5 • HPV vaccination women from the general needed
Hypothetical model of the natural history of cancer cervix population and 25 years
of age for women living
When a woman presents symptoms of suspicion for with HIV
cervical cancer, she must be referred to an appropriate Girls and boys should Treatment of
facility for further evaluation, diagnosis and treatment. The also be offered, invasive cancer

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symptoms of early-stage cervical cancer may include : as appropriate at any age
(a) irregular blood spotting or light bleeding between periods • Health information • Screening with a • Surgery
in women of reproductive age; (b) postmenopausal spotting and warnings about high-performance • Radiotherapy
tobacco use test equivalent or • Chemotherapy
or bleeding; (c) bleeding after sexual intercourse; and • Palliative care
• Sex education better than HPV test
(d) increased vaginal discharge, sometimes foul smelling. tailored to age and • Followed by
As cervical cancer advances, more severe symptoms may culture immediate treatment
appear including : (a) persistent back, leg or pelvic pain; • Condom promotion or as quickly as
(b) weight loss, fatigue, loss of appetite; (c) foul-smell and provision for possible after an
those engaged in HPV molecular
discharge and vaginal discomfort; and (d) swelling of a leg sexual activity positive test.
or both lower extremities. • Male circumcision
Other severe symptoms may arise at advanced stages
depending on which organs the cancer has spread to. Cervical cancer prevention should encompass a
multidisciplinary, including components from community
(b) Causative agent : There is evidence pointing to education, social mobilization, vaccination, screening,
Human papilloma virus (HPV) - sexually transmitted - as treatment and palliative care.
the cause of cervical cancer (33). This virus was once
supposed to produce only vegetant warts. More than 90 per HPV vaccination
cent of the infected population eventually clear the
infection. But now virus is acknowledged as responsible for HPV vaccines work best if administered prior to exposure
a much wider clinical and subclinical lesions. The virus is to HPV. Therefore, to prevent cervical cancer WHO
found in more than 95% of the cancers. Current evidence recommends vaccinating girls aged 9 to 14 years, when most
suggests that the virus is a necessary cause of the disease. It have not started sexual activity. Some countries have started
takes 15-20 years for cervical cancer to develop in women to vaccinate boys as the vaccination prevents HPV related
with normal immune system. It can take only 5-10 years in cancers in males as well HPV vaccination does not replace
women with weakened immune system, such as those with cervical cancer screening. In countries where HPV vaccine is
untreated HIV infection (20). introduced, population-based screening programmes are still
needed to identify and treat cervical pre-cancer and cancer to
RISK FACTORS reduce cervical cancer incidence and deaths.
(a) AGE : Cancer cervix affects relatively young women
with incidence increasing rapidly from the age of 25 to 45, 3. Breast cancer
then levelling off, and finally falling again, (b) GENITAL Female breast cancer has now surpassed lung cancer as
WARTS : Past and/or present occurrence of clinical genital the leading cause of global cancer incidence in 2020,
warts has been found to be an important risk factor (33). with an estimated 2.3 million new cases, representing
(c) MARITAL STATUS : Cases are less likely to be single, 11.7 per cent of all cancer cases. It is the fifth leading cause
more likely to be widowed, divorced or separated and of cancer mortality worldwide, with 6,85,000 deaths.
having multiple sexual partners. The fact that cancer of the Among women, breast cancer accounts for 1 in 4 cancer
cervix is very common in prostitutes and practically cases and for 1 in 6 cancer deaths, ranking first for incidence
unknown among virgins suggests that the disease could be in the vast majority of countries (159 of 185 countries), and

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442 NON-COMMUNICABLE DISEASES

for mortality in 110 countries. There are exceptions, most Over time, cancerous cells may spread to other organs
notably in terms of deaths, with the disease preceded by including the lungs, liver, brain and bones. Once they reach
lung cancer in Australia/New Zealand, Northern Europe, these sites, new cancer-related symptoms such as bone pain
Northern America, and China (part of Eastern Asia) and by or headaches may appear.
cervical cancer in many countries in sub-Saharan Africa (3).
Incidence rates are 88 per cent higher in transitioned RISK FACTORS
countries than in transitioning countries (55.9 and 29.7 per The established risk factors of breast cancer include the
100,000, respectively), with the highest incidence rates following:
(>80 per 100,000) in Australia/New Zealand, Western (a) AGE : Breast cancer is uncommon below the age of
Europe (Belgium has the world’s highest incidence), 35, the incidence increasing rapidly between the ages of 35
Northern America, and Northern Europe, and the lowest and 50. A slight bimodal trend in the age distribution has
rates (<40 per 100,000) in Central America, Eastern and been observed (37) with a dip in incidence at the time of
Middle Africa, and South Central Asia. However, women menopause. A secondary rise in frequency often occurs after
living in transitioning countries have 17 per cent higher the age of 65. Women who developed their first breast
mortality rates compared with women in transitioned cancer under the age of 40, had three times the risk of
countries (15.0 and 12.8 per 100,000, respectively) because developing a second breast cancer than did those who
of high fatality rates, with the highest mortality rates found developed their first cancer after the age of 40 (38). Indeed
in Melanesia, Western Africa, Micronesia/Polynesia, and the the aetiologies of pre-menopausal and post-menopausal
Caribbean (Barbados has the world’s highest mortality) (3,). breast cancer appears to be different (39).
In India, breast cancer is the top most cancer with about Breast cancer is not only infrequent in Indian women, but
178,361 (13.6 per cent) new cases diagnosed in 2020. The also it occurs in them a decade earlier than in Western
incidence rate is about 25.8 per 100,000 population. women - the mean age of occurrence is about 42 in India,
In India, breast cancer was estimated to cause 13.3 as compared to 53 in the white women.
deaths per 100,000 population in the year 2020. The (b) FAMILY HISTORY : The risk is high in those with a
survival rate decreased by 2.7 times for breast cancer, in positive family history of breast cancer, especially if a mother
case of detection at stage IV as against stage I. A total of or sister developed breast cancer when premenopausal.
90,408 women died of cancer breast in 2020 in India (7).
(c) PARITY : MacMahon, et al (40) in their international

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THE DISEASE (36) case-control study found that the risk of breast cancer is
Breast cancer most commonly presents as a painless lump directly related to the age at which women bear the first
or thickening in the breast. It is important that women child. An early first, full-term pregnancy seems to have a
finding an abnormal lump in the breast consult a health protective effect. Those whose first pregnancy is delayed to
practitioner without a delay of more than 1-2 months even their late thirties are at a higher risk than multiparous
when there is no pain associated with it. Seeking medical women. Unmarried women tend to have more breast
attention at the first sign of a potential symptom allows for tumours than married single women, and nulliparous
more successful treatment. women had the same risk.
Generally, symptoms of breast cancer include: (d) AGE AT MENARCHE AND MENOPAUSE : Early
menarche and late menopause are established risk factors
• a breast lump or thickening; (41). The risk is reduced for those with a surgically induced
• alteration in size, shape or appearance of a breast; menopause. Forty or more years of menstruation doubles
• dimpling, redness, pitting or other alteration in the skin; the risk of breast cancer as compared with 30 years (42).
• change in nipple appearance or alteration in the skin (e) HORMONAL FACTORS : The association of breast
surrounding the nipple (areola); and/or cancer with early menarche and late menopause suggests
• abnormal nipple discharge. that ovary appears to play a crucial role in the development
There are many reasons for lumps to develop in the of breast cancer. Evidence suggests that both elevated
breast, most of which are not cancer. As many as 90% of oestrogen as well as progesterone are important factors in
breast masses are not cancerous. Non-cancerous breast increasing breast cancer risk (43). In short, hormones appear
abnormalities include benign masses like fibroadenomas to hold the key to the understanding of breast cancer.
and cysts as well as infections. (f) PRIOR BREAST BIOPSY : Prior breast biopsy for
Breast cancer can present in a wide variety of ways, benign breast disease is associated with an increased risk of
which is why a complete medical examination is important. breast cancer.
Women with persistent abnormalities (generally lasting more (g) DIET : Current aetiological hypotheses suggest that
than one month) should undergo tests including imaging of cancer of the breast is linked with a high fat diet and obesity.
the breast and in some cases tissue biopsy to determine if a It is not known how dietary fat influences breast cancer risk
mass is malignant or benign. at a cellular level (43).
Advanced cancers can erode through the skin to cause (h) SOCIO-ECONOMIC STATUS : Breast cancer is
ulceration but are not necessarily painful. Women with common in higher socio-economic groups. This is explained
breast wounds that do not heal should have a biopsy by the risk factor of higher age at first birth.
performed.
(i) OTHERS : (i) Radiation : An increased incidence of
Breast cancers may spread to other areas of the body and breast cancer has been observed in women exposed to
trigger other symptoms. Often, the most common first radiation, (ii) Oral contraceptives : Oral contraceptive
detectable site of spread is to the lymph nodes under the appears to have little overall effect on breast cancer,
arm although it is possible to have cancer-bearing lymph although prolonged use of oral pills before the first
nodes that cannot be felt.

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 CANCER 443
pregnancy or before the age of 25 may increase the risk in Radiotherapy also plays a very important role in treating
younger women (44). breast cancer. With early stage breast cancer, radiation can
prevent a woman having to undergo a mastectomy. With
PREVENTION later stage cancer, radiotherapy can reduce cancer
Behavioural choices and related interventions that reduce recurrence risk even when a mastectomy has been
the risk of breast cancer include (36) : performed. For advanced stage of breast cancer, in some
circumstances, radiation therapy may reduce the likelihood
• prolonged breastfeeding; of dying of the disease.
• regular physical activity;
The effectiveness of breast cancer therapies depends on
• weight control; the full course of treatment. Partial treatment is less likely to
• avoidance of harmful use of alcohol; lead to a positive outcome.
• avoidance of exposure to tobacco smoke; The strategies for improving breast cancer outcomes
• avoidance of prolonged use of hormones; and depend on fundamental health system strengthening to
• avoidance of excessive radiation exposure. deliver the treatments that are already known to work. For
example, having reliable referral pathways from primary
Unfortunately, even if all of the potentially modifiable risk care facilities to district hospitals to dedicated cancer
factors could be controlled, this would only reduce the risk centres.
of developing breast cancer by at most 30 per cent.
Female gender is the strongest breast cancer risk factor. GLOBAL BREAST CANCER INITIATIVE (36)
Approximately 0.5-1 per cent of breast cancers occur in The objective of the WHO Global Breast Cancer Initiative
men. The treatment of breast cancer in men follows the (GBCI) is to reduce global breast cancer mortality by 2.5 per
same principles of management as for women. cent per year, thereby averting 2.5 million breast cancer
In the past, all breast cancers were treated surgically by deaths globally between 2020 and 2040. Reducing global
mastectomy (complete removal of the breast). When cancers breast cancer mortality by 2.5 per cent per year would avert
are large, mastectomy may still be required. Today, the 25% of breast cancer deaths by 2030 and 40 per cent by
majority of breast cancers can be treated with a smaller 2040 among women under 70 years of age. The three pillars
procedure called a “lumpectomy” or partial mastectomy, in toward achieving these objectives are: health promotion for

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which only the tumor is removed from the breast. In these early detection; timely diagnosis; and comprehensive breast
cases, radiation therapy to the breast is generally required to cancer management.
minimize the chances of recurrence in the breast.
Lymph nodes are removed at the time of cancer surgery 4. Lung cancer
for invasive cancers. Complete removal of the lymph node MAGNITUDE OF THE PROBLEM
bed under the arm (complete axillary dissection) in the past
was thought to be necessary to prevent the spread of cancer. Lung cancer has been known in industrial workers from
A smaller lymph node procedure called “sentinel node the late 19th century. It came into prominence as a public
biopsy” is now preferred as it has fewer complications. It health problem in the Western world in 1930s - at first in
uses dye and/or a radioactive tracer to find the first few men, and later (in 1960s) among women (45), and has
lymph nodes to which cancer could spread from the breast. followed the increasing adoption of cigarette smoking first
by men and later by women. According to WHO reports,
Medical treatments for breast cancer, which may be given between 1960 and 1980, the death rate due to lung cancer
before (“neoadjuvant”) or after (“adjuvant”) surgery, is increased by 76 per cent in men an? by 135 per cent in
based on the biological subtyping of the cancer. Cancers women (46, 28). In countries where cigarette smoking has
that express the estrogen receptor (ER) and/or progesterone only recently begun to be widely adopted, lung cancer
receptor (PR) are likely to respond to endocrine (hormone) deaths still remain low, but it may be expected that they will
therapies such as tamoxifen or aromatase inhibitors. These rise soon. In others, such as Poland, where the use of
medicines are taken orally for 5-10 years, and reduce the cigarettes began earlier, the rise is already occurring. The
chance of recurrence of these “hormone-positive” cancers total burden of lung cancer in any country is directly related
by nearly half. Endocrine therapies can cause symptoms of to the amount and duration of cigarette smoking.
menopause but are generally well tolerated.
With an estimated 2.2 million new cancer cases and
Cancers that do not express ER or PR are “hormone 1.8 million deaths, lung cancer is the second most commonly
receptor negative” and need to be treated with diagnosed cancer and the leading cause of cancer deaths in
chemotherapy unless the cancer is very small. The 2020, representing approximately one in 10 (11.4 per cent)
chemotherapy regimens available today are very effective in cancers diagnosed and one in 5 (18.0 per cent) deaths. Lung
reducing the chances of cancer spread or recurrence and are cancer is the leading cause of cancer morbidity and mortality
generally given as outpatient therapy. Chemotherapy for in men, whereas, in women, it ranks third for incidence, after
breast cancer generally does not require hospital admission breast and colorectal cancer, and second for mortality, after
in the absence of complications. breast cancer. Incidence and mortality rates are roughly
Breast cancers may independently overexpress a 2 times higher in men than in women, although the male-to-
molecule called the HER2/neu oncogene. These “HER2 female ratio varies widely across regions, ranging from 1.2 in
positive” cancers are amenable to treatment with targeted Northern America to 5.6 in Northern Africa. Lung cancer
biological agents such as trastuzumab. These biological incidence and mortality rates are 3 to 4 times higher in
agents are very effective but also very expensive, because transitioned countries than in transitioning countries; this
they are antibodies rather than chemicals. When targeted pattern may well change as the tobacco epidemic evolves
biological therapies are given, they are combined with given that 80% of smokers aged >15 years resided in
chemotherapy to make them effective at killing cancer cells. low-income and middle-income countries (3).

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444
'IT T NON-COMMUNICABLE DISEASES

In India, the age standardized incidence rate for the year cigarettes. Methods of controlling the smoking epidemic
2020 was : total 8.4 per 100,000 population; for men have been described by the WHO expert committees in their
7.8 per 100,000 population and women 3.1 per 100,000 reports. Broadly these methods include :
population. The estimated deaths were 66,279. The rate was a. Public information and education
4.9 per 100,000 population (7).
b. Legislative and restrictive measures
EPIDEMIOLOGICAL FEATURES c. Smoking cessation activities
d. National and international coordination
a. AGE AND SEX
About a third of all lung cancer deaths occur below the a. Public information and education
age of 65. In many industrialized countries, the incidence of The need of the hour is to create public awareness about
lung cancer is at present increasing more in females than in the hazards of smoking through mass media. The target
males (47). population should be the entire population with greater
b. RISK FACTORS emphasis laid on young people and school children. Nothing
less than a national anti-smoking campaign will be needed
(i) Smoking : Tobacco smoking was first suggested as a to change human behaviour or life styles associated with
cause of lung cancer in the 1920s. Subsequent studies smoking. Curtailment of smoking must be an essential part
proved the causal relationship between cigarette smoking of national health policy.
and lung cancer. Two studies in India showed that the lung
cancer risk for cigarette smokers is 8.6 times the risk for non- b. Legislative and restrictive measures
smokers (48, 49). The risk is strongly related to the number
of cigarettes smoked, the age of starting to smoke and Legislation and restrictive measures have been suggested
smoking habits, such as inhalation and the number of puffs in the following areas : control of sales promotion; health
and the nicotine, the tar content and the length of cigarettes. warnings on cigarette packets and advertisements; product
Those who are highly exposed to “passive smoking” description showing yield of harmful substances; imposition
(somebody else’s smoke) are at an increased risk of of upper limits for harmful substances in smoking materials;
developing lung cancer. It has been calculated that in taxation; sales restrictions; restriction on smoking in public
countries where smoking has been a widespread habit, it is places; restriction on smoking in places of work, etc.

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responsible for 90 per cent of lung cancer deaths (50). The The Government of India have provided legislative
strongest evidence that cigarette smoking is responsible for support to the anti-smoking campaign. “The Cigarettes
lung cancer is the incidence reduction that occurs after (Regulation of production, supply and distribution) Act of
cessation of smoking. This has been convincingly 1975” which came into force from 1 April 1976, requires all
demonstrated in a 20 year prospective study on male British manufacturers or persons trading in cigarettes to display
doctors (51). prominently the statutory warning “Cigarette Smoking is
The most noxious components of tobacco smoke are tar, Injurious to Health” on all cartons or packets of cigarettes
carbon monoxide and nicotine. The carcinogenic role of tar that are put on sale. Most of the State Governments in India
is well established. Nicotine and carbon monoxide, have promulgated laws prohibiting smoking in closed areas,
particularly, contribute to increased risk of cardiovascular e.g., cinemas, buses, educational institutions, and hospitals.
diseases through enhancement of blood coagulation in the Again in the year 2003, a comprehensive tobacco control
vessels, interference with myocardial oxygen delivery, and legislation titled "The Cigarettes And Other Tobacco
reduction of the threshold for ventricular fibrillation (9). Products (Prohibition of Advertisement and Regulation of
Trade and Commerce, Production, Supply and Distribution)
A study in India has shown that there is no difference
Act 2003 was passed by the Govt of India. Refer to chapter 7
between the tar and nicotine delivery of the filter and
“National cancer control programme” for the details.
non-filter cigarettes smoked in India, so that a filter gives no
protection to Indian smokers. The “king-size” filter cigarettes c. Smoking cessation activities
deliver more tar and nicotine than ordinary cigarettes.
Bidi smoking appears to carry a higher lung cancer risk than Research continues on different methods of smoking
cigarette smoking owing to the higher concentration of cessation. In all countries well over 90 per cent of those who
carcinogenic hydrocarbons in the smoke (9). give up smoking do so of their own volition, i.e., without use
of any specific therapy. The basic role of most treatments for
(ii) Other factors : Besides cigarette smoking, there are
smoking cessation would be to relieve the smoker of
other factors which are implicated in the aetiology of lung
“abstinence symptoms” (e.g., sleeplessness, craving for
cancer. These include air pollution, radioactivity, and
smoking, dizziness, constipation, etc). The report of the
occupational exposure to asbestos, arsenic and its
WHO expert committee on smoking control contains
compounds, chromates, particles containing polycyclic
information on specific smoking cessation methods such as
aromatic hydrocarbons and certain nickel-bearing dusts.
smoking cessation clinics, nicotine substitutes, hypnosis, etc.
A number of studies have shown an interaction between
smoking and asbestos exposure. d. National and International coordination
PREVENTION Since smoking is a worldwide epidemic, it requires
coordinated political and non-political approaches at local,
1. PRIMARY PREVENTION national and international levels to contain the smoking
In lung cancer control, primary prevention is of greatest epidemic.
importance. The most promising approach is to control the
“smoking epidemic”, because 80 to 90 per cent of all cases 2. SECONDARY PREVENTION
of lung cancer in developed countries are due to smoking of This rests on early detection of cases and their treatment.

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 CANCER 445
At present, there are only two procedures capable of References
detecting presymptomatic, early-stage lung cancer. These
1. WHO (1997). The World Health Report 1997, Report of the Director
are the chest X-ray and sputum cytology. But screening for General WHO.
early-stage lung cancer is less attractive, more expensive 2. WHO (2020). Global Cancer Observatory, Nov. 2020.
and appears to have less potential for reducing mortality 3. Hyuna Sung et al (2021), Global Cancer Statistics 2020, Globocan
than primary prevention. Therefore, mass screening for estimates of incidence and mortality worldwide for 36 cancers in 185
lung cancer is not recommended as a routine public health countries.
policy (47). 4. WHO (2014), World Cancer Fact Sheet, Cancer Research UK, January
2014.
Efforts to find effective treatment for lung cancer have 5. Freddie Bray et. al. (2018), Global Cancer Statistics 2018, Globocan
met with only limited success. For untreated patients, the estimates of incidence and mortality worldwide for 36 cancers in 185
median survival is 2 to 3 months, compared to 10-14 countries.
months for patients receiving combined chemotherapy. In 6. WHO (2003), World Cancer Report, Ed. by Bernard W. Stewart and
view of these limitations, primary prevention merits greater Paul Kleihues.
attention. An important part of treatment is relief of pain so 7. Globocan (2020), The Global Cancer Observatory, Fact Sheet, India,
Dec. 2020.
that each dying patient has the right to spend his last days as 8. WHO (1999). Health Situation in the South-East Asia Region 1994-
pain-free as possible. 1997, Regional office for SEAR, New Delhi.
9. WHO (1983). Techn. Rep. Ser., No. 695.
5. Stomach cancer 10. Rabat, G.C. et al (1986). Int. J. Epi., 15 (4) 494-501.
Stomach cancer remains an important cancer worldwide 11. Rothman, K.J. (1980). Preventive Medicine, 9 :174-179.
and is responsible for over 1.089 million new cases in 2020 12. Doll, R and R. Peto (1981). J. Nat/. Cancer Inst., 61 : 1191-1308.
and an estimated 768,793 deaths, equating to 7.7 per cent 13. Broder, S. etal (1984). Ann. Int. Med., 100 : 543.
of all cancer deaths, making it the fifth most frequently 14. Reddy, D.J. (1968). Cancer, Customs, Habits, Usages and
Environment, Current Technical Literature, Mumbai.
diagnosed cancer, and third leading cause of cancer deaths.
15. WHO (1985). World Health Forum, 6 (2) 160-164.
The rates are 2-fold higher in men than women. 16. WHO (1986). Techn. Rep. Ser., No. 731.
Although they are often reported as a single entity, gastric 17. WHO (1976). WHO Handbook for Standardized Cancer Registers
cancer can generally be classified into 2 topographical (hospital based). WHO Offset Publ No. 25.
categories. Rates of noncardia gastric cancer (arising from 18. WHO (1979). Techn. Rep. Ser., No. 632.

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distal regions) have steadily declined over the last 50 years 19. WHO (1986). Cancer Pain Relief, WHO, Geneva.
in most populations. Cancers of the gastric cardia (arising in 20. WHO (2022), Fact sheet, Cervical cancer, 22nd Feb. 2022.
the area adjoining the oesophageal-gastric junction) have 21. Govt, of India, WHO (2006), Guidelines for Cervical Cancer
Screening Programme, Department of Cytology and Gynaecological
epidemiological characteristics more similar to those of Pathology, Postgraduate Institute of Medical Education and Research,
oesophageal adenocarcinoma and important risk factors Chandigarh, India.
include obesity and gastroesophageal reflux disease. The 22. Editorial (1985). Lancet, 1 : 851.
incidence of these cancers are increasing particularly in 23. Tucker, A.K. (1985). Practitioner, 229-217.
high-income countries (3). 24. Mehta, F.S. et al (1982), Bull WHO, 60 (3) 441 - 446.
In India the age-standardized incidence rate for stomach 25. Gupta, PC. etal (1980), Community Dentistry and Oral Epidemiology,
8:287-333.
cancer in 2020 was 6.1 per 100,000 population in men, and 26. WHO (1984). Bull WHO, 62 (6) 817-830.
3.4 per 100,000 population in women. The crude mortality 27. Wahi, P.N. (1968), Bull WHO, 38 : 495.
rate was 6.3 per 100,000 population. As a total, 53,253 28. WHO (1985). Wkly Epi,Rec., 60 (17). 125-129.
people died of cancer stomach in 2020 (7). 29. Reddy, C.R.R.M. et al (1976). Ind. J .Cancer, 13 : 161.
The constant decline of stomach cancer in industrialized 30. WHO (1984). Bull WHO, 62 (6) 861-869.
countries is linked to improved food preservation practices; 31. Warnakulasuriya, K.A.A.S. et al (1984). Bu// WHO, 62 (2) 243-250.
better nutrition more rich in vitamins from fresh vegetables 32. Ken, Stanley (1981). World Health, Sept-Oct, pp 21-23.
and fruits; and less consumption of preserved, cured and 33. Zaninetti, P. etal (1986). Int.J.Epi. 15 (4) 477.
salted foods. Infection with the bacterium Helicobacter 34. Brinton, L.A. et al (1986). Int.J.Cancer, 38 : 339.
pylori contributes to the risk, probably by interacting with 35. The WHO Collaborative Study of Neoplasis and Steroid
Contraceptives (1985). Brit.Med.<J., 290 : 961-965.
the other factors. 36. WHO (2021), Fact sheet, Breast cancer, 26th March 2021.
Symptoms are non-specific, which explains why most of 37. Clemmesen, J. (1979). In: Measurement of Levels of Health, WHO
the cases are diagnosed when the disease is at an advanced Reg.Publ.EURO Ser.No.7, p. 199.
stage. Patients may complain of weight loss, fatigue or 38. Hughes L.E. and Courtney, S.P (1985). Brit.Med.J. 290 : 1229
(editorial).
gastric discomfort. Diagnosis is performed by barium X-rays
39. Hislop, T.G. etal (1986). Int.J.Epi., 15.(4) 469.
and with biopsy.
40. MacMahon, B. etal (1970). Bull WHO, 43 : 209-217.
This cancer is treated by surgical removal of the tumour, 41. Miller, A.B. and Bulbrook, R.D. (1980). N.Eng.J.Med., 303 : 1246-
with or without adjuvant chemotherapy. 1248.
42. Marks, M. (1985). Practitioner, 229 : 225.
Stomach cancer cases have a generally poor survival 43. Pike, M.C. and R.K. Ross (1984). Br.Med.Bull., 40 (4) 351-354.
prognosis, averaging no more than 20% survival after five 44. Pike, M.C. etal (1983). Lancet, 2 : 926-929.
years. If the tumour is localized to the stomach, about 60% 45. Muir, C.S. (1981). World Health, Sept-Oct, pp8-ll.
of patients survive five years or more. However, only about 46. WHO (1985). WHO Chronicle, 39 (3) 109-111.
18% of all cases are diagnosed at this early stage. Screening 47. WHO (1982). Bull WHO, 60 (6) 809-819.
by photofluoroscopy has been widespread in Japan since 48. Notani, PN. etal (1977). Int.J.Cancer, 14 : 115.
the late 1960s and mortality rates are declining. It is 49. Jussawalla, D.J. and Jain, D.K. (1979). Brit. J.Cancer 40 : 437.
unclear whether this trend can be attributed to mass 50. WHO (1979). Techn.Rep.Ser., No. 636.
screening alone. 51. Doll, R. and Peto, R. (1976). Brit.Med.J., 2 : 1525.

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 NON-COMMUNICABLE DISEASES
446
I DIABETES MELLITUS
Classification of diabetes (2019)
Ideally a single classification system for diabetes would
The term diabetes describes a group of metabolic facilitate three primary purposes: clinical care, aetio-
disorders characterized and identified by the presence of pathology and epidemiology. With this in mind, the Expert
hyperglycaemia in the absence of treatment. The group considered it best to define a classification system that
heterogeneous aetio-pathology includes defects in insulin prioritizes clinical care and helps health professionals
secretion, insulin action, or both, and disturbances of choose appropriate treatment, and whether or not to start
carbohydrate, fat and protein metabolism. The long-term treatment with insulin, particularly at the time of diagnosis.
specific effects of diabetes include retinopathy, nephropathy The WHO classification of diabetes is as shown in Table 1 (2).
and neuropathy, among other complications. People with
diabetes are also at increased risk of other diseases including Type 1 diabetes (Insulin-dependent diabetes mellitus) is
heart, peripheral arterial and cerebrovascular disease, the most severe form of the disease. Its onset is typically
obesity, cataracts, erectile dysfunction, and non-alcoholic abrupt and is usually seen in individuals less than 30 years of
fatty liver disease. They are also at increased risk of some age. It is lethal unless promptly diagnosed and treated. This
infectious diseases, such as tuberculosis (1). form of diabetes is immune-mediated in over 90 per cent of

TABLE 1
Types of diabetes
Type of diabetes Brief description Change from previous
classification
Type 1 diabetes f-cell destruction (mostly immune-mediated) and absolute insulin deficiency; Type 1 sub-classes
onset most common in childhood and early adulthood removed
Type 2 diabetes Most common type, various degrees of p-cell dysfunction and insulin resistance; Type 2 sub-classes
commonly associated with overweight and obesity removed
Hybrid forms of diabetes New type of diabetes

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Slowly evolving, Similar to slowly evolving type 1 in adults but more often has features of the Nomenclature changed -
immune-mediated metabolic syndrome, a single GAD autoantibody and retains greater previously referred to as
diabetes of adults (3-cell function latent autoimmune
diabetes of adults (LADA)
Ketosis-prone Presents with ketosis and insulin deficiency but later does not require insulin; No change
type 2 diabetes common episodes of ketosis, not immune-mediated
Other specific types
Monogenic diabetes Caused by specific gene mutations, has several clinical manifestations
- Monogenic defects of requiring different treatment, some occurring in the neonatal period, others Updated nomenclature
p-cell function by early adulthood for specific genetic
- Monogenic defects in Caused by specific gene mutations; has features of severe insulin resistance without defects
insulin action obesity; diabetes develops when (3-cells do not compensate for insulin resistance
Diseases of the exocrine Various conditions that affect the pancreas can result in hyperglycaemia No change
pancreas (trauma, tumor, inflammation, etc.)
Endocrine disorders Occurs in diseases with excess secretion of hormones that are insulin antagonists No change
Drug- or chemical- Some medicines and chemicals impair insulin secretion or action, some can No change
induced destroy P-cells
Infection-related diabetes Some viruses have been associated with direct B-cell destruction No change
Uncommon specific forms of Associated with rare immune-mediated diseases No change
immune-mediated diabetes
Other genetic syndromes Many genetic disorders and chromosomal abnormalities increase the risk of No change
sometimes associated diabetes
with diabetes
Unclassified diabetes Used to describe diabetes that does not clearly fit into other categories. This New types of
category should be used temporarily when there is not a clear diagnostic diabetes
category especially close to the time of diagnosis
Hyperglycaemia first detected during pregnancy
Diabetes mellitus in Type 1 or type 2 diabetes first diagnosed during pregnancy No change
pregnancy
Gestational diabetes Hyperglycaemia below diagnostic thresholds for diabetes in pregnancy Defined by 2013
mellitus diagnostic criteria
Diagnostic criteria for diabetes : fasting plasma glucose >7.0 mmol/L or 2-hour post-load plasma glucose >11.1 mmol/L or
Hbalc >48 mmol/mol
Diagnostic criteria for gestational diabetes: fasting plasma glucose 5.1-6.9 mmol/L or 1-hour post-load plasma glucose >10.0 mmol/L
or 2-hour post-load plasma glucose 8.5-11.0 mmol/L

Source : (2)

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 DIABETES MELLITUS 447
cases and idiopathic in less than 10 per cent cases. The rate and the Region of the Americas (11% for both sexes) and
of destruction of pancreatic 0 cell is quite variable. Rapid in lowest in the WHO European and Western Pacific Regions
some individuals and slow in others. Type 1 diabetes is (9% for both sexes). The magnitude of diabetes and other
usually associated with ketosis in its untreated state. It occurs abnormalities of glucose tolerance are considerably higher
mostly in children, the incidence is highest among 10-14 than the above estimates if the categories of ‘impaired
year old group, but occasionally occur in adults. It is fasting’ and ‘impaired glucose tolerance’ are also included.
catabolic disorder in which circulating insulin is virtually The estimated prevalence of diabetes was relatively
absent, plasma glucagon is elevated, and the pancreatic consistent across the income groupings of countries. Low-
P cells fail to respond to all insulinogenic stimuli. Exogenous income countries showed the lowest prevalence (8% for
insulin is therefore required to reverse the catabolic state, both sexes), and the upper-middle-income countries showed
prevent ketosis, reduce the hyperglucagonaemia, and reduce the highest (10% for both sexes) (5).
blood glucose (3). Unfavourable modification of lifestyle and dietary habits
Type 2 diabetes is much more common than type 1 that are associated with urbanization are believed to be the
diabetes. It is often discovered by chance. It is typically most important factors for the development of diabetes. The
gradual in onset and occurs mainly in the middle-aged and prevalence of diabetes is approximately twice in urban areas
elderly, frequently mild, slow to ketosis and is compatible than in rural population.
with long survival if given adequate treatment. Its clinical A bulk of evidence from studies on migrants indicates
picture is usually complicated by the presence of other that the ethnic, presumably genetic, vulnerability of Asians
disease processes. manifests into diabetes when subjected to unfavourable life­
Gestational diabetes is hyperglycaemia with blood styles. Population-based surveys completed recently in
glucose values above normal but below those diagnostic of Bangladesh, India and Indonesia have shown considerable
diabetes, occurring during pregnancy. Women with increase in the prevalence rate of the disease in both urban
gastational diabetes are at an increased risk of complications and rural dwellers when compared to results obtained
during pregnancy and at delivery. They and their children earlier.
are also at increased risk of type 2 diabetes in the future. Diabetic patients, if undiagnosed or inadequately treated,
Impaired glucose tolerance (IGT) describes a state develop multiple chronic complications leading to
intermediate- “at-risk” group - between diabetes mellitus irreversible disability and death. Coronary heart disease and

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and normality. It can only be defined by the oral glucose stroke are more common in diabetics than in the general
tolerance test (see Table 3). population. Microvascular complications like diabetic renal
disease and diabetic retinopathy and neuropathy are serious
insulin resistance syndrome (Syndrome X) health problems resulting in deterioration of the quality of
life and premature death. In fact, diabetes is listed among
In obese patients with type 2 diabetes, the association of the five most important determinants of the cardiovascular
hyperglycaemia, hyperinsulinaemia, dyslipidaemia and disease epidemic in Asia. Lower limb amputation are at least
hypertension, which leads to coronary artery disease and 10 times more common in diabetic than in non-diabetic
stroke, may result from a genetic defect producing insulin individuals in developed countries, more than half of all
resistance, with the latter being exaggerated by obesity. It non-traumatic lower limb amputations are due to
has been proposed that insulin resistance predisposes to diabetes (5). Metabolic disorders in pregnant diabetic
hyperglycaemia, which results in hyperinsulinaemia (which women as well as those caused by gestational diabetes
may or may not be of sufficient magnitude to correct the (diabetes diagnosed for the first time during pregnancy)
hyperglycaemia) and this excessive insulin level then pose a high health risk, to both the mother and foetus.
contributes to high levels of triglycerides and increased Unfortunately, there is still inadequate awareness about
sodium retention by renal tubules, thus inducing the real dimension of the problem among the general public.
hypertension. High levels of insulin can stimulate There is also a lack of awareness about the existing
endothelial proliferation to initiate atherosclerosis (3). interventions for preventing diabetes and the management
of complications. Inadequacies in primary health care
Problem statement systems, which are not designed to cope with the additional
WORLD challenges posed by the chronic non-communicable
diseases, result in poor detection of cases, suboptimal
Diabetes is an “iceberg” disease. Although increase in treatment and insufficient follow-up leading to unnecessary
both the prevalence and incidence of type 2 diabetes have disabilities and severe complications, often resulting in early
occurred gloablly, they have been especially dramatic in death.
societies in economic transition, in newly industrialized The age-adjusted mortality rates among the people with
countries and in developing countries. During year 2014, diabetes are 1.5 to 2.5 times higher than in the general
the number of cases of diabetes worlwide is estimated to be population (6). In Caucassian population, much of the
around 422 million, of these more than 90 per cent are type excess mortality is attributable to cardiovascular disease,
2 diabetes. In 2019, an estimated 1.5 million people died especially coronary heart disease; amongst Asian and
from consequences of high blood sugar (4). More than 80 American Indian population, renal disease is a major
per cent diabetes deaths occur in low and middle income contributor (6); whereas in some developing societies,
countries. infections are an important cause of death. It is conceivable
The apparent prevalence of hyperglycaemia depends on that the decline in mortality due to coronary heart disease
the diagnostic criteria used in epidemiological surveys. The which has occurred in many affluent countries may be
global prevalence of diabetes in 2014 was estimated to be halted or even reversed if rates of type 2 diabetes continue
8.5% in adults aged 18+ years (4). The prevalence of to rise. This may occur if the coronary risk factors associated
diabetes was highest in the Eastern Mediterranean Region with diabetes increase to the extent that the risk they

by R△J
448 NON-COMMUNICABLE DISEASES

mediate outweighs the benefit accrued from improvements 2. HOST FACTORS

in conventional cardiovascular risk factors, and the (a) AGE : Although diabetes may occur at any age,
improved care of patients with established cardiovascular
surveys indicate that prevalence rises steeply with age. Type
disease (6). 2 diabetes usually comes to light in the middle years of life
In addition to non-insulin dependent diabetes, which is and thereafter begins to rise in frequency. Malnutrition
rather silent, chronic, often unidentified killer mostly among related diabetes affects large number of young people. The
the adult population, the insulin dependent form of the prognosis is worse in younger diabetics who tend to develop
disease (type 1) makes an even more dramatic appearance complications earlier than older diabetics, (b) SEX : In some
in affected children. They develop symptoms of ketoacidosis countries (e.g., UK) the overall male-female ratio is about
and often die, since the majority do not have access to equal (10). In south-east Asia, an excess of male diabetics
adequate medical care, and since insulin is not available or has been observed, but this is open to question.
too expensive. It is estimated that the prevalence of type 1 (c) GENETIC FACTORS: The genetic nature of diabetes is
diabetes in Asia is relatively low, accounting for about undisputed. Twin studies showed that in identical twins who
9.7 per cent of all diabetes mellitus cases in the Region. The developed type 2 diabetes, concordance was approximately
insulin dependent diabetes registry at Chennai (India) 90 per cent (11), thus demonstrating a strong genetic
reported an incidence of 10.5 per 100,000 children in the component. In type 1 diabetes, the concordance was only
age group of 10-12 years (7). about 50 per cent indicating that type 1 diabetes is not totally
a genetic entity, (d) GENETIC MARKERS : Type 1 diabetes is
INDIA associated with HLA-B8 and B15, and more powerfully with
The population in India has an increased susceptibility to HLA-DR3 and DR4. The highest risk of type 1 diabetes is
diabetes mellitus. This propensity was demonstrated by carried by individuals with both DR3 and DR4. On the other
multiple surveys of migrant Indians residing in Fiji, hand type 2 diabetes is not HLA-associated (11).
Singapore, South Africa, U.K. and USA. The rates of (e) IMMUNE MECHANISMS : There is some evidence of
diabetes in migrants from the Indian subcontinent have both cell-mediated and of humoral activity against islet cells.
consistently shown to exceed those of the local population. Some people appear to have defective immunological
India is home to 77 million diabetics, second only to mechanisms, and under the influence of some environmental
China in the world. The Govt, of India and diabetic “trigger”, attack their own insulin producing cells.
(f) OBESITY: Obesity particularly central adiposity has long

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retinopathy survey 2019 found 11.8 per cent prevalence of
diabetes in India. Males showed prevalence of 12 per cent been accepted as a risk factor for type 2 diabetes and the risk
and females 11.7 per cent. There is no sex difference. Nearly is related to both the duration and degree of obesity. The
40 per cent of known diabetics were diagnosed 1 to 4 years association has been repeatedly demonstrated in
back, while 5.3 per cent of known diabetics reported longitudinal studies in different populations, with a striking
diagnosis within one-year (8). Majority of cases are of type 2 gradient of risk apparent with increasing level of BMI, adult
diabetes. In the year 2016, about 2 per cent deaths were weight gain, waist circumference or waist to hip ratio. Indeed
attributable to diabetes. In the age group 30-69 years, waist circumference or waist to hip ratio (reflecting
75,900 males and 51,700 females died of diabetes and in abdominal or visceral adiposity) are more powerful
the age group 75 and above, about 46,800 males and determinants of subsequent risk of type 2 diabetes than BMI
45,600 females died of diabetes (9). The prevalence was (6). Central obesity is also an important determinant of
higher in urban areas ranging between 10.9 to 14.2 per insulin resistance, the underlying abnormality in most cases
cent. In rural areas it was 3.0 to 7.8 per cent in population of type 2 diabetes. In some instances obesity reduces the
aged 20 years and above. number of insulin receptors on target cells. Voluntary weight
loss improves insulin sensitivity and in several randomized
National programme for prevention and control of controlled trials has shown to reduce the risk of progression
non-communicable diseases are operational in India and it from impaired glucose tolerence to type 2 diabetes (12, 13).
includes diabetes and diabetes registry. For details please However, many obese subjects are not diabetic. Thus obesity
refer to chapter 7. by itself is inadequate to account for all, or even most, cases
Natural history of type 2 diabetes; physical inactivity and/or deficiencies of
specific nutrients may also be involved (11). Obesity appears
Epidemiological determinants to play no role in type 1 diabetes pathogenesis (14).
(g) MATERNAL DIABETES : Offsprings of diabetic
1. AGENT pregnancies including gestational diabetes are often large
The underlying cause of diabetes is insulin deficiency and heavy at birth, tend to develop obesity in childhood and
which is absolute in type 1 diabetes and partial in type 2 are at high risk of developing type 2 diabetes at an early age.
diabetes. This may be due to a wide variety of mechanisms: Those born to mothers after they have developed diabetes
(a) pancreatic disorders - inflammatory, neoplastic and have a three-fold higher risk of developing diabetes than
other disorders such as cystic fibrosis, (b) defects in the those born before. Maternal diabetes associated with
formation of insulin, e.g., synthesis of an abnormal, intrauterine growth retardation and low birth weight, when
biologically less active insulin molecule; (c) destruction of associated with rapid growth catch-up later on, appears to
beta cells, e.g., viral infections and chemical agents, increase the risk of subsequent diabetes in the child (6).
(d) decreased insulin sensitivity, due to decreased numbers
of adipocyte and monocyte insulin receptors, (e) genetic 3. ENVIRONMENTAL RISK FACTORS
defects, e.g., mutation of insulin gene; and (f) auto­ Susceptibility to diabetes appears to be unmasked by a
immunity. Evidence is accumulating that the insulin number of environmental factors acting on genetically
response to glucose is genetically controlled. The overall susceptible individuals. They include : (a) SEDENTARY
effect of these mechanisms is reduced utilization of glucose LIFESTYLE : Sedentary life style appears to be an
which leads to hyperglycaemia accompanied by glycosuria. important risk factor for the development of type 2 diabetes.

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 ___________________________DIABETES MELLITUS |^M|

Lack of exercise may alter the interaction between insulin kwashiorkor (11). (e) ALCOHOL : Excessive intake of
and its receptors and subsequently lead to type 2 diabetes alcohol can increase the risk of diabetes by damaging the
(11). (b) DIET : A high saturated fat intake has been pancreas and liver and by promoting obesity (11). (f) VIRAL
associated with a higher risk of impaired glucose tolerance, INFECTIONS: Among the viruses that have been implicated
and higher fasting glucose and insulin levels (6). Higher are rubella, mumps, and human coxsackie virus B4. Viral
proportions of saturated fatty acids in serum lipid or muscle infections may trigger in immunogenetically susceptible
phospholipid have been associated with higher fasting people a sequence of events resulting in P-cell destruction.
insulin, lower insulin sensitivity and a higher risk of type 2 (g) CHEMICAL AGENTS : A number of chemical agents are
diabetes. Higher unsaturated fatty acids from vegetable known to be toxic to beta cells, e.g., alloxan, streptozotocin,
sources and polyunsaturated fatty acids have been the rodenticide VALCOR, etc (17). A high intake of cyanide
associated with reduced risk of type 2 diabetes and lower producing foods (e.g., cassava and certain beans) may also
fasting and 2-hour glucose concentrations. Higher have toxic effects on p-cells. (h) STRESS : Surgery, trauma,
proportions of long-chain polyunsaturated fatty acids in and stress of situations, internal or external, may “bring out”
skeletal muscle phospholipids have been associated with the disease, (i) OTHER FACTORS : High and low rates of
increased insulin sensitivity (6). In human intervention diabetes have been linked to a number of social factors such
studies, replacement of saturated by unsaturated fatty acids as occupation, marital status, religion, economic status,
leads to improved glucose tolerence and enhanced insulin education, urbanization and changes in life style which are
sensitivity. However, long chain polyunsaturated fatty acids elements of what is broadly known as social class. One of
do not appear to confer additional benefit over the most important epidemiological features of diabetes is
monounsaturated fatty acids. When total fat intake is high that it is now common in the lower social classes whereas
(greater than 37 per cent of total energy), altering the quality 50 years ago, the gradient was the reverse. One reason
of dietary fat appears to have little effect (15). (c) DIETARY could be rapid changes in lifestyle in lower classes.
FIBRE : In many controlled experimental studies, high
intakes of dietary fibre have been shown to result in reduced SCREENING FOR DIABETES
blood glucose and insulin levels in people with type 2
diabetes and impaired glucose tolerance (16). Moreover an In the past, the commonest approach to diabetes
increased intake of wholegrain cereals, vegetables and fruits screening was a preliminary, semi-quantitative test for
(all rich in NSP) was a feature of diets in randomized glucose in a urine sample, followed by an oral glucose

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controlled trials. Thus the evidence for a potential protective tolerance test for those found to have glycosuria. The
effect of dietary fibre appears strong. A minimum daily underlying assumption is that early detection and effective
intake of 20 grams of dietary fibre is recommended (6). control of hyperglycaemia in asymptomatic diabetics
Table 2 shows a summary of lifestyle and dietary factors reduces morbidity.
associated with diabetes.(d) MALNUTRITION : Malnutrition
1. Urine examination
(PEM) in early infancy and childhood may result in partial
failure of P-cell function. Damage to beta cells may well Urine test for glucose, 2 hours after a meal, is commonly
explain the associated impaired carbohydrate tolerance in used in medical practice for detecting cases of diabetes. All
those with glycosuria are considered diabetic unless
otherwise proved by a standard oral glucose tolerance test.
TABLE 2 Most studies now confirm that although glucose is found in
Summary of strength of evidence on lifestyle factors urine in the most severe cases of diabetes, it is often absent
______ and risk of developing type 2 diabetes in milder forms of the disease, and such cases are likely to
be missed by urine test. This is known as lack of
Decreased Increased
Evidence risk risk
“sensitivity”. To be more precise, the sensitivity of the test
(i.e., proportion of people with disease who have a positive
Convincing Voluntary weight loss Overweight and test) varies between 10-50 per cent. The lack of sensitivity
in overweight and obesity means that many diabetics would have been missed if this
obese people Abdominal had been the only test. That is, the test yields too many
obesity
Physical activity Physical inactivity “false-negatives”. Further, glycosuria may be found in
Maternal diabetes3 perfectly normal people; this gives rise to “false-positives”.
Probable NSP1 Saturated fats
Since the specificity of the test is over 90 per cent, the yield
Intrauterine of false-positives is not very high. For these reasons, urine
growth retardation testing is not considered an appropriate tool for case-finding
Possible t]-3fatty acids Total fat intake or epidemiological surveys of the population (11).
Low glycaemic Trans-fatty acids
index foods 2. Blood sugar testing
Exclusive breast-feedingb Because of the inadequacies of urine examination,
Insufficient Vitamin E Excess alcohol “standard oral glucose test” remains the cornerstone of
Chromium diagnosis of diabetes. Mass screening programmes have used
Magnesium glucose measurements of fasting, postprandial or random
Moderate alcohol
blood sample. The measurement of glucose levels in random
1 NSP = Non-starch Polysaccharides, blood samples is considered unsatisfactory for
a Includes gestational diabetes. epidemiological use; at the most, it can give only a crude
b As a global public health recommendation, infants should be estimate of the frequency of diabetes in a population (11).
exclusively breast-fed for the first six months of life to achieve The fasting value alone is considered less reliable since true
optimal growth, development and health.
fasting cannot be assured and spurious diagnosis of diabetes
Source : (6) may more readily occur. Therefore, for epidemiological

by R△J
450 NON-COMMUNICABLE DISEASES

purposes, the 2-hour value after 75 g oral glucose may be b. HIGH-RISK STRATEGY
used either alone or with the fasting value (11). Automated There is no special high-risk strategy for type 1 diabetes.
biochemistry has now made it possible to screen thousands of At present, there is no practical justification for genetic
samples for glucose estimation. The criteria for the diagnosis counselling as a method of prevention (11).
of diabetes, proposed by WHO, are given in Table 3.
Since NIDDM appears to be linked with sedentary life­
Target population style, over-nutrition and obesity, correction of these may
reduce the risk of diabetes and its complications. Since alcohol
Screening of the whole population for diabetes is not can indirectly increase the risk of diabetes, it should be
considered a rewarding exercise (18, 19). However, avoided. Subjects at risk should avoid diabetogenic drugs like
screening of “high-risk” groups is considered more oral contraceptives. It is wise to reduce factors that promote
appropriate. These groups are: (i) those in the age group 40 atherosclerosis, e.g., smoking, high blood pressure, elevated
and over; (ii) those with a family history of diabetes; (iii) the
cholesterol and high triglyceride levels. These programmes
obese; (iv) women who have had a baby weighing more may most effectively be directed at target population groups.
than 4.5 kg (or 3.5 kg in constitutionally small populations);
(v) women who show excess weight gain during pregnancy; 2. Secondary prevention
and (vi) patients with premature atherosclerosis.
When diabetes is detected, it must be adequately treated.
PREVENTION AND CARE The aims of treatment are : (a) to maintain blood glucose
levels as close within the normal limits as is practicable (see
1. Primary prevention Table 3), and (b) to maintain ideal body weight. Treatment is
Two strategies for primary prevention have been based on (a) diet alone - small balanced meals more
suggested: (a) population strategy, and (b) high-risk frequently, (b) diet and oral antidiabetic drugs, or (c) diet
strategy (11). and insulin. Good control of blood glucose protects against
the development of complications. Please see in chapter 10
a. POPULATION STRATEGY “Nutrition and health” under title “Nutritional factors in
selected diseases” for details.
The scope for primary prevention of type 1 diabetes is
limited on the basis of current knowledge and is probably Proper management of the diabetic is most important to
not appropriate (11). However, the development of prevent complications. Routine checking of blood sugar, of

telegram-@Cherry_2412
prevention programmes for type 2 diabetes based on urine for proteins and ketones, of blood pressure, visual acuity
elimination of environmental risk factors is possible. There is and weight should be done periodically. The feet should be
pressing need for primordial prevention - that is, examined for any defective blood circulation (Doppler
prevention of the emergence of risk factors in countries in ultrasound probes are advised), loss of sensation and the
which they have not yet appeared. The preventive measures health of the skin. Primary health care is of great importance
comprise maintenance of normal body weight through to diabetic patients since most care is obtained at this level.
adoption of healthy nutritional habits and physical exercise. Glycosylated haemoglobin : There should be an estimation
The nutritional habits include an adequate protein intake, a of glycated (glycosylated) haemoglobin at half-yearly
high intake of dietary fibre and avoidance of sweet foods. intervals. This test provides a long-term index of glucose
Elimination of other less well defined factors such as protein control. This test is based on the following rationale: glucose
deficiency and food toxins may be considered in some in the blood is complexed to a certain fraction of haemoglobin
populations. These measures should be fully integrated into to an extent proportional to the blood glucose concentration.
other community-based programmes for the prevention of The percentage of such glycosylated haemoglobin reflects the
non-communicable diseases (e.g., coronary heart disease). mean blood glucose levels during the red cell life-time (i.e.,
about the previous 2-3 months) (20).
TABLE 3 Self-care : A crucial element in secondary prevention is
The WHO recommendations for self care. That is, the diabetic should take a major
the diagnostic criteria for diabetes (2019) responsibility for his own care with medical guidance - e.g.,
adherence to diet and drug regimens, examination of his
Measurement Diagnostic cut-off value own urine and where possible blood glucose monitoring; self
Fasting venous or capillary* >7.0 mmol/L administration of insulin, abstinence from alcohol,
plasma glucose (126 mg/dL) maintenance of optimum weight, attending periodic
check-ups, recognition of symptoms associated with
2-hour post-load venous >11.1 mol/L
plasma glucose glycosuria and hypoglycaemia, etc.
(200 mg/dL)
Table 4 shows some of the individual interventions in
2-hour post-load capillary** >12.2 mmol/L
plasma glucose (220 mg/dL) diabetes with evidence of efficacy.
Random plasma glucose Home blood glucose monitoring : Assessment of control
>11.1 mmol/L
(200 mg/dL) has been greatly aided by the recent facility of immediate,
reasonably accurate, capillary blood glucose measurements
HbAlc*** 6.5% (48 mmol/mol) either by one of the many meters now available or the direct
Overnight fast of 8-14 hours. reading Haemoglucotest strips (21).
** If laboratory measurement is not available, point of care, The patient should carry an identification card showing
(“finger stick”) devices can be used (they report glucose values his name, address, telephone number (if any) and the details
in capillary plasma). of treatment he is receiving. In short, he must have a
*** Plasma glucose is preferred in people with symptoms who are working knowledge of diabetes. All these mean education of
suspected of having type 1 diabetes.
patients and their families to optimize the effectiveness of
Source : (1) primary health care services.

by R△J
 OBESITY 451
TABLE 4 16. Marshal JAet al. (1994), Dietary fat predicts conversion from impaired
Individual interventions in diabetes with evidence of efficacy glucose tolerance to NIDDM, The San Luis Valley Diabetes Study
Diabetes Care, 1994, 17 : 50-56.
Interventions with evidence Benefit 17. Arky, R.A. (1983). Nutrition Reviews, 41 (6) 165.
of efficacy 18. Melins, J.M. (1974). Lancet, 2 : 1367.
19. Redhead, I.H. (1975). In: Screening in General Practice, C.R. Hart
Lifestyle interventions for Reduction of 35-58% in (ed), Churchill Livingstone.
preventing type 2 diabetes in incidence 20. Anonymous (1978). Glycosylated Haemoglobin and Diabetic Control
people of high risk Brit, Med. J., 1:1373-4.
Metformin for preventing type 2 Reduction of 25-31% in 21. Sonksen, PH. et al (1978). Home Monitoring of Blood Glucose.
diabetes for people at high risk incidence Lancet, 1: 729-32.
22. Diabetic Clinics Today and Tomorrow: Brit. Med. J. (1973) 2 :534 and
Glycaemic control in people Reduction of 30% in Brit. Med. J. (1971)4: 161.
with HbAlc greater than 9% microvascular disease per 1
percent drop in HbAlc
OBESITY
Blood pressure control in Reduction of 35% in
people whose pressure is macrovascular and Obesity may be defined as an abnormal growth of the
higher than 130/80 mmHg microvascular disease per adipose tissue due to an enlargement of fat cell size
10 mmHg drop in (hypertrophic obesity) or an increase in fat cell number
blood pressure
(hyperplastic obesity) or a combination of both (1). Obesity
Annual eye examinations Reduction of 60 to 70% in is often expressed in terms of body mass index (BMI)
serious vision loss (see Table 1). Overweight is usually due to obesity but can
Foot care in people with high Reduction of 50 to 60% in arise from other causes such as abnormal muscle
risk of ulcers serious foot disease development or fluid retention (2).
Angiotensin converting Reduction of 42% in
enzyme inhibitor use in nephropathy; 22% drop TABLE 1
all people with diabetes in cardiovascular disease Adult weights and heights corresponding to recommended
cut-off values for body mass index
Source : (5) BMI

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16.0 17.0 18.5 20.0 22.0 25.0 30.0 40.0
3. Tertiary prevention Height Thinness Overweight
(cm)___
Diabetes is major cause of disability through its
Body weight (kg)
complications, e.g., blindness, kidney failure, coronary
thrombosis, gangrene of the lower extremities, etc. The main 140 31.4 33.3 36.2 39.2 43.1 49.0 58.8 78.4
objective at the tertiary level is to organize specialized clinics 142 32.3 343 37.3 40.3 44.4 50.4 60.5 80.7
(Diabetic clinics) and units capable of providing diagnostic 144 33.2 35.3 384 41.5 45.6 51.8 62.2 82.9
and management skills of a high order. There is a great need 146 34.1 36.2 39.4 42.6 46.9 533 63.9 85.3
to establish such clinics in large towns and cities (22). The 148 35.0 37.2 40.5 43.8 48.2 54.8 65.7 87.6
tertiary level should also be involved in basic, clinical and 150 36.0 38.2 41.6 45.0 49.5 56.3 67.5 90.0
epidemiological research. It has also been recommended 152 37.0 39.3 42.7 46.2 50.8 57.8 69.3 92.4
that local and national registries for diabetics should be
154 37.9 40.3 43.9 47.4 52.2 59.3 71.1 94.9
established (11).
156 38.9 41.4 45.0 48.7 53.5 60.8 73.0 97.3
References 158 39.9 42.4 46.2 49.9 54.9 62.4 74.9 99.9
160 41.0 43 5 47.4 51 2 56.3 64.0 76.8 102.4
1. WHO (2020). Diagnosis and Management of Type 2 Diabetes.
2. WHO (2019). Classification of Diabetes Mellitus, 2019. 162 42.0 446 48.3 52 5 57.7 65.6 78.7 105.0
3. Lawrence M. Tierney, Jr. Stephen J. McPhee Maxine A. Papadakis 164 43.0 45.7 49.8 53.8 59.2 672 80.7 107.6
(2002), Current Medical Diagnosis and Treatment, 41st ed., Lange 166 44.1 46.8 51.0 55.1 60.6 68.9 82.7 110.2
Publication. 168 45.2 48.0 52.2 56.4 62.1 70.6 84.7 112.9
4. WHO (2022), Diabetes Fact Sheet, 16th Sept. 2022. 170 46.2 49.1 53.5 57.8 63.6 72.3 86.7 115.6
5. WHO (2011), Global Status Report on Non-communicable Diseases,
2010. 172 47.3 50.3 54.7 59.2 65.1 74.0 88.8 118.3
6. WHO (2003), Tech. Rep. Ser., N 916. 174 48.4 51.5 56.0 60.6 66.6 75.7 90.8 121.1
7. WHO (2002), Health Situation in the South-East Asia Region 1998- 176 49.6 52.7 573 62.0 68.1 77.4 92.9 123.9
2000, New Delhi. 178 50.7 53.9 58.6 63.4 69.7 79.2 95.0 126.7
8. Govt, of India (2019), Govt, of India Survey 2018-2019for Diabetes. 180 51.9 55.1 59.9 64.8 71.3 81.0 97.2 129.6
9. WHO (2016), Diabetes Country Profile, India, 2016. 182 53.0 56.3 61.3 662 72.9 82.8 99.4 132.5
10. Drury, M.I. (1979). Diabetes Mellitus, Blackwell, Oxford. 184 54.2 57.6 62.6 67.7 74.5 84.6 101.6 135.4
11. WHO (1985). Techn. Rep. Ser., No. 727.
186 555 58.8 64.0 69.2 76.1 86.5 103.8 138.4
12. Tuomilento J. et al. (2002), Prevention of type 2 diabetes Mellitus by
changes in lifestyle among subjects with impaired glucose tolerance, 188 56.6 60.1 65.4 70.7 77.8 88.4 106.0 141.4
New England Journal of Medicine, 2002, 344 :1343-1350. 190 57.8 61.4 66.8 72.2 794 90.3 108.3 144.4
13. Knowler WC et al. (2002), Reduction in the incidence of type 2 For easy reference and calculation of BMI values corresponding to
diabetes with lifestyle intervention of metformin, New England Journal
of Medicine, 2002, 346 : 393-403. recommended cut-offs, first find the height of the individual in the
left hand column. The weights given in the row for that height
14. Keen, H. (1985). In: Oxford Textbook of Public Health, Vol.4, p.268. correspond to various recommended cut-off values for adult BMI.
15. Vessby B. et al. (2001), Substituting dietary saturated for Weight for two normal BMI values are also included.
monounsaturated fat impairs insuline sensitivity in healthy men and
women : the KANWU study. Diabetologia, 2001, 44 : 312-319. Source : (5)

by R△J
452 NON-COMMUNICABLE DISEASES

However, obese individuals differ not only in the amount overweight or obese women increases steadily, from
of excess fat that they store, but also in the regional 5 per cent of women age 15-49 to 37 per cent of
distribution of the fat within the body. The distribution of fat women age 40-49.
induced by the weight gain affects the risk associated with • The proportion of thin women is higher in rural areas
obesity, and the kind of disease that results. It is useful (21%) than in urban areas (13%) and the reverse is
therefore, to be able to distinguish between those at observed for the prevalence of overweight or obesity
increased risk as a result of “abdominal fat distribution” or (33% in urban areas and 20% in rural areas).
“android obesity” from those with the less serious “gynoid”
fat distribution, in which fat is more evenly and peripherally • There is a steady decrease in the proportion of thin
distributed around the body. women as household wealth increases (from 28% in
the lowest wealth quintile to 10% in the highest wealth
Prevalence quintile), which is accompanied by a steady increase
in the proportion of overweight or obese women
Obesity is perhaps the most prevalent form of
malnutrition. As a chronic disease, prevalent in both (from 10% in the lowest wealth quintile to 39% in the
developed and developing countries, and affecting children highest wealth quintile).
as well as adults, it is now so common that it is replacing the • The highest proportion of thin women is observed in
more traditional public health concerns including Jharkhand and Bihar (26% each), followed by Gujarat
undernutrition. It is one of the most significant contributors and Dadra & Nagar Haveli and Daman & Diu
to ill health. For industrialized countries, it has been (25% each). The highest proportion of overweight or
suggested that such increase in body weight have been obese women is found in Puducherry (46%),
caused primarily by reduced levels of physical activity, Chandigarh (44%), Delhi, Tamil Nadu, and Punjab
rather than by changes in food intake or by other factors. It (41% each), and Kerala and Andaman & Nicobar
is extremely difficult to assess the size of the problem and Islands (38% each).
compare the prevalence rates in different countries as no (b) 16 per cent of men age 15-49 are thin, 23 per cent are
exact figures are available and also because the definitions overweight and obese, and 61 per cent have BMI in
of obesity are not standardized. normal range. The patterns by background characteristics
Overweight and obesity are the fifth leading risk of global are (4) :
deaths. Worldwide, obesity has more than doubled since

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• The patterns of nutritional status by background
1980. In 2016, more than 1.9 billion adults, 18 years and
characteristics among men are similar to those among
older, were overweight. Of these over 650 million men and
women.
women were obese (3).
In 2019, more than 38.2 million children under 5 years of • The proportion of thin men decreases with age, from
age were overweight or obese. Once considered a high- 41 per cent of men age 15-19 to 8 per cent of men
income country problem, overweight and obesity are now age 40-49, whereas the proportion of overweight or
rising in low-and middle-income countries, particularly in obese men increases from 7 per cent of men age
urban settings (3). Close to 30 million overweight children 15-19 to 32 per cent of men age 40-49.
are living in developing and 10 million in developed • The proportion of thin men is higher in rural areas
countries (3). Childhood obesity is associated with a higher (18%) than in urban areas (13%), whereas 30 per cent
chance of obesity, premature death and disability in of men are overweight or obese in urban areas,
adulthood. In addition, it is associated with future risk of compared with 19 per cent in rural areas.
increased breathing difficulties, increased risk of fractures, • There is steady decrease in the proportion of thin men
hypertension, early markers of cardiovascular disease, with increasing household wealth (from 24% in the
insulin resistance and psychological effects. lowest wealth quintile to 9% in the highest wealth
At least 3.4 million adults die each year as a result of quintile), and a steady increase in the proportion of
being overweight or obese. In addition, 44 per cent of the overweight or obese men (from 10% in the lowest
diabetes burden, 23 per cent of ischaemic heart disease wealth quintile to 37% in the highest wealth quintile).
burden and between 7 to 41 per cent of certain cancer • The proportion of thin men is highest in Bihar (22%),
burdens are attributable to overweight and obesity (3). followed by Madhya Pradesh and Gujarat (21% each).
Overweight and obesity are linked to more deaths The highest proportion of overweight or obese men is
worldwide than underweight.
observed in Andaman & Nicobar Island (45%),
INDIA followed by Puducherry (43%) and Lakshadweep
(41%).
The National Family Health Survey-5 (2019-2021)
calculated Body Mass Index (BMI) of men and women (aged As obesity is a key risk factor in natural history of other
15-49 years) interviewed to know the trend of nutritional chronic and non-communicable diseases, the typical time
status of the population. The trend of obesity and sequence of emergence of chronic diseases following the
overweight persons are as follows : increased prevalence of obesity is important in public health
planning. The first adverse effects of obesity to emerge in
(a) 19 per cent of women age 15-49 are thin, 24 per cent are population in transition are hypertension, hyperlipidaemia
overweight or obese, and 57 per cent are in the normal and glucose intolerence, while coronary heart disease and
range. The patterns by background characteristics the long-term complications of diabetes, such as renal failure
are (4) : begin to emerge several years (or decades) later (6). It is
• The proportion of thin women decreases with age, matter of time before same mortality rates for such diseases
from 40 per cent for women age 15-19 to 9 per cent will be seen in developing countries as those prevailing
for women age 40-49, whereas the proportion of 30 years ago in industrialized countries (7).

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 OBESITY 453
Epidemiological determinants deposition of triglycerides in the adipose tissue resulting in
The aetiology of obesity is complex, and is one of obesity (12). Nowadays television and print media is playing
multiple causation : an important role in producing obesity by heavy
advertisement of fast food outlets of energy-dense,
(a) AGE : Obesity can occur at any age, and generally micronutrient poor food and beverages (usually classified
increases with age. Infants with excessive weight gain have under the “eat least” category in diet guidelines) of
an increased incidence of obesity in later life (8). About multinational corporations, which influence the daily eating
one-third of obese adults have been so since childhood (1). habits. The consumer demand by itself may be influenced by
It has been well established that most adipose cells are advertising, marketing, culture, fashion and convenience
formed early in life and the obese infant lays down more of (7). It has been calculated that a child whose energy
these cells (hyperplastic obesity) than the normal infant. requirement is 2000 kcal/day and who consumes
Hyperplastic obesity in adults is extremely difficult to treat 100 kcal/day extra will gain about 5 kg a year (9). The
with conventional methods. accumulation of one kilo of fat corresponds to 7,700 kcal of
(b) SEX : Women generally have higher rate of obesity energy (14).
than men, although men may have higher rates of (g) PSYCHOSOCIAL FACTORS : Psychosocial factors
overweight. In the Framingham, USA study, men were found (e.g., emotional disturbances) are deeply involved in the
to gain most weight between the ages of 29 and 35 years, aetiology of obesity. Overeating may be a symptom of
while women gain most between 45 and 49 years of age (9), depression, anxiety, frustration and loneliness in childhood
i.e. at menopausal age. It has been claimed that woman’s as it is in adult life. Excessively obese individuals are usually
BMI increases with successive pregnancies. The recent withdrawn, self-conscious, lonely and secret eaters. An
evidence suggested that this increase is likely to be, on an insight into the circumstances in which the obesity has
average, about 1 kg per pregnancy. On the other hand in developed is essential for planning the most suitable
many developing countries, consecutive pregnancies at management.
short intervals are often associated with weight loss rather (h) FAMILIAL TENDENCY : Obesity frequently runs in
than weight gain (7). families (obese parents frequently having obese children), but
(c) GENETIC FACTORS : There is a genetic component this is not necessarily explained solely by the influence of
in the aetiology of obesity. Twin studies have shown a close genes.

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correlation between the weights of identical twins even (i) ENDOCRINE FACTORS : These may be involved in
when they are reared in dissimilar environments (10). The occasional cases, e.g., Cushing’s syndrome, growth
profile of fat distribution is also characterized by a significant hormone deficiency.
heritability level of the order of about 50 per cent of the total
human variation. Recent studies have shown that the (j) ALCOHOL : A recent review of studies concluded that
amount of abdominal fat was influenced . by a genetic the relationship between alcohol consumption and adiposity
was generally positive for men and negative for women (6).
component accounting for 50-60 per cent of the individual
differences (7). (k) EDUCATION : In most affluent societies, there is an
inverse relationship between educational level and
(d) PHYSICAL INACTIVITY : There is convincing
prevalence of overweight (5).
evidence that regular physical activity is protective against
unhealthy weight gain. Where as sedentary lifestyle (l) SMOKING : Reports that the use of tobacco lowers
particularly sedentary occupation and inactive recreation body weight began to appear more than 100 years ago, but
such as watching television promote it, physical activity and detailed studies have been reported only during the past
physical fitness are important modifiers of mortality and 10 years or so. In most populations, smokers weigh
morbildity related to overweight and obesity (11). In some somewhat less than ex-smokers; individuals who have never
individuals a major reduction in activity without the smoked fall somewhat between the two.
compensatory decrease in habitual energy intake may be (m) ETHNICITY : Ethnic groups in many industrialized
the major cause of increased obesity, e.g. in athletes when countries appear to be especially susceptible to the
they retire and in young people who sustain injuries etc. development of obesity and its complications. Evidence
Physical inactivity may cause obesity, which in turn restricts suggests that this may be due to a genetic predisposition to
activity. This is a vicious circle. It is the reduced energy obesity that only become apparent when such groups are
output that is probably more important in the aetiology of exposed to a more affluent lifestyle (7).
obesity than used to be thought (10).
(n) DRUGS : Use of certain drugs, e.g., cortico-steroids,
(e) SOCIO-ECONOMIC STATUS : The relationship of contraceptives, insulin, 3-adrenergic blockers, etc. can
obesity to social class has been studied in some detail. There promote weight gain (7).
is a clear direct relationship between socio-economic status
and obesity. Within some affluent countries, however, Use of BMI to classify obesity
obesity has been found to be more prevalent in the lower Body mass index (BMI) is a simple index of weight-for-
socio-economic groups. height that is commonly used to classify underweight,
(f) EATING HABITS : Eating habits (e.g., eating in overweight and obesity in adults. It is defined as the
between meals, preference to sweets, refined foods and fats) weight in kilograms divided by the square of the height in
are established very early in life. The composition of the metres (kg/m2).
diet, the periodicity with which it is eaten and the amount of For example, an adult who weighs 70 kg and whose
energy derived from it are all relevant to the aetiology of height is 1.75 m will have a BMI of 22.9
obesity. A diet containing more energy than needed may
lead to prolonged post-prandial hyperlipidaemia and to BMI = 70 (kg)/1.752 (m2) = 22.9

by R△J
 NON-COMMUNICABLE DISEASES
454
The classification of overweight and obesity, according lipoprotein lipase (LPL) and higher LPL activity in the
to BMI, is shown in Table 2. Obesity is classified as a gluteal and femoral subcutaneous regions, which contain fat
BMI > 30.0. The classification shown is in agreement with cells larger than those in men, but these differences
that recommended by WHO (11), but includes an additional disappear after menopause (7).
subdivision at BMI 35.0-39.9 in recognition of the fact that
management options for dealing with obesity differ above a Assessment of obesity
BMI of 35. The WHO classification is based primarily on the Before we consider assessment of obesity, it will be useful
association between BMI and mortality. to first look at body composition as under;
TABLE 2 a. the active mass (muscle, liver, heart etc.)
Classification of adults according to BMI b. the fatty mass (fat)
c. the extracellular fluid (blood, lymph, etc.)
Classification BMI Risk of comorbidities d. the connective tissue (skin, bones, connective tissue)
Underweight < 18.50 Low (but risk of other Structurally speaking, the state of obesity is characterized
clinical problems increased) by an increase in the fatty mass at the expense of the other
Normal range 18.50-24 99 Average parts of the body. The water content of the body is never
Overweight: >25.00 increased in case of obesity.
Pre-obese 25.00-29.99 Increased
Obese class I 30 00-34.99 Moderate Although obesity can easily be identified at first sight, a
Obese class II 35 00-39.99 Severe precise assessment requires measurements and reference
Obese class III >40.00 Very severe standards. The most widely used criteria are :

Source : (11) 1. BODYWEIGHT

These BMI values are age-independent and the same for Body weight, though not an accurate measure of excess
both sexes. The table shows a simplistic relationship fat, is a widely used index. In epidemiological studies it is
between BMI and the risk of comorbidity, which can be conventional to accept 4- 2 SD (standard deviations) from
affected by a range of factors, including the nature of the the median weight for height as a cut-off point for
diet, ethnic group and activity level. The risks associated overweight and + 3 SD for obesity.

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with increasing BMI are continuous and graded and begin at For adults, some people calculate various other indicators
a BMI above 25. such as (9) :
Although it can generally be assumed that individuals (1) Body mass index (Quetelet’s index)
with a BMI of 30 or above have an excess fat mass in their
body, BMI does not distinguish between weight associated Weight (kg)
with muscle and weight associated with fat. As a result, the
relationship between BMI and body fat content varies Height2(m)
according to body build and proportion, and it has been
(2) Ponderal index
shown repeatedly that a given BMI may not correspond to
the same degree of fatness across populations. Polynesians, Height (cm)
for example, tend to have a lower fat percentage than
Caucasian Australians at an identical BMI. In addition, the Cube root of body weight (kg)
percentage of body fat mass increases with age up to 60-65
(3) Brocca index
years in both sexes, and is higher in women than in men of
equivalent BMI. In cross-sectional comparisons, therefore, - Height (cm) minus 100
BMI values should be interpreted with caution if estimates of For example, if, a person’s height is 160 cm,
body fat are required. his ideal weight is (160—100) = 60 kg

INTRA-ABDOMINAL (CENTRAL) FAT (4) Lorentz's formula

Ht (cm) - 150
ACCUMULATION AND INCREASED RISK = Ht (cm) - 100 ----- -------------------------------
Compared with subcutaneous adipose tissue, intra­ 2 (women) or 4 (men)
abdominal adipose tissue has more cells per unit mass, (5) Corpulence index
higher blood flow, more glucocorticoid (cortisol) receptors,
probably more androgen (testosterone) receptors, and Actual weight
greater catecholamine-induced lipolysis. These differences
make intra-abdominal adipose tissue more susceptible to Desirable weight
both normal stimulation and changes in lipid accumulation This should not exceed 1.2
and metabolism. Furthermore, intra-abdominal adipocytes
are located upstream from liver in the portal circulation. This The body mass index (BMI) and the Brocca index are
means that there is a marked increase in the flux of widely used. A FAO/WHO/UNLJ Report gives the much
nonesterified fatty acid to the liver uia the portal blood in needed reference tables for body mass index (see Table 1)
patients with abdominal obesity. which can be used internationally as reference standards for
There is good evidence that abdominal obesity is assessing the prevalence of obesity in a community.
important in the development of insulin resistance, and in
the metabolic syndrome (hyperinsulinaemia, dyslipidaemia, 2. SKINFOLD THICKNESS
glucose intolerance, and hypertension) that link obesity with A large proportion of total body fat is located just under
CHD (7). Premenopausal women have quantitatively more the skin. Since it is most accessible, the method most used is

by R△J
 OBESITY 455
the measurement of skinfold thickness. It is a rapid and TABLE 3
“non-invasive” method for assessing body fat. Several Relative risk of health problems associated with obesity3
varieties of callipers (e.g., Harpenden skin callipers) are
available for the purpose. The measurement may be taken Greatly Moderately Slightly increased
increased increased
at all the four sites - mid-triceps, biceps, subscapular and
suprailiac regions. The sum of the measurements should be Type 2 diabetes CHD Cancer (breast cancer in
less than 40 mm in boys and 50 mm in girls (14). postmenopausal women,
Unfortunately standards for subcutaneous fat do not exist endometrial cancer,
for comparison. Further, in extreme obesity, measurements colon cancer)
Gall bladder Hypertension Reproductive hormone
may be impossible. The main drawback of skinfold disease abnormalities
measurements is their poor repeatability. Dyslipidaemia Osteoarthritis Polycystic ovary syndrome
(knees)
3. WAIST CIRCUMFERENCE AND WAIST : Insulin resistance Hyperuricaemia Impaired fertility
HIP RATIO (WHR) and gout
Waist circumference is measured at the mid point Breathlessness Low back pain due to
obesity
between the lower border of the rib cage and the iliac crest. Sleep apnea Increased risk of anaesthesia
It is a convenient and simple measurement that is unrelated complications
to height, correlates closely with BMI and WHR and is an Fetal defects associated with
approximate index of intra-abdominal fat mass and total maternal obesity
body fat. Changes in waist circumference reflect changes in
a All relative risk values are approximate.
risk factors for cardiovascular disease and other forms of
chronic diseases. There is an increased risk of metabolic Source : (7)
complications for men with a waist circumference > 102 cm,
and women with a waist circumference >88 cm (11). Prevention and control
According to WHO guidelines, it has become accepted Weight control is widely defined as approaches to
that a high WHR (> 0.9 in men and > 0.85 in women) maintaining weight within the ‘healthy’ (i.e. ‘normal’ or
indicates abdominal fat accumulation (4). ‘acceptable’) range of body mass index of 18.5 to 24.9 kg/

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m2 throughout adulthood (WHO Expert Committee, 1995).
4. OTHERS It should also include prevention of weight gain of more
In addition to the above, three well-established and more than 5 kg in all people. In those who are already over­
accurate measurements are used for the estimation of body weight, a reduction of 5-10 per cent of body weight is
fat. They are measurement of total body water, of total body recommended as an initial goal (6).
potassium and of body density. The techniques involved are Prevention of obesity should begin in early childhood.
relatively complex and cannot be used for routine clinical Obesity is harder to treat in adults than it is in children. The
purposes or for epidemiological studies (7). The introduction control of obesity centres around weight reduction. This can
of measuring fat cells has opened up a new field in obesity be achieved by dietary changes, increased physical activity
research. and a combination of both, (a) DIETARY CHANGES: The
following dietary principles apply both to prevention and
Hazards of obesity treatment : the proportion of energy-dense foods such as
Obesity , is a health hazard and a detriment to well-being simple carbohydrates and fats should be reduced; the fibre
which is reflected in the increased morbidity and mortality: content in the diet should be increased through the
(a) INCREASED MORBIDITY : Obesity is a positive risk consumption of common un-refined foods; adequate levels
factor in the development of hypertension, diabetes, gall of essential nutrients in the low energy diets (most
bladder disease and coronary heart disease and certain conventional diets for weight reduction are based on
types of cancers, especially the hormonally related and large 1000 kcal daily model for an adult) should be ensured, and
bowel cancers. There are in addition, several associated reducing diets should be as close as possible to existing
diseases, which, although not usually fatal, cause a great nutritional patterns (15). The most basic consideration is
deal of morbidity in the community, e.g., varicose veins, that the food energy intake should not be greater than what
abdominal hernia, osteoarthritis of the knees, hips and is necessary for energy expenditure. It requires modification
lumbar spine, flat feet and psychological stresses particularly of the patient’s behaviour and strong motivation to lose
during adolescence. Obese persons are exposed to increased weight and maintain ideal weight. Unfortunately, most
risk from surgery. Obesity may lead to lowered fertility. attempts to reduce weight in obese persons by dietary
Table 3 shows the relative risk of health problems associated advice remain unsuccessful, (b) INCREASED PHYSICAL
with obesity, (b) INCREASED MORTALITY : The ACTIVITY: This is an important part of weight reducing
Framingham Heart Study in United States showed a programme. Regular physical exercise is the key to an
dramatic increase in sudden death among men more than increased energy expenditure, (c) OTHERS: Appetite
20 per cent overweight as compared with those with normal suppressing drugs have been tried in the control of obesity.
weight. The increased mortality is brought about mainly by They are generally inadequate to produce massive weight
the increased incidence of hypertension and coronary heart loss in severely obese patients. Surgical treatment
disease. There is also an excess number of deaths from renal (e.g., gastric bypass, gastroplasty, jaw-wiring, to eliminate
diseases. Obesity lowers life expectancy. More information is the eating of solid food have all been tried with limited
needed about the relationship between different degrees of success (16). In short, one should not expect quick or even
obesity and morbidity and mortality. Please see in chapter tangible results in all cases from obesity prevention
11 under heading “Nutritional factors in selected diseases” programmes. Health education has an important role to play
for dietary factors of obesity. in teaching the people how to reduce overweight and

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456 NON-COMMUNICABLE DISEASES

prevent obesity. A fruitful approach will be to identity those The problem

children who are at risk of becoming obese and find way of
preventing it. WORLD
Globally, 2.2 billion people have a near or distance visual
References impairment. In at least 1 billion people impairment could
1. Hager, A. (1981). Br. Med. Bull., 37 (3) 287. have been prevented or has yet to be addressed. This 1
2. Aykroyd, W.R. and J.Mayer (1968). Food and Nutrition Terminology. billion people includes those with moderate or severe
In : WHO Doc NUT/68.6, Geneva. distance vision impairment or blindness due to unaddressed
3. WHO (2021), Obesity and Overweight, Fact sheet, 9th June 2021. refractive error (88.4 million), cataract (94 million),
4. Govt, of India (2022), National Family Health Survey-5, Ministry of
Health and Family Welfare, New Delhi.
glaucoma (7.7 million), corneal opacities (4.2 million),
5. WHO (1995). Tech. Rep. Ser. No. 854. diabetic retinopathy (3.2 million), and trachoma (2 million),
6. WHO (2002), International Agency for Research on Cancer, IARC as well as near vision impairment caused by unaddressed
Handbooks of Cancer Prevention - Weight Control and Physical presbyopia (826 million) (4).
Activity, IARC Press, Lyon 2002. About 80 per cent of blindness is avoidable (treatable or
7. WHO (2000). Tech. Rep. Ser. No. 894. potentially preventable). However, a large proportion of
8. Charney, E. et al (1976). N. Eng. J. Med., 295 : 6.
those affected remain blind for want of access to affordable
9. International Children’s Centre, Paris (1984). Children in the Tropics,
No.151. eye care. Blindness leads not only to reduced economic and
10. Falkner, F.ed (1980). Prevention in Childhood of Health Problems in social status but may also result in premature death. The
Adult Life, WHO, Geneva. major causes of moderate to severe vision impairment are as
11. WHO (2003), Tech. Rep. Ser. No. 916. follows (5):
12. Oliver, M.F. (1981). Br. Med. Bull., 37 (1) 49.
13. Beaton, G.H. (1976). In: Nutrition in Preventive Medicine Annex 2, P. 1. LJncorrected refractive errors, 53 per cent;
482. Beaton, G.H. and J.M. Bengoa (eds). WHO, Geneva, Monograph 2. Un-operated cataract, 25 per cent;
Ser.No. 62.
14. James, W.P.T. (1982). Medicine International, 1 (15) 664. 3. Age-related macular degeneration, 4 per cent;
15. Tasher, T. (1986). Food and Nutrition Bull., 8 (3) 12. The United 4. Glaucoma, 2 per cent; and
Nations University. 5. Diabetic retinopathy 1 per cent.
16. Garrow, J.S. (1981). In : Recent Advances in Medicine, Vol 18,

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Churchill Livingstone. The major causes of blindness are (5).
1. Un-operated cataract 35 per cent;
VISUAL IMPAIRMENT AND BLINDNESS 2. Un-corrected refractive error 21 per cent; and
3. Glaucoma 8 per cent.
A compilation published by WHO in 1966 (1) lists
65 definitions of blindness. As might be expected the About 82 per cent of all people who are visually impaired
definitions differed widely. Terms such as total blindness, are aged 50 years and older, while this age group comprises
economic blindness, and social blindness were in vogue. The about 20 per cent of the world’s population. With an
25th World Health Assembly in 1972 noted the complexity of increasing elderly population in many countries, more
the problem and considered the need for a generally people will be at risk of age-related visual impairment. An
accepted definition of blindness and visual impairment for estimated 19 million children are visually impaired. Of these,
national and international comparability. Taking into 12 million children are visually impaired due to refractory
consideration existing definitions, the WHO proposed a errors, a condition that could be easily diagnosed and
uniform criterion and defined blindness as “visual acuity of corrected. 1.4 million are irreversibly blind for the rest of
less than 3/60 (Snellen) or its equivalent” (2). their lives (5).
The International Classification of Disease 11 (2018) The most frequent causes of blindness in developed
classifies vision impairment into two groups, distance and countries are accidents, glaucoma, diabetes, vascular
near presenting vision impairment. diseases (hypertension), cataract and degeneration of ocular
tissues especially of the retina, and hereditary conditions.
Distance vision impairment: In South-East Asia Region, cataract is the single most
Mild - Presenting visual acuity worse than 6/12 common cause of blindness being responsible for 50-80 per
Moderate - Presenting visual acuity worse than 6/18 cent of all blindness. Uncorrected refractive errors are being
increasingly recognized as a cause of blindness and low
Severe - Presenting visual acuity worse than 6/60 vision. Vitamin A deficiency, which has been responsible for
Blindness - Presenting visual acuity worse than 3/60 most childhood blindness in the Region is gradually
declining. The emerging causes of blindness include
Near vision impairment: glaucoma, age-related macular degeneration, diabetic
Presenting near vision acuity worse than N6 or M0.8 at retinopathy, corneal ulcer and ocular trauma (6).
40 cm with existing correction. Among the leading causes of childhood blindness in the
A person’s experience of vision impairment varies region are xerophthalmia, congenital cataract, congenital
depending upon many different factors. This includes, for glaucoma and optic atrophy due to meningitis, retinopathy
example, the availability of prevention and treatment of prematurity, and uncorrected refractive errors.
interventions, access to vision rehabilitation (including Xerophthalmia is largely under control with vitamin A
assistive products such as glasses or white canes), and distribution in immunization programmes.
whether the person experiences problems with inaccessible There are an estimated 3-4 million persons blind, due to
buildings, transport information etc. (3). corneal opacity. With declining incidence of trachoma and

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 VISUAL IMPAIRMENT AND BLINDNESS 457
xerophthalmia, the consequences of ocular trauma and TABLE 1
corneal ulceration are emerging as important causes. Causes of blindness in India
According to an estimate, 6.5 million people are affected (2015-19 National survey on blindness)
with, and 1.3 million eyes become blind due to corneal ulcer
every year in the region (6). Trachoma remains an Refractive error 0.1 per cent
important cause in pockets in some countries although its Aphakia uncorrected 1.7 per cent
importance as a cause of blindness has declined over the Cataract untreated 66.2 per cent
years (7). Cataract surgical complications 7.2 per cent
Trachomatous corneal opacity 0.8 per cent
Overall, visual impairment worldwide has decreased
Non-trachomatous corneal opacity 7.4 per cent
since the early 1990s. This decrease is principally the result
Phthisis 2.8 per cent
of a reduction of visual impairment from infectious diseases
Glaucoma 5.5 per cent
through public health action, overall socio-economic
Diabetic retinopathy 1.2 per cent
development, increased availability of eye care services and
ARMD 0 7 per cent
awareness of the general population about solution to the
Other posterior segment disease 5.9 per cent
problems related to vision impairment (surgery, refraction 0.5 per cent
All other globe/CNS abnormalities
devices, etc.). However, it is estimated that the number of
people with vision impairment could triple due to Source : (10)
population growth and ageing (5).
Retinopathy of prematurity (ROP) is emerging as an
INDIA important cause of childhood blindness. With the advent of
hyperbaric oxygen and opening of large number of private
India has changed its over four-decade-old definition of and governmnet NICUs, the survival of the premature
blindness, bringing it in line with the WHO criteria. babies (born before 30 weeks of gestation and 1500 grams
According to the new definition, a person who is unable to of weight at birth) has improved considerably. These babies
count fingers from a distance of three meters would be are at risk of developing ROP and there is dire necessity to
considered blind as against the earlier stipulation of six create awareness not only in public but also amongst
meters, which was adopted in 1976. The notification in this opthalmologists and paediatricians to detect and treat ROP
regard has been issued by the Union Health Ministry. in time.

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According to this definition, the population of blind
□eople in India will reduce from 1.20 crore (as per National Epidemiological determinants
Blindness Survey 2007 data) to 80 Lacs (8). (a) AGE : About 30 per cent of the blind in India are said
The nomenclature of the programme is also changed to lose their eyesight before they reach the age of 20 years,
irom “National Programme for Control of Blindness” to and many under the age of 5 years. Refractive error,
trachoma, conjunctivitis and malnutrition (vitamin A
“National Programme for Control of Blindness and visual
impairment” (8). deficiency) are important causes of blindness among
children and the younger age groups; cataract, refractive
The prevalence of blindness according to rapid national error, glaucoma and diabetes are causes of blindness in
survey on blindness 2006-2007 was 1.0 per cent. In the middle age; accidents and injuries can occur in all age
current survey (2015-2019) the projected prevalence rate is groups, but more importantly in the age group 20 to 40
0.36 per cent (10). years, (b) SEX : A higher prevalence of blindness is reported
The National Survey on Blindness 2015-19 conducted in in females than in males in India. This has been attributed to
the country recognized the main causes responsible for a higher prevalence of trachoma, conjunctivitis and cataract
visual impairment and blindness. As shown in Table 1, the among females than in males (12). (c) MALNUTRITION :
principal cause of blindness in India today is cataract, Malnutrition as a cause of blindness was hardly recognized a
responsible for about 66.2 per cent of all cases. Cataract few years ago. It is closely related not only with low vitamin
occurs more frequently with advancing age. Senile cataract A intake, but also with infectious diseases of childhood
occurs a decade earlier in India relative to Europe and especially measles and diarrhoea (which precipitate
America. Uncorrected refractive error are responsible for malnutrition). In many cases protein energy malnutrition
(PEM) is also associated with blindness. Severe blinding
Per cent blindness; overall prevalence of
corneal destruction due to vitamin A deficiency (e.g.,
rc^ucoma was about 5.5 per cent; posterior segment
keratomalacia) is largely limited to the first 4-6 years of life
pathology accounts for about 5.9 per cent cases (10). In a
and is especially frequent among those 6 months to 3 years
camp based study, glaucoma prevalence was found to be of life, (d) OCCUPATION : It has long been recognized that
about 3.07 per cent with a slight female preponderance people working in factories, workshops and cottage
(males 2.9 per cent and females 3.19 per cent). Primary industries are prone to eye injuries because of exposure to
open angle glaucoma was more common (about 1.7 per dust, airborne particles, flying objects, gases, fumes,
cent) than primary angle closure glaucoma (0.73 per cent) radiation (usually welding flash), electrical flash, etc. Many
(9). In the others group, injuries as a cause of blindness workers including doctors are known to have developed
accounts for 1.2 per cent (11). There is evidence that premature cataracts while exposed to X-rays, ultraviolet rays
injuries are on the increase due to increase in cottage or heat waves, (e) SOCIAL CLASS : There is a close
industry (e.g. carpentry, black smithy, stone crushing, relationship between the incidence of blindness and socio­
chiselling and hammering and chopping wood), and rapid economic status. Surveys indicate that blindness is
industrialization in the country. The other causes in this twice more prevalent in the poorer classes than in the
group includes congenital disorder, ' uveitis, retina well-to-do (12). (f) SOCIAL FACTORS: Many people lose
detachment, tumours, diabetes, hypertension, diseases of their eyesight because of meddlesome ophthalmology by
the nervous system, leprosy, etc. quacks. The basic social factors are ignorance, poverty, low

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458 NON-COMMUNICABLE DISEASES

standard of personal and community hygiene, and region by prevalence surveys. This knowledge is essential for
inadequate health care services. setting priorities and development of appropriate intervention
programmes.
Changing concepts in eye health care
Recent years have witnessed a change from acute 2. METHODS OF INTERVENTION (15)
intervention (cure) typical of clinical ophthalmology to (a) Primary eye care
comprehensive eye-health care which includes the following
concepts : A wide range of eye conditions (e.g., acute conjunctivitis,
ophthalmia neonatorum, trachoma, superficial foreign
1. Primary eye care bodies, xerophthalmia) can be treated/prevented at the
One of the most significant developments in the field of eye grass-root level by locally trained primary health workers
health care over the last few years has been the concept of (e.g., village health guides, multi-purpose workers) who are
primary eye care, that is, the inclusion of an eye-care the first to make contact with the community. For this
component in primary health care system. The idea of primary purpose, they are provided with essential drugs such as
eye care, as one of the main ingredients of a primary health topical tetracycline, vitamin A capsules, eye bandages,
care approach to blindness, has rapidly gained acceptance the shields, etc. They are also trained to refer difficult cases
world over. It is today recognized as a model for eye care at the (e.g., corneal ulcer, penetrating foreign bodies, painful eye
community level. The promotion and protection of eye health, conditions and infections which do not respond to treatment)
together with on-the-spot treatment for the commonest eye to the nearest PHC or district hospital. Their activities also
diseases, are its cornerstones. The final objective of primary involve promotion of personal hygiene, sanitation, good
eye care is to increase the coverage and quality of eye health dietary habits and safety in general. Currently, there is one
care through primary health care approach and thereby village health guide for 1000 population and 2 multipurpose
improve the utilization of existing resources. workers for 5000 population in India.
In short, primary eye care is based firmly in primary
2. Epidemiological approach health care which is “.............. essential health care..............made
The epidemiological approach which involves studies at universally accessible to individuals and families in the
the population level has been recognized. It focuses, among community through their full participation and at a cost that
other things, on the measurement of the incidence, the community and country can afford ....” (Article VI of the

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prevalence of diseases and their risk factors. The local Declaration of Alma Ata, 1978).
epidemiological situation will determine the action needed.
(b) Secondary care
3. Team concept Secondary care involves definitive management of
In many developing countries, there is only one eye common blinding conditions such as cataract, trichiasis,
specialist for more than a million people. Increasingly, entropion, ocular trauma, glaucoma, etc. This care is
therefore, health care leans on the use of auxiliary health provided in PHCs and district hospitals where eye
personnel to fill many gaps. In India this gap is filled by departments or eye clinics are established. The secondary
village health workers, ophthalmic assistants, multi-purpose care may involve the use of mobile eye clinics. For instance,
workers, and voluntary agencies. cataract accounts for over 62 per cent of blindness in India.
The eye camp approach to make cataract surgery available
4. Establishment of national programmes has been highly successful, and has received wide popular
Another important development in connection with the support. Apart from cataract operations, these camps
prevention of blindness has been the establishment of undertake general health surveys for the early detection of
national programmes. Many of these programmes were first visual defects as well as education of the masses. For mobile
started by voluntary agencies concerned with blindness services to be effective, there must be good community
prevention (e.g., eye camps) and some of them focused on a participation in the programme. Adequate follow-up and
single disease, such as trachoma. The increasing recognition evaluation must also be provided. The “mobile units”,
of the primary health care approach to blindness resulted in though valuable, lack permanence and are being utilized as
part of a comprehensive strategy for eye care. The great
comprehensive national programmes for the prevention of
advantage of this strategy is, it is problem-specific and makes *
blindness (13) from all causes.
the best use of local resources and provides inexpensfVl pee
Prevention of blindness care to the population at the peripheral level (16). n
The concept of avoidable blindness (i.e., preventable (c) Tertiary care
or curable blindness) has gained increasing recognition
These services are usually established in the national or
during recent years. A great many of the causes of blindness
regional capitals and are often associated with Medical
lend themselves to prevention and/or control - whether by
improving nutrition, by treating cases of infectious diseases, Colleges and Institutes of Medicine. They provide
sophisticated eye care such as retinal detachment surgery,
or by controlling the organisms which cause infection., or by
improving safety conditions - particularly on the roads, at corneal grafting and other complex forms of management not
work or in the home (14). available in secondary centres. The majority of States in India
has passed the Corneal Grafting Acts which have helped the
The components for action in national programmes for establishment of Eye Banks. Other measures of rehabilitation
the prevention of blindness comprise the following : comprise education of the blind in special schools and
utilization of their services in gainful employment. The central
1. INITIAL ASSESSMENT government has established National Institute for the Blind in
The first step is to assess the magnitude, geographic Dehradun (U.P.) to work out new approaches and strategies
distribution and causes of blindness within the country or for solving the problems of the blind.

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 VISUAL IMPAIRMENT AND BLINDNESS 459
(d) Specific programmes 1950. In 1974, by invitation of WHO, the organizations
(i) Trachoma control: Endemic trachoma and associated concerned with blindness and with its prevention came
infections are a major cause of preventable blindness in together to build a new agency, the “International Agency
many developing countries. Early diagnosis and treatment for Prevention of Blindness”. The Agency’s primary task is
will cure trachoma. National programmes have been to prevent blindness. There is a growing movement for direct
mounted against trachoma in many countries. Mass technical cooperation among the developing countries.
campaigns with topical tetracycline and the improvement of Neighbouring countries may provide training, exchange
socio-economic conditions have markedly reduced the workers, share plans, and, in a variety of ways enrich and
severity of trachoma and associated bacterial conjunctival stimulate their programmes (18).
infections. The Trachoma Control Programme launched in
India in 1963 was merged with the National Programme for National Programme for the Control of
the Control of Blindness in 1976. Blindness and Visual Impairment
(ii) School eye health services : This is another useful See chapter 7 for details.
approach to the eye health problems in the community. Vision 2020 : The Right to Sight
School children who form a sizable segment of the community
can be screened and treated for defects such as refraction Vision 2020 : The Right to Sight, a global initiative to
errors, squint, amblyopia, trachoma, etc. Health education is eliminate avoidable blindness was launched by WHO on
an important component of school health service. Students 18th Feb. 1999. One significant way in which this initiative
should be taught to practise the principles of good posture, differs from previous ones is that the concept centres around
proper lighting, avoidance of glare, proper distance and angle Rights issues. Recognition of sight as a fundamental human
between the books and the eyes. Use of suitably readable type right by all countries can be an important catalyst of
style in textbooks should be encouraged. initiatives for the prevention and control of blindness. The
objective of Vision 2020 is to assist member countries in
(iii) Vitamin A prophylaxis : Under the vitamin A developing sustainable systems which will enable them to
distribution scheme in India, 200,000 IU of vitamin A are eliminate avoidable blindness from major causes, i.e.
given orally at 6-monthly intervals between the ages cataract, xerophthalmia and other causes of childhood
1-6 years. To be able to control xerophthalmia, the whole blindness, refractive error and low vision, trachoma and
family should be kept under surveillance for one year and other causes of corneal blindness by the year 2020 (10, 6).

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children for 5 years (17).
(iv) Occupational eye health services: This is to prevent/ Global eye health action plan 2014-2019 (19)
treat eye hazards in industries. Education on the prevention The global eye health action plan 2014-2019 aims to
of occupational eye hazards and the use of protective reduce avoidable visual impairment as a global public health
devices in some occupations (like welding) is essential. The problem and to secure access to rehabilitation services for
key to the prevention of accidents in factories is to improve the visually impaired.
the safety features of machines, to have proper illumination
of the working area, to select workers with the requisite The global eye health action plan is based on five
alertness and good vision, and to encourage the use of principles and approaches which underpin the plan:
protective devices (15). universal access and equity, human rights, evidence-based
practice, a life course approach, and empowerment of
3. LONG-TERM MEASURES people with visual impairment. As there have been
Long-term measures also have a part to play in significant shifts in the pattern of causes of visual
controlling eye infections. Broadly these measures are aimed impairment, the action plan is structured to particularly
at improving the quality of life and modifying or attacking address the global trend towards an increasing incidence of
the factors responsible for the persistence of eye health chronic eye diseases related to ageing . These are expected
problems, e.g., poor sanitation, lack of adequate safe water to be the most prevalent causes of avoidable visual
supplies, little intake of foods rich in vitamin A, lack of impairment in the next decades.
personal hygiene, etc. Health education is an important The global eye health action plan is built using the health
long-term measure in order to create community awareness system approach, which encompasses the integration of eye
of the problem; to motivate the community, to accept total care programmes into the wider health care system at all
’^health care programmes, and to secure community levels (primary, secondary and tertiary). As a global target,
nj&rticipation. the reduction in prevalence of avoidable visual impairment
by 25 per cent by 2019, from the baseline of 2010 has been
4. EVALUATION selected for this action plan.
Evaluation should be an integral part of intervention There are three indicators at the goal and purpose levels
programmes to measure the extent to which ocular diseases to measure progress at the national level : (1) The
and blindness have been alleviated, assess the manner and prevalence and causes of visual impairment; (2) The number
degree to which programme activities have been carried out, of eye care personnel; and (3) Cataract surgery.
and determine the nature of other changes that may have
been produced (18). References
National and International agencies 1. WHO (1966). Epi and Vital Statis Rep., 19:437.
2. WHO (2011), Change the Definition of Blindness.
The National Association for the Blind (NAB), a 3. WHO (2018), Visual Impairment and Blindness, fact sheet, 18th Oct.
voluntary organization which came into existence in 1952 2018.
has been active in the field of providing welfare services to 4. WHO (2021), Fact sheet, 14th Oct. 2021.
the blind throughout India. The Royal Commonwealth 5. WHO (2017), Blindness and visual impairment, Fact sheet, 11th Oct.
Society for the Blind has been working in the field since 2017

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460_ NON-COMMUNICABLE DISEASES

6. WHO (2002), Health Situation in the South-East Asia Region 1998- TABLE 1
2000, New Delhi. Burden of oral diseases (Multi-centric survey 2007), India
7. WHO (2000), Strategic Plan for Vision 2020 : The Right to sight,
Elimination of Avoidable Blindness in the South-East Asia Region, Disease Prevalence
New Delhi.
8. Govt, of India (2018), National Programme for Control of Blindness Dental Caries 40-45%
and Visual Impairment, 2017-2018, Ministry of Health and Family Periodontal diseases >90% (Advanced disease in 40%)
welfare, New Delhi.
Malocclusion 30% of children
9. Govt, of India (2018), Annual Report 2017-2018, Ministry of Health
and Family Welfare, New Delhi. Cleft lip and palate 1.7 per 1000 live births
10. Govt, oflndia (2020), Annual Report 2019-20, Ministry of Health and Oral cancer 12.6 per lakh population
Family Welfare, New Delhi.
Oral submucous fibrosis 4 per 1000 adults in rural India
11. Kapoor, P.M. and A.K. Kundu (1985). J. Com. Dis., 17 (2) 118.
( premalignant and crippling
12. Sharma, K.L. and B.G. Prasad (1962). Ind. J. Med. Res., 50 : 842.
condition of mouth)
13. Thylefors, B. (1987). World Health, May.
14. Bietti, G.B. (1976). World Health, Feb-March. Dental fluorosis Endemic in 230 districts of 19
States
15. WHO (1984). Strategies for the Prevention of Blindness in National
Programmes, WHO, Geneva. Edentulousness (tooth loss) 19-32% of elderly population
16. WHO (1980). WHO Chronicle, 34 (9) 332. >65 years
17. Madan Mohan (1984). Swasth Hind, 28 (5) 105. Oral lesions due to HIV/AIDS 72% of HIV/AIDS patients
18. WHO (1979). Guidelines for Programmes for the Prevention of Birth defects involving 0.82 to 3.36 per 1000 live births
Blindness, WHO, Geneva. oro-facial complex
19. WHO (2013), Universal eye health, A global action plan 2014-2019.
Others: Traumatic injuries,
• Mucosal lesions associated with radiation and chemotherapy
ORAL DISEASES • Morbidity and deformity following oral cancer surgery.
Oral diseases are the most common non-communicable Source : (2)
diseases and affect people throughout their lifetime, causing
pain, discomfort, disfigurement and even death. Oral health Taking into account the oral health situation in the
is a key indicator of overall health, wellbeing and quality of country, Govt, of India has initiated a National Oral Health
life. WHO defines oral health as “a state of being free from Programme during the year 2014-2015, to provide

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chronic mouth and facial pain, oral and throat cancer, oral integrated and comprehensive oral health care in the
infection and sores, periodontal (gum) disease, tooth decay, existing health care facilities (3).
tooth loss, and other diseases and disorders that limit an RISK FACTORS
individual’s capacity in biting, chewing, smiling, speaking,
and psychosocial wellbeing” (1) Most oral diseases and conditions share modifiable risk
factors (such as tobacco use, alcohol consumption and
Problem Statement unhealthy diets high in free sugars) common to the four
leading NCDs (cardiovascular diseases, cancer, chronic
WORLD respiratory diseases and diabetes). In addition, it is reported
Seven oral diseases and conditions account for most of that diabetes mellitus is linked in a reciprocal way with the
the oral disease burden. They include dental caries (tooth development and progression of periodontitis. Moreover,
decay), periodontal (gum) diseases, oral cancers, oral there is a causal link between high sugars consumption and
manifestations of HIV, oro-dental trauma, cleft lip and diabetes, obesity and dental caries.
palate, and noma. Almost all diseases and conditions are
either largely preventable or can be treated in their early Oral health inequalities :
stages. It is estimated that oral diseases affected at least 3.58 Oral health inequalities are caused by a broad range of
billion people in 2016 worldwide, with caries of the interacting biological, socio-behavioural, psychosocial,
permanent teeth being the most prevalent of all conditions societal and political factors that create ‘the conditions in
assessed. Globally, it is estimated that 2.4 billion people which people are born, grow, live, work and age’ - the so-called
suffer from caries of permanent teeth and 486 million social determinants. Oral diseases disproportionally affect the
children suffer from caries of primary teeth. In most middle poor and socially-disadvantaged members of society. There is
and low income countries, with increasing urbanization and a very strong and consistent association betv^^n
changes in living conditions, the prevalence of oral diseases socioeconomic status (income, occupation and educations
continues to increase notably due to inadequate exposure to level) and the prevalence and severity of oral diseases. This
fluoride and poor access to primary oral health care association exists across the life course from early childhood to
services. Heavy marketing of sugars, tobacco and alcohol older age, and across populations in high, middle and low-
leads to growing consumption of unhealthy products. income countries. Oral health inequalities are therefore
considered as differences in oral health that are avoidable, and
INDIA deemed both unfair and unjust in modern society (1)
Two large scale oral health surveys have been conducted
in India: (i) National Oral Health Survey & Fluoride Oral diseases (1)
Mapping by Dental Council of India in 2003; and (ii) Oral
Health in India : Report of multi-centric oral health survey Dental caries (tooth decay)
by Ministry of Health and Family Welfare in collaboration Dental caries results when microbial biofilm (plaque)
with dental department of AIIMS in 2007. These two surveys formed on the tooth surface converts the free sugars
indicate the prevalence of some of the oral diseases and contained in foods and drinks into acids that dissolve tooth
conditions in the country. The burden of diseases are as enamel and dentine over time. With continued high intake
shown in Table 1. of free sugars, inadequate exposure to fluoride and without

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 ORAL DISEASES J61
regular microbial biofilm removal, tooth structures are Noma (1)
destroyed, resulting in development of cavities and pain, Noma is a necrotizing disease that affects children
impacts on oral-health-related quality of life, and, in the between the ages of 2 and 6 years suffering from
advanced stage, tooth loss and systemic infection. malnutrition, affected by infectious disease, living in extreme
Periodontal (gum) disease poverty and with weakened immune systems.
Periodontal disease affects the tissues that both surround Noma is mostly prevalent in sub-Saharan Africa, but rare
and support the tooth. This often presents as bleeding or cases are reported in Latin America and Asia. Noma starts as
swollen gums (gingivitis), pain and sometimes as bad breath. a soft tissue lesion (a sore) of the gums, inside the mouth.
In its more severe form, loss of gum attachment to the tooth The initial gum lesion then develops into an ulcerative,
and supporting bone causes “pockets” and loosening of necrotizing gingivitis that progresses rapidly, destroying the
teeth (periodontitis). Severe periodontal disease, which may soft tissues and further progressing to involve the hard
result in tooth loss, was the 11th most prevalent disease tissues and skin of the face.
globally in 2016. The main causes of periodontal disease are In 1998, WHO estimated that there were 140,000 new cases
poor oral hygiene and tobacco use. of noma annually. Without treatment, noma is fatal in 90% of
cases. Where noma is detected at an early stage, its progression
Tooth loss can be rapidly halted, through basic hygiene, antibiotics and
♦Dental caries and periodontal diseases are major causes of nutritional rehabilitation. Such early detection helps to prevent
1*" h loss. Severe tooth loss and edentulism (no natural teeth suffering, disability and death. Survivors suffer from severe
r< .pining) are widespread and particularly seen among older facial disfigurement, have difficulty speaking and eating, face
people. Severe tooth loss and edentulism was one of the social stigma, and require complex surgery and rehabilitation.
leading ten causes of years lived with disability (YLD) in some Cleft lip and cleft palate
high income countries due to their aging populations.
Clefts of the lip and palate are heterogeneous disorders
Oral cancer that affect the lips and oral cavity, and occur either alone
Oral cancer includes cancers of lip and all subsites of the (70%) or as part of a syndrome, affecting more than 1 in 1000
oral cavity, and oropharynx. The age-adjusted incidence of newborns worldwide. Although genetic predisposition is an
oral cancer (cancers of the lip and oral cavity) in the world is important factor for congenital anomalies, other modifiable

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estimated at 4 cases per 100,000 people. However, there is risk factors such as poor maternal nutrition, tobacco
wide variation across the globe: from no recorded cases to consumption, alcohol and obesity during pregnancy also play
around 20 cases per 100,000 people. Oral cancer is more a role. In low-income settings, there is a high mortality rate in
common in men, in older people, and varies strongly by the neonatal period. If lip and palate clefts are properly
socio-economic condition. In some Asian-Pacific countries, treated by surgery, complete rehabilitation is possible.
the incidence of oral cancer ranks among the three top Prevention of oral diseases (1)
cancers. Tobacco, alcohol and areca nut (betel quid) use are
among the leading causes of oral cancer. In regions like The burden of oral diseases can be reduced through
North America and Europe, “high risk” human public health interventions by addressing common risk
papillomavirus infections are responsible for a growing factors. These are :
percentage of oro-pharyngeal cancers among young people. - Promoting a well-balanced diet:
- Low in free sugars to prevent development of dental
Oral manifestations of HIV infection caries, premature tooth loss and other diet-related NCDs;
Oral manifestations occur in 30-80% of people with HIV, - With adequate fruit and vegetable intake, which may
with considerable variations depending on the situations such have a protective role in oral cancer prevention;
as affordability of standard antiretroviral therapy (ART). Oral - Reducing smoking, the use of smokeless tobacco
manifestations include fungal, bacterial or viral infections of including chewing of areca nuts, and alcohol
which oral candidiasis is the most common and often the first consumption to reduce the risk of oral cancers,
symptom early in the course of the disease. Oral HIV lesions periodontal disease and tooth loss; and
cause pain, discomfort, dry mouth, eating restrictions and are
- Encouraging use of protective equipment in sports and
a constant source of opportunistic infection. Early detection of when traveling in motor vehicles, to reduce the risk of
HIV-related oral lesions can be used to diagnose HIV infection, facial injuries.
monitor the disease’s progression, predict immune status and
result in timely therapeutic intervention. The treatment and Dental caries can be largely prevented by maintaining a
management of oral HIV lesions can considerably improve oral constant low level of fluoride in the oral cavity. Optimal
health, quality of life and wellbeing. fluoride can be obtained from different sources such as
fluoridated drinking water, salt, milk and toothpaste. Twice-
Oro-dental trauma daily tooth brushing with fluoride-containing toothpaste
Oro-dental trauma is an impact injury to the teeth and/or (1000 to 1500 ppm) should be encouraged. Long-term
other hard or soft tissues within and around the mouth and exposure to an optimal level of fluoride results in substantially
oral cavity. The world prevalence of traumatic dental injuries lower incidence and prevalence of tooth decay across all ages.
in either dentition (primary and permanent) is around 20%. Oral health inequalities must be reduced by tacking the
Oro-dental trauma can be caused by oral factors broader social determinants through a range of
(e.g. increased overjet); environmental factors (for example; complementary downstream, midstream and integrated
unsafe playgrounds or schools); risk-taking behaviour; and upstream policies such as: water fluoridation; regulation of
violence. Treatment is costly and lengthy and sometimes can the marketing and promotion of sugary foods to children and
even lead to tooth loss, resulting in complications for facial taxes on sugar-sweetened beverages. Moreover, promoting
and psychological development and quality of life. healthy settings such as healthy workplaces and health

by R△J
 NON-COMMUNICABLE DISEASES
462
promoting schools is critical to building comprehensive fatalities as a ratio of the number of vehicles per kilometre or
supporting environments to promote oral health. passengers per kilometre, (v) Deaths of vehicle occupants
per 1000 vehicles per year, etc.
References
1. WHO (2018), Fact sheet on Oral Health, 24th Sept. 2018. b. MORBIDITY
2. Govt, of India (2015), Operational guidelines, National Oral Health Morbidity is measured in terms of “serious injuries” and
programme, Ministry of Health and Family Welfare, New Delhi.
“slight injuries” (4). The seriousness of the injury is assessed
3. Govt, of India (2018), Annual Report 2017-2018, Ministry of Health
and Family Welfare, New Delhi. by a scale known as “Abbreviated Injury Scale” (3).
Morbidity rates are generally less reliable because of under­
ACCIDENTS AND INJURIES reporting and mis-reporting.
An accident has been defined as : “an unexpected, c. DISABILITY
unplanned occurrence which may involve injury” (1). A
An important outcome of the accident process is
WHO Advisory Group in 1956 defined accident as an
“unpremeditated event resulting in recognizable damage” disability, which may be temporary or permanent, partial or
(2). According to another definition, an accident is that total. Measurement of disability in terms of its duration is a
“occurrence in a sequence of events which usually produces limited concept; it does not take into consideration the
unintended injury, death or property damage”. psychological or social aspects of an accident or injury (5).
The International classification of “Functioning, Disabf ’
Accidents represent a major epidemic of non- and Health” (ICF) is an attempt by WHO (6) to estimate* >
communicable disease in the present century. They are no
disability of individuals at a given moment.
longer considered accidental. They are part of the price we
pay for technological progress. The problem
Accidents have their own natural history and follow the
same epidemiological pattern as any other disease - that is, WORLD
the agent, the host and the environment interacting together
Injuries constitute a variable epidemic. Injuries are
to produce injury or damage. They occur more frequently in
commonly classified based on “intentionality”. Most road
certain age-groups, at certain times of day and week and at
traffic injuries, poisoning, falls, fire and burn injuries and

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certain localities. Some people are more prone to accidents
than others and susceptibility is increased by the effect of drowning are unintentional. Intentional injuries include
alcohol and other drugs as well as physiological state such as interpersonal violence (homicide, sexual assault, neglect ands
fatigue. Lastly, a majority of accidents are preventable. abandonment, and other maltreatment), suicide and collective
violence (war). Evidence suggests that some children and
Measurement of the problem adolescents are more vulnerable to certain types of injuries.
For example poisoning, drowning, burns and maltreatment by
a. MORTALITY caregivers affects primarily small children, while road traffic
The following epidemiological indices will be useful in accidents, interpersonal violence and sports injuries tend to
assessing the magnitude of the problem : (i) Proportional affect older children, adolescents and adults (7).
mortality rate : That is, the number of deaths due to The leading cause of injury deaths is road traffic injury,
accidents per 100 (or 1000) total deaths, (ii) Number of followed by suicide, falls and interpersonal violence. Other
deaths per million population : The term “killed” (in a road important cause of injuries include drowning, fires and burns,
traffic accident) is defined as any person who was killed poisoning, and war or conflict (1). Table 1 shows the global
outright or who died within 30 days as a result of the estimated deaths by type of injury, percentage of total deaths,
accident (3). (iii) Death rate per 1000 (or 100,000) crude death rate per lakh population and age specific death rate
registered vehicles per year, (iv) Number of accidents or per lakh population due to injuries during the year 2016 (8).
TABLE 1
Leading causes of injuries and deaths worldwide, 2016 4

T Deaths % of total Crude death rate Age specific death rate

Type offinjury (000) deaths (per lakh population) (per lakh population)

A. Unintentional injuries 3,429 6.0 46.0 45.0

1. Road injury 1,402 2.5 18.8 18.7
2. Poisonings 107 0.2 1.4 1.4
3. Falls 660 1.2 8.8 8.4
4. Fire, heat & hot substance 153 0.3 2.0 2.0
5. Drowning 322 0.6 4.3 4.3
6. Exposure to mechanical forces 150 0.3 2.0 2.0
7. Natural disasters 2 0.0 0.0 0.0
8 Other unintentional injuries 633 1.1 8.5 8.2
B. Intentional injuries 1,454 2.6 19.5 19.4
1. Self harm 793 1.4 10.6 10.5
2. Interpersonal violence 477 0.8 6.4 6.4
3. Collective violence and legal intervention 184 0.3 2.5 2.5
Total 4,883 8.6 65.4 64.4
Sources: (8)

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 ACCIDENTS AND INJURIES —463
Injuries and violence are included in multiple Sustainable TABLE 3
Development Goals targets. Road traffic injuries and Reported number of accidental deaths in
unintentional injuries are included in the health goal SDG 3 India by main cause (2018-2019)
with targets related to violence and disasters part of other
goals. Table 2 enumerates the indicators related to the goal Causes
No. of Deaths
targets, the global and Indian scenario. 2018 2019
TABLE 2 A. Natural Calamity 6,891 8,145
Selected indicators of SDG, global and India scenario B. Un-natural Causes
Cause Global India Air-Crash 15 12
Collapse of Structures 2,017 1,929
Average death rate due to natural disaster <0.1 <0.1 Drowning 30,187 32,671
(per 100,000 population) 2016 Electrocution 12.154 13,432
Mortality rate due to homicide 6.4 2.1 Explosions 696 655
(per 100,000 population) 2016
Falls 20,201 20,901
Estimated direct deaths from major conflicts 2.5 <0.1
(per 100,000 population) 2016 Factory/Machine accidents 694 1,001
2.5 1.9 Fire 12,748 10,915
Mortality rate unintentional poisoning
(per 100,000 population) 2016 Fire Arms 528 320
'cide mortality rate 10.6 14 7 Sudden Deaths 46,003 47,295
2r 100,000 population) 2016 Killed by Animals 1,130 1,425
Road traffic mortality rate 18.8 8.0 Mines or quarry disaster 125 82
(per 100,000 population) 2016 Poisoning 21,646 21,196
Stampede 6 12
Source : (8) Suffocation 1,921 1,598
INDIA Traffic accidents 1,78,832 1,81,113
Causes Not Known 58,010 58,576
Accidents are definitely on an increase in India, Other Causes 14,634 16,666
increasing mechanization in agriculture and industry,
Total (B) 4,01,547 4,09,799
induction of semi-skilled and unskilled workers in various

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operations and rapid increase in vehicular traffic have Total (A+B) 4,08,438 4,17,944
resulted in an increase in morbidity and mortality due to
Source : (9)
accidents. Overcrowding, lack of awareness and poor
implementation of essential safety precautions result in an in high-income countries where the average rate is 8.3
increasing number of accidents. Consumption of poisonous deaths per 100,000 population. The variation in rates of
substances accidentally or intentionally is also on the rise. death observed corresponds with differences in the types of
Deaths, disabilities and hospitalization due to injuries road users most affected. Vulnerable road users -
continue to have impact of socio-economic loss to pedestrians, cyclists and motor cyclists represent more than
individuals, families, society and infrastructure. The half of all global deaths. Pedestrians and cyclists represent
traditional view of injury as an accident, has resulted in the 26 per cent of all deaths while those using motorized two or
neglect of this aspect of public health. Today injuries are low three wheelers comprise another 28 per cent. Car occupants
in priority for policy makers, and only few plans are drawn make up 29 per cent of all deaths (11).
for injury prevention. In addition, there are as many as 20-50 million non-fatal
Table 3 shows the reported number of accidental deaths injuries and 10-20 million serious injuries requiring long
by main causes in India. period of expensive care, nursing and treatment. From a
young age, males are more likely to be involved in road
TYPES OF ACCIDENTS traffic crashes than females. They are almost 3 times as likely
to be killed in a car crash as young females (10, 12).
1. Road traffic accidents
The number of road traffic deaths continues to rise INDIA (13A)
steadily, reaching 1.35 million in 2016. However, the rate of Road Accidents (55,442 cases) accounted for 97.4% of
death relative to the size of the world’s population has total traffic accidents in 53 mega cities during 2021.
remained constant. When considered in context of the Chennai accounted for 9.1% (5,034 cases) of total road
increasing global population and rapid motorization that has accidents reported, followed by Delhi City 8.1% (4,505
taken place over the same period. This suggest that existing cases) and Bengaluru 5.8% (3,213 cases). However, the
road safety efforts may have mitigated the situation from largest number of fatal road accidents were reported in Delhi
getting worse. City (1,172 deaths) followed by Chennai (998 deaths),
As progress is made in the prevention and control of accounting for 8.8% and 7.5% of total deaths due to road
infectious diseases, the relative contribution of deaths from accidents respectively during 2021.
injuries have increased. Road traffic injuries are the Cause-wise analysis of road accidents revealed that most
8th leading cause death for children and young adults aged of road accident deaths (including unmanned railway
5-29 years. A number of countries have seen success in crossing) in 53 mega cities were due to over-speeding which
reducing road traffic deaths over the last few years, but accounted for 55.4% (7,415 out of 13,396 deaths) of total
progress varies significantly between different regions and deaths due to road accidents during 2021. Dangerous or
countries of the world. With an average rate of 27.5 deaths Careless driving/Over-taking etc. also caused 29.0% of total
per 100,000 population, the risk of a road traffic death is deaths due to road accidents. Driving under influence of
more than three times higher in low-income countries than drug/alcohol had caused 2.0% (262) of fatalities in road

by R△J
464 NON-COMMUNICABLE DISEASES

accidents. Most of fatalities due to driving under influence of - If correctly installed and used, child restraints reduce
drug/alcohol were reported in Ranchi (54 out of 262 deaths). deaths among infants by approximately 70%, and deaths
Place of occurrence-wise deaths in road accidents reveals among small children by between 54% and 80%.
that most of fatalities due to road accidents have taken place Distracted driving
near residential area, contributing 30.2% (4,045 out of
13,396 deaths) of deaths, followed by 9.6% (1,281) near There are many types of distractions that can lead to
factory/industrial area and 7.4% near schools/ college/other impaired driving, but recently there has been a marked
educational institutions (987). Out of 53 mega cities, increase around the world in the use of mobile phones by
Ahmedabad (161 deaths) followed by Delhi City (63 deaths) drivers that is becoming a growing concern for road safety.
have reported maximum cases of road accidents at The distraction caused by mobile phones can impair driving
pedestrian crossing. As per road-wise classification of road performance in a number of ways, e.g. longer reaction times
accidents, 21.5% of total road accidents were reported at (notably braking reaction time, but also reaction to traffic
the National Highways. 29.0% of fatalities in road accidents signals), impaired ability to keep in the correct lane, and
shorter following distances.
were reported at the National Highways during 2021.
- Text messaging also results in considerably reduced
Risk factors (11) driving performance, with young drivers at particular risk
of the effects of distraction resulting from this use;
Speed - Drivers using a mobile phone are approximately £?ur
An increase in average speed is directly related both to times more likely to be involved in a crash than whes 4
the likelihood of a crash occurring and to the severity of the driver does not use a phone. Hands-free phones are nut
consequences of the crash. Some other facts are as below. much safer than hand-held phone sets;
- Pedestrians have a 90% chance of surviving a car crash - While there is little concrete evidence yet on how to reduce
at 30 km/h or below, but less than a 50% chance of mobile phone use while driving, governments need to be
surviving an impact of 45 km/h or above. proactive. Actions that can be taken include adopting
legislative measures, launching public awareness
- 30 km/h speed zones can reduce the risk of a crash and campaigns, and regularly collecting data on distracted
are recommended in areas where vulnerable road users driving to better understand the nature of this problem.
are common (e.g. residential areas, around schools).

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Developing countries are very different from the
- Apart from reducing road traffic injuries, lower average industrialized countries with regard to the environment and
traffic speeds can have other positive effects on health the mix of vehicles in the traffic stream. The following are"
outcomes (e.g. by reducing respiratory problems the more important differences (13):
associated with car emissions).
1. Large numbers of pedestrians and animals share
Drink-driving the roadway with fast-moving and slow-moving
(e.g., bullock carts) vehicles. There is almost no
Drinking and driving increases both the risk of a crash
segregation of pedestrians from wheeled traffic;
and the likelihood that death or serious injury will result.
2. Large numbers of old, poorly maintained vehicles;
- The risk of being involved in a crash increases 3. Large numbers of motor cycles, scooters, and
significantly above a blood alcohol concentration (BAC) mopeds;
of 0.04 g/dl.
4. Low driving standards;
- Laws that establish BACs of 0.05 g/dl or below are 5. Large numbers of buses, often overloaded;
effective at reducing the number of alcohol-related
6. Widespread disregard of traffic rules;
crashes.
7. Defective roads, poor street lighting, defective
- Enforcing sobriety check-points and random breath lay-out of cross roads and speed breakers; and
testing can lead to reductions in alcohol-related crashes 8. Unusual behaviour of men and animals.
by about 20%, and have shown to be very cost-effective.
In South-East Asia region countries, semi-urban and rural
Motorcycle helmets areas contribute 60-80 per cent of road accident injuries,
- Wearing a motorcycle helmet correctly can reduce the although all media attention is focussed on urban road
risk of death by almost 42% and the risk of severe head accidents.
injury by over 69%. Road traffic injuries cause the considerable economic loss
- When motorcycle helmet laws are enforced effectively, to victims, their families, and to the nation as a whole. These
helmet wearing rates can increase to over 90%. losses arise from the cost of treatment (including
rehabilitation and incident investigation) as well as reduced/
- Requiring helmets to meet a recognized safety standard is
lost productivity (e.g. in wages) for those killed or disabled
important to ensure that helmets can effectively reduce the
by their injuries, and for family members who need to take
impact of a collision to the head in the event of a crash.
time off work (or school) to care for the injured (12).
Seat-belts and child restraints Multiple causation
- Wearing car seat-belt reduces the risk of fatality among Accidents are a complex phenomena of multiple causation
front-seat passengers by 40-50% and of rear-seat (Fig. 1). The aetiological factors may be classified into two
passengers by between 25-75%. broad categories - human and environmental. Upto 90 per
- Mandatory seat-belt laws and their enforcement have cent of the factors responsible for accidents are attributed to
been shown to be very effective at increasing seat-belt human failure. Many of the psychological circumstances in
wearing rates. which accidents occur are still poorly known (5).

by R△J
 ACCIDENTS AND INJURIES

HUMAN FACTORS ENVIRONMENTAL FACTORS

Age Relating to road

defective, narrow roads
Sex - defective lay-out of
cross-roads and
Education K speed-breakers
F
Medical conditions poor lighting
sudden illness lack of familiarity
- heart attack
- impaired vision
Fatigue Relating to vehicle
- excessive speed
Psycho-social factors - old, poorly maintained
- lack of experience - large number of
J
risk-taking 2 or 3 wheelers
impulsiveness - overloaded buses
- defective judgement - low driving standards
- delay in decisions Bad weather
- aggressiveness Inadequate enforcement of
poor perception existing laws
family dysfunction
Lack of body protection Mixed traffic (slow and
- helmets fast moving, pedestrians

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and animals)
- safety belts

Increased
vulnerability
and/or
risk situation

Precipitating factors Precipitating factors

Heightened emotional Special traffic conditions
tension Social pressure
Alcohol and drugs (travelling in groups)
Use of stolen vehicles

ACCIDENT

FIG. 1
Primary factors in accidents

PREVENTION police have a statutory duty in many countries to investigate

Accidents don’t just happen; they are caused. The causes accidents, for legal as well as preventive purposes; the data
in a given situation must be identified by epidemiological collecting systems should recognize this and take police
methods. Since accidents are multifactorial, they call for an records as their starting point (3). Without adequate data
intersectoral approach to both prevention and care of the collection, analysis and interpretation there could be no
injured. The various measures comprise the following : effective counter-measures, evaluations and strategies for
prevention.
1. Data collection
There should be a basic reporting system of all accidents. 2. Safety education
The national data should be supplemented by special There is a widespread belief that accidents are inevitable;
surveys and in-depth studies. These studies will bring out the this fatalistic attitude must be curbed. Safety education must
risk factors, the circumstances and chain of events leading begin with school children. The drivers need to be trained in
upto the accident. These details are rarely provided by the proper maintenance of vehicles and safe driving. Young
basic reporting system. Detailed environmental data relating people need to be educated regarding risk factors, traffic
to the road, vehicle, weather, etc must also be collected. The rules and safety precautions. They should also be trained in

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466 NON-COMMUNICABLE DISEASES

first aid. It has been aptly said that “if accident is a disease, 9. Accident research
education is its vaccine”. The future of accident prevention is in research. Such
research will be concerned with gathering precise
3. Promotion of safety measures information about the extent, type and other characteristics
(a) Seat belts: The use of seat belts reduces the number of of accidents, correlating accident experience with personal
fatalities and non-fatal injuries by approximately 50 per cent attributes and the environments in which accidents occur,
each. They should be made compulsory for cars, light trucks investigating new and better methods of altering human
and similar vehicles (3). (b) Safety helmets: They reduce the behaviour; seeking ways to make environments safer; and
risk of head injury by 30 per cent on an average and that of evaluating more precisely the efficiency of control measures.
fatalities by 40 per cent (5). They prevent laceration of the This area is now termed accidentology.
scalp to a great extent. Recently, the full-face integral helmet 2. Domestic accidents
has become very popular, (c) Children: Another safety
measure is to ensure that children remain seated when they By “domestic accident” is meant an accident which takes
are in a vehicle. They should be prohibited to take the front place in the home or in its immediate surroundings, and,
more generally, all accidents not connected with traffic,
seats of cars (5). A few countries have introduced laws which
vehicles or sport (14). The most frequent causes of domesf c
require that children of under 12-15 years in cars to be in
accidents are :
the rear seats only, (d) Others: These comprise use of door
locks, proper vehicle design, use of laminated high- 1. drowning;
penetration resistance windscreen glass, etc. 2. burns (by a flame, hot liquid, electricity, crackers
or fire works, chemicals);
4. Alcohol and other drugs 3. falls;
4. poisoning (e.g., drugs, insecticides, rat poisons,
Alcohol impairs driving ability and increases the risk of an
kerosene);
accident as well as the severity of its consequences.
5. injuries from sharp or pointed instruments; and
Conclusions of surveys carried out in several countries have
shown that alcohol is the direct cause of 30 to 50 per cent of 6. bites and other injuries from animals.
severe road accidents. Drowning (15)
Drugs such as barbiturates, amphetamines, and cannabis

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Drowning is the process of experiencing respiratory
impair one’s ability to drive safely. They should be avoided impairment from submersion/immersion in liquid.
totally.
Victims of drowning have a very slim chance of survival
5. Primary care after immersion. The victim loses consciousness after
approximately 2 minutes of immersion, and irreversible
Planning, organization and management of trauma brain damage can take place after 4-6 minutes. Therefore,
treatment, and emergency care services should be a prevention strategies are very important.
fundamental element of health service managerial process.
In 2016, an estimated 322,000 people died from
Emergency care should begin at the accident site, continued
drowning, making drowning a major public health problem
during transportation, and conclude in the hospital worldwide. Injuries account for nearly 9% of total global
emergency room. At any of these stages a life may be saved mortality. Drowning is the 3rd leading cause of unintentional
or lost, depending upon the skill of the health care worker injury/ death. It accounts for 7% of all injury-related deaths.
and the availability of needed emergency equipment. To It is a common method of suicide (16).
achieve these ends, there should be an Accident Services
Organization and one fully equipped specialized trauma care The global burden and death from drowning is found in
hospital in all major cities. all economies and regions, however; low and middle-income
countries account for 90% of unintentional drowning
6. Elimination of causative factors deaths; over 50% of the world's drowning occurs in the
WHO Western Pacific Region and WHO South-East Asia
The factors which tend to cause accidents must be sought Region; China and India have particularly high drowning
out and eliminated, e.g., improvement of roads, imposition mortality rates and together contribute 43% of the world's
of speed limits and marking of danger points. drowning deaths and 41% of the total global DALYs
(disability-adjusted life years) lost related to drowning.
7. Enforcement of laws
There is a wide range of uncertainty around the estimate
Legislation embodies codified set of rules. These are of global drowning deaths. It is important to point out that
enforced by the State to prevent accidents. These include the global problem is much greater than the above figures
driving tests, medical fitness to drive, enforcement of speed reveal; due to the way data are classified, global numbers
limits, compulsory wearing of seat-belts and crash-helmets, exclude drowning due to floods (cataclysms), boating and
checking of blood alcohol concentration, road-side breath water transport mishaps. Non-fatal drowning statistics in
testing for alcohol, regular inspection of vehicles, periodic many countries are not readily available or are unreliable.
re-examination of drivers over the age of 55, etc.
Risk factors (15)
8. Rehabilitation services
1. Age : Age is one of the major risk factor for drowning.
Rehabilitation consists of a number of elements which This relationship is often associated with a lapse in
each injured person should benefit from. These are medical supervision. In general, children under 5 years of age have
rehabilitation, social rehabilitation, occupational the highest drowning mortality rates worldwide. Canada and
rehabilitation, etc. The aim of rehabilitation is to prevent, New Zealand are the only exceptions, where adult males
reduce or compensate disability and thereby handicap. drown at higher rates.

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 ACCIDENTS AND INJURIES 467
2. Gender : Males are especially at risk of drowning with The problem
twice the overall mortality rate of females. They are more
Burns are a global public health problem, accounting for
likely to be hospitalized than females for non-fatal drowning. an estimated 180,000 deaths annually. About 11 million
Studies suggest that the higher drowning rates among males people worldwide require medical attention due to severe
are due to increased exposure to water and riskier behaviour
burns. The majority of these occur in low and middle­
such as swimming alone, drinking alcohol before swimming income countries and almost half occur in the South-East
alone, and boating. Asia Region.
3. Access to water : Increased access to water is another In many high-income countries, burn death rates have
risk factor for drowning. Individuals with occupations such been decreasing, and the rate of child deaths from burns is
as commercial fishing or fishing for subsistence, using small currently over seven times higher in low and middle-income
boats in low-income countries, are more prone to drowning. countries than in high-income countries.
Children who live near open water sources, such as ditches,
ponds, irrigation channels, or pools are especially at risk. Non-fatal burns are a leading cause of morbidity,
including prolonged hospitalization, disfigurement and
4. Other risk factors : There are other factors that are disability, often with resulting stigma and rejection.
associated with an increased risk of drowning, such as :
It is estimated that over one million people are
a. infants left unsupervised or alone, or with another moderately or severely burnt every year in India. In
child in a bathtub; Bangladesh 1.73 lac children get moderate or severe burns
b. unsafe or overcrowded transportation vessels every year with about 17 per cent getting temporary
lacking flotation devices; disability and 18 per cent permanent disability. Burns are
c. alcohol use, near or in the water; the second most common injury in rural Nepal accounting
d. medical conditions, such as epilepsy; for 5 per cent disabilities.
e. tourists unfamiliar with local water risks and
features; and Risk factors (17)
f. floods and other cataclysmic events like tsunamis. Gender : Females suffer burns more frequently than
males. Women in the South-East Asia Region have the
Prevention (15) highest rate of burns, accounting for 27% of global burn
deaths and nearly 70% of burn deaths in the region. The

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Drowning prevention strategies should be comprehensive high risk for females is associated with open fire cooking, or
and include: engineering methods which help to remove the inherently unsafe cookstoves, which can ignite loose
hazard, legislation to enforce prevention and assure clothing. Open flames used for heating and lighting also
decreased exposure, education for individuals and pose risks, and self-directed or interpersonal violence are
communities to build awareness of risk and to aid in also important factors (although understudied).
response if a drowning occurs.
Age : Along with adult women, children are particularly
Engineering methods to eliminate exposure to water vulnerable to burns. Burns are the 11th leading cause of
hazards are the most effective strategy for drowning death of children aged 1-9 years and are also the fifth most
prevention. Examples include : common cause of non-fatal childhood injuries. While a major
- development and implementation of safe water systems, risk is improper adult supervision, a considerable number of
such as drainage systems, piped water systems, flood burn injuries in children result from child maltreatment.
control embankments in flood prone areas;
Socio-economic factors
- building four-sided pool fences or barriers preventing
access to standing water; People living in low and middle-income countries are at
higher risk for burns than people living in high-income
- creating and maintaining safe water zones for recreation;
countries. Within the countries also, burn risk correlates with
- covering of wells or open cisterns; socio-economic status.
- emptying buckets and baths, and storing them upside­
down. Other risk factors
Laws or regulations which target risk factors for drowning There are a number of other risk factors for burns,
include laws requiring regular safety checks of transportation including :
vessels, and laws on alcohol use while boating or swimming. - occupations that increase exposure to fire;
Individual and community education on drowning - poverty, overcrowding and lack of proper safety
awareness, learning water survival skills and ensuring the measures;
presence of lifeguards at swimming areas are promising - placement of young girls in household roles such as
strategy to prevent drowning. cooking and care of small children;
- underlying medical conditions, including epilepsy,
Burns (17)
peripheral neuropathy, and physical and cognitive
A burn is an injury to the skin or other organic tissue disabilities;
primarily caused by heat or due to radiation, radioactivity, - alcohol abuse and smoking;
electricity, friction or contact with chemicals. Thermal (heat) - easy access to chemicals used for assault (such as in acid
burns occur when some or all of the cells in the skin or other violence attacks);
tissues are destroyed by :
- use of kerosene (paraffin) as a fuel source for non­
- hot liquids (scalds) electric domestic appliances;
- hot solids (contact burns), or - inadequate safety measures for liquefied petroleum gas
- flames (flame burns). and electricity.

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468 NON-COMMUNICABLE DISEASES

Burns occur mainly in the home and workplace. responsible for 17 million DALYs lost. Over 80% of fall-
Community surveys in Bangladesh and Ethiopia showed related fatalities occur in low and middle-income countries,
that 80-90% of burns occur at home. Children and women with regions of the Western Pacific and South East Asia
usually get burns in domestic kitchens, from upset accounting for more than two-thirds of these deaths. In all
receptacles containing hot liquids, or flames, or from regions of the world, death rates are highest among adults
cookstove explosions. Men are more likely to get burns in over the age of 65 years (18).
the workplace due to fire, scalds, chemicals and electricity. Falls are responsible for the largest number of hospital
Prevention (17) visits for non-fatal injuries, especially for children and young
adults. Falls from rooftops, balconies, windows and stair
Burns are preventable. High-income countries have cases are common. Factors specific to SEAR countries are
made considerable progress in lowering rates of burn falls from trees of workers picking fruits or coconuts, tapping
deaths, through a combination of prevention strategies and toddy, children falling from rooftops while flying kites, high
improvemetns in the care of people affected by burns. Most incidence of falls among construction and forestry workers.
of these advances in prevention and care have been As life expetancy increases in these countries, the incidence
incompletely applied in low and middle-income countries. of hip and other fractures due to fall among the elderly are
Increased efforts to do so would likely lead to significant also assuming greater proportions (19).
reduction in rates of burn-related death and disability.
Some of the risk factors include (18) :
Prevention strategies should address the hazards for
specific burn injuries, education for vulnerable populations - occupations at elevated heights or other hazardous
and training of communities in first-aid. An effective burn working conditions;
prevention plan should be multisectoral. There are a number - alcohol or substance use;
of specific recommendations for individuals, communities - socio-economic factors including poverty,
and public health officials to reduce burn risk. overcrowded housing, young maternal age;
- underlying medical conditions, such as neurological,
FIRST-AID (17) cardiac or other disabling conditions;
Do's - side-effects of medication, physical inactivity and loss
of balance, particularly among older people;

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1. Stop the burning process by removing clothing and
irrigating the burns. - unsafe environments, particularly for those with poor
balance and limited vision.
2. Use cool running water to reduce the temperature of the
burn. Prevention (18)
3. Extinguish flames by allowing the person to roll on the For children, effective interventions include multifaceted
ground, or by applying a blanket, or by using water or community programmes; engineering modifications of
other fire-extinguishing liquids. nursery furniture, playground equipment, and other
4. In chemical burns, remove or dilute the chemical agent products; and legislation for the use of window guard.
by irrigating with large volumes of water. For older individuals, fall prevention programmes can
5. Wrap the patient in a clean cloth or sheet and transport include a number of components to identify and modify risk,
to the nearest appropriate facility for medical care. such as :
Dorits - screening within living environments for risks for falls;
- clinical interventions to identify risk factors, such as
1. Do not start first-aid before ensuring your own safety medication review and modification, treatment of low
(switch off electrical current, wear gloves for chemicals blood pressure, Vitamin D and calcium supplementation,
etc.) treatment of correctable visual impairment;
2. Do not apply paste, oil, haldi (turmeric) or raw cotton to - home assessment and environmental modification for
the burn. those with known risk factors or a history of falling;
3. Do not apply ice because it deepens the injury. - prescription of appropriate assistive devices to address
4. Avoid prolonged cooling with water because it may lead physical and sensory impairments;
to hypothermia. - muscle strengthening and balance retraining prescribed
5. Do not open blisters until topical antimicrobials can be by a trained health professional;
applied, by a health-care provider.
Poisoning
6. Do not apply any material directly to the wound as it
might become infected. Poisoning was responsible for an estimated 252,000
deaths during the year 2008 worldwide. In India about
7. Avoid application of topical medication until the patient 28,012 poisoning deaths were reported during the year
has been placed under appropriate medical care. 2010 (20). The most common agents responsible for
poisoning are pesticides, kerosene, prescription drugs, and
Falls household chemicals. Pesticides are widely used in many
Globally, falls are a major public health problem. An countries where agriculture is an important part of the
estimated 646,000 fatal falls occur each year, making it the economy. Reports from India, Indonesia, Sri Lanka, and
second leading cause of unintentional injury death, after Thailand indicate that common availability and use of toxic
road traffic injuries. Though not fatal 37.3 million falls are pesticides is responsible for intentional and unintentional
severe enough to require medical attention. Such falls are morbidity and mortality.

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 ACCIDENTS AND INJURIES 469
In Sri Lanka, pesticides are one of the main agents used MANAGEMENT AT COMMUNITY OR
in attempted suicide in rural areas. The use of VILLAGE LEVEL (23)
organophosphorous insecticides in suicide events has been
reported to be as high as 20-30 per cent. Paraquat
intoxication is known to cause irreversible damage in A. First-aid
patients. Many countries also report accidental ingestion of The Government of India developed a national snake­
kerosene as a leading cause of poisoning, especially among bite protocol in 2007 which includes following advice :
children (19). A study from Thailand revealed that 54 per 1. Reassure the patient. 70% of all snake bites are from
cent of cases of poisoning among pre-school children non-venomous species. Only 50% of bites by venomous
involved therapeutic drugs. species actually envenomate the patient;
Snake bite 2. Immobilize in the same way as a fractured limb. Use
bandages or cloth to hold the splints, not to block the
Snake bite is a neglected public health issue in many blood supply or apply pressure. Do not apply any
tropical and subtropical countries. About 5 million snake compression in the form of tight ligatures, they don't
bites occur each year, resulting in upto 2.4 million work and can be dangerous;
envenomings (poisoning from snake bites) at least 94,000-
125,000 deaths and around 400,000 amputations and other 3. Do not give alcoholic beverages or stimulants. They are
permanent disabilities. Most of these occur in Africa, Asia known vasodilators and they speed up the absorption of
and Latin America. In Africa alone there are an estimated venom;
1 million snake bites annually with about half needing 4. Remove any items or clothings which may constrict the
treatment. This type of injury is often found among women, bitten limb if it swells (rings, bracelets, watches,
children and farmers in poor rural communities in low and footwear, etc.);
middle-income countries (21).
5. Do not incise or manipulate the bitten site. Do not apply
The outcome of snake bite depends on numerous factors, ice; and
including the species of snake, the area of the body bitten,
the amount of venom injected, and the health condition of 6. Transport the patient to a medical faculty for definitive
the victim. Feelings of terror and panic’are common after a treatment.

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snake bite and can produce a characteristic set of symptoms
B. At the Rural Clinic, Dispensary, Health Post,
mediated by the autonomic nervous system, such as a
tachycardia and nausea. Bites from non-venomous snakes or Primary Health Centre
can also cause injury, often due to lacerations caused by the 1. Assess for signs of local and systemic envenoming : carry
snake's teeth, or from a resulting infection. A bite may also out a simple medical assessment including history and
trigger an anaphylactic reaction, which is potentially fatal. simple physical examination - local swelling, painful
First-aid recommendations for bite depends on the snakes tender enlarged local lymph glands, persistent bleeding
inhabiting the region, as effective treatment for bite inflicted from the bite wound, blood pressure, pulse rate,
by some species can be ineffective for others. bleeding (gums, nose, vomit, stool or urine), level of
The venom of poisonous snakes may be predominantly consciousness, drooping eyelids (ptosis) and other signs
neurotoxic or predominantly cytolytic. Neurotoxins cause of paralysis. Monitor these signs hourly.
respiratory paralysis and cytolytic venoms cause tissue 2. Check : 20 minute whole blood clotting test (20WBCT),
destruction by digestion and haemorrhage due to urine examination (appearance, sticks testing for blood
haemolysis and destruction of the endothelial lining of the etc.). Identify the snake or a photo of it (if brought).
blood vessels. The manifestations of rattlesnake 3. Analgesia : give analgesia by mouth if required:
envenomation are mostly local pain, redness, swelling and paracetamol (acetaminophen) (adult dose 500 mg to lg
extravasation of blood. Perioral tingling, metallic taste, maximum, 4g in 24 hours; children 10-15 mg/kg,
nausea, and vomiting, hypotension and coagulopathy may maximum lOOmg/kg/day) or codeine phosphate (adult
also occur. Neurotoxic envenomation may cause ptosis,
dose 30-60 mg, maximum 240 mg in 24 hours; children
dysphagia, diplopia, and respiratory failure. Venom emitted
more than 2 years old, 0.5 mg/kg, maximum 2 mg/kg/
from some types of cobras, almost all vipers cause necrosis
day) can be given every 4-6 hours by mouth as required
of muscle tissue. Muscle tissues begin to die throughout the
(not aspirin or non-steroidal anti-inflammatory drugs
body and it results in accumulation of myoglobin in the renal
which can cause bleeding).
tubules which leads to acute renal failure.
4. Antivenom : if the patient fulfils criteria for antivenom
Early clues that a patient has severe envenoming (22) : treatment and if the necessary skills, equipment,
- Snake identified as a very dangerous one; antivenom, adrenaline and other necessary drugs are
available, give antivenom. These skills include ability to
- Rapid early extension of local swelling from the site of diagnose local and systemic envenoming, set up
the bite;
intravenous infusion or intravenous injection, identify the
- Early tender enlargement of local lymph nodes, early signs of anaphylaxis and treat it with intramuscular
indicating spread of venom in the lymphatic system; adrenaline. Re-assess for repeated dose(s) of antivenom.
- Early systemic symptoms: collapse (hypotension, shock), If no antivenom is available, transfer to a hospital.
nausea, vomiting, diarrhoea, severe headache, 5. If the patient is in shock/hypotensive : give cautious
“heaviness” of the eyelids, inappropriate (pathological) intravenous fluid challenge (adult 250-500 ml of 0.9%
drowsiness or early ptosis/ophthalmoplegia; saline) to correct hypovolaemia shock.
- Early spontaneous systemic bleeding; 6. If the patient has evidence of respiratory paralysis : give
- Passage of dark brown/black urine. oxygen by mask, consider atropine and neostigmine,

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470___ NON-COMMUNICABLE DISEASES

and transfer to a hospital. It is assumed that assisted 3. If the patient has evidence of acute renal failure
ventilation other than by a tight-fitting face mask peritoneal orhaemodialysis or haemofiltration.
connected to an anaesthetic (Ambu) bag will not be 4. Implement rehabilitation by physiotherapists.
possible at this level.
7. If the patient is oliguric : initiate conservative Strengthening of health system in managing snakebite
management. To reduce complications and deaths from snakebites,
8. The bite wound : if necrotic, tampered with (incisions health systems need to be improved at various levels. The
etc.) or obviously septic, give antibiotics and tetanus government must develop a policy for snakebite, making it a
prophylaxis. notifiable disease, developing a snakebite programme that
includes standard treatment guidelines, training of health
9. Assess the need and feasibility of transporting the patient personnel and ensure an adequate supply, distribution and
to a higher level of the health service (see A above) storage of good quality antivenom.
especially in case of:
a. Substantial bleeding, 20WBCT still positive (non­ ANTIVENOM (22)
clotting) 6 hours after initial antivenom dose Until the advent of antivenom, bites from some species of
b. Progressive paralysis (muscle weakness) or respiratory snake were almost universally fatal. Despite huge advances
difficulty in emergency therapy, antivenom is often still the only
c. Reduced urine output effective treatment for envenomation. The first antivenom
d. Anaphylaxis - unresponsive to adrenaline was developed in 1895 by French physician Albert Calmette
e. Shock/hypotension - unresponsive to fluids for the treatment of Indian cobra bites. Antivenom is made
by injecting a small amount of venom into an animal
f. Severe local necrosis or signs suggestive of
(usually a horse or sheep) to initiate an immune system
compartment syndrome
response. The resulting antibodies are then harvested from
10. Discourage the use of ineffective and potentially harmful the animal's blood.
drugs (e.g. corticosteroids, antihistamines, and heparin).
Antivenom is injected into the person intravenously, and
C. At the District Hospital (23) works by binding to, and neutralizing venom enzymes. It
cannot undo damage already caused by venom, so

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Proceed as in B above plus : antivenom treatment should be sought as soon as possible.
1. Assessment : carry out a more detailed clinical and Modern antivenoms are usually polyvalent, making them
laboratory assessment including biochemical and effective against the venom of numerous snake species.
haematological measurements, ECG or radiography, as Pharmaceutical companies which produce antivenom
indicated. target their products against the species native to a
2. Antivenom : if no antivenom is available, transfer to a particular area. Although some people may develop serious
hospital that has antivenom or treat conservatively; this adverse reactions to antivenom, such as anaphylaxis, in
may require transfusion of blood or fresh frozen plasma. emergency situations this is usually treatable and hence the
3. Analgesia : (see B above) and, if required, consider benefit outweighs the potential consequences of not using
stronger parenteral opioid drugs as required, all with antivenom.
great caution (e.g. subcutanous, intramuscular or even 3. Industrial accidents
intravenous pethidine, initial adult dose 50-100 mg;
children 1-1.5 mg/kg; or morphine, initial adult dose There are approximately 580 million workers in the
5-10 mg; children 0.03-0.05 mg/kg,). South-East Asia Region. Approximately 60-80 per cent of
these workers are employed in agriculture, fisheries, home
4. If the patient has evidence of local necrosis (gangrene) : industries, and small-scale units. Injuries due to these
give tetanus toxoid booster, antibiotics and do surgical occupations result in an estimated 120 million injuries and
debridement of dead tissue. 200,000 deaths per year (19).
5. If the patient has evidence of bulbar or respiratory Though reliable estimates for work related injuries and
paralysis : insert endotracheal tube, laryngeal mask deaths in the Region are not available, partly because a
airway or i-gel airway. If there is evidence of respiratory majority of the workers are employed in unorganized
failure, assist ventilation manually by anaesthetic sectors, few studies indicate that nearly one per cent of
(Ambu) bag or mechanical ventilator. deaths and 10 per cent of permanent impairment result from
6. If the patient has evidence of acute kidney injury : treat agricultural injuries. Agriculture workers are exposed to wide
with peritoneal dialysis. If this is not available, transfer to variety of physical, chemical (pesticide and fertilizers),
a specialized hospital. biological (animal bites and animal related injuries) and
7. If the patient is bleeding severely or is already seriously mechanical injuries. The estimates from agriculture injury
anaemic : cross-match and transfuse. vary from 22-29 per 1000 workers. The incidence rate of
injury among agriculture workers in India is estimated to be
8. Rehabilitation : encourage exercising of bitten limb. 116 per 100,000 workers. In a study population of 23,000 in
rural Haryana, nearly 31 per cent of the injuries were related
D. At the Referral (Specialized) Hospital (23) to agricultural activity (24). Of these, serious injuries were
Proceed as in B and C above plus : caused by mechanized equipment and tractors (19).
1. More advanced surgical management of local necrosis Rapid industrialization has also resulted in mortality and
(e.g. split skin grafting). morbidity of many workers in hazardous industries.
2. More advanced investigations including bacterial The unique features common to the workplace in this
cultures and imaging (CT scans) as indicated. region are that the manual labour content is high and the
by R△J
 ACCIDENTS AND INJURIES 471
man-machine interaction is unsafe. In addition, there is in Sri Lanka, and 5.9 per lac in Thailand; per year have
greater emphasis on attempts to change the worker’s been reported in 2016 (8). Nearly 70 per cent of suicides in
behaviour, but designs that provide automatic protection are all countries have been reported in the age group of 15-34
ignored. Children and people who are challenged physically years with male-female ratio of 1:1.2 to 1:3 from different
as well as mentally are at a greater risk of encountering countries. Poisoning, hanging, self-immolation and
occupational injuries (19). drowning are the most commonly reported methods of
suicide (24).
4. Railway accidents
In India, an average of 369 suicides take place every day,
With the increase in number of trains and passengers, the out of these 248 are committed by males and 121 by
increase in the number of accidents and casualties resulting females (62 are house wives). Family problems (89) and
therefrom is not unexpected. During 2020, about 8,700 illness (72) are the main cause of suicides. Majority cases are
people died of railway accidents in India (9). The main below 29 years of age (136) followed by 30-44 years of age
factor involved in railway accidents is human failure. group (125) (26).
5. Violence References
Homicide and collective violence account for around 1. Hogarth, J. (1978). Glossary of Health Care Terminology, WHO,
10% of global, injury-related death. In 2016, there were an Copenhagen.
estimated 477,000 murders. Four fifths of homicide victims 2. WHO (1957). Techn. Rep. Ser., No.118.
are men, and 60% of victims, males age 15-44. The low- 3. WHO (1984). Techn. Rep. Ser., 703.
and middle-income countries of the Region of the Americas 4. WHO (1976). The Epidemiology of Road Traffic Injuries, European
has the most homicides, with 28.5 per 100,000 population, Sr. No.2, WHO Copenhagen.
while the lowest murder rate, almost 14 times lower (2.1 per 5. WHO (1982). The Epidemiology of Accident Traumas and Resulting
Disabilities, EURO Reports and Studies, 57, WHO, Copenhagen.
100,000 population), is found in the low- and middle­
6. WHO (2013), How to use the ICE, A Practical Manual for using the
income countries of The Western Pacific Region (25). International Classification of Functioning, Disability and Health (ICF).
Violence is reported to be increasing rapidly. It also follow 7. WHO, Children's Environmental Health, Injuries.
the same epidemiological pattern as any other disease (host, 8. WHO (2018), Global Health Estimates 2016, April 2018.
agent and environment), i.e. a motivated person who 9. Govt, of India (2021), National Health Profile 2021, Ministry of
Health and Family Welfare, New Delhi.

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injures; a suitable target; and a suitable environment or the
10. WHO (2022), Fact Sheet, Road Traffic Injuries, June 2022.
absence of a guardian, all coinciding in time and space.
11. WHO (2018), Global Status Report on Road Safety, 2018.
Often, it may only be possible to initiate steps for prevention
12. WHO (2012), Road Traffic Injuries, Fact sheet No. 358, Sept 2012.
after an episode of violence has already taken place.
13. WHO (1981). Seat belts and other devices to reduce injuries from
Some of the risk factors for violent behaviour are (19) : traffic accidents, EURO Reports and Studies 40, WHO, Copenhagen.
13A. Govt, of India (2021). Accidental Deaths and Suicides in India, 2021.
- Exposure to violence and societal acceptability of
14. Govt, of India (1979). Swasth Hind, 25 (12) 329.
violence as a means to solve problems. The image of
15. WHO (2020), Drowning, Fact Sheet 3rd Feb., 2020.
violence as an acceptable and effective tool for solving
16. WHO (2018), Fact Sheet or Drowning, 15th Jan., 2018.
problems, whether across international borders, on 17. WHO (2018), Burns, Fact Sheet 6th. March, 2018.
the street, or around the home, may spill over into real 18. WHO (2018), Falls, Fact Sheet 16th Jan., 2018.
behaviour; ....... 19. WHO (2002), Injuries in South-East Asia Region, Priorities for Policy
- Availability of lethal weapons like fire-arms and Action, SEA / Injuries / Al.
significantly increases the possibility of both fatal and 20. WHO (2011), Estimates of Deaths by Causes for the year 2008
non-fatal injuries; Summary Tables.
- Consumption of alcohol and other drugs is linked to 21. WHO (2018), Snake envenoming, Fact sheet, 5th Feb. 2018.
almost 2/3 of cases of violence according to several 22. WHO (2016), Guidelines for the Management of Snake-bites,
Regional Office of SEAR, New Delhi.
studies. 23. WHO (2010), Guidelines for the Management of Snake-bites, 2nd
Violence due to war and political unrest is fairly common Ed., Regional Office for SEAR.
in several countries. Organized and unorganized, ethnic and 24. WHO (2002), Health Situation in the South-East Asia Region 1998-
communal violence are well known in some places. 2000, Regional Office for SEAR, New Delhi.
25. WHO (2015), Health in 2015 from MDGs. Millennium Development
Suicides have been increasing at an alarming rate in Goals to SDGs - Sustainable Development Goals.
SEAR countries. Crude death rates of 8.7 per lac population 26. Lancet Public Health (2019), India state-level disease burden
in Bangladesh, 14.7 per lac population in India, 6.4 per lac initiative, Road Injury, Dec. 24th, 2019.

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 Since India became independent, several measures have rapid response; (ii) Integrated vector management (IVM) for
been undertaken by the National Government to improve transmission risk reduction including indoor residual spraying in
the health of the people. Prominent among these measures selected high-risk areas, use of insecticide treated bed-nets, use
are the NATIONAL HEALTH PROGRAMMES, which have of larvivorous fish, anti-larval measures in urban areas, source
been launched by the Central Government for the control/ reduction and minor environmental engineering; and (iii)
eradication of the communicable diseases, improvement of Supportive interventions including behaviour change
environmental sanitation, raising the standard of nutrition, communication (BCC), public private partnership and inter­
control of population and improving rural health. Various sectoral convergence, human resource development through
international agencies like WHO, UNICEF, UNFPA, World capacity building, operational research including studies on
Bank, as also a number of foreign agencies like SIDA, drug resistance and insecticide susceptibility, monitoring and
DANIDA, NORAD and USAID have been providing evaluation through periodic reviews/field visits, web based

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technical and material assistance in the implementation of management information system, vaccination against JE and
these programmes. A brief account of these programmes annual mass drug administration against lymphatic filariasis (1).
which are currently in operation is given below :
(A) MALARIA
NATIONAL VECTOR BORNE DISEASE The programme began originally as National Malaria
CONTROL PROGRAMME_______ Control Programme in 1953, during the First Five Year Plan.
Because of the spectacular success achieved in the control of
The National Vector Borne Disease Control Programme malaria, the control programme, was converted in 1958 into
(NVBDCP) is implemented in the State/UT's for prevention an eradication programme, with the objective of eradicating
and control of vector borne diseases namely Malaria, malaria once and for all from the country. Since then the
Filariasis, Kala-azar, Japanese Encephalitis (JE), Dengue programme has undergone many changes and the milestones
and Chikungunya. The Directorate of NVBDCP is the nodal of malaria control activities in India are as shown below (2) :
agency for planning, policy making and technical guidance Milestones of malaria control activities in India
and monitoring and evaluation of programme
implementation in respect of prevention and control of these Year Milestone
vector borne diseases under the overall umbrella of NRHM. Prior to 1953 Estimated malaria cases in India - 75 million;
The States are responsible for planning, implementation Deaths due to malaria - 0.8 million.
and supervision of the programme. The vector borne 1953 Launching of National Malaria Control
diseases are major public health problems in India. Programme (NMCP).
Chikungunya fever which has re-emerged as epidemic
1958 NMCP was changed to National Malaria
outbreaks after more than three decades has added to the
Eradication Programme.
problem. The prevention and control of vector borne
diseases is complex; as their transmission depends on 1965 Cases reduced to 0.1 million.
interaction of numerous ecological, biological, social and Early 1970's Resurgence of malaria.
economic factors including migration (1). 1976 Malaria cases - 6.46 million.
Out of the six vector borne diseases, malaria, filariasis, 1977 Modified Plan of Operations implemented.
japanese encephalitis, dengue and chikungunya are 1997 World Bank assisted Enhanced Malaria
transmitted by different kind of vector mosquitoes, while Control Project (EMCP) launched.
kala-azar is transmitted by sand flies. The transmission of 1999 Renaming of programme to National Anti
vector borne diseases in any area is dependent on frequency Malaria Programme (NAMP).
of man-vector contact, which is further, influenced by 2002 Renaming of NAMP to National Vector
various factors including vector density, biting time, etc. Borne Disease Control Programme.
Mosquito density is directly related with water collection, 2005 Global Fund assisted Intensified Malaria
clean or polluted, in which the mosquitoes breed. Control Project (IMCP) launched.
Under NVBDCR the three pronged strategy for prevention 2005 NVBDCP became integral part of NRHM.
and control of VBDs is as follows : (i) Disease management 2005 Introduction of RDT in the programme.
including early case detection and complete treatment, 2006 ACT introduced in areas showing
strengthening of referral services, epidemic preparedness and chloroquine resistance in falciparum malaria.

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 MALARIA

2008 ACT extended to high Pf predominant have been established in many places headed by the DVBDC
districts covering about 95% Pf cases. officer to assist the CMO/DHO. This office is the key unit for
2008 World Bank supported National Malaria the planning and monitoring of the programme. Spray
Control Project launched. operations are the direct responsibility of DMO/DVBDC
2009 Introduction of LLINs. officer in the entire district under overall supervision of CMO
2010 New drug policy 2010. and collaborative supervision/monitoring by PHC's Medical
2012 Introduction of bivalent RDT. Officer. There is one Assistant Malaria Officer (AMO) and
2013 New drug policy 2013. Malaria Inspectors (Mis) to assist him (2).
2016 National Framework for Malaria Elimination In many districts, District Vector Borne Disease Control
in India launched. Societies (now merged with District Health Societies under
2017 National Strategic Plan for Malaria NRHM) have been established to assist the management of
Elimination in India 2017-2022 launched. funds and planning, and monitoring of programme activities.
The laboratories have been decentralized and positioned
The main activities of the programme are at the PHCs. The medical officer - PHC has the overall
1. Formulating policies and guidelines. responsibility for surveillance and laboratory services, and
2. Technical guidance. also supervises the spray. Case detection management and
3. Planning. community outreach services are carried out by MPWs as
4. Logistics. well as ASHAs and other community health volunteers.
5. Monitoring and evaluation. DRUG DISTRIBUTION CENTRES AND FEVER
6. Coordination of activities through the States/Union TREATMENT DEPOTS
Territories and in consultation with national organizations
such as National Centre for Disease Control (NCDC), With the increasing number of malaria cases, the demand
National Institute of Malaria Research (NIMR). for antimalarial drugs has increased tremendously. It became
7. Collaboration with international organizations like the clear that drug supply only through the surveillance workers
WHO, World Bank, GFATM and other donor agencies. and medical institutions was not enough. This led to the
8. Training. establishment of a wide network of Drug Distribution
Centres and Fever Treatment Depots and malaria clinics at

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9. Facilitating research through NCDC, NIMR, Regional
Medical Research Centres etc. some sub-centres. Drug Distribution Centres are only to
dispense the anti-malarial tablets as per NMEP schedules.
10. Coordinating control activities in the inter-state and
Fever Treatment Depots collect the blood slides in addition
inter-country border areas.
to the distribution of antimalarial tablets. These centres are
Organization (2) manned by voluntary workers from the community.
There are 19 Regional Offices for Health and Family URBAN MALARIA SCHEME
Welfare under Directorate General of Health Services, Ministry
The urban malaria scheme was launched in 1971 to
of Health and Family Welfare, located in 19 states, which play
reduce or interrupt malaria transmission in towns and cities.
a crucial role in monitoring the activities under NVBDCP
The methodology comprises vector control by intensive
These offices are equipped with malaria trained staff.
antilarval measures and drug treatment.
The state governments are required to plan and implement
About 7.4 per cent of the total cases of malaria and
the malaria control operations in their respective states. Every
10.9 per cent of deaths due to malaria are reported from
state has a Vector Borne Disease Control Division under its
urban areas. Maximum cases are reported from Chennai,
Department of Health and Family Welfare. It is headed by the
Vadodara, Visakhapatnam, Ahmedabad, Kolkata, New
State Programme Officer (SPO) who is responsible for
Mumbai, Vijayawada etc. (3). The vector of malaria in the
supervision, guidance and effective implementation of the
urban areas breeds largely in man-made containers including
programme and for coordination of the activities with the
overhead tanks and underground water storage tanks, water
neighbouring States/UTs. States are responsible for the
coolers, cisterns, roof gutters, flower vases, bottles and
procurement of certain insecticides for indoor residual spray
ornamental ponds, old tyres etc., which can collect water.
(IRS), spray equipment and certain anti-malarials, the central
Large construction activities provide suitable breeding sites
government supplies DDT and larvicides.
for the mosqitoes. Influx of migrant labour, from malarious
Each state has established a State Vector Borne Disease zones contribute to increase in incidence. Control of urban
Control Society, which includes civil society and sometimes malaria lies primarily in the implementation of civil bye-laws
private sector representation. These are now merged with to prevent mosquito breeding in the domestic and
similar entities for other centrally sponsored schemes into a peridomestic areas. Use of larvivorous fish in the water
single state-level Health and Family Welfare Society. The bodies such as slow moving streams, ornamental ponds etc.
main role of these societies is to channelize funds from GO1 is recommended. Larvicides are used for water bodies which
to the states and onwards to districts for financing of the are unsuitable for fish use (2). The urban malaria scheme
programmes. They also play a role in district level planning under national vector disease control programme is presently
and in monitoring of programme activities within districts. protecting 130 million population from malaria and other
At the divisional level, zonal officers have technical and mosquito borne diseases in 131 towns in 19 states and Union
administrative responsibilities of the programme in their Territories. The civic bye-laws have been enacted and
areas under the overall supervision of Senior Divisional implemented in Delhi, Mumbai, Kolkata, Chandigarh,
Officers (SDOs). Bengaluru, Chennai, Ahmedabad and Goa etc (3).
At the district level, the Chief Medical Officer (CMO)/ The Expert Committee on Malaria had recommended the
District Health Officer (DHO) has the overall responsibility of inclusion of all urban areas with more than 50,000
the programme. At the district level, district malaria offices population and reporting slide positivity rate of 5 per cent
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 HEALTH PROGRAMMES IN INDIA
474
and above, under Urban Malaria Scheme and introduction Category 1 states/UTs are: Himachal Pradesh, Punjab,
of active surveillance under this scheme. Jammu & Kashmir, Kerala, Manipur, Puducherry,
Chandigarh, Uttarakhand, Haryana, Sikkim, Rajasthan,
National Framework for Malaria Elimination in Daman & Diu, Goa, Delhi and Lakshadweep.
India (2016-2030) (4) Category 2 states/UTs are: Bihar, Tamil Nadu, Telangana,
Encouraged by the success achieved in malaria control in Uttar Pradesh, Karnataka, West Bengal, Andhra Pradesh,
recent years, the vision of India’s malaria control programme Assam, Maharashtra, Gujarat and Nagaland.
has been now shifted to sustained malaria elimination to Category 3 states/UTs are: Andaman & Nicobar islands,
contribute more effectively to improved health and quality of life Madhya Pradesh, Dadar & Nagar Haveli, Jharkhand,
of the people. The National Framework for malaria elimination Arunachal Pradesh, Chhattisgarh, Odisha, Meghalaya,
in India 2016-2030 was launched in February 2016. Tripura and Mizoram.
Goals Category 1 states/UTs generally have very low
In line with the WHO Global Technical Strategy (GTS) for proportion of P falciparum cases except Kerela, Manipur
Malaria 2016-2030 and the Asia Pacific Leaders Malaria and Sikkim. On the other hand, category 3 states/UTs have a
Alliance Malaria Elimination Roadmap, the goals of the National high proportion of P falciparum except in Andaman &
Framework for Malaria Elimination in India 2016-2030 are: Nicobar islands and Dadar and Nagar Haveli (4).
- Eliminate malaria (zero indigenous cases) throughout the Milestones and targets (4)
entire country by 2030; and
The milestones and targets set for malaria elimination in
- Maintain malaria-free status in areas where malaria India are as follows:
transmission has been interrupted and prevent re-
introduction of malaria. By the end of the year 2016
Objectives All states and UTs to have included malaria elimination in
The National Framework for Malaria Elimination in India their broader health policies and planning framework.
has formulated the following objectives:
By the year 2020
- By 2022, transmission of malaria interrupted and zero

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indigenous cases to be attained in all 26 States/UTs that 1. All 15 states/UTs that were under category 1 (elimination
were under Categories 1 and 2 in 2014; phase) in 2014 to completely interrupted malaria
transmission and achieved zero indigenous cases and
- By 2024, incidence of malaria to be reduced to less than
deaths due to malaria;
1 case per 1000 population in all States and UTs, and
their districts; 2. All 11 states/UTs under category 2 (pre-elimination
phase) in 2014 to enter into category 1 (elimination
- By 2027, indigenous transmission of malaria to be
phase);
interrupted in all States and UTs of India; and
- By 2030, malaria to be eliminated throughout the entire 3. 5 states/UTs under category 3 (intensified control
phases) in 2014 to enter into category 2 (pre-elimination
country, and re-establishment of transmission prevented.
phase)
Programme phasing 4. 5 states/UTs under category 3 (intensified control phase)
in 2014 to reduce disease burden but continue to remain
Malaria elimination in India will be carried out in a
in category 3; and
phased manner because the various States/UTs have
different levels of malaria burden. While some low burden 5. Estimated malaria burden at national level to reduce by
states are in a position to plan action for malaria elimination 15-20% as compared to 2014.
right now, the high burden states will need to reduce the Additionally, states with stronger health systems such as
malaria burden first before proceeding towards elimination. Gujarat, Maharashtra and Karnataka may implement
Therefore, states and UTs have been categorized into accelerated malaria elimination programmes to achieve
phases, based on their API as primary criterion with due interruption of transmission and demonstrate early
consideration given to ABER and SPR as secondary criteria. elimination followed by sustenance of zero indigenous cases.
The categorization is given in Table 1.
By the year 2022
TABLE 1
1. All 26 states/UTs that were under categories 1 and 2 in
Classification of States/UTs for malaria
2014 to interrupt malaria transmission and achieved
elimination in India (2014)
zero indigenous cases and deaths due to malaria;
Category Definition 2. 5 states/UTs which were under category 3 (intensified
Category 0
control phases) in 2014 to enter into category 1
States/UTs with zero indigenous
Prevention of cases of malaria (currently, no (elimination phase);
re-establishment phase state/UT) 3. 5 states/UTs which were under category 3 (intensified
Category 1 States/UTs with API less than one,
control phases) in 2014 to enter into category
Elimination phase and all their districts reporting 2 (pre-elimination phase); and
AP1<1 (15 states/UTs) 4. Estimated malaria burden at national level reduced by
Category 2 States/UTs with API < 1, but some 30-35% as compared to 2014.
Pre-elimination phase of their districts reporting
API >1(11 states) By the year 2024
Category 3 States/UTs with API > 1 1. All states and UTs and their districts to reduce API to less
Intensified control phase (10 states/UTs) than 1 case per 1000 population at risk, sustain zero
by R△J
 MALARIA

deaths due to malaria and establish fully functional 2. API > 0 to < 1
malaria surveillance to track, investigate and respond to 3. API 1 to < 2
each case; 4. API 2 to < 5
2. 31 states/UTs to interrupt transmission of malaria and 5. API > 5 :•
zero indigineous cases and deaths attained; and
3. 5 states/UTs which were under category 3 (intensified Strategies (4)
control phases) in 2014 to enter into elimination phase. The overall objectives of the malaria elimination
programme are rapid reduction of transmission in areas with
By the year 2027 high malaria incidence; interruption of malaria transmission
Indigenous transmission of malaria interrupted and the in low transmission areas; and prevention of re­
entire country to have no indigenous cases and no deaths establishment of malaria in areas where transmission has
due to malaria. been interrupted.
The broad strategies of the malaria elimination
By the year 2030
framework are:
The entire country to sustain status of zero indigenous
• Early diagnosis and radical treatment
cases and deaths due to malaria for 3 consecutive years; and
India to initiate the processes for certification of malaria • Case-based surveillance and rapid response
elimination status. • Integrated vector management (IVM)
- Indoor residual spray (IRS)
Focus on High-Endemic Areas and Tribal Population: - Long-lasting insecticidal nets (LLINs) / Insecticide
Most of the malaria cases in India are reported from Andhra treated bed nets (ITNs)
Pradesh, Chhattisgarh, Jharkhand, Madhya Pradesh, - Larval source management (LSM)
Maharashtra, Meghalaya, Mizoram, Odisha, Telangana and • Epidemic preparedness and early response
Tripura. The high incidence in these states is particularly noted • Monitoring and evaluation
in tribal populations living in foothills forested or conflict - • Advocacy, coordination and partnerships
affected areas. The malaria programme plans to scale up
interventions in these areas along with innovative strategies. • Behaviour change communication and community

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mobilization
Special strategy for P vivax elimination (4) • Programme planning and management
India accounts for more than 50% of the estimated The key interventions recommended for each category of
P. vivax cases in the world. Elimination of P vivax from India states/UTs are detailed below.
is a serious challenge due to its magnitude as well as the
need for a special strategy as P vivax usually disappears Category 3 (Intensified control phase: States/UTs with
from an area much after P. falciparum, because: (1) P vivax API >1)
hypnozoites prolong the parasite's lifespan and are difficult 1. Massive scaling up of existing disease management and
to detect; (2) RDTs currently available to detect P vivax are preventive approaches and tools, aimed at a significant
less sensitive than RDTs for P. falciparum detection; reduction in the prevalence and incidence of malaria as
(3) Radical treatment for P vivax requires 14 days of well as associated deaths.
primaquine therapy to kill the hypnozoites whereas 2. Screening of all fever cases suspected for malaria.
treatment for P falciparum can be completed in only 3 days; 3. Classification of areas as per local malaria epidemiology
and (4) P. vivax strains have a longer incubation period. and grading of areas as per risk of malaria transmission
The states and UTs with P vivax preponderance will now followed by implementation of tailored interventions.
initiate special measures for elimination of P vivax by 4. Strengthening of intersectoral collaboration. Special
expanding bivalent RDTs and quality microscopy services to interventions for high-risk groups such as tribal
detect all P vivax infections; ensuring compliance of the 14- populations and populations residing in conflict affected
days radical treatment by affected individuals; and tackling or hard-to-reach areas.
urban malaria by targeting An. stephensi by antilarval 5. One-stop centres or mobile clinics on fixed days in tribal
measures.
or conflict affected areas to provide malaria diagnosis
and treatment, and increasing community awareness
District as the unit of planning and implementation:
with the involvement of other agencies and service
States and UTs should categorize their districts so that providers as required.
even if the given state/UT is not yet in the elimination phase, 6. Timely referral and treatment of severe malaria cases to
their districts with API < 1 could be considered eligible for reduce malaria-related mortality. Strengthening all
initiating elimination phase activities. In addition, each district and sub-district hospitals in malaria endemic
district may sub-categorize its blocks into different phases areas as per Indian Public Health Standards with
based on their API; and further each block into its PHCs, facilities for management of severe malaria cases.
PHC into SCs and SC to villages. This would facilitate some
7. Establishment of a robust supply chain management
category 2 districts to start elimination activities in their
system.
blocks falling in category 1. Stratification may be done in
this manner up to the subcentre level (4). 8. Maintenance of an optimum level of surveillance using
appropriate diagnostic measures.
Each district should stratify its PHCs and sub-centres 9. Equipping all health institutions (primary health care level
(with their population) into the following five strata, as those and above), especially in high-risk areas, with microscopy
with:
facilities and RDTs for emergency use and injectable
1. Zero cases artemisinin derivatives for treatment of severe malaria.
by R△J
47£_ HEALTH PROGRAMMES IN INDIA

Category 2 (Pre-elimination phase : States/UTs with Category 0 (prevention of re-establishment phase)

API < 1, but some of their districts reporting API > 1) When any area, whether a state/LJT or a district within a
The states/UTs in pre-elimination phase are those close to state/UT has, achieved malaria elimination, the specific
entering the elimination phase. Therefore, malaria objectives will be as follows:
elimination interventions will be introduced with particular 1. Detect any re-introduced case of malaria;
focus on setting up an elimination surveillance system and 2. Notify immediately all detected cases of malaria;
initiating elimination phase activities in those districts where 3. Determine the underlying causes of resumed local
the API has been reduced to less than 1 case per 1000 transmission;
population at risk per year. The planning of elimination
4. ,Apply rapid curative and preventive measures;
measures will be based on epidemiological investigation
and classification of each malaria case and focus. 5. Prevent re-introduction and possible re-establishment of
malaria transmission; and
Category 1 (Elimination phase : States/UTs withAPIcl, 6. Maintain malaria-free status in these areas.
and all their districts reporting API < 1) Surveillance (2, 4)
1. All efforts will be directed at interrupting local The malaria surveillance system in India was initially set
transmission in all active foci of malaria. up in the early 1960s. The system has since been adapted to
2. Mandatory notification of each case of malaria from the the needs of control and now monitors malaria incidence
private sector, other organized government sectors or trends and geographic distribution. The aim is to target
any other health facility. control interventions in high transmission areas and
3. Adequate case-based surveillance and complete case assessing their impact. Surveillance also plays a key role in
management established and fully functional across the the early detection of outbreaks.
entire country to handle each case of malaria. Active case detection (ACD) is carried out in rural areas
4. Investigation and classification of all foci of malaria. with blood smears collected by MPWs/ANM during
5. A strict total coverage of all active foci by effective vector fortnightly house visits. Passive case detection (PCD) is done
control measures. in fever cases reporting to peripheral health volunteers/
ASHAs and at sub-centres, malaria clinic, CHC, and other
6. Early detection and treatment of all cases of malaria by

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secondary and tertiary level health institutions that patients
means of ACD and/or PCD to prevent onward visit for treatment. ASHA and other volunteer workers
transmission. provide diagnostic services by RDTs, and at PHCs by
7. State and national level malaria elimination database examination of blood smears. In villages where no ASHA or
established and made operational. other volunteer has been trained and deployed for providing
8. Implementation of interventions for effective screening, early diagnosis and effective treatment, ACD and case
management and prevention of malaria among mobile management is done by the MPWs.
and migrant populations. The surveillance data of NVBDCP reflects malaria trends
9. Establishment of an effective epidemic forecasting and reasonably well because the ABER in the country as a whole
response system. has remained relatively constant at about 10%, and the
10. Ensuring rigorous quality assurance of all medicines and surveillance system has not undergone any major changes.
diagnostics. The ABER is, however, low in a few states, while in most of
tlje high endemic areas it is much above 10%. Microscopy
11. Setting up a national-level reference laboratory to serve remains the best method of diagnosis on account of its high
following two functions: sensitivity and specificity. It is also more economical in
(a) All positive and a fixed percentage of negative slides* facilities where large number of slides are examined daily.
will be referred to this laboratory for confirmation oF4*1 There are about 100 million blood slides collected from
diagnosis and cross-checking. After elimination has fever cases in India annually from which about 1.5 million
been achieved in each State/UT, 100% of cases will mafferia cases are detected. The new norms for case
be notified to this laboratory for confirmation of ■: management emphasize quality care for patients. The
diagnosis. The laboratory will be notified implementation of use of Rapid Diagnostic Tests (RDTs) and
immediately on all positive cases of malaria by each Artesunate combination therapy (ACT) and the
state/UT through either SMS, e-mail or telephone improvements in service delivery is expected to attract
with information on name, gender, address (village greater number of fever cases to the programme in the
and district), date and type of testing and type of coming years. The programme also plans to supply RDT kits
parasite for each positive case of malaria so that a to private providers in return for data. The current level of
national level database can be maintained. screening of 100 million fever cases will not be reduced as it
(b) Training of master trainers and accreditation/ is aimed to screen 10% of the population, even though the
certification of microscopists as per Indian Public disease transmission is expected to reduce.
Health Standards shall also be undertaken at this
laboratory. During 2003, the NVBDCP introduced the use of RDT for
early diagnosis of malaria. In the year 2012, bivalent RDT
12. During investigation of foci, all suspected cases of were introduced in the programme to detect P. vivax and
malaria are to be screened for malaria. These could P. falciparum. Since then, the programme has procured and
include household members, neighbours, school distributed RDTs to community level workers/volunteers who
children, workplace colleagues and relatives. have been trained to use them to enable timely diagnosis in
13.Surveillance of special groups, migrant populations or these areas. In remote and inaccessible rural and tribal
populations residing in the vicinity of industrial areas are areas, RDTs are now the established method of choice for
also to be covered under surveillance operations. malaria diagnosis.
by R△J
 MALARIA

Parameters of malaria surveillance The population living in areas with API > 5 is planned to
By definition, surveillance also implies the continuing be covered by LLINs and population living in endemic areas
scrutiny of all aspects of occurrence and spread of a disease, registering API > 2 is covered with conventional net treated
that are pertinent to effective control. Included in these are with insecticides and IRS. Conventional nets treated with
the systematic collection and evaluation of field insecticides will continue to be used in areas registering API
investigations, etc. The following parameters are widely used 2 to 5. IRS is still the preferred method of vector control in
in the epidemiological surveillance of malaria : (a) Annual areas with very hot summers and where ITNs are not
acceptable to population.
parasite incidence (API); (b) Annual blood examination rate
(ABER); (c) Annual falciparum incidence (AFI); (d) Slide A population of about 80 million is at present being
positivity rate (SPR); and (e) Slide falciparum rate (SFR). covered by IRS in the country (2). DDT is the insecticide of
choice; in areas where the vector has shown resistance to
Sentinel surveillance DDT, the alternatives are malathion and synthetic
One of the weakness of the existing malaria surveillance pyrethroids. Two rounds of spraying are done for DDT and
system is the lack of articulation with hospitals, which means synthetic pyrethroids to provide protection during the entire
that severe malaria cases are not reported separately and transmission season, and in the case of malathion, three
that only a small fraction of malaria deaths are recorded. rounds of spraying are required. About 60 per cent of the
Therefore, sentinel surveillance is being established in high high risk areas targeted under IRS are under coverage with
endemic districts, by selecting in each district, depending on DDT. The real coverage by IRS is, however, limited by the
its size, 1-3 sentinel sites in large hospitals for recording of low community acceptance due to the white marks left on
all out-patient and in-patient cases of malaria, and malaria plastered surface, acrid smell associated with malathion, re­
related deaths. plastering of walls after completion of IRS etc. (4).

Case management Malaria paradigms/ecotypes (2)

According to the revised drug policy, there is no scope of The association between malaria and various ecological
presumptive treatment in malaria control. The new drug situations have been studied in India since the early part of
policy of 2013 is being followed in the country. For further the 20th century. There is considerable heterogenicity in
details please refer to page 307, chapter 5. malaria transmission characteristics between and within the
states of the country, and many ecotypes/paradigms of

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Integrated vector management (IVM) malaria have been recognized. They are discussed in detail
The NVBDCP aims to achieve effective vector control by on page 301 chapter 5.
the appropriate biological, chemical and environmental Presently, malaria burden in the country is highly
interventions of proven efficacy, separately or in concentrated in a few forest-tribal states and areas. In most of
combination as appropriate to the area through the optimal these states, vector control interventions are limited ter
use of resources. Efforts are made for collaboration with villages with API > 5 or other high risk criteria, due to resource
various public and private agencies and community constraints. The North-East has specific difficulties in
participation for vector control. Integration of IVM is done implementation and monitoring due to various reasons. A
by using identical vector control methods to control malaria large section of tribal population lives in inaccessible terrains,
and leishmaniasis in rural areas, and malaria and dengue in forest, hilly and riverbed conditions, and characterized by
urban areas, to achieve cost-effectiveness and synergy. The high degree of mobility, poverty, inadequate clothing,
IVM includes safe use of insecticides and monitoring of outdoor sleeping habits, forest based economy etc. Presence
•insecticide resistance. The measures of vector control and of efficient vectors, triple insecticide resistance and
protection include : innumerous breeding sites add to the problem. Moreover,
- Measures to control adult mosquitoes : Indoor Residual health infrastructure is generally found to be inadequate in
these areas. Alldhese factors maintain malaria as one of the
Spray (IRS).
most important catase of morbidity and mortality affecting
- Antilarval measures : chemical, biological and tribal populations. The predominant parasite species in tribal
environmental. areas is P. falciparum which is known to cause severity and
- Personal protection : use of bed-nets, including lead to mortality if timely treatment is not provided.
insecticide treated nets.
A tribal-specific strategy is being envisaged to be
The national malaria control programme is currently implemented through a Tribal Malaria Action Plan (TMAP).
using IRS as the primary method of vector control in rural Category 2 and 3 districts are planned to be covered initially.
settings, and anti-larval measures in the urban areas. This will enable concentration of available resources to high
Insecticide treated bed-nets have been introduced in the endemic areas. The key interventions are as follows (4) :
programme and the programme envisages a scale up in their
use as vector control option for full population coverage, 1. Strengthening surveillance : Introduction of mobile­
which will replace IRS in areas, where operational factors based surveillance, where routine health services/
indicate that this method alone will give sufficient impact. facilities are not available.
2. Provision of hamlet-wise ASHAs instead of village-wise.
As much as possible, the village is to be the unit of
intervention, but in some districts, data available with 3. Wherever engagement of ASHAs is not possible,
knowledge of ecological conditions may make it more anganwadi workers of ICDS, faith healers, local medical/
rational to classify whole sub-centre areas as high-risk areas. health care providers, village headmen, PRIs or school
High risk areas and populations will be re-defined at least teachers may be trained and provided relevant logistics
annually. Such villages shall be protected by indoor residual to diagnose and treat malaria cases. In forest areas,
spray and insecticide treated nets and the coverage will be involvement of forest department in diagnosis and
more than 80 per cent, whatever may be the intervention. treatment may be done.

by R△J
478 HEALTH PROGRAMMES IN INDIA

4. In areas with civic disturbance, provision of well- BCC is a key supportive strategy for malaria prevention and
informed and pre-scheduled mobile health services. treatment under NVBDCP.
5. Involvement of locally available, credible NGOs. BCC is directed at : (a) early recognition of signs and
6. Strengthening of PHCs with quality microscopy facilities. symptoms of malaria; (b) early treatment seeking from
7. Provision of diagnosis and treatment facilities by appropriate provider; (c) adherence to treatment regimens;
contractors/owners of development projects to the (d) ensuring protection of children and pregnant women;
labours on site, should be made mandatory. (e) use of ITNs/LLINs; and (f) acceptance of IRS, etc.
8. On the spot, species-specific radical treatment of all
positive cases of malaria. Anti-malaria month campaign
9. Identification of serious cases and early referral to Anti-malaria month is observed every year in the month
specialized health facilities, ensuring free transport of June throughout the country, prior to the onset of
services. monsoon and transmission season, to enhance the level of
10. Follow up and epidemiological tracking of all positive cases. awareness and encourage community participation through
11. Mass screening of migrants wherever necessary. mass media campaign and inter-personal communication
12. Integrated Vector Management (IVM) for appropriate and consolidate inter-sectoral collaborative efforts with
vector control. Prioritization of villages according to other government departments, corporate and voluntary
degree of risk for taking appropriate vector control agencies at national, state and district levels.
measures (IRS/LLINs or treatment of community- owned
bed nets with insecticides). Interaction of malaria control with other health
13. Social marketing to increase usage of bed nets. programmes
14. Minor environmental engineering like cleaning/de-silting The other main public health programmes related to
of drainage, filling pits and ditches, solid waste malaria control are :
management through Village Health, Sanitation and (1) Integrated Disease Surveillance Project (IDSP) : The
Nutrition Committee (VHSNC) as well as MNREGA. project, with weekly fever alerts is increasingly providing
15. Regular and efficient supply chain management. the early warning signals on malaria outbreaks.
16. Intensive training for all cadres of staff, ASHAs/ (2) Other vector borne diseases : Dengue and malaria
community volunteers.

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control activities overlap in many urban areas, malaria
17. Community mobilization by utilizing traditional IEC/BCC and kala-azar in a few districts of Jharkhand, and
tools and practices. malaria and filariasis in some areas including a few
Table 2 summarizes the key indicators that will be used to districts of Odisha.
measure the country's progress towards elimination at (3) Reproductive and child health : Antenatal care services
national and sub-national level. are utilized in distribtuion of LLINs to pregnant women
in some areas of the country. Janani Suraksha Yojana
Behaviour change communication (BCC) also makes provision of bed-nets distribution to pregnant
BCC is a systematic process that motivates individuals, women. Changes in the malaria case management
families and communities to change their inappropriate or norms have been included in the Integrated
unhealthy behaviour, or to continue a healthy behaviour. Management of Neonatal and Childhood Illness.

TABLE 2
Key indicators to measure progress towards malaria elimination

IMPACT

1 Number and incidence rate of confirmed malaria cases classified according to sex, age, parasite species and other relevant parameters.
2 Number and incidence of severe malaria cases as well as case fatality rate.
3 Number of malaria cases in pregnancy.
4 Number and type of malaria focifin areas eligible for elimination).
5 Number of confirmed deaths due to malaria.
6 Number of states/UTs which have eliminated malaria and are currently in the phase of prevention of re-establishment of
local transmission.
7 Number of states/UTs which are in elimination phase.
8 Number of states/UTs which are in pre-elimination phase.
9 Number of states/UTs which are in intensified control phase
OUTCOME
1 Proportion of population at risk who slept under insecticide-treated net/LLINin the previous night.
2 Proportion of population at risk protected by indoor residual spraying within the past 12 months.
3 Proportion of patients with confirmed malaria who received anti-malarial treatment as per national policy.
4 Proportion of cases investigated and classified(in areas eligible for elimination).
5 Proportion of foci investigated and classified(in areas eligible for elimination)
6 Proportion of expected monthly reports received from health facilities at the national and subnational level.

Source: (5)

by R△J
 MALARIA 479
Achievements under National Framework for January 2018-March 2021 Intensified Malaria Elimination
Malaria Elimination in India (6) : Project (IMEP) was implemented in 7 North-eastern states
and Madhya Pradesh. At present, Intensified Malaria
1. India has made considerable progress in malaria
Elimination Project-2 is being implemented in 7 North­
reduction. The country has achieved a reduction of 84%
eastern states (Arunachal Pradesh, Assam, Meghalaya,
in malaria morbidity and 76% in malaria mortality
Mizoram, Nagaland, Manipur& Tripura), Odisha, Jharkhand
between 2015 and 2020.
and Chhattisgarh, covering 166 million population in 155
2. India has achieved National Annual Parasite Incidence districts within the existing framework of National Vector
(API) less than 1 per 1000 population in 2012. In 2020, Borne Disease Control Programme. At present Global Fund
National API was 0.14 per 1000 population. In 2020, supports for LLINs, human resources, monitoring etc.
total 34 States/UTs have achieved API less than 1 except
Chhattisgarh (1.19) and Mizoram (6.82) have API more
than 1. Only 32 districts have Annual Parasite Incidence (B) ELIMINATION OF LYMPHATIC FILARIASIS
(API) one and above. 116 districts in the country have The disease is endemic in 256 districts in 16 states and
reported ‘zero malaria case’. 5 UTs. According to recent estimates about 630 million
3. Among 177 tribal districts, there has been 86.6% people are exposed to the risk of infection (7).
reduction in malaria morbidity and 83.4% reduction in
The National Filaria Control Programme has been in
malaria mortality between 2015 and 2020.
operation since 1955. In June 1978, the operational
4. Malaria has been made notifiable in 31 States/ UTs component of the NFCP was merged with the urban malaria
(Andhra Pradesh, Arunachal Pradesh, Assam, scheme for maximum utilization of available resources. The
Chhattisgarh, Goa, Gujarat, Haryana, Himachal training and research components, however, continue to be
Pradesh, Jammu & Kashmir, Jharkhand, Karnataka, with the Director, National Institute of Communicable
Kerala, Madhya Pradesh, Manipur, Mizoram, Nagaland, Diseases, Delhi.
Odisha, Punjab, Rajasthan, Sikkim, Tamil Nadu,
Telangana, Tripura Uttar Pradesh, Uttarakhand, West Training in filariology is being given at three Regional
Bengal, Puducherry, Chandigarh, Daman & Diu, D&N Filaria Training and Research Centres situated at Calicut
Haveli and Lakshadweep). (Kerala), Rajahmundry (A.P.) and Varanasi (U.P.) under the
5. Till September 2021, 28 States have constituted State National Institute of Communicable Diseases, Delhi. Besides,

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Task Force and District Task Force for malaria 12 headquarters bureaux are functioning at the state level.
elimination. Remaining States/UTs are under process of Filaria control strategy includes vector control through anti
constituting State Task Force and District Task Force. larval operations, source reduction, detection and treatment
6. Malaria microscopy, the gold standard for malaria of microfilaria carriers, morbidity management and IEC.
elimination, has also been strengthened by national National Filaria Control Programme is being implemented
refresher trainings and certification of a core group of through 206 filaria control units, 199 filaria clinics and
laboratory technicians from different states. 27 survey units, primarily in endemic urban towns. In rural
7. Award to Districts/States for achieving ‘Zero indigenous areas anti filaria medicines and morbidity management
case status’ and maintaining it for three consecutive services are provided through primary health care system.
years on attaining sub-national malaria elimination, In India, the National Health Policy (2002), envisages
instituted for Year 1 and Year 3. elimination of lymphatic filariasis (ELF) by 2015 and
8. Mass Screening and Treatment (MSAT) campaign has National Health Policy 2017 to maintain elimination status.
been initiated in the high burden districts of Tripura, The elimination is defined as “lymphatic filariasis ceases to
Mizoram and Chhattisgarh to break the ongoing be public health problem, when the number of microfilaria
transmission cycle of malaria in asymptomatic carriers. carriers is less than 1 per cent and the children born after
9. Availability of Bivalent Rapid Diagnostic Tests (RDTs) initiation of ELF are free from circulating antigenaemia
and anti-malarials with ASHAs for early diagnosis and (presence of adult filaria worm in human body).
prompt treatment at community level. The strategy of lymphatic filariasis elimination is through :
During the last 6 years, 9.7 crore LLINs have been (a) Annual Mass Drug Administration (MDA) of single dose
distributed in the high malaria endemic areas of various of antifilarial drug for 5 years or more to the eligible
states/UTs. population (except pregnant women, children below
High Burden and High Impact (HBHI) initiative of WHO 2 years of age and seriously ill persons) to interrupt
has been started in four states i.e. West Bengal, Jharkhand, transmission of the disease.
Chhattisgarh and Madhya Pradesh in July, 2019 for (b) Home based management of lymphoedema cases and
intensification of malaria elimination activities in these states. up-scaling of hydrocele operations in identified CHCs/
Setting up of health web based reporting system for the district hospitals/medical colleges.
whole country on Integrated Health Information Platform To achieve elimination of lymphatic filariasis, during 2004
(IHIP) - malaria included, and mapping of high malaria- the Govt, of India launched annual MDA with single dose of
prone areas using GIS maps and hotspots. DEC tablets in addition to scaling-up home based foot care
and hydrocele operation. The co-administration of
Global Fund Supported Malaria Elimination DEC + Albendazole has been upscaled since 2007. The
Project (6) : programme covered 202 districts in 2004 whereas by the year
The Global Fund to fight AIDS, Tuberculosis & Malaria 2007, all the 250 LF endemic districts were covered. The
(GFATM) is supporting malaria control in India since 2005. mass drug administration starts in the month of November.
GF supported Intensified Malaria Control Projects (IMCP) I to Presently, antifilarial drug i.e., DEC + Albendazole (DA)/
ill were implemented from July 2005-December 2017. From Ivermectin + DEC + Albendazole (IDA) is administered.

by R△J
 HEALTH PROGRAMMES IN INDIA

The achievements of the programme are as follows : conforming to the case definition of kala-azar and PKDL to the
treatment centres for definitive diagnosis and treatment (3).
Key achievements Status 2020
An incentive amount of Rs. 300 is provided to ASHA for
Total endemic identifying each case of kala-azar and Rs. 100 for ensuring
Stage in the programme districts in 2020 one round and Rs. 200 for two rounds of insecticide spraying.
Total Lymphatic Filariasis endemic districts 272 Even the patient being treated in the hospital will be given Rs.
500 as compensation of daily wage for the time he spends in
Districts conducted MDA in 2020 97
the hospital during the treatment for kala-azar and Rs. 2,000
DEC + Albendazole administered 89 for PKDL. This revised strategy of total eradication of kala-
Ivermectin 4- DEC + Albendazole administered 8 azar was launched on 2nd September 2014.
Districts cleared 1st Transmission Assessment 98 The new strategy also includes introduction of Rapid
Survey (TAS) and Stopped MDA Diagnostic Kit developed by ICMR into the programme and
Districts cleared 2nd Transmission 88 single dose treatment with Liposomal Amphotericin B,
Assessment Survey (TAS) which is given intravenously in 10 mg/kgbw dose. It is to
Districts cleared 3rd Transmission 42 reduce the human reservoir of infection. WHO will supply
Assessment Survey (TAS) the drug free of cost (8).
Source : (6)
Achievements (6)
The line listing of lymphoedema and hydrocele cases In 2020, out of 633 endemic blocks, only 16 blocks (12
were initiated since 2004 by door-to-door survey in filaria blocks in Jharkhand & 4 blocks in Bihar) reported above
endemic districts. The updated figure till December 2014 elimination threshold. Remaining 97.5 per cent blocks
reveals about 12.5 lakh cases with clinical manifestation of achieved the elimination target. Till August 2021, only two
filariasis were line listed which includes 8.7 lakh cases of blocks of Jharkhand have reported above elimination
lymphoedema and 3.8 lakh cases of hydrocele. Initiation has threshold. West Bengal and Uttar Pradesh have sustained
also been taken to demonstrate the simple washing of foot to the elimination target since 2017 & 2019, respectively.
maintain hygiene for prevention of secondary bacterial and There has been 40 per cent decline in KA cases up to August
fungal infection in chronic lymphoedema cases, so that the 2021, compared to corresponding period of 2020. PKDL
patients get relief from frequent acute attacks.

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cases have increased in (Aug) 2021 by 17 per cent
The microfilaria survey in all the implementation units is compared to corresponding period of 2020.
being done through night blood survey before MDA. The
survey is done in 4 sentinel and 4 random sites collecting (D) JAPANESE ENCEPHALITIS
total 4000 slides (500 from each site). There is definite
evidence of microfilaria reduction in the MDA districts. Japanese encephalitis is a disease with high mortality rate
However, the coverage of population with MDA should be and those who survive do so with various degrees of
above 80 per cent persistently for 5-6 years, which would neurological complications. During the last few years it has
reduce microfilaria load in the community, and thereby, become a major public health problem. States of Andhra
interrupt the transmission (3). Pradesh, West Bengal, Assam, Tamil Nadu, Karnataka,
Bihar, Maharashtra, Manipur, Haryana, Kerala and Uttar
(C) KALA-AZAR Pradesh are reporting maximum number of cases.
The strategies for prevention and control of Japanese
Kala-azar is now endemic in 33 districts of Bihar, encephalitis include strengthening of the surveillance
4 districts of Jharkhand, 11 districts of West Bengal and activities through sentinel sites in tertiary health care
6 districts of Uttar Pradesh, besides sporadic cases in few institutions, early diagnosis and proper case management,
other districts of Uttar Pradesh. A centrally sponsored integrated vector control, particularly personal protection and
programme was launched in 1990-91. This has brought use of larvivorous fishes, capacity building and behaviour
down the incidence of the disease from 77,102 cases in change communication. As the JE vectors are outdoor resters,
1992 to 2,052 cases in 2020 (6). indoor residual spray is not effective. The government of India
The strategies for Kala-azar elmination are : (a) Enhanced provides need-based assistance to the states, including
case detection and complete treatment including support for training programmes and social mobilization.
introduction of rK39 rapid diagnostic kits and oral drug As there is no specific cure for this disease, early case
Miltefosine for treatment of Kala-azar cases; (b) Interruption management is very important to minimize the risk of
of transmission through vector control. It has been decided complications and death. JE vaccination is recommended for
to replace DDT with synthetic pyrethroid for the purpose of children between 1 to 15 years of age. In addition, health
fogging to eliminate sandfly, as the insect is becoming education through different media and interpersonal
resistant to DDT; (c) Communication for behavioural impact communication for the community is crucial. Emphasis
and intersectoral convergence; (d) Capacity building; should be given on keeping pigs away from human dwellings,
(e) Monitoring, supervision and evaluation; and (f) Research or in pigsties, particularly during dusk to dawn, which is the
guidelines on prevention and control of Kala-azar have been biting time of vector mosquitoes. Use of clothes which cover
developed and circulated to the states. the body fully to avoid mosquito bites are advocated. Use of
ACTIVE CASE SEARCH : The frequency of case searches bed-nets is also very important precaution. Since early
has been increased from a single annual case search to reporting of case is important to avoid complications, the
quarterly case searches. The active case searches are carried community should be given full information about the signs
out during a fortnight designated as the “Kala-azar Fortnight”, and symptoms of the disease, and the health facilities
during which the peripheral health workers and volunteers are available at health centres/hospitals. The states are advised to
engaged to make door-to-door search and refer the cases use malathion for outdoor fogging as outbreak control

by R△J
 NATIONAL LEPROSY “ERADICATION” PROGRAMME

measure in the affected areas (9). Epidemiological (F) CHIKUNGUNYA FEVER

monitoring of the disease for effective implementation of
preventive and control measure and technical support is Chikungunya fever is a debilitating non-fatal viral illness,
provided on request by the state health authorities. re-emerging in the country after a gap of three decades. Govt,
of India is continuously monitoring the situation. Guidelines
(E) DENGUE FEVER/ for prevention and control of the disease have been prepared.
DENGUE HAEMORRHAGIC FEVER Since same vector is involved in the transmission of dengue
and chikungunya, strategies for transmission risk reduction
During 1996, an outbreak of dengue was reported in Delhi. by vector control are also the same. Support in the form of
Since then dengue has been reported from other states also. In logistics and funds are provided to the states.
view of this major outbreak of the disease a “Guideline of For carrying out proactive surveillance and enhancing
Preparation of Contingency Plan in case of outbreak/epidemic diagnostic facilities for chikungunya, the 521 sentinel
of Dengue/Dengue haemorrhagic fever” was prepared and surveillance hospitals involved in dengue in the affected
sent to all the states. It includes all the important aspects of states also carry out chikungunya tests. The diagnostic kits
control measures like identification of outbreak, demarcation are provided through National Institute of Virology, Pune, by
of affected area, containment of outbreak, case management, the central government.
vector control, IEC activities about Do’s and Dont’s for
prevention of dengue, monitoring and reporting etc. NATIONAL LEPROSY “ERADICATION”
Since early reporting of cases is crucial to avoid any PROGRAMME ________________
complication and mortality, the community is given full
information about the signs and symptoms as well as The National Leprosy Control Programme (NLCP) has
availability of health services at health centres/hospitals. been in operation since 1955, as a centrally aided
Alerting the hospitals for making adequate arrangements for programme to achieve control of leprosy through early
management of dengue/dengue haemorrhagic fever cases detection of cases and DDS (dapsone) monotherapy on an
has also been advised. ambulatory basis. The NLCP moved ahead initially at a slow
pace, presumably for want of clear-cut policies or
Government of India in consultation with states has operational objectives for nearly two decades (10). The
identified 521 sentinel surveillance hospitals with laboratory programme gained momentum during the Fourth Five Year
support for augmentation of diagnostic facilities in the Plan after it was made a centrally-sponsored programme. In

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endemic states. Further, for advanced diagnosis and back-up 1980 the Government of India declared its resolve to
support 14 Apex Referral Laboratories have been identified “eradicate” leprosy by the year 2000 and constituted a
and linked with sentinel surveillance hospitals. To make these Working Group to advise accordingly. The Working Group
functional IgM capture ELISA test kits are provided through submitted its report in 1982 and recommended a revised
National Institute of Virology, Pune free of cost. Contingency strategy based on multi-drug chemotherapy aimed at leprosy
grant is also provided to meet the operational costs. “eradication” through reduction in the quantum of infection
For early diagnosis ELISA based NSI kits have been in the population, reduction in the sources of infection, and
introduced under the programme which can detect the cases breaking the chain of transmission of disease. In 1983 the
from 1st day of infection. IgM capture ELISA tests can detect control programme was redesignated National Leprosy
the cases after 5th day of infection. “Eradication” Programme with the goal of eradicating the
disease by the turn of the century. The aim was to reduce
The GOI has taken the following steps for prevention and
case load to 1 or less than 1 per 10,000 population.
control of dengue (6) :
To strengthen the process of elimination of leprosy in the
- Monitoring the situation through reports received from
country, the first World Bank supported project was introduced
state health authorities.
in 1993. On completion of this project, the 2nd phase of project
- A mid-term plan for prevention and control of dengue with World Bank support was started in 2001-02 which ended
has been developed in 2011 and circulated to the states in December 2004. Since then, the programme is being
for implementation. The main components of mid term continued with Government of India funds with technical
plan for prevention and control of dengue are as follows : support from WHO and International Federation of Anti­
(a) Surveillance: Disease and entomological surveillance. Leprosy Association (ILEP) organizations. The programme has
(b) Case mangement: Laboratory diagnosis and clinical been integrated with general health care system in 2002-03,
management. since then leprosy diagnosis and treatment services are
(c) Vector management : Environmental management available at all PHCs and government hospitals.
for source reduction, chemical control, personal The components of the programme are as follows :
protection and legislation.
(1) Decentralized integrated leprosy services through
(d) Outbreak response : Epidemic preparedness and general health care system;
media management.
(2) Capacity building of all general health services
(e) Capacity building : Training, strengthening human
functionaries;
resource and operational research.
(3) Intensified information, education and communication;
(f) Behavioural change communication : Social
mobilization, and information, education and (4) Prevention of disability and medical rehabilitation; and
communication (IEC). (5) Intensified monitoring and supervision.
(g) Inter-sectoral coordination : with ministries of urban After introduction of MDT, the recorded case load of leprosy
development, rural development, panchayati raj, came down from 57.6 cases per 10,000 population in 1981 to
surface transport and education sector. less than one at the national level in December 2005, and the
(h) Monitoring and supervision : Analysis of reports, country could achieve the goal of leprosy elimination at
review, field visit and feed-back. national level as set by the National Health Policy (2002).

by R△J
 HEALTH PROGRAMMES IN INDIA

34 states/UTs achieved the status of leprosy elimination. Only will again reduce chances of disability occurring in
2 states/UTs viz. Chhattisgarh and Dadra & Nagar Haveli are yet cases under treatment.
to achieve elimination. Odisha, who has achieved elimination (c) Advise and motivate self-care practices by disabled
status earlier, show PR > 1 per 1000 population (6). cases for proper care of their hands and feet during
A total of 209 high endemic districts were identified for the follow-up period. This will improve quality of life
special action during 2012-13. 1792 blocks and 150 urban of the affected persons and prevent deterioration of
areas were identified for special activities, i.e., house to disabilities.
house survey along with IEC and capacity building of the (d) Spreading awareness.
workers and volunteers (1). (e) There are 612 self settled colonies in the country
where more than 50,000 leprosy affected persons
Major initiatives reside. Free medical facilities like care of ulcers, self
Major initiatives taken are as follows : care training, counselling and MCR footwear are
(1) More focus has now been given to new case detection provided to leprosy affected persons residing in these
than prevalence which only gives the number of cases on colonies through para-medical workers/NGOs on
record at a point in time. The new case detection rate is weekly/fortnightly basis.
the main indicator for programme monitoring. 6. Intensive IEC campaign with a theme “Towards Leprosy
(2) Treatment completion rate has been taken as an important Free India” has been carried out towards further
indicator, to be calculated by states at yearly basis. reduction of leprosy burden in the community, early
reporting of cases and their treatment completion,
(3) More emphasis is being given on providing disability provision of quality leprosy services and reduction of
prevention and medical rehabilitation (DPMR) services to stigma and discrimination against leprosy affected
leprosy affected persons. The aid provided is as follows : persons. Awareness generation activities are carried out
(a) Dressing materials, supportive medicines and ulcer kits through mass media and local media.
are provided to leprosy affected persons with ulcers and
wounds. These services are also provided to leprosy Disability prevention and medical rehabilitation
affected persons residing in self settled colonies. (DPMR)
(b) Micro-cellular rubber footwear is provided for The main activities carried out under DPMR are as
protection of insensitive feet. 41 NGOs in the country follows (12) :

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and 42 Government Medical Colleges have been
strengthened for providing reconstructive surgery (1) Implementation of DPMR activities as per guidelines and
services to leprosy affected persons for correction of reporting its outcome eg. treatment of leprosy reaction,
their disability, thus totalling to 83 centres for ulcers, physiotherapy, reconstructive surgery and,
conducting reconstructive surgeries in the country. providing MCR footwear.
(c) An amount of Rs. 8,000/- is provided as incentive to (2) Integrating DPMR services - There are provision of
each leprosy affected person from BPL family services to persons with disability by various
undergoing reconstructive surgery in these identified departments under different ministries. Convergence of
institutions to compensate for loss of wages. NLEP services into NRHM facilitates this integration.
(d) Support is also provided to government institutions/ (3) To develop a referral system to provide prevention of
PMR centres in the form of Rs 5,000/- per disability services to all leprosy disabled persons in an
reconstructive surgery conducted. integrated set-up.
(4) ASHAs have been involved in bringing out suspected The DPMR activities are planned to be carried out in a
leprosy cases from their villages for diagnosis and three tier system i.e. the primary level care (First level),
treatment at PHC and follow-up of confirmed cases for secondary level care (Second level) and the tertiary level
their treatment completion. To facilitate the involvement care (Third level). The primary level care institutions are all
of ASHA in the programme, they are being paid PHCs, CHCs, Sub-divisional hospitals and urban leprosy
incentive money as below (6) : centres/dispensaries. The secondary level care institutions
(a) On confirmed diagnosis of case brought by them - are all District Head Quarter Hospitals and District Nucleus
Rs. 250/-. Units. The tertiary level care institutions are :
(b) On completion of full course of treatment of the case 1. Central Government Institutes (CLTRI Chengalpattu and
within specified time - PB leprosy case - Rs. 400/-, RLTRI at Aska/Gauripur/Raipur).
and MB leprosy case - Rs. 600/-. 2. ICMR Institute JALMA, Agra.
(c) An early case before onset of any visible deformity - 3. ILEP supported Leprosy Hospitals.
Rs. 250/-. 4. All PMR Institutes and departments of medical colleges.
(d) A new case with visible deformity in hands, feet or The other support units are :
eye - Rs. 200/-. (1) Orthopaedics and plastic surgery departments of medical
Activities to be performed by ASHA are as follows : colleges.
(2) Identified NGO institutions.
(a) Search for suspected cases of leprosy i.e. before any sign (3) All National Institutes under Ministry of Social Justice
of disability appears. Such early detection will help in and Empowerment.
prevention of disability and also cut down transmission (4) Contractual surgeons skilled in RCS and Rehabilitation
potential. ASHA based surveillance for leprosy suspects Programmes.
(ABSULS) was launched on 1st July 2019 (11).
(b) Follow-up all cases for completion of treatment in The referral system in NLEP is as summarized in Fig. 1.
scheduled time. During follow up visit, also look for Decentralization and institutional development: Integration
symptoms of any reaction due to leprosy and refer of leprosy services into the general health care system has been
them to the Health Workers/PHC for treatment. This completed. Services are available from all PHCs, and other

by R△J
 NATIONAL LEPROSY “ERADICATION” PROGRAMME

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FIG. 1
Referral System in NLEP
Source : (12)

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 HEALTH PROGRAMMES IN INDIA

health centres where a medical officer is available. District Programme strategy (13)
nucleus has been formed to supervise and monitor the To achieve the objectives of the plan, the main strategies
programme. State leprosy societies formed will merge with the to be followed are :
state health society under the National Rural Health Mission.
- Integrated leprosy services through general health care
Services in the urban areas (13) system.
The health services in the urban areas differ from the - Early detection and complete treatment of new leprosy
rural areas because of non-availability of infrastructure like cases.
PHC and manpower for providing services upto domiciliary - Carrying out house-hold contact survey for early
level. The services in urban areas are provided mainly detection of cases.
through institutional level. Multiple organizations provide - Involvement of Accredited Social Health Activist (ASHA)
health services in urban localities without much of in the detection and completion of treatment of leprosy
coordination amongst them. cases on time.
More number of cases are detected in urban localities due - Strengthening of disability prevention and medical
to migration of people, availability of good quality rehabilitation (DPMR) services.
institutions with easy accessibility, but treatment completion Case detection and management (13)
rate is less as compared to rural areas.
It is expected that the new cases will continue to occur
For the implementation of special action under the plan, regularly but the people are still hesitant to come forward to get
about 524 urban localities have been identified out of 4,388 themselves diagnosed and treated due to the stigma associated
urban areas (census 2011). These localities are having with the disease. Detection of the new cases at the early stage is
population more than 100,000. Remaining areas will be the only solution to cut down the transmission potential in the
covered by PHC services as in rural areas (13). These urban community, and also to provide relief to the leprosy affected
areas are divided into 4 categories : (a) Town and city persons by preventing disabilities. It is therefore suggested that
(population 1 lac to 5 lacs) - 432 areas; (b) Medium city the states will draw up innovative plans :
(population >5 lac to 1 million) - 53 areas; (c) Mega city
(population >1 million to 4.5 million) - 34 areas; and (i) To improve access to services.
(d) Areas with >4.5 million population - 5 areas. (ii) To involve women including leprosy affected persons in
case detection.

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Programme Implementation Plan for 12th Plan (iii) To organize skin camps for detecting leprosy patients
period (2012-13 to 2016-17) while providing services for other skin conditions.
As the disease is still prevalent with moderate endemicity (iv) To undertake contact survey to identify the source in the
in about 15 per cent of the country, the plan objectives are neighbourhood of each child or multibacillary case.
set as follows (13). (v) To increase awareness through the ANM, AWW, ASHA
and other health workers visiting the villages and people
a. Elimination of leprosy i.e. prevalence of less than 1 case
affected by leprosy, to motivate leprosy affected persons
per 10,000 population in all districts of the country.
for early reporting to the medical officer.
b. Strengthen disability prevention and medical
rehabilitation of persons affected by leprosy. Integrated leprosy services through all the primary health
c. Reduction in the level of stigma associated with leprosy. care facilities will continue to be provided in the rural areas.
However, for providing technical support to the primary
Targets (13) health care system, to strengthen the quality of services
The plan targets are as shown in Table 3. being provided, a team of dedicated workers including
medical officer and para-medical workers are placed at
TABLE 3 district level. This will be known as “District Leprosy Cell”.
Targets for the plan period 2012-13 to 2016-17 Three pronged strategy was introduced in the National
Baseline Targets
Leprosy Eradication Programme from 2016-2017. The
Indicator components of the strategy are:
(2011-12) (by March 2017)
1. Leprosy Case Detection Campaign (LCDC);
Prevalence Rate (PR) 543 districts 642 districts
< 1/10,000 (84.6%) (100%) 2. Focused Leprosy Campaign; and
Annual New Case Detection 445 districts 642 districts 3. Special plan for hard to reach areas.
Rate (ANCDR) <10/100,000 (69.3%) (100%) During 2016-17, LCDC was carried out in 163 districts of
population 20 states, wherein 34,672 cases were detected and were put
Cure rate multi bacillary 90.56% >95% on treatment. The activity was aimed at early case detection
leprosy cases (MB)
and timely treatment. The success of the campaign, as
Cure rate pauci bacillary 95.28% >97%
leprosy cases (PB) shown by the drastic decline of grade 2 disability, led to
Gr.II disability rate in
continuation of LCDC and during 2017-18 about 305
3 04% * 35% reduction
percentage of new cases 1.98% districts in 23 states were identified for LCDC phase I (14).
Stigma reduction Percentage 50% reduction In the year 2016-17, Focused Leprosy Campaign was
reported over the carried out by house to house survey in the village/ urban
(NSS 2010-11)** percentage areas (covering 300 households) wherein one case of
reported by NSS grade 2 disability due to leprosy was detected.
* Gr-II disability rate among new cases per million population to The purpose of the special plan for hard to reach areas is
be reduced by 35% i.e. from 3 (2011-12) to 2 per million to find the cases in population in areas of difficult terrains,
population by end of the 12th Plan. naxalite affected areas and other geographically difficult
** Based on the National Sample Survey (NSS) report, 2010-11. locations (14).

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 NATIONAL TB ELIMINATION PROGRAMME 485
Sparsh leprosy awareness campaign (DPMR) i.e., reaction management, provision of
Sparsh leprosy awareness campaign was launched in the Microcellular Rubber (MCR) footwear, aids & appliances,
year 2017 through Gram Sabhas and carried out with the self-care kits etc.
help of Panchayat and Village Health and Sanitation 6. Reconstructive Surgeries (RCS) are conducted at District
Community. The aim was to generate awareness, reduce Hospitals/Medical Colleges/ Central Leprosy Institutes,
stigma and improve self-reporting of the cases. The and welfare allowance of Rs 8,000 is paid to each patient
campaign activity was carried out in 60 per cent of the total undergoing RCS.
villages across India (7). The campaign continued during the ILEP Agencies
year 2018.
The International Federation of Anti-Leprosy Associations
Survey education and treatment (SET) scheme is actively involved as partner in NLEP. In India, ILEP is
constituted by 10 agencies viz. The Leprosy Mission, Damien
Under the SET scheme, the NGOs are presently involved
Foundation of India Trust, Netherland Leprosy Relief,
in disability prevention and ulcer care, IEC, referral of
German Leprosy Relief Association, Lepra India, ALES,
suspected cases, referral for reconstruction surgery (RCS),
AIFO, Fontilles-India, AERF-India and American Leprosy
research and rehabilitation. NGO support is mainly required
Mission. ILEP is providing support in the form of planning,
for follow-up of under treatment cases in urban locations
monitoring and supervision of the programme, capacity
and difficult to reach areas. building of general health care staff, IEC, providing re­
constructive surgery services and socio-economic
Incentive to patient (7)
rehabilitation of persons affected with leprosy. 36 NGOs
An incentive of Rs. 8000/- will be paid to all patients conducting re-constructive surgeries for disability correction
affected by leprosy undergoing major reconstructive surgery in leprosy affected persons are also supported by ILEP (1).
irrespective of their financial status. The payment will be r
Non Government Organizations have been involved in
made by the district leprosy officer. As on January 2017,
the programme for many decades and have provided
there were 115 recognized RCS centres (61 Government
valuable contribution in reducing the burden of leprosy.
and 54 NGO) in the country. Presently, 54 NGOs are getting grant-in-aid from
Government of India under SET scheme. NGOs serve in
Information, education and communication
remote, inaccessible areas, urban slums, industrial/labour

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(IEC/BCC) population and other marginalized population groups. IEC,
The IEC strategy during the 12th plan period was focus prevention of disability, case detection and referral, and
on communication for behavioural changes in general follow-up for treatment completion are some important
public against the stigma and discrimination against the activities taken up by NGOs (1).
leprosy affected persons. Making the public aware about the The leprosy scene in India is passing through an
availability of MDT,. correction of deformity through surgery important phase of transition - from a high burden country
and that the leprosy affected person can live a normal life of leprosy to a relatively low burden country, from a partially
with the family. vertical programme to a more integrated one, from a
Research into the basic problems of leprosy is also part of programme aimed at increase in coverage for leprosy
the activities of the NLEP. This is mainly carried out in the services to one of sustaining quality services, and from
Government sector, viz. the Central JALMA Institute of centralization to decentralization (16).
Leprosy, at Agra and the Central Leprosy Teaching and WHO has announced Global Leprosy Strategy
Training Institute at Chengalpattu, Chennai supported by 2016-2020 : “Accelerating towards a leprosy-free world” for
Regional Training and Referral Institutes at Aska (Orissa), further reducing the disease burden due to leprosy. Please
Raipur (Chhattisgarh) and Gouripur (West Bengal). refer to page 363 for details.
The present day strategy (6, 15) :
NATIONAL TB ELIMINATION PROGRAMME
1. A well laid out operational strategy for active case
detection and regular surveillance has been put in place, National Tuberculosis Programme (NTP) has been in
both in rural and urban areas, through ASHAs and operation since 1962. However, the treatment success rates
frontline workers in order to ensure detection of leprosy were unacceptably low and the death and default rates
cases on regular basis and at an early stage in order to remained high. Spread of multidrug resistant TB was
prevent grade II disabilities. threatening to further worsen the situation.
2. Leprosy screening has been integrated with Rashtriya In 1993, in order to overcome these lacunae, the
Bal Swasthya Karyakram (RBSK) and Rashtriya Kishore Government of India decided to give a new thrust to TB
Swasthya Karyakram (RKSK) for screening of children control activities by revitalizing the NTP, with the assistance
(0-18 years). from international agencies. The Revised National TB
3. Leprosy screening has been integrated with the activities Control Programme (RNTCP) thus formulated, adopted the
of Comprehensive Primary Health Care under internationally recommended Directly Observed Treatment
Ayushman Bharat - Health and Wellness Centre (AB- Short-course (DOTS) strategy, as the most systematic and
HWC) for screening of people above 30 years of age. cost-effective approach to revitalize the TB control
4. Contact tracing is done and Post Exposure Prophylaxis programme in India. Political and administrative
(PEP) is administered to the eligible contacts of Index commitment, to ensure the provision of organized and
case (Person diagnosed with leprosy) in order to interrupt comprehensive TB control services was obtained. Adoption
the chain of transmission at the community level. of smear microscopy for reliable and early diagnosis was
5. Various services are provided under the programme for introduced in a decentralized manner in the general health
Disability Prevention and Medical Rehabilitation services. DOTS was adopted as a strategy for provision of

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 HEALTH PROGRAMMES IN INDIA

treatment to increase the treatment completion rates. Supply NTEP Organogram (18)
of drugs was also strengthened to provide assured supply of
NTEP structure comprises of five levels: National, state,
drugs to meet the requirements of the system (17). district, sub-district and peripheral health institution levels as
The objectives of the RNTCP are : shown in Fig. 2 (18).
1. Achievement of at least 85 per cent cure rate of
infectious cases of tuberculosis, through DOTS involving National level
peripheral health functionaries; and Central TB Division (CTD) manages the National TB
2. Augmentation of case finding activities through quality Control Programme for the entire country at the central level
sputum microscopy to detect at least 70 per cent of under AS&DG (RNTCP & NACO) through a national
estimated cases. programme manager, Deputy Director General TB (DDG
The revised strategy was introduced in the country in a TB). The financial and administrative control of the
phased manner. The RNTCP has expanded rapidly over the programe is managed by the Joint Secretary from the
years and since March 2006, it covers the whole country. administrative arm of the MoHFW.
The RNTCP has now entered into it’s second phase in which The CTD is supported by a National TB Institute (NTI)
the programme aims to consolidate the gains made to date, Bengaluru, six National Reference Laboratories (NRL)
to widen services in terms of activities and access and to including NTI, National Institute for Research in
sustain the achievements. The new initiatives and the wider Tuberculosis (N1RT), Chennai, National Institute of
collaboration with other sectors aim to provide standardized Tuberculosis and Respiratory Diseases (NITRD), Delhi,
treatment and diagnostic facilities to all TB patients National Japanese Leprosy Mission for Asia (JALMA),
irrespective of the health care facility from which they seek Institute for Leprosy and other mycobacterial diseases, Agra,
treatment. The RNTCP also envisages improved access to Regional Medical Research Centre, Bhubaneswar and
marginalized groups such as urban slum dwellers and tribal Bhopal Memorial Hospital & Research Centre - (BMHRC),
groups etc. Bhopal. The CTD is also supported by National Task Force
RNTCP is built upon infrastructure already established by for collaboration of Medical Colleges activities in the country
the previous national tuberculosis programme, while through ZTF/STF.
incorporating the elements of the internationally Various committees of experts to guide the programme at
recommended DOTS. different levels on technical & policy matters are there

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DOTS strategy adopted by Revised National TB Control supporting Central TB Division.
Programme initially had the following five main
State Level
components:
1. Political will and administrative commitment. The states have total ownership and accountability for
the TB control in their state. State health society or its
2. Diagnosis by quality assured sputum smear microscopy. equivalent under National Health Mission of the state
3. Adequate supply of quality assured short course manages the TB control programme. A full-time State
chemotherapy drugs. Tuberculosis Officer (STO), trained at national level and
4. Directly observed treatment. based at the State TB Cell (STC), is responsible for planning,
training, supervising and monitoring the programme in all
5. Systematic monitoring and accountability. the districts of their respective states. STO is administratively
In 2006, STOP TB strategy was announced by WHO and
adopted by RNTCP. The components are as follows : Supporting facilities Ministry of Health &
- Pursuing quality DOTS - expansion and enhancement. Family Welfare

- Addressing TB/HIV and MDR-TB. - National Institutes (3)

- National Reference Central TB Division
- Contributing to health system strengthening. Laboratories (6)
- Engaging all care providers. - Intermediate Reference
State TB Cell
- Empowering patients and communities. Laboratories (34)
37 states / UTs
- Enabling and promoting research (diagnosis, treatment, - State TB Training and
vaccine). Demonstration
Centre (26) District TB Centre
Many of the initiatives like developing and piloting the - Culture and DST 767 Districts
feasibility of National Airborne Infection Control Guidelines, Laboratories (87)
____________ x_____________
developing and piloting strategy for ‘Practical Approach to - Nodal DR-TB TB Unit
Lung Health’ are the examples of initiatives taken by Centre (173) One per 1.5-2.5 lakh population
RNTCP under the comprehensive strategy of STOP TB (17). - CBNAAT
Laboratories (3165) ______________ x_______________
In 2014, the World Health Assembly unanimously Designated Microscopy Centre
approved to end global TB epidemic by "End TB 50,000 to 1 Lakh population
Strategy”, a 20 year programme with vision of a world with
zero death, disease and suffering due to TB. For details
please refer to page 237. Peripheral Health Institute

In view of End TB targets, the programme has

been renamed from Revised National Tuberculosis Control FIG. 2
Programme (RNTCP) to National Tuberculosis Elimination Organization structure of NTEP
Programme (NTEP). Source : (6, 18)

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 NATIONAL TB ELIMINATION PROGRAMME

accountable to the state government, technically follows the at a state level institution. MO-TC has the overall
instructions of the CTD, and coordinates with CTD and the responsibility of management of TB Control Programme at
districts, and is assisted by other technical & secretarial staff. the TU and is expected to undertake supervisory visits for
State TB cell is being supported by State TB Training and seven days in a month. The team of STS and STLS are
Demonstration Centre (STDC) in many states through its under the administrative supervision of the MO-TC and the
three units - a training unit, supervision and monitoring unit DTO. The TU will have one Microscopy Centre for every
and an Intermediate Reference Laboratory (IRL) supporting 100,000 population (50,000 in tribal, desert, remote and
an effective quality assurance system of the sputum smear hilly regions) referred to as the Designated Microscopy
microscopy network and laboratary services for PMDT Centre (DMC, however, for complete geographic coverage
(molecular DR testing and C&DST) in the State. Operational National programme envisages to expand sputum smear
Research is also a component of STDC. microscopy services at PHC level). Microscopy Centres may
also be established beyond population norms in Medical
Each state also has one fully operational State Drug Store colleges, corporate hospitals, ESIC, railways, NGOs, private
(SDS) for each 5 crore of population. It is responsible for hospitals, etc.
effective management of medicines and other logistics, and
ensuring uninterrupted supply of good quality 1st & 2nd line Peripheral Health Institutions (PHIs)
anti-TB medicines for adults and paediatric population.
For the purpose of NTEP, a PHI is a health facility which
District level is manned by at least a medical officer. At this level, there
are dispensaries, PHCs, CHCs, referral hospitals, major
The key level for the management of primary health care hospitals, speciality clinics or hospitals (including other
services is the district. The Chief District Health Officer health facilities), TB hospitals, ART Centres and medical
(CDHO)/Chief District Medical Officer (CDMO)/Civil colleges within the respective district. All health facilities in
Surgeon or an equivalent functionary in the district is the private and NGO sectors participating in NTEP are also
responsible for all medical and public health activities considered as PHIs by the programme. Some of these PHIs
including control of TB. The District Tuberculosis Centre also function as DMCs. Peripheral health institution
(DTC) is the nodal point for TB control activities in the undertake tuberculosis case-finding and treatment activities
district. A full-time District Tuberculosis Officer (DTO), as a part of the general health services. In situations where
trained at national level & based at the DTC, is responsible more than one MO is posted in any of the peripheral health

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for planning, training, supervising and monitoring the centres, one of them may be identified and entrusted with
programme in the district. DTO is assisted by other technical the responsibilities of the NTEP. There is 1 TB Health Visitor
& secretarial staff. The primary role of the DTC is a (TBHV) per one lakh urban population to support the urban
managerial one. TB control activities (18).
Sub-District Level (Tuberculosis Unit Level) TB laboratory services (18)
Integrating the TB control programme with the health The services of the laboratory are utilized for diagnosing
system increases effectiveness and efficiency of TB care and TB & DR-TB cases and for monitoring of treatment of these
control. India’s TB control programme has been patients. The laboratory network under NTEP is a 3-tier
mainstreamed efficiently with National Health Mission system for provision of diagnostic services and maintaining
(NHM). its quality.
A major organizational change in NTEP is the creation of A. The peripheral laboratories are situated in the public
a sub-district level (Tuberculosis Unit-TU). The TU is the sector like the dispensaries, PHCs, CHCs, referral
nodal point for TB control activities in the sub-district. TUs hospitals, major hospitals, specialty clinics/other sector
are based mainly in NHM health blocks with the overall aim hospitals/TB hospitals/medical colleges and in the
to align with NHM Block Programme Management Unit private/NGO sectors. For establishment of microscopy
(BPMU) for optimum resource utilization and appropriate centre in a lab, it must have adequate physical
monitoring. In urban areas the TUs have been created based infrastructure, Binocular microscope and a trained LT.
on a population of 1 per 2,00,000 (range 1.5-2.5 lakh) These laboratories are covered under quality assurance
for rural and urban population and 1 per 1,00,000 (0.75-
mechanisms
1.25 lakh) population in hilly/tribal/difficult areas. The
Tuberculosis Unit (TU) consists of a designated Medical i. Some of the labs not having facility for sputum
Officer - Tuberculosis Control (MO-TC), as well as one full- microscopy, function as a sputum collection centres,
time supervisory staff - Senior Treatment Supervisor (STS). and such facilities are also established in areas such as
However, One Senior TB Laboratory Supervisor (STLS) will the tribal, hilly, desert and difficult to reach areas of
continue to be in 5 lakh population (one per 2.5 lakh the country for improving the access to diagnostic
population for tribal/hilly/difficult areas). There is a provision services.
of additional STS if more than 300 TB cases are registered in ii. In addition, large hospitals and medical colleges have
public sector annually in a TU; additional STS if more than facilities of digital X-Ray, rapid molecular test
50 private health establishments are registered in NIKSHAY (Cartridge based nucleic acid amplification test -
in a TU and more than 200 TB patients are notified from CBNAAT & Line Probe Assay-LPA), Fine Needle
these private health establishments annually in a TU. Aspiration Cytology (FNAC), histopathology, and
culture & DST for diagnostic services of TB.
The Block Medical Officer also functions as a Medical
Officer TB Control (MO-TC). For the urban TB Units, a B. At the state level a nodal laboratory is designated as
medical officer from the health facility where TU is located intermediate reference laboratory (IRL) which is usually
should be designated, in coordination with CMHO/DHO to situated in the State TB Training and Demonstration
function as a MO-TC. All MO-TCs should be trained in NTEP Centre (STDC)/medical college/public health laboratory.

by R△J
488 HEALTH PROGRAMMES IN INDIA

The main functions of IRLs are monitoring of laboratory New Initiatives

services across the state and maintenance of its quality 1. NIKSHAY: TB surveillance using case based, web
through external quality assurance. There are 27 IRLs
with facilities for culture & DST using Phenotypic (Solid based IT system (19)
- LJ & Liquid Culture - MGIT) and Genotypic Central TB Division in collaboration with National
technology (LPA & CBNAAT). Informatics Centre has undertaken the initiative to develop
a case based web based application named Nikshay. The
CBNAAT sites word is combination of two Hindi words NI and KSHAY,
In addition to the culture DST laboratories, CBNAAT meaning eradication of TB.
centres are also established to diagnose Rifampicin This software was launched in May 2012 and has
resistance among all TB patients (Universal DST). Usually following functional components.
these are established in DTCs, TB units and medical - Master management
colleges. The country is in the process of expanding - User details
CBNAAT site network. They also serve to diagnose TB
- TB patient registration and details of diagnosis, DOT
among presumptive TB cases from key population.
provider, HIV status, follow-up, contact tracing, outcomes.
DRTB Centres (18) - Details of solid and liquid culture and DST, LPA,
CBNAAT details.
DRTB Centres are specialized centres for clinical
management of drug resistant TB. At state/regional/division - DR-TB patient registration with details.
level, there are Nodal DRTB Centres (NDRTBC), to manage - Referral and transfer of patients.
seriously ill DRTB cases, DRTB with extensive resistance and - Private health facility registration and TB notification.
DRTB cases to be treated with regimes containing new drugs - Mobile application for TB notification.
(Bedaquiline and Delamanid). - SMS alerts to patients on registration.
At the district level, there are district DRTB centres - SMS alerts to programme officers.
(DDRTBC), to manage DRTB cases with MDRTB, and H - Automated periodic reports:
mono/poly-resistance. These centres will function under the
a. Case finding
guidance of NDRTBCs.

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b. Sputum conversion
C. At the central level there are six designated National
Reference Laboratories (NRLs) namely National c. Treatment outcome.
Tuberculosis Institute, Bengaluru, National Institute for The programme has started using IT enabled adherence
Research in Tuberculosis (NIRT), Chennai, National tools like 99 DOTS for HIV-TB patients. This will be
Institute of Tuberculosis and Respiratory Diseases expanded to all TB patients with implementation of daily
(NITRD), Delhi, National JALMA Institute, Agra, regimen (7).
Regional Medical Research Centre, Bhubaneswar and
Bhopal Memorial Hospital & Research Centre (BMHRC), 2. TB Notification
Bhopal. NIRT Chennai is also a Supra National In order to ensure proper diagnosis and management of
Reference Lab (SNRL) for World Health Organization TB cases, and to reduce TB transmission and the emergence
(WHO) for the South East Asia Region. NTI is a WHO and spread of MDR-TB, it is essential to have complete
collaborating centre for training, while NITRD is WHO information of all TB cases. According to the Government of
centre of excellence in TB laboratory services. The NRLs India notification dated 7th May 2012, it is now mandatory
are mainly responsible for external quality assurance of for all healthcare providers to notify every TB case to local
Lab network, drug resistance surveillance, training and authorities i.e. District Health Officer/Chief Medical Officer
research. of a district and Municipal health officer, every month in a
given format (20).
NTEP endorsed TB diagnostics (1)
1. Smear microscopy for acid fast bacilli. 3. Ban on TB Serology
a. Sputum smear stained with Ziehl-Neelsen staining; or The serological tests are based on antibody response,
which is highly variable in TB and may reflect remote
b. Fluoresence stains and examined under direct or infection rather than active disease. Currently available
indirect microscopy with or without LED. serological tests are having poor specificity and should not
2. Culture be used for the diagnosis of pulmonary or extra-pulmonary
a. Solid (Lowenstein Jensen) media; or TB. Their import, manufacturing, sale, distribution and use
is banned by the Government of India (19).
b. Liquid media (Middle Brook) using manual semi­
automatic or automatic machines, e.g., Bactec, MGIT 4. Direct benefit transfer schemes
etc.
Direct beneficiary transfer systems are being established
3. Rapid diagnostic molecular test by linking TB patients reported in NIKSHAY with AADHAR
a. Conventional PCR based Line Probe Assay for MTB and PEMS to effectively deliver benefits to TB patients and
complex; or their providers (7).
b. Real-time PCR based Nucleic Acid Amplification Test Initiation of treatment
NAAT for MTB complex, e.g. GeneXpert.
Early identification of people with high probability of
4. Radiography where available. having active TB (presumptive TB) is the most important
5. Tuberculin skin test. activity of the case finding strategy. Patients presenting
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 MANAGEMENT OF DRUG RESISTANT TB 489
themselves with symptoms suspicious of tuberculosis are slums, old age homes, prisons, orphanages, transit camps
screened through 2 sputum smear examinations. Sputum etc.) The campaign was conducted in priority districts
microscopic examination is done in designated RNTCP selected based on burden of TB, case finding efforts, HIV-
microscopy centres. They are located either in the CHC, TB and drug resistant TB in the respective districts (7).
PHC, Taluka Hospitals or in the TB dispensary. Each centre The drugs are supplied in patient-wise boxes containing
has a skilled technician to ensure quality control, a senior TB the full course of treatment, and packaged in blister packs.
laboratory supervisor is appointed for every 5 microscopy For the intensive phase, each blister pack contains one day’s
centres. The senior TB laboratory supervisor rechecks all the medication. For the continuation phase, each blister pack
positive slides and 10 per cent of the negative slides of these contains one weeks supply of medication. The combipack
five microscopy centres. Thus the error in diagnosing a drugs for extension of intensive phase are supplied
patient is minimized. It is essential to examine 2 sputum separately. The boxes are coloured according to the
specimens of each patient before a conclusive diagnosis can category of the regimen, red for category I patients, blue for
be made. One sputum sample is not sufficient for diagnosis category II patients.
as the chance of detecting smear positive case is only 80 per
cent. Sputum microscopy not only confirms the diagnosis, Paediatric tuberculosis
but also indicates the degree of infectivity and response to Please refer to page 221 for details.
treatment. Fig. 1 on page number 206 shows the criteria of
diagnosis and initiation of treatment. Drug resistance surveillance (DRS) under
All patients are provided short-course chemotherapy free NTEP (2014-2016) (17)
of charge. During the intensive phase of chemotherapy all The prevalence of drug resistance to TB can be taken as
the drugs are administered under direct supervision called an indicator of the effectiveness of the TB control activities
Direct Observed Therapy Short-term (DOTS). DOTS is a over a period of time and, therefore, RNTCP has taken steps
community based tuberculosis treatment and care strategy to measure this important indicator.
which combines the benefits of supervised treatment, and
the benefits of community based care and support. It ensures The aim of DRS is to determine the prevalence of
high cure rates through its three components: appropriate antimycobacterial drug resistance among new sputum smear
medical treatment, supervision and motivation by a health or positive pulmonary tuberculosis (PTB) patients, and also
non-health worker, and monitoring of disease status by the amongst previously treated sputum smear positive PTB

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health services. DOTS is given by peripheral health staff such patients. Drug-resistant TB has frequently been encountered
as MPWs, or through voluntary workers such as teachers, in India, and its presence has been known virtually from the
anganwadi workers, dais, ex-patients, social workers etc. time anti-TB drugs were introduced for the treatment of TB.
They are known as DOT ‘Agent’ and paid incentive/ To obtain a more precise estimate of Multi-Drug Resistant
honorarium of Rs 150 per patient completing the treatment. TB (MDR-TB) burden in the country, RNTCP carried out
drug resistance surveillance (DRS) surveys (2014-2016) in
Newer initiatives (11) accordance with global guidelines in selected states. The
1. Daily regimen for paediatric TB : In order to transition results of these surveys indicate prevalence of MDR-TB to be
the country to the updated guidelines for paediatric about 2.84 per cent in new cases and 11.60 per cent in
treatment in the STCI, which follow the current WHO retreatment cases (18).
dosing guidelines, the government has decided to
introduce a daily dosing regimen using child-friendly MANAGEMENT OF DRUG RESISTANT TB
fixed dosage combinations (FDCs). The procurement of
The services for quality diagnosis and treatment of drug
anti-TB drugs in daily fixed dose combination (FDC) has
resistant TB cases were initiated in 2007 in Gujarat and
been initiated. Treatment with FDCs of anti-Tb drugs will
Maharashtra. These services since then have been scaled up
be in six weight bands for paediatric patients. An option
and currently these services are available across the
for family members to provide Directly Observed
country from March 2013. For full details about the patient
Treatment (DOT) to paediatric patients has been
regimens, please refer to page 222. The milestones in the
incorporated in the guidelines.
evolution of PMDT are as shown in Fig. 3.
2. Daily regimen for all forms of TB in the country.
3. Pilots for universal access to TB cases. State-level structure and responsibilities (22)
4. Universal drug susceptibility testing (DST) : Expansion of While a national expert technical working group has
rapid molecular diagnostics have been scaled up to 3164 developed national policies, technical and operational
CBNAAT/TrueNat, covering all districts for decentralized guidelines, the state-level is where the majority of planning
diagnosis of drug resistant TB services. Nearly 55 per activities, implementation and monitoring occur. The state
cent of all notified TB cases were offered universal drug PMDT Committee is responsible for developing the plan of
susceptibility testing in 3rd quarter of 2019. action for implementation, expansion, maintenance,
5. Shorter regimen and Bedaquiline : In 2018, shorter supervision, monitoring and quality enhancement of PMDT
regimen and Bedaquiline for treatment of drug resistant services in the respective state.
TB patients have been expanded in the country. From
2018, more than 46,129 DR-TB patients have been Drug-resistant tuberculosis centre (22)
initiated on shorter regimen and 7,973 DR-TB patients Programmatic and clinical management of DR-TB is
on newer drug containing regimen. complex but feasible when the health system is strengthened to
6. Campaign mode - Active case finding : To reach the effectively integrate what is necessary. Treatment of drug­
unreached, the programme has carried out systematic resistant TB is not completely based on centralized and
active TB screening among high risk populations through institutionalized care for the entire duration. In fact, clinical
house visits or targeted setting visit (tribal population, care needs the presence of a clinical and patient support expert

by R△J
490 HEALTH PROGRAMMES IN INDIA

Expansion ofDR-TB services National Strategic Plan 2017-25

• Establishment and expansion of LPA and LC-DST for Ending TB
services and initiation of Baseline SL-DST • Introduction of Truenat
• Testing all follow-up positive for MDR-TB for early • Nation-wide coverage of UDST, Dim,
detection shorter, longer oral MDR-TB regimen
• Treatment services for M/XDR-TB

2007 2012-2017

Till 2012 Till 2020

Initiation ofDR-TB services National Strategic Plan 2012-17

• Diagnosis by Solid culture & • Introduction and expansion of
DST in specific labs CBNAAT (GeneXpert)
• Limited testing only of patients • Universal drug susceptibility testing is a
with unfavourable outcome national policy
• Standardized treatment only for MDR-TB • Introduction of newer drugs - Bdq & Dim

FIG. 3
Milestones in evolution of PMDT in India
Source : (21)

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resource centre. This is the DR-TB Centre, which is a 20-30 - Minimizing travel of patients, thereby transmission risks
bedded tertiary care facility established.to serve a population during travels;
of approximately 10 million, with an airborne infection control - Accountability of the district programme management
compliant ward, facilities for pretreatment evaluations, units; and
treatment initiations, follow-up monitoring and management - Rationalizing utilization of existing DR-TBCs to enable
of adverse drug reactions, prevention and relief of physical and them to concentrate in more complex clinical decisions
social suffering caused by the disease and its treatment, and ensuring quality assurance of treatment and
complications and co-morbidities. All these activities are research.
supported by the programme staff in addition to having
counselling for patients and undertaking data management. 1. District DR-TB centre (22)
By 2017, 147 DR-TBCs were established across India, The DDR-TBC is responsible for the initiation and
designated as Nodal DR-TB centre, one for approximately management of uncomplicated DR-TB patients like RR-TB
every 10 million population, including some in private or H mono/poly DR-TB in a district, not only on inpatient
institutes partnering with RNTCP. About 5 to 10 districts are basis, but also on outpatient basis, wherever advisable and
attached to each centre. DR-TB patients are admitted for a possible. The DDR-TBC can be established at institutes in a
short period and once stabilized on treatment, discharged certain order of preference, namely, medical colleges,
with advance intimation to the districts and referred back to district hospitals, TB hospitals and NGO/private/corporate
their districts for continuation and completion of treatment. institutes/other sector hospitals with the availability of
During treatment they are referred back to DR-TBCs for required clinical expertise.
change of regimens and management of adverse reactions.
To decentralize the pretreatment evaluation, treatment 2. Nodal DR-TB centre (22)
initiation of RR-TB or H mono/poly DR-TB and follow-up Patients with additional resistance to second-line drugs,
processes, two distinct types of DR-TBCs will be established. drug intolerance, contraindications, failing regimen, patients
The existing nodal DR-TB centre (NDR-TBC) will continue returning after treatment interruption of >1 month,
for approximately 10 million population. One District DR-TB emergence of any exclusion criteria for standard regimen for
centre (DDR-TBC) will be established for every district. RR-TB or H mono/poly DR-TB regimen, non-TB
Some of the states have already established these centres. mycobacterium (NTMs) and those needing palliative care
The advantages of decentralized “test and treat would be managed at NDR-TBC.
approach” are (22): The requirements for the NDR-TB centre are as follows:
- Early and faster initiation of treatment of all diagnosed - Should preferably be a tertiary care institute;
DR-TB patients; - Separate ward for male and female patients should be
- Bringing care closer to the residence of majority of the available with at least 10 beds in each;
DR-TB patients; - All PMDT services (beds, investigations, ECG and
- Significant reduction in catastrophic expenditure ancillary drugs for management of adverse drug
including loss of work hours and family income; reactions) to be provided free of cost to the patient;
- Rationally minimizing the need and duration for - Relevant specialties including respiratory medicine,
hospitalization; general medicine, psychiatry, dermatology, ENT,
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 MANAGEMENT OF DRUG RESISTANT TB 491
ophthalmology, gynaecology, paediatrician, health sectors as well. The advantages and disadvantages of
anaesthesiologist and cardiologist should be available public and private sector are as shown below:
directly or through linkages;
- NDR-TBC committee to be formed; Public sector Private sector
- National training of NDR-TBC committee members Advantages • Free diagnosis • Wide choices (> 5
(including Chairperson); • Free treatment lakh practitioners)
- National A1C guidelines to be implemented in DR-TB • Standardized regimen • Better access
• Referral and transfer - Convenient timings
wards and outpatients setting.
system - Shorter distances
- Routine clinical laboratory investigation facility to be • Supervision and - Personal attention
made available for pretreatment evaluation and monitoring and care
monitoring; • Accountability of - Projected discounts
- Ancillary drugs should be available; treatment outcome • Faith and perceptions
of better care
- Management of adverse drug reaction as per PMDT
guidelines; Disadvantages • Staff’s non-response • Cost of clinical
- Doctors, nursing and support staff should be available to symptoms examination fees
• Delays between tests • Cost of diagnostic
from the institute;
and receiving tests
- Reports and records to be maintained for PMDT; and results • Cost of drugs
- Quarterly report to be submitted electronically. • Difficulty in • Irrational
transporting prescriptions
The overall structure and roles of different level of PMDT specimens • Infrequent use of
services are summarized in Fig. 4. • Financial expenditure quality sputum tests
on travel, food, daily for diagnosis of TB
TB care services in the private sector necessities, extra • No adherence
medicines tracking mechanisms
The private sector is everything outside the ambit of the • Fear of losing patient
• Perceived low quality
Government run public health services. It varies widely in its of services if involved in RNTCP
size, nature of service delivery and the socio-economic
groups served. It holds a factual predominance of health Source : (23)

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care service delivery in India. As per National Sample The strategic vision of RNTCP is to lay down guidelines and
Survey Organization report, about 70 per cent patients seek norms for TB care in country. The underlying principle is for
care in private clinics and hospitals (23). RNTCP to extend public services to privately managed
Delays in diagnosis, over-diagnosis of TB due to an over­ patients. Standards for TB care in India, mandatory TB
dependence on X-rays, the use of multiple non-standard notification, NIKSHAY, ban on serodiagnostics are among the
regimens for inappropriate durations, the lack of a mechanism tools to improve TB care services in private sector. Regulatory
to ensure full course of treatment and to record treatment tools, however, are limited and partnership is preferred.
outcomes are some issues of concern in the private sector. Programme staff should understand that RNTCP needs private
Similar problems in varying degrees are encountered in other providers more than private providers need the RNTCP.

C & DST lab Nodal DR-TB Centre State drug store

• Receive diagnosis and FU specimens • Maintain ward & AIC measures • Prepare & ship drug boxes to district
• Provide rapid results to district, Field • Undertake pre-treatment evaluation & level
and DR-TB centre initiate treatment • Manage supply chain for diagnostics
• Maintain records in Nikshay (LIMS) • Manage major ADR and drugs
• Quality assurance of results • Mentor/supervise concerned DDR-TBC • Maintain record in Nikshay Aushadh
as expert resource

NAAT sites District DR-TB District

• Diagnose TB & RR-TB patients at • Initiate DR-TB treatment regimen • Coordinate for test results
district/sub-district level • Manage ADR and Record ADR • Refer patients to N/DDR-TBC
• Maintain records & Nikshay • Consult for complications • Coordinate care and drug flow from
• Reflex transportation of 2nd sample to • Maintain records and Nikshay district drug store to field level
concerned C&DST Lab for FL-LPA & • Coordinate with NDR-TBC/ Field • Maintain records, Nikshay, monitor &
SL-LPA supervise
• Monitor DR-TB treatment

Health facility (HF)

• Identify presumptive case, Collect/transport specimens • Manage minor adverse effects

• Identify treatment supporter • Refer patient for the treatment initiation
• Support, supervise DR-TB patients during treatment • Collect and refer follow-up specimens
• Communicate results to patients
FIG. 4
Overall PMDT structure and roles
Source : (21)

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492 HEALTH PROGRAMMES IN INDIA

Monitoring (24) Large scale active TB case finding campaigns were

The program is continuously monitored at the block, undertaken with massive screening and testing in
district, state, and national levels by the respective program communities, health outreach workers and community
managers, with the aid of the reports generated from volunteers were engaged to facilitate surveillance of
Nikshay database The NTEP is also part of all the important symptoms within households, doorstep collection of samples
health review meetings held under the chairpersonship of and delivery of monthly medicine stock to help patients stick
elected representatives, Principal Secretary (Health), to treatment regimens, and tele-consultations with patients.
Mission Directors and District Magistrates/Collectors. Private sector TB care facilities were reopened, call centres
were fully activated, digital tools were rolled out along with
The Central TB Division also releases quarterly, and bi­ support like direct cash transfers and supplementary food
annual rankings of the states and districts based on the TB provisions were delivered to people’s home. Contact tracing
Score. This aids the states to identify the areas of lacunae, systems and testing for TB linked to COVID-19 contact
identify challenges and expedite their resolution on a real­ tracing were also quickly set up throughout the country.
time basis. Nikshay Dashboard plays an important role in
real-time monitoring of the program performance. By December 2020, NTEP had managed notifying a total
of 18,05,670 patients which was 11% more than the
TB Score estimated projections made in April 2020 in view of the
ongoing COVID-19 pandemic. The private sector too
For continuous monitoring of the programme contributed notification of 5.49 lakh patients (31% of total
performance at the national, state as well as district level, a notifications), 3% more than in 2019. Despite the pandemic,
composite score calculated from a selected list of key 95% of total patients notified were put on treatment during
performance indicators from various thematic areas in the 2020. During the year 2021, a total of 15,79,410 (Jan-Sep)
National Tuberculosis Elimination Programme. Appropriate patients were notified with 95% of patients put on treatment.
weightage has been given to each of these indicators and Treatment Success Rate of TB notified patients remains at
each state is scored for the performance in each indicator. 81% in 2021 despite the pandemic.
The individual indicators sum up to a total of 100.
The NTEP has also initiated Sub-National Certification of
The TB index helps in objectively measuring the Districts/States/UTs for achieving "Progress towards TB Free
performance of the state, identify areas where guidance/ Status" under Bronze, Silver and Gold categories measured

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resolution of challenges are necessary as well as promote a with graded milestones of decline in TB incidence compared
healthy competition towards ending TB. to 2015 levels. Districts/States/UTs are certified under the
categories upon independent verification by a national team
The achievements during COVID-19 comprising of National Institute of Epidemiology, WHO
pandemic (6) India and Indian Association of Preventive and Social
The onset of the COVID-19 pandemic triggered Medicine.
lockdowns, restrictions in movement, repurposing of
available NTEP and health system resources, infrastructure, TB-HIV coordination (25)
diagnostics, treatment centers and manpower to fight this Since the advent of the collaborative efforts in 2001,
emerging threat, and disrupted ongoing TB elimination TB-HIV activities have evolved to cover most of the
efforts and services all over the country. NTEP’s response recommendations as per the latest WHO policy statement
plan and mitigation efforts included integrated TB-COVID issued in 2012. In 2007, the first national framework for
bi-directional screening, diagnostic and treatment capacity. joint TB-HIV collaborative activities was developed which

The TB Index currently in usage consists of 9 indicators

S.No. Parameter Indicator Score allotted

1 Achievement of TB notification among the target identified % of Target TB notification achieved (Source: Nikshay) 20
2. HIV testing/ screening of TB notified patients % of net TB notified patients with known HIV status 10
(Source: Nikshay)
3. UDST coverage among the TB notified patients % of net TB notified patients with UDST done 10
(Source: Nikshay)
4. Treatment Success Rate of TB notified patients Treatment Success Rate for net TB patients 15
(Source: Nikshay)
5. Nikshay Poshan Yojana implementation % of Eligible beneficiaries paid at least once under 10
Nikshay Poshan Yojana (Source: Nikshay)
6. DRTB treatment initiation among the diagnosed patients % of MDR/ RR patients initiated on treatment out of 15
net diagnosed (Source: PMDT Quarterly Reports)
7. Utilisation of the allotted budget % of expenditure amongst ROP (Source: PFMS) 10
% of children <5/<6 years given chemoprophylaxis
against the total eligible children identified 5
(Source: Nikshay)
8. Latent TB infection management
% of PLHIV given IPT against total eligible PLHIV 5
(Source: NACP)
Source : (24)
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 MANAGEMENT OF DRUG RESISTANT TB 493
endorsed a differential strategy reflective of the Tuberculosis in pregnancy
heterogeneity of TB-HIV epidemic. Coordinated TB-HIV Please refer to page 230 for details.
interventions were implemented including establishment of
a coordinating body at national and state level, dedicated NATIONAL STRATEGIC PLAN (2017-2025)
human resources, integration of surveillance, joint FOR TB ELIMINATION
monitoring and evaluation, capacity building and
operational research. The National Strategic Plan (NSP) 2017-2025 for TB
elimination builds on the success of last NSP. It is a three
The implementation of collaborative TB/HIV activities year costed plan and an eight year strategic document. It
are as follows : provides goals and strategies for the country's response to
1. Intensified TB case finding has been implemented the disease during the period 2017-2025 to bring about
nationwide at all HIV testing centres (known as significant changes in the incidence, prevalence and
integrated counselling and testing centres, or ICTCs), mortality of TB, and attain the global End TB targets five
and has now been extended to all ART centres. years ahead of Sustainable Development Goals of TB free
2. HIV testing of TB patients is now routine through India. The VISION is - TB free India with zero deaths,
provider initiated testing and counselling (PITC), disease and poverty due to TB (26).
implemented in all states with the intensified TB-HIV
package. Objectives:
3. Persons found to be HIV-positive are eligible for free HIV The main objectives of NPS are:
care at a network of antiretroviral treatment (ART) 1. Find all drug sensitive TB and drug resistant TB cases
centres. ART centres are located in medical colleges, with an emphasis on reaching TB patients seeking care
mainly staffed and operated by the state AIDS control from private providers, and undiagnosed TB in high-risk
societies, and a few are situated within the facilities of populations.
private or NGO partners. As of December 2017, there 2. Initiate and sustain all patients on appropriate anti-TB
were 536 ART centres operating in the country, 1120 treatment wherever they seek care, with patient friendly
link-ART centres and 158 link-ART plus centres. Ten systems and social support.
Regional Centres of Excellence provide second-line ART 3. Prevent the emergence of TB in susceptible populations.
services for PLHIV, and 24 centres provide second line 4. Build and strengthen enabling policies, empowered

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ART (ART-plus centres). HIV-infected TB patients who institutions, additional human resources with enhanced
are on protease inhibitor based second line ART are capacities, and provide adequate financial resources.
getting rifabutin-based TB treatment in place of
Rifampicin. The key strategies are as follows:
4. Policy decision has been taken by National Technical 1. Private sector engagement
Working Group on TB/HIV collaborative activities 2. Active case finding
(NTWG on TB/HIV) to expand coverage of whole blood 3. Drug resistant TB case management
finger prick HIV screening test at all DMC without a 4. Addressing social determinants including nutrition
stand-alone or F-ICTC. 5. Robust surveillance system
5. Provider initiated HIV testing and counselling (PITC) 6. Community engagement and multi-sectoral approach
among presumptive TB cases (TB suspects) is now a
policy - Expected outcome:
a. In high HIV prevalent states/settings - The The aim of the National Strategic Plan is to achieve
implementation will be done in a phased manner, elimination of TB by 2025. During plan period, targets for
starting with high prevalent states and then in A and TB are:
B category districts in rest of the country.
1. 80% reduction in TB incidence (i.e. reduction from 211
b. In low HIV prevalent states/settings - HIV testing
per lakh to 43 per lakh)
among presumptive TB cases should be routinely
implemented in the age-group of 25-54 years in low 2. 90% reduction in TB mortality /i.e. reduction from 32
HIV prevalent districts (C & D) at places where there per lakh to 3 per lakh
are co-located TB and HIV testing facilities. 3. 0% patient having catastrophic expenditure due to TB
6. Intensified case finding activities to be specifically New comprehensively deployed interventions are
monitored among HIV infected pregnant women and required to accelerate the rate of decline of incidence of TB
children living with HIV to more than 10-15 per cent annually. The requirements of
moving towards TB elimination have been integrated into
7 The National AIDS Control Programme (NACP) and
four strategic pillars of Detect-Treat-Prevent-Build (DTPB).
RNTCP have taken the policy decision to adopt isoniazid
By taking the DTPB approach, the national programme can
prophylaxis therapy (IPT) as a strategy for prevention of achieve significant positive change and make a real
TB among PLHIV The implementation will be in a difference in the lives of many people it serves.
phased manner.
Table 4 highlights the core impact, outcome indicators
8. The RNTCP has prioritized presumptive TB cases among and targets of the NSP. The four priority areas include
people living with HIV for diagnosis of TB and private sector engagement, ensuring a seamless efficient TB
Rifampicin resistance with rapid diagnostic tools having care cascade, active TB case-finding among key population
high sensitivity e.g. Xpert MTB/RIF. (socially vulnerable and clinically high risk), and preventing
The treatment guidelines are discussed in detail on progression from latent TB infection (LTBI) to active TB in
page 235. high risk groups.

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494 HEALTH PROGRAMMES IN INDIA

TABLE 4
NSP 2017-25 results framework
Baseline Target
Impact indicators
2015 2020 2023 2025

To reduce estimated TB incidence rate 217 142 77 44

(per 100,000 population) (112-355) (76-255) (49-185) (36-158)
To reduce estimated TB prevalence 320 170 90 65
(per 100,000 population) (280-380) (159-217) (81-125) (56-93)
To reduce estimated mortality due to TB 32 15 6 3
(per 100,000 population) (29-35) (13-16) (5-7) (3-4)
To ensure no family should suffer catastrophic cost due to TB 35% 0% 0% 0%
Outcome Indicators
Total TB patient notification (in millions) 1.74 3.6 2.7 2
Total patient private providers notification (in millions) 0.19 2 1.5 1.2
MDR/RR TB patients notified 28,096 92,000 69,000 55,000
Proportion of notified TB patients offered DST 25% 80% 98% 100%
Proportion of notified patients initiated on treatment 90% 95% 95% 95%
Treatment success rate among notified DSTB 75% 90% 92% 92%
Treatment success rate among notified DRTB 46% 65% 73% 75%
Proportion of identified targetted key affected population 0% 100% 100% 100%
undergoing active case finding
Proportion of notified TB patients receiving financial 0% 80% 90% 90%
support through Direct Benefit Transfers (DBT)

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Proportion of identified/eligible individuals for preventive 10% 60% 90% 95%
therapy/LTBIs - initiated on treatment

Source : (23)

Financial resources 1992- NACP-I launched to slow down the spread of

HIV infection.
The programme is being assisted by the World Bank and
the Department for International Development (DFID) via - National AIDS Control Board constituted.
WHO. In addition, the RNTCP is supported by the Global TB - NACO set-up.
Drug Facility (GDF), Global Fund to Fight AIDS, Tuberculosis
and Malaria (GFATM), the United States Agency for 1999- NACP-II begins, focussing on behaviour change,
International Development (USAID) and DANIDA. increased decentralization and NGO involvement.
Government of India provides 100 per cent grant-in-aid to - State AIDS Control Societies established.
the implementing agencies i.e., states/UTs, besides free 2002 - National AIDS Control Policy adopted.
drugs. The states are expected to use the existing
infrastructure and also to provide some manpower resources. - National Blood Policy adopted.
2004- Anti-retroviral treatment initiated.
NATIONAL AIDS CONTROL PROGRAMME 2006- National Council on AIDS constituted under
chairmanship of the Prime Minister.
National AIDS Control Programme was launched in India
in the year 1987. The Ministry of Health and Family Welfare - National Policy on Paediatric ART formulated.
has set up National AIDS Control Organization (NACO) as a 2007- NACP-III launched for 5 years (2007-2012).
separate wing to implement and closely monitor the various 2014- NACP-IV launched for 5 years (2012-2017).
components of the programme. The aim of the programme
is to prevent further transmission of HIV, to decrease 2017- National Strategic Plan for HIV/AIDS and STIs
morbidity and mortality associated with HIV infection and to 2017-2024
minimize the socio-eonomic impact resulting from HIV The national strategy has the following components :
infection. establishment of surveillance centres to cover the whole
The milestones of the programme are summarized as country; identification of high-risk group and their
follows (23A) : screening; issuing specific guidelines for management of
1986- First case of HIV detected. detected cases and their follow-up; formulating guidelines
for blood bank, blood product manufacturers, blood donors
- AIDS Task Force set up by the ICMR.
and dialysis units; information, education, and
- National AIDS Committee established under the communication activities by involving mass media and
Ministry of Health. research for reduction of personal and social impact of the
1990- Medium Term Plan launched for four states and disease; control of sexually transmitted diseases; and
the four metros. condom programme.

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 NATIONAL AIDS CONTROL PROGRAMME
495
The Government of India initiated programmes of - Free first-line and second-line Anti-Retroviral Therapy
prevention and raising awareness under the Medium (ART) through ART centres and Link ART Centres
Term Plan (1990-92), NACP-I (1992-99), NACP-II (LACs), Centres of Excellence (CoE) and ART plus
(1999-2006) and NACP-III (2007-2012). Based on the centres.
lessons learnt and achievements made in Phase I, II and III. - Paediatric ART for children.
India developed the Fourth National Programme
Implementation Plan (NACP-IV, 2012-2017). The primary - Early infant diagnosis for HIV exposed infants and
goal of NACP-IV is to halt and reverse the epidemic in India children below 18 months.
over the next 5 years by integrating programmes for - Nutritional and psycho-social support through Care
prevention, care, support and treatment. and Support Centres (CSC).
The package of services under NACP-IV are as - HIV/TB coordination (cross-referral, detection and
follows (27) : treatment of co-infections).
- Treatment of opportunistic infections.
1. Prevention services
- Drop-in centres for PLHIV networks.
- Targeted interventions for high-risk groups (female sex
workers, men who have sex with men, transgenders/ Organizational structure
hijras, injecting drug users) and bridge population
(truckers and migrants). The National AIDS Control Organization (NACO) is
presently established as a division under the Ministry of
- Needle-syringe exchange programme and opioid
Health and Family Welfare, headed by the Additional
substitution therapy for IDUs.
Secretary, Ministry of Health and Director General, NACO
Prevention interventions for migrant population at Govt, of India. The technical divisions are headed by
source, transit and destination. officers at the level of Deputy Director General/DGHS. The
- Link worker scheme for HRGs and vulnerable finance division is headed by Director-Finance while Admin
population in rural areas. and Procurement is headed by the Joint Secretary, Ministry
of Health. Fig. 5 shows the NACO structure.
- Prevention and control of sexually transmitted
infections/reproductive tract infections. Country scenario
- Blood safety.

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Based on sentinel surveillance data, the HIV prevalence
- HIV counselling and testing services. in adult population can be broadly classified into three
- Prevention of parent to child transmission. groups of States/UTs in the country.
- Condom promotion. Group 1 High Prevalence States : includes states of
Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh,
- Information, education and communication and
Manipur and Nagaland where the HIV infection has crossed
behaviour change communication (BCC). 5 per cent mark in high-risk group and 1% or more in
- Social mobilization, youth interventions and antenatal women.
adolescence education programme.
Group II Moderate Prevalence States : includes states of
- Mainstreaming HIV/AIDS response. Gujarat, Goa and Puducherry where HIV infection has
- Work place interventions. crossed 5% or more among high risk groups but the
infection is below 1% in antenatal women.
2. Care, support and treatment services Group III Low Prevalence States : includes remaining
- Laboratory services for CD4 testing and other states where the HIV infection in any of the high risk groups is
investigations still less than 5% and is less than 1% among antenatal women.

FIG. 5
NACO Structure
Source : (28)

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 HEALTH PROGRAMMES IN INDIA

Categories of Districts testing procedures by two ERS (i.e., when HIV testing is
carried out without indentification of name of samples
In the country, the districts have been classified according
collected for other purposes e.g., VDRL in STD clinics. The
to the epidemiological and vulnerability-criteria using the
objective of surveillance may be fulfilled in this example
sentinel surveillance data for the last 3 years (Table 5).
whereas the positive person is not identified). The number
Accordingly, 156 districts have been classified as category A.
39 districts as category B, 296 as category C and 118 as of samples to be screened must represent the risk group
category D districts. The planning for HIV related services under study and the sample size is determined accordingly.
Clinical based approach for such collection has many
has also been graded as per categorization of districts. This
approach has been implemented since March 2007. advantages including the procedure for collection of samples
which should be carried out on the above lines to avoid
HIV surveillance “selection bias” and “participation bias”
Different types of surveillance activities are being carried To start with, the HIV sentinel surveillance for HIV was
out in the country to detect the spread of the disease and to taken up from 1994 in 55 sentinel sites attached to the
make appropriate strategy for prevention and control viz., existing surveillance centres and were increased to 180 in
area specific targeted intervention and best practice 1998. While the number of the high risk groups of HIV
approach. The types of surveillance are : (a) HIV Sentinel sentinel sites were increased every year, with change of sites,
Surveillance, (b) HIV Sero-Surveillance, (c) AIDS Case these 180 sites have remained consistent. Inclusion of data
Surveillance, (d) STD Surveillance, (e) Behavioural from high-risk population through targeted intervention sites
Surveillance, and (f) Integration with surveillance of other and the additional sub-set of rural samples through ante­
diseases like tuberculosis etc. natal clinics are the key features of HIV sentinel surveillance.
Pregnant women attending antenatal clinics are taken as
HIV SENTINEL SURVEILLANCE After the
proxy for general population. The number of HIV sentinel
establishment of the fact that HIV infection is present in wide
surveillance sites for different population groups during
geographic areas, the aim of surveillance was redefined to
2016-17 are as shown in Table 6.
monitor the trends of HIV infection. The objectives of the
surveillance are as follows (30) :
TABLE 6
1. To determine the level of HIV infection among general
Number of HIV sentinel surveillance sites
population as well as high-risk groups in different states;

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(2016-2017)
2. To understand the trends of HIV epidemic among
general population as well as high-risk groups in different
states;
3. To understand the geographical spread of HIV infection
and to identify emerging pockets;
4. To provide information for prioritization of programme
resources and evaluation of programme impact; and
5. To estimate HIV prevalence and HIV burden in the
country.
The objective of the surveillance is best achieved by
annual cross-sectional survey of the risk group, in the same
place over few years by unlinked anonymous serological
Source : (31)
TABLE 5
The strategy adopted for collection and testing of samples
Categories of districts during HIV Sentinel Surveillance Round 2016-2017 was as
Category of Districts
follows (Table 7).

More than 1% ANC/PTCT prevalence in district at A Counselling and HIV testing services
any time in any of the sites in the last 3 years
The Basic Service Division of the department of AIDS
Less than 1 % ANC/PTCT prevalence in all the sites B control provides HIV counselling and testing services for
during last 3 years associated with more than 5%
prevalence in any HRG group (STD/CSW/MSM/IDU) HIV infection. The national programme is offering these
services since 1997 with the goal to identify as many people
Less than 1% in ANC prevalence in all sites during C living with HIV, as early as possible (after acquiring the HIV
last 3 years with less than 5% in all STD clinic attendees
or any HRG with known hot spots (Migrants, truckers, infection), and linking them appropriately and in a timely
large aggregation of factory workers, tourist etc.). manner to prevention, care and treatment services. The
introduction of ART services for people living with HIV/AIDS
Less than 1% in ANC prevalence in all sites during last D
3 years with less than 5% in all STD clinic attendees or in 2004, gave a major boost to counselling and testing
any HRG OR, poor HIV data with no known services in India. The HIV counselling and testing services
hot spots. include the following components:
1. Integrated Counselling and Testing Centres (ICTC).
ANC - Antenatal clinic
2. Prevention of parent-to-child transmission of HIV
PTCT - Parent to child transmission
(PPTCT).
Source : (29) 3. HIV/tuberculosis collaborative activities.

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 _________________________________ NATIONAL AIDS CONTROL PROGRAMME |

TABLE 7
HIV sentinel surveillence round 2016-2017
High risk groups: Bridge population: General population-
IDU/MSM/FSW/TG SMM/LDT Pregnant women attending ANC clinics
Sentinel site Targeted interventions (TI) projects STD clinic, TI projects Antenatal clinic
Sample size 250 250 400
Duration 3 months 3 months 3 months
Frequency Once in 2 years Once in 2 years Once in 2 years
Sampling method Consecutive/random Consecutive Consecutive
Age group 15-49 years 15-49 years 15-49 years
Testing strategy Unlinked anonymous with Unlinked anonymous at STD, Unlinked anonymous
informed consent with informed consent at TI sites
Blood specimen Dried blood spot Serum at STD, DBS at TI sites Serum
Testing protocol Two test protocol Two test protocol Two test protocol

SMM - Single male migrants, LDT - Long distance truckers

Source : (31)

INTEGRATED COUNSELLING AND TESTING early detection of HIV, provision of basic information on
CENTRES modes of transmission and prevention of HIV/AIDS for
promoting behavioural change and reducing vulnerability,
Diverse models of HIV counselling and testing services and linking PLHIV with other HIV prevention, care and
are available to increase access to HIV diagnosis, these treatment services. The ICTC have been classified into two
include testing services in health care facilities, standalone types: Fixed facility ICTC and Mobile ICTC.
sites and community-based approaches at various levels of

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public health systems in India from state, district, sub-district 1. Fixed facility ICTCs are located within an existing
and village/community levels as depicted in Fig. 6. healthcare facility/hospital/health centre, and are of two
types - Standalone ICTC and Facility-integrated
Types of facilities for HIV counselling and testing counselling and testing centres.
services a. Standalone ICTC (SA-ICTC): The client load is high
Integrated Counselling and Testing Centres (ICTC): A in these centres, with full-time counsellor and
person is counselled and tested for HIV at ICTC, either of his laboratory technician who provide HIV counselling
own free will (client initiated) or as advised by a medical and testing services. SA-ICTC are located in medical
provider (provider initiated). Functions of ICTC include colleges, district hospitals, sub-district hospitals,
CHCs etc.
b. Facility-integrated counselling and testing centres
(F-ICTCs): Considering the need for rapid scale-up
and sustainability of HIV counselling and testing
services, the F-ICTCs have been set up below the
block levels at 24 x 7 PHC, etc. Staff of the existing
health facilities are trained in counselling and testing
services of HIV. The HIV service delivery is ensured
with logistic support from DAC. Similar to F-ICTC at
24 x 7 PHC, the Public Private Partnership (PPP)-
ICTCs were established in private facilities (for profit/
not-for-profit hospitals, laboratories, non­
governmental organizations etc.), and have been
supported by DAC/SACs in supply of rapid HIV
testing kits, training of existing staff, quality
assurance, supply of protective kits and prophylactic
drugs for post-exposure prophylaxis for staff, supply
of IEC materials such as flip charts, posters etc.
required for ICTC.
2. Mobile,ICTC: Mobile counselling and testing centre is a
van with a room to conduct general examination,
counselling and space for collection and processing
blood samples by a team of paramedical healthcare
providers (a health educator/ANM, counsellor and
FIG. 6 laboratory technician). Mobile ICTC are set up as
Level of HIV counselling and testing services in India temporary clinics in hard-to-reach areas with flexible
Source : (32) working hours and provide a wide range of services like

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 HEALTH PROGRAMMES IN INDIA

counselling and testing services for HIV, syndromic 6. Provision of nutrition, counselling and psychosocial
management of STI/RTI and other minor ailments, along support for HIV infected pregnant women.
with regular health check-ups, antenatal, immunization 7. Provision of counselling and support for initiation of
services etc. exclusive breast-feeds within an hour of delivery as the
Community based HIV screening: In order to offer HIV preferred option and continued for 6 months.
testing to every pregnant woman in the country, so as to 8. Provision of ARV prophylaxis to infants from birth upto a
detect all HIV positive pregnant women and eliminate minimum of 6 months.
transmission of HIV from parent to child, the community­
based HIV screening is conducted by frontline health 9. Integrating follow-up of HIV-exposed infants into routine
workers (Auxiliary Nurse Midwives) at the sub-centre level. healthcare services including immunization.
10. Ensuring initiation of Co-trimoxazole Prophylactic
PREVENTION OF PARENT-TO-CHILD Therapy (CPT) and Early Infant Diagnosis (EID) using
TRANSMISSION OF HIV HIV-DNA PCR at 6 weeks of age onwards, as per the EID
The prevention of parent-to-child transmission of HIV/ guidelines.
AIDS (PPTCT) programme was started in the country in the 11. Strengthening community follow-up and outreach
year 2002. Currently there are more than 15,000 ICTCs in through local community networks to support HIV­
the country which offer PPTCT services to pregnant women. positive pregnant women and their families.
The aim of the PPTCT programme is to offer HIV testing to
every pregnant woman (universal coverage) in the country, HIV TESTING OF TB PATIENTS
so as to cover all estimated HIV positive pregnant women Detection of HIV by offering HIV tests to diagnosed TB
and eliminate transmission of HIV from mother-to-child. patients is being implemented by NACP and RNTCP jointly
In India, PPTCT interventions under NACP was started in since 2007-08. States with high HIV prevalence cover about
2002, using SD-NVP prophylaxis for HIV positive pregnant 90% TB patients for HIV testing, but case fatality rate among
women during labour and also for her new born child HIV infected TB cases remains 13-14%, as compared to less
immediately after birth. With the department of AIDS than 4% in HIV negative TB cases, indicating delayed
control adopting “Option B” of the World Health detection of HIV/TB inspite of good coverage. Therefore,
Organization recommendations (2010), India has also NACP and RNTCP have jointly decided to offer HIV testing
transitioned from the single dose Nevirapine strategy to that upstream during evaluation of patients for TB when they

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of multi-drug ARV prophylaxis from September 2012. This present with TB symptoms. This activity is expected to
strategy was executed in the three southern high HIV expedite detection of HIV within 2-4 weeks of TB positivity,
prevalence states of Andhra Pradesh, Karnataka and Tamil leading to early linkage to HIV treatment and hence
Nadu. The national strategic plan for PPTCT services using reduction in mortality. HIV testing in presumptive TB cases
multi-drug ARVs in India was developed in May-June 2013 was rolled-out in India in October 2012 in Karnataka,
for nationwide implementation in a phased manner. Based followed by Maharashtra, Andhra Pradesh and Tamil Nadu.
on the new WHO guidelines (June 2013) and on the It is planned to extend this strategy to high HIV prevalence
suggestions from the technical resource groups during districts i.e. A and B category districts. Further the NTWG
December 2013, department of AIDS control has decided to has recommended implementation of this strategy among
initiate lifelong ART (using the triple drug regimen) for all 25-54 years age group in the rest of the country.
pregnant and breast-feeding women living with HIV, The four pronged strategy for HIV-TB coordination
regardless of CD4 count or WHO clinical stage, both for activity to reduce mortality are summarized in Fig. 7.
their own health and to prevent vertical HIV transmission,
and for additional HIV prevention benefits. Care, support and treatment
The PPTCT services provide access to all pregnant The care, support and treatment (CST) component of
women for HIV diagnostic, prevention, care and treatment NACP aims to provide comprehensive services to people
services. As such, the key goal is to ensure the integrated living with HIV (PLHIV) to improve the survival and quality
PPTCT service delivery with the existing Reproductive and of life. The policy package includes the following (7):
Child Health (RCH) programme.
- Free universal access to life long standardized
The essential package of PPTCT services in India are as antiretroviral therapy (ART);
follows (32) : - Free laboratory diagnostic and monitoring services
1. Routine offer of HIV counselling and testing to all (baseline tests, CD4 testing, targeted viral load);
pregnant women enrolled into antenatal care, with an - Facilitating long term retention in care;
‘opt out’option. - Prevention, diagnosis and management of opportunistic
2. Ensuring involvement of spouse and other family infection; and
members, and move from an “ANC-Centric” to a - Linkage to care and support services and linkage to
“Family-Centric” approach. social protection scheme.
3. Provision of life-long ART (TDF+3TC + EFV) to all
pregnant and breast-feeding HIV infected women, The country has adopted fast track target of 90-90-90
regardless of CD4 count and clinical stage of HIV and more recently 95-95-95 target which aims at ending
progression. AIDS as public health threat by 2030 by achieving fast track
targets by 2020. They are as follows:
4. Promotion of institutional deliveries of all HIV infected
pregnant women. 1. 95 per cent of PLHIV know their status, of which
5. Provision of care for associated conditions (STI/RTI, TB 2. 95 per cent of PLHIV are on ART, of which
and other opportunistic infections). 3. 95 per cent of PLHIV have viral suppression.

by R△J
 NATIONAL AIDS CONTROL PROGRAMME
499
z
Prevention Early detection of TB/HIV
1. Isoniazid preventive treatment 1. 100% coverage of PITC in TB patients
2. Air borne infection control 2. PITC in presumptive TB cases
3. Awareness generation 3. Rapid diagnostics for detection of TB and
DR-TB in PLHIV
4. ICF activities at all HIV settings - ICTC, ART,
LAC and TI settings
Tlu/niv
khI\/ rn.nvniniah tn roniiPA
Lu*viuiii<iiiuii itsuucts inuiictlily

Prompt treatment of TB/HIV Management of special TB/HIV cases

1. Early initiation of ART 1. TB/HIV patients on PI based ARV
2. Prompt initiation of TB treatment 2. TB/HIV in children
3. TB/HIV pregnant women
4. Drug resistant TB/HIV

>
FIG. 7
Activities to reduce HIV-TB mortality
PITC - Provider initiated HIV testing and counselling; ICF - Intensified case finding;
LAC - Link ART centres; TI - Targeted interventions
Source : (33)

A significant step of rolling out “test and treat” policy has Services provided
been taken towards achieving these targets. 1 First-line ART: First-line ART is provided free of cost to

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CST services are provided through ART centres all eligible PLHIV through ART centres. Positive cases
established by DAC in health facilities across the country. referred by ICTCs are registered in ART centres for pre­
These are linked to Centres of Excellence (CoE) and ART- ART and ART services. The assessment for eligibility for
Plus centres at selected institutions, while some of the ART is done through clinical examination and CD4
services have been decentralized through Link ART Centres count. Patients are also provided counselling on
(LAC). ART centres are also linked to ICTCs, STI clinics, treatment adherence, nutrition, positive prevention and
PPTCT services and other clinical departments in the positive living. Follow-up of patients on ART is done by
institutions of their location, as well as with the Revised assessing drug adherence, regularity of visits, periodic
National Tuberculosis Programme (RNTCP), in order to examination and CD4 count (every six months).
ensure proper management of TB-HIV co-infected patients. Treatment for opportunistic infections is also provided
Fig. 8 gives a graphic view of this service delivery model. through ART centres. Till Sept. 2021, 14.06 lakh PLHIV
As of September 2021, about 645 ART centres, 1,261 were on first-line ART.
link ART centres, 17 centres of excellence, 7 paediatric 2. Alternative first-line ART: It has been observed that a
centres of excellence, 93 ART Plus centres and 310 care and small number of patients initiated on first-line ART
support centres are functioning in the country (6). experience acute/chronic toxicity/intolerance to first-line
ARV drugs, thus necessitating change of ARV drugs to
alternative first-line drugs. Presently, the provision of
alternative first-line ART is done through the Centres of
Excellence and ART-Plus centres across the country.
3. Second-line ART: The second-line ART began in
January 2008 at two sites - GHTM, Tambaram, Chennai
and JJ Hospital, Mumbai on a pilot basis, and was then
further expanded to the other CoEs in January 2009.
Further decentralization of second-line ART was done
through capacitating and upgrading some well­
functioning ART centres as ART-Plus Centres’. Till Sept.
2021, 1,01,069 patients were receiving second-line
drugs at CoEs and ART-Plus centres. All ART centres are
linked to CoE/ART-Plus centres. For the evaluation of
patients for initiation on second-line and alternate first-
line ART, a State AIDS Clinical Expert Panel (SACEP)
has been constituted by DAC at all CoEs and ART-Plus
centres. This panel meets once in a week for taking
decisions on patients referred to them with treatment
FIG. 8 failure/major side effects.
Model of HIV treatment services 4. Third -Line ART: Some patients on second-line ART also
Source : (32) experience treatment failure. National programme rolled

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500 HEALTH PROGRAMMES IN INDIA

out third-line regimen for them in 2015. Currently Jharkhand. All PLHIVs with symptoms suggestive of
Raltegravir and Darunavir are used for third-line Kala-azar are screened for Kala-azar and those found
regimen (7) as on Sept. 2021, 4,528 patients were on infected are referred for appropriate treatment.
3rd line treatment (34). d. Other opportunistic infection: PLHIVs are regularly
National paediatric HIV/AIDS initiative: The national screened for co-infection and co-morbidities. Those
paediatric HIV/AIDS initiative was launched on 30 November diagnosed having these are treated appropriately at ART
2006. Till March 2014, nearly 1,06,824 children living with center or are referred to concerned facility. Those who
HIV/AIDS (CLHIV) were registered in HIV care at ART are vulnerable to opportunistic infections due to low
centres, of whom 42,015 were receiving free ART. Paediatric CD4 count or any other reasons are provided with
formulations of ARV drugs are available at all ART centres. prophylaxis, for eg. Co-trimoxazole.
Paediatric second-line ART: While the first-line therapy is TARGETTED INTERVENTIONS FOR HIGH RISK
efficacious, certain proportion of children do show evidence GROUPS: The main objective of targeted interventions (TI) is
of failure. There is not much data available on the failure to improve health-seeking behaviour of high risk groups
rate of Nevirapine-based ART in children. However, WHO (HRG) and reduce their risk of acquiring sexually transmitted
estimates that the average switch rate from first to second- infections (STI) and HIV infections. High risk groups under TI
line ART is 2-3% per year for adults. It is likely that similar include female sex workers (FSW), men who have sex with
rates are applicable for children as well. Currently, second- men (MSM), transgenders (TG)/hijras and injecting drug
line ART for children has been made available at all CoE users (IDU), and bridge populations include high risk
and ART-Plus centres. behaviour migrants and long distance truckers. Targeted
Early infant diagnosis: In order to promote confirmatory interventions provide the information, means and skills
diagnosis for HIV exposed children, a programme on Early needed to prevent HIV transmission and improve their access
Infant Diagnosis (EID) was launched by DAC. All children to care, support and treatment services. These programmes
with HIV infection confirmed through EID have been linked also focus on improving sexual and reproductive health and
to ART services. general health of high-risk population.
Follow-up and monitoring: Patients initiated on ART are The services offered through targeted interventions include:
regularly followed up on monthly basis. The basic - Detection and treatment for sexually transmitted
examination including weight measurement, clinical infections.
evaluation, and screening for opportunistic infections is done

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- Condom distribution (except in TIs for bridge population).
on every visit. Assessment of adherence is done by counsellor
on every visit and necessary support is provided as per - Condom promotion through social marketing (for HRG
requirement. CD4 testing is done every six months to monitor and bridge population).
the response of ART. During each visit, patients are - Behaviour change communication.
encouraged to visit care and support centers for psycho-social - Creating an enabling environment with community
support and availing various social beneficiary scheme (7). involvement and participation.
Management of Opportunistic infection (7): Screening - Linkages to integrated counselling and testing centres.
prophylaxis and management of various opportunistic - Linkages with care and support services for HIV positive
infections is an important part of comprehensive HIV care. HRGs.
Following intervention are done at ART centers for this: - Community organization and ownership building.
a. HIV-TB: TB is the most common opportunistic infection - Specific interventions for IDUs.
among PLHIVs. All patients attending ART centers - Distribution of clean needles and syringes.
including new registrations, pre-ART and on ART - Abscess prevention and management.
patients are screened verbally for 4 symptom complex. In - Opioid substitution therapy.
case any one of the symptom is present, patients are - Linkage with detoxification/rehabilitation services.
referred for TB testing. Those diagnosed with co­ - Specific interventions for MSM/TGs.
infection are initiated on Anti TB treatment from ART
center followed by ART. When TB is ruled out, Isoniazid - Provision of lubricants.
prophylaxis is offered. NACP works in close coordination - Specific interventions for TG/hijra populations.
with RNTCP for managing co-infections. - Provision of project-based STI clinics.
b. HIV-Hepatitis B and Hepatitis C: The PLHIV are at high The targeted interventions (TIs) supported by NACO as
risk of co-morbidity with hepatitis B and C. It is on September 2021 are as follows (6) :
important to ensure timely detection and initiation of FSW 313
hepatitis B or C treatment in HIV/viral hepatitis co­ MSM 94
infected patients to minimize hepatitis-related liver
disease and its long-term negative impact on HIV IDU 200
outcomes. Hepatitis B and C detection and treatment for Transgender/Hijaras - 40
PLHIV will be provided at ART centers. Hepatitis B Migrants - 210
treatment is available as part of ART programme since Truckers - 70
ART regimens containing tenofovir (TDF) plus a second Link worker scheme: The Link worker scheme is a
NRTI active against HBV (3TC/FTC) have been shown to community-based outreach strategy to address HIV
suppress both HIV and HBV viral replication. Treatment prevention and care needs of HRG and vulnerable
for Hepatitis C needs direct acting antivirals (DAAs) such population in rural areas. The specific objectives of the
as sofosbuvir, grazoprevir, glecaprevir etc. (28). scheme include reaching out to these groups with
c. HIV - Kala-azar: Kala-azar or Visceral Leishmaniasis is information and knowledge on prevention and risk reduction
endemic in some districts of states like UR Bihar and of HIV and STI, condom promotion and distribution,

by R△J
 NATIONAL AIDS CONTROL PROGRAMME
501
providing referral and follow-up linkages for various services. be strengthened through free distribution and social
It includes counselling, testing and treatment of STI and marketing channels, non-traditional outlets, female condoms,
opportunistic infections through link workers, creating an etc. aided by an effective communication strategy. The
enabling environment for PLHIV and their families, and programme will continue to link prevention with care,
reducing stigma and discrimination against them. In support and treatment. This will promote positive prevention.
partnership with various development partners, the link On the basis of HIV prevalence and family planning
worker scheme has been expanded and as on September needs, the districts have been mapped and classified into
2021, it is being implemented in 16 states covering four categories: (a) High prevalence of HIV and high fertility
143 highly vulnerable districts covering 1500 villages. (HPHF); (b) High prevalence of HIV and low fertility (HPLF);
The population covered under the link worker scheme (c) Low prevalence of HIV and low fertility (LPLF); and (d)
from January to September 2021 are as follows (6) : Low prevalence of HIV and high fertility (LPHF). During
2014 the coverage of condom social marketing programme
Population Line Listed Covered implementation was spread across 395 districts, i.e. 141
FSW 55,448 49,990 HPHF, 84 HPLF and 170 LPHF districts in 11 states (31).
IDU 8,573 7,573 STD CONTROL PROGRAMME : STD control is linked to
MSM 8,543 7,676 HIV/A1DS control as behaviour resulting in the transmission
TG 554 456 of STD and HIV are same. HIV is transmitted more easily in
Migrant 4,38,043 2,10,368 the presence of another STD. Hence, early diagnosis and
Trucker 75,170 48,628 treatment of STD is now recognized as one of the major
Other-Vul. Pop 5,85,151 3,34,107 strategies to control spread of HIV infection. The following
TB cases 23,081 9,135 approach is adopted for the STD control (35) :
ANC 88,517 65,181 a. Management of STDs through syndromic approach
PLHIV 34,265 25,788 (management of sexually transmitted diseases based
Blood transfusion services: The division of blood on specific symptoms and signs and not dependent on
safety has been renamed as the division of blood transfusion laboratory investigations). Please refer to page 381
services. The change in nomenclature is to broaden the chapter 5 for details.
b. STDs among women, though highly prevalent, are

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horizon of blood safety to include transfusion transmitted
infections, immuno-hematology, quality management suppressed because of the social stigma attached to
systems, logistics and other processes involved to improve the disease. It has, therefore, been decided to integrate
confidence in the “safe blood”. services for treatment of reproductive tract infections
(RTIs) and sexually transmitted diseases (STDs) at all
Blood transfusion services have been considered as an levels of health care. Department of Family Welfare
integral part of the health care system. Blood Transfusion
and NACO will coordinate their activities for an
Councils have been set-up at national and state levels. effective implementation of such integration. STDs
Professional blood donation has been prohibited in the Clinics at district / block/ First Referral Unit (FRU) level
country since 1st January 1998. Only licensed blood banks would function as referral centres for treatment of
are permitted to operate in the country and voluntary blood STDs referred from peripheries. STDs clinics in all
donation is encouraged. The strategy is to ensure safe district hospitals, medical colleges and other centres
collection, processing, storage and distribution of blood and would be strengthened by providing technical support,
blood products. Zonal blood testing centres have been equipment, reagents and drugs. A massive orientation­
established to provide linkage with other blood banks training programme would be undertaken to train all
affiliated to public, private and voluntary sectors. As per the medical and paramedical workers engaged in
national blood safety policy, testing of every unit of blood is providing STDs/RTIs services through a syndromic
mandatory for detecting infections like HIV, hepatitis B, approach. All STDs clinics would also provide
hepatitis C, malaria and syphilis. counselling services and good quality condoms to the
Access to safe blood for the needy is the primary STD patients. Services of NGOs would be utilised for
responsibility of NACO. It is supporting a network of 1,131 providing such counselling services at the STDs clinics.
blood banks, including 590 Blood Component Separation NACO has branded the STI/RTI services as “Suraksha
Units (BCSU) and 34 Model Blood Banks, 108 major blood Clinic”, and has developed a communication strategy for
banks and 591 district level blood banks (7). NACO generating demand for these services (3).
supported the installation of BCSU and has given funds for
modernization of all major blood banks at state and district PRE-PACKED STI/RTI COLOUR CODED KITS : Pre­
levels. Besides enhancing awareness about the need to packed colour coded STI/RTI kits have been provided for
procure safe blood and blood products, NACO has free supply to all designated STI/RTI clinics. These kits are
supported the procurement of equipment, test kits and being procured centrally and supplied to all State AIDS
reagents, and is helping in the recurring expenditure of Control Societies.
government blood banks and those run by voluntary/ The colour code is as follows (36) :
charitable organizations, that were modernized. Kit 1 - grey, for urethral discharge, ano-rectal discharge
In order to ease the situation of shortage of availability of and cervicitis.
blood in the rural areas, where it is not feasible to operate a Kit 2 - green, for vaginitis.
blood bank, Govt, has decided to establish blood storage Kit 3 - white, for genital ulcers.
centres at First Referral Units (FRUs), at sub-district levels, Kit 4 - blue, for genital ulcers.
for wider availability of safe blood, particularly for Kit 5 - red, for genital ulcers.
emergency obstetric care and trauma care services. Kit 6 — yellow, for lower abdominal pain.
Condom promotion: Condom promotion strategies will Kit 7 - black, for inguinal bubo.
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502 HEALTH PROGRAMMES IN INDIA

National Strategic Plan for HIV/AIDS and STI Objective 6 : Facilitate sustainable NACP service
2017-2024 (28) delivery by 2024
The National Strategic Plan for HIV/AIDS and STI Achievement of these objectives by 2024 would result in
(2017-2024) is developed with a vision of an AIDS free India. the following: (28):
The mission is to attain universal coverage of HIV prevention, 1. Estimated new infections will reduce from 102,226
testing, treatment to care continuum that is effective, inclusive, (2010) to < 21,000 per year
equitable and adapted to population and local needs. 2. 2.14 million PLHIV of the total estimated PLHIV (2.25
Goal : The goal is to achieve zero new infection, zero million) would know their status
AIDS-related deaths and zero AIDS related stigma and 3. 2.03 million PLHIV would be put on ART
discrimination.
4. 1.93 million PLHIV would be retained on treatment and
Strategic framework: The NSP is designed around a have HIV VL < 1000 copies/ml
results-based framework that reflects the fast-track targets 5. Attainment of <50 cases of new paediatric HIV
and the ‘ending of AIDS’ commitment. The framework is infections per 100,000 live births with a mother-to-child
based on a causal relationship between the vision, mission, transmission rate <5% by 2020 and maintenance of
goal and the outcomes. This will be articulated in terms of same thereof
inputs, outputs and costs in the implementation plan. While
there are several external and internal risks that may 6. Attainment of <50 cases of congenital syphilis per
positively or adversely affect results, the combination of 100,000 live births and maintenance of same thereof
strategies adopted will be calibrated according to the 7. HIV/AIDS will be perceived as chronic manageable
epidemiological, health priorities and resource scenarios of disease with no stigma and discrimination attached to it.
different State/UTs and in cognisance of needs of people 8. Key components of the NACP such as prevention
living with HIV and the communities. outreach, testing, treatment, prevention of mother-to-
Based on this strategic framework, a specific planning child transmission, viral load suppression, care and
approach is required which helps differentiate States and support, as well as social protection schemes will
Union Territories (UT) according to three predominant continue through 100% domestic funding.
epidemiological contexts (28):

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Information, education and communication
(i) States/UT with a ‘mature’ epidemic where HIV incidence
and prevalence are high in key, bridge and other at-risk Communication is the key to generating awareness on
populations and, in some cases, in other segments of the prevention as well as motivating access to testing, treatment,
general population. care and support. Communication in NACP-IV is directed at:
(ii) Those States/UT where there are ‘emerging’ epidemics a. To increase knowledge among general population
with relatively new and rising rates of infection among (especially youth and women) on safe sexual behaviour;
key, bridge and other at-risk populations. b. To sustain behaviour change in high risk groups and
(iii) States/UT with Tow’ or stable epidemics where there is bridge populations;
still a need to focus on potential risks among key, bridge c. To generate demand for care, support and treatment
and other at-risk populations, to maintain the low services; and
infection rates and eliminate HIV transmission.
d. To make appropriate changes in societal norms that
While a range of services is needed in all the three case reinforce positive attitude, beliefs and practices to reduce
scenarios, the mix and relative weight of each set of stigma and discrimination.
interventions and service-delivery models may need to vary
Adolescence Education Programme: This programme runs
accordingly. The * most critical interventions include
in secondary and senior secondary schools to built up life skills
prevention, outreach, testing and counselling, treatment,
of adolescents to cope with the physical and psychological
PPTCT, viral load suppression, care and support, as well as
changes associated with growing up. Under the programme,
social protection. Programmatic support components (e.g.
16 hour sessions are scheduled during the academic terms of
monitoring and evaluation, surveillance, research, laboratory
class IX and XL State AIDS control society have further
services, procurement etc.) remain relevant across all three
adapted the modules after state level consultations with
contexts. However, the service delivery modality, the level of
NGOs, academicians, psychologists and parent-teacher
integration into health systems and corresponding budget
bodies. This programme is being implemented in 23 states
requirements will vary according to the epidemiological, social
and currently 50,000 schools have been covered.
and demographic characteristics of the above three contexts.
Red Ribbon Clubs: The purpose of Red Ribbon Club
Objectives: This NSP proposes six objectives towards
formation in colleges is to encourage peer-to-peer
fulfilling its vision of an AIDS free India. These are:
messaging on HIV prevention and to provide a safe space
Objective 1 : Reduce 80% new infections by 2024 for young people to seek clarifications of their doubts and
(Baseline 2010) myths surrounding HIV/AIDS. The RRCs also promote
Objective 2 : Ensure 95% of estimated PLH1V know voluntary blood donation among youth. Currently, 12,546
their status by 2024 Red Ribbon Clubs are functioning under the programme.
Objective 3 : Ensure 95% PLHIV have ART initiation
and retention by 2024, for sustained viral Achievement on Key Indicators under NACP during
suppression FY 2021-22 :
Objective 4 : Eliminate mother-to-child transmission of The key indicators across the domain of Output,
HIV and syphilis by 2020. Outcome and Impact have been summarised below. These
Objective 5 : Eliminate HIV/AIDS related stigma and indicators are used to report to various forums including
discrimination by 2020 NITI Aayog’s Output Outcome Monitoring Framework.
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 NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS
503 I
Achievement on Key Indicators under NACP during Main objectives of the programme in the 12th Five Year
FY 2021-22 (April to November 2021) Plan period are:
Indicator(s) Annual Target Achievement 1. To continue three ongoing signature activities, i.e.,
(2021-22) (April- Nov. 2021) performance of 66 lacs cataract operations per year;
school eye screening and distribution of 9 lacs free
No. of High-Risk Group and 83.87 lakh 41.17 Lakh spectacles per year to school children suffering from
Bridge Population covered
through Targeted refractive errors; and collection of 50,000 donated eyes
Interventions per year for keratoplasty (6).
No. of High-Risk Groups & 18 53 lakh 7 59 lakh 2. To reduce the backlog of avoidable blindness through
Vulnerable Population identification and treatment of curable blind at primary,
covered through LW$ secondary and tertiary levels, based on assessment of
No. of ST1/RTI patients 100.16 lakh 53 94 lakhs the overall burden of visual impairment in the country;
managed as per
national protocol
3. Develop and strengthen the strategy of NPCB for “Eye
Health for All” and prevention of visual impairment,
No. of persons trained 1.49 lakh 1.44 lakh
through provision of comprehensive universal eye-care
under mainstreaming
training programmes services and quality service delivery;
No. of condoms free 30.19 crore 17.02 crore 4. Strengthening and upgradation of Regional Institutes of
distributed (in pieces) pieces pieces Ophthalmology (RIOs) to become centre of excellence in
No. of General Clients 252 lakh 145.0 lakhs various sub-specialities of ophthalmology and also other
tested for HIV partners like Medical Colleges, District Hospitals, Sub­
No of Pregnant Women 252 lakh 162 2 lakhs district Hospitals, Vision Centres, NGO Eye Hospitals;
tested for HIV 5. Strengthening the existing infrastructure facilities and
No. of HIV-TB cross referrals 35 lakh 18.32 lakh developing additional human resources for providing
No. of PLHIV on 15.30 lakh 15.21 lakh high quality comprehensive eye care in all districts of the
ART* (Cumulative) country;
No of opportunistic 6. To enhance community awareness on eye care and lay

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3.5 lakh 2.00 lakh
infections treated stress on preventive measures;
No of viral load test 11.00 lakh 6.55 lakh 7. Increase and expand research for prevention of blindness
conducted among
PLHIV on ART
and visual impairment; and
8. To secure participation of voluntary organizations/
inclusive of 1.06 lakh PLHIV on ART in private sector
private practitioners in delivering eye care.
Progress on Output and Impact Indicators Salient features/strategies adopted to achieve the
during 2020 objectives are:
Indicator(s) Target National Global 1. Continued emphasis on free cataract surgery through the
Achievement Z Achievement health care delivery system as well as by the involvement
Decline in annual new 75% 48% 31% of NGO sector and private practitioners.
HIV infections (%) 2. Emphasis on the comprehensive eye care programmes
People living with HIV 90% 78% 84% by covering diseases other than cataract, like diabetic
(PLHIV) who know their retinopathy, glaucoma, corneal transplantation, vitreo-
HIV status (%) retinal surgery, treatment of childhood blindness etc.
PLHIV who know their HIV 90% 83% 87% These emerging diseases need immediate attention to
Positive status and are on eliminate avoidable blindness from the country.
Antiretroviral Therapy (%) 3. Reduction in the backlog of blind persons by active
PLHIV on Antiretroviral 90% 85% 90% screening of population above 50 years age, organizing
Therapy and virally screening eye camps and transporting operable cases to
suppressed (%)
fixed eye care facilities.
Decline in annual AIDS- 75% 82% 42%
related deaths (%)
4. Refractive error comprises a major part of avoidable
blindness. Screening of children for identification and
HIV positive mother on 95% 52% 85% treatment of refractive errors and provision of free glasses to
Antiretroviral Therapy (%)
those affected and belonging to poor socio-economic strata.
Source : (6) 5. Coverage of underserved area for eye care services
through public-private partnership.
NATIONAL PROGRAMME FOR CONTROL OF 6. Capacity building of health personnel for improving their
BLINDNESS knowledge and skill in delivery of high quality eye services.
The National Programme for Control of Blindness was 7. Information Education Communication (IEC) activities
launched in the year 1976 as a 100 per cent centrally for creating awareness on eye-care within the community.
sponsored programme and incorporates the earlier trachoma 8. Regional Institutes of Ophthalmology and Medical
control programme started in the year 1968. The programme Colleges of the states to be strengthened in a phased
was launched with the goal to reduce the prevalence of manner with latest equipments and training of
blindness from 1.4 to 0.3 per cent. As per 2015-19 survey manpower so that they can be upgraded as Centres of
the prevalence of blindness was 0.36 per cent (11). Excellence in the regions.
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 HEALTH PROGRAMMES IN INDIA

9. The district hospitals to be strengthened by upgrading SCHOOL EYE SCREENING PROGRAMME : 6-7 per
infrastructure, equipment and providing adequate cent of children aged 10-14 years have problem with their
manpower like ophthalmologists and PMOAs on eye sight affecting their learning at school. Children are
contractual basis and provide earmarked funds for basic being first screened by trained teachers. Children suspected
medicines and drugs. to have refractive error are seen by ophthalmic assistants
10. Continuing emphasis on primary healthcare (eye care) and corrective spectacles are prescribed or given free for
by establishing vision centres in all PHCs with a PMOA persons below poverty line.
in position. COLLECTION AND UTILIZATION OF DONATED
11. Multipurpose District Mobile Ophthalmic Units for better EYES : During 2018-19 nearly 68,409 donated eyes were
coverage. collected for corneal implantation (11), Hospital retrieval
To avoid duplicity of work, State Ophthalmic Cell has programme is the major strategy for collection of donated
been merged with State Blindness Control Society, and after eyes, which envisage motivation of relatives of terminally ill
the launch of NRHM, State Blindness Control Societies have patients, accident victims and others with grave diseases to
been further merged with State Health Society. Likewise, donate eyes. Eye donation fortnight is organized from
District Blindness Control Societies have also been merged 25th August to 8th September every year to promote
with District Health Societies. Facilities for intra-ocular lense eye donation/eye banking. Gujarat, Tamil Nadu,
implantation have been expanded to taluka level. Maharashtra and Andhra Pradesh are leading states in this
The problem of blindness is acute in rural areas, and activity (1).
hence the programme has tried to expand the accessibility of The voluntary organizations such as Lions International
eye services in these areas. At present there are 80 central and its branches, Rotary International and its branches,
mobile units attached to medical colleges and 341 district NSPB India etc. are encouraged to organize eye camps in
mobile units to provide eye care in mobile eye camps. These remote rural and urban areas as per guidelines, with the
units have a vehicle, ophthalmic surgeon and other permission from the state authorities. They have been active
paramedical staff. Most of the cataract surgeries in rural in providing eye health education, preventive, rehabilitative
population are conducted through these mobile camps.
and surgical services for control of blindness.
Primary health centres are the basic units in the rural areas.
Community health education is a built-in component at

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The findings of the survey conducted during 2001-2002,
all levels of implementation of National Blindness Control
in randomly selected districts of the states covered by World
Bank Project shows that dependence on eye camps has Programme. The programme also includes regular eye
reduced, except in remote and tribal areas; involvement of check-up and provision of vitamin A prophylaxis and service
PHC/CHC doctor in the programme has increased; higher facilities in rural areas.
percentage of cataract operated persons consult the doctor WHO assistance for prevention of blindness : This
at an early stage; there is an increase in demand for modern includes intra-country fellowships in corneal transplantation,
techniques like intra-ocular lenses and suture-less surgeries; vitreo-retinal surgery, lasers in ophthalmology and
and about 84 per cent of cataract operated persons receive paediatric ophthalmology; pilot survey on childhood
free spectacles from the health facilities. blindness in Delhi; training in district programme
The organizational structure for the national programme management; study on situational analysis of eye care
for control of blindness is as shown in Fig. 9. infrastructure and human resources in India; high quality
workshops in eye care for faculty of medical colleges; and
Administration developement of plan of action for “Vision 2020 : The Right
Central Ophthalmology Section, Directorate to Sight” initiative.
General of Health Services, Ministry

State
( of Health & FW, New Delhi

State Ophthalmic Cell, Directorate of

Health Services, State Health Societies
Vision 2020 : The Right to Sight
It is a global initiative to reduce avoidable (preventable
and curable) blindness by the year 2020. India is also

District ( District Blindness Control Society

committed to this initiative. The plan of action for the
country has been developed with following main features :
1. Target diseases are cataract, refractive errors,
Service Delivery and Referral System childhood blindness, corneal blindness, glaucoma,
Tertiary Regional Institutes of diabetic retinopathy.
Level Ophthalmology & Centres 2. Human resource development as well as infrastructure
of Excellence in Eye Care and technology development at various levels of
Medical Colleges health system. The proposed four tier structure
includes Centres of Excellence (20), Training Centres
Secondary District Hospital and
Level (200), Service Centres (2000), and Vision Centres
NGO Eye Hospital
(20,000).
Primary Sub-district level hospitals/CHCs Fig. 10 shows the proposed structure for primary,
Level Mobile Ophthalmic Units secondary and tertiary eye care.
Upgraded PHCs,
Link Workers/Panchayats
Universal eye health : a global action plan
FIG. 9 2014-2019 (38)
Organizational structure for national programme
for control of blindness WHO estimates that in 2010 there were 285 million
Source : (37) people visually impaired, of which 39 million were blind. If
by R△J
 IODINE DEFICIENCY DISORDERS (IDD) PROGRAMME 505
Proposed Structure
IODINE DEFICIENCY DISORDERS (IDD)
_________ PROGRAMME________________
India commenced a goitre control programme in 1962,
based on iodized salt. At the end of three decades, the
prevalence of the disease still remained high.
Centres of
Excellence 20 As a result, a major national programme - “The IDD
• Professional
Leadership Control Programme” was initiated in which nation-wide,
• Strategy rather than area-specific use of iodized salt is being
development
• Continued Medical
promoted. It was decided as a national policy to fortify all
Education (CME) edible salt in a phased manner by end of 8th Plan. The
Laying of standards and essential components of a national IDD programme are use
quality assurance
• Research of iodized salt in place of common salt, monitoring and
Training Centres 200 surveillance, manpower training and mass communication.
• Tertiary eye care including retinal
surgery, corneal transplantation, The objectives of the programme are (1) :
glaucoma surgery etc.;
• Training and CME 1. Surveys to assess the magnitude of the Iodine Deficiency
Service Centres 2000 Disorders in districts.
• Cataract Surgery
• Other common eye surgeries
2. Supply of iodized salt in place of common salt.
• Facilities for refraction 3. Resurveys to assess iodine deficiency disorders and the
• Referral services impact of iodized salt after every 5 years in districts.
Vision Centres 20000
• Refraction and prescription of glasses
4. Laboratory monitoring of iodized salt and urinary iodine
• Primary eye care excretion.
• School eye screening programme 5. Health education and publicity.
• Screening and referral services
Significant achievements
FIG. 10 Consequent upon liberalization of iodized salt

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Proposed structure for Vision 2020 : The Right to Sight production, Salt Commissioner has issued licenses to 824
salt manufacturers out of which 777 units have commenced
Source : (37)
production. These units have an annual production capacity
of 222 lakh metric tonnes of iodized salt.
just the two major causes of visual impairment were
considered priorities and control measures were The production/supply of iodized salt from April 2015 to
implemented consistently by providing refractive services August 2015 was 26.44 lakh tonnes and 25.12 lakh tonnes.
and offering cataract surgery to the people in need, two- Notification banning the sale of non-iodized salt for
thirds of the visually impaired people could recover good different human consumption in the entire country is already
eye sight. issued under “Food Safety & Standards Act 2006 and
Regulations 2011”.
Provision of effective and accessible eye care services is
the key to control measures. The preference should be given For effective implementation of National Iodine
to strengthening eye care services through their integration Deficiency Disorders Control Programme 34 States/UTs
into the primary health care and health system have established Iodine Deficiency Disorders Control Cells
development, as almost all causes of visual impairment are in their State Health Directorate.
avoidable, e.g., diabetes mellitus, smoking, premature birth,
rubella, vitamin A deficiency etc., and visual impairment is UNIVERSAL IMMUNIZATION PROGRAMME
frequent among older age groups. Improvements in the
areas of maternal, child and reproductive health and the Experience with smallpox eradication programme
provision of safe drinking water and basic sanitation are showed the world that immunization was the most powerful
important. Eye health should be included in the broader and cost-effective weapon against vaccine preventable
non-communicable and communicable disease frameworks, diseases. In 1974, the WHO launched its “Expanded
as well as those addressing ageing populations. There are Programme on Immunization” (EPI) against six, most
three indicators to measure progress at the national level. common, preventable childhood diseases, viz. diphtheria,
They are: pertussis (whooping cough), tetanus, polio, tuberculosis and
measles. From the beginning of the programme UNICEF has
1. The prevalence and causes of visual impairment. As a been providing significant support to EPI.
global target, reduction in prevalence of avoidable visual
“Expanded” in the WHO definition meant adding more
impairment by 25 per cent by 2019 from the baseline of
disease controlling antigens of vaccination schedules,
2010 has been selected for this action plan;
extending coverage to all corners of a country and spreading
2. The number of eye care personnel; and services to reach the less privileged sectors of the
3. Cataract surgical service delivery. The cataract surgical society (39).
rate (number of surgeries performed per year, per million The primary health care concept as enunciated in the
population) and cataract surgical coverage (number of 1978 Alma-Ata Declaration included immunization as one of
individuals with bilateral cataract causing visual the strategies for reaching the goal of “Health For All” by the
impairment, who have received cataract surgery on one year 2000. While the WHO’s programme is called EPI, the
or both eyes). UNICEF in 1985 renamed it as “Universal Child

by R△J
 HEALTH PROGRAMMES IN INDIA

TABLE 8

1978
Immunization milestones - India
Expanded programme of immunization BCG,DPT,OPV, typhoid (urban areas)
—
1983 TT vaccine for pregnant women
1985 Universal Immunization Programme - measles added, typhoid removed. Focus on children less than 1 yr of age
1990 Vitamin-A supplementation
1995 Polio National Immunization Days
1997 VVM introduced on vaccines in UIP
2002 Hep B introduced as pilot in 33 districts and cities of 10 states
2005 • National Rural Health Mission Launched
• Auto disable (AD) syringes introduced into UIP
2006 JE vaccine introduced after campaigns in endemic districts
2007-08 Hep B expanded to all districts in 10 states and schedule revised to 4 dose from 3 dose
2010 Measles 2nd dose introduced in RI and MCUP (14 states)
2011 • Hepatitis B universalized and Haemophilus influenza type b introduced as pentavalent in 2 states
• Open Vial Policy for vaccines in UIP
2013 • Pentavalent expanded to 9 states
• Second dose of JE vaccine
2014 India and South East Asia Region certified POLIO-FREE
2015 • India validated for Maternal and Neonatal Tetanus elimination
• Pentavalent expanded to all states
• IPV Introduced
2016 • Rotavirus vaccine introduced in 4 states in Phase 1

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• tOPV to bOPV Switch.
• Switch to fractional IPV (Phased)
2017 • MR Vaccine introduced
• PCV (Phased launch)
• Use of adrenaline IM by ANM in AEFI (Adverse event following immunization)
2020 Covishield and Covaxin against COVID-19 introduced

Source : (41)

Immunization” (UCI). There was absolutely no difference Immunization of Vulnerable Population, specially Children”
between these two. The goal was the same, i.e., to achieve was set up to cover all aspects of the immunization activity
universal immunization by 1990. EPI is regarded as the from research and development to actual delivery of
instrument of UCI (40). services to the target population (43).
The first vaccine to be introduced in India was BCG in The immunization services are being provided through
1962 as part of the National Tuberculosis Programme. Over the existing health care delivery system (i.e., MCH centres,
the years, various new vaccines have been introduced and primary health centres and subcentres, hospitals,
many milestones achieved. Table 8 gives a chronological dispensaries and ICD units). There is no separate cadre of
listing of some important milestones in India’s immunization staff for EPI. The recommended immunization schedule is
programme. on page 136.
The Government of India launched its EPI in 1978 with Although the target was “universal” immunization by
the objective of reducing the mortality and morbidity 1990, in practice, no country, even in the industrialized
resulting from vaccine-preventable diseases of childhood, world, has ever achieved 100 per cent immunization in
and to achieve self-sufficiency in the production of vaccines. children. ‘Universal’ immunization is, therefore, best
Universal Immunization Programme was started in India in interpreted as implying the ideal that no child should be
1985. It has two vital components: immunization of denied immunization against tuberculosis, diphtheria,
pregnant women against tetanus, and immunization of whooping cough, tetanus, polio and measles. It is, however,
children in their first year of life against the six EPI target generally agreed that when immunization coverage
diseases. The aim was to achieve 100 per cent coverage of reaches a figure of 80 per cent or more, then disease
pregnant women with 2 doses of tetanus toxoid (or a booster
transmission patterns are so severely disrupted as to provide
dose), and at least 85 per cent coverage of infants with 3
a degree of protection even for the remaining children who
doses each of DPT, OPV, one dose of BCG and one dose of
have not been immunized, because of “herd immunity”
measles vaccine by 1990. Universal immunization was first
taken up in 30 selected districts and catchment areas of 50 (44). It is also important that children are immunized during
Medical Colleges in November 1985. The programme now the first year of life and that levels of immunization are
covers entire country and practice areas of all the 242 sustained so that each new generation is protected.
Medical colleges, thus creating a base for wider coverage Significant achievements have been made in India. At the
(42). A “Technology Mission on Vaccination and beginning of the programme in 1985-86, vaccine coverage

by R△J
 UNIVERSAL IMMUNIZATION PROGRAMME 5Q7
ranged between 29 per cent for BCG and 41 per cent for type-2 component from OPV. Polio Endgame Strategic Plan
DPT. By the end of 2021, coverage levels had gone up thus recommends replacing tOPV with bOPV. However, this
significantly to about 85 per cent for tetanus toxoid for puts the recent birth cohort at the time of switch at risk of
pregnant women, about 85 per cent for BCG, 85 per cent for VDPV and wild polio virus type 2 due to silent/ongoing
DPT 3 doses, 85 per cent for OPV 3 doses, 85 per cent for transmission of VDPV type-2 and also to potential leakage
HepB3, 85 per cent for Hib3and 81 per cent for MCV2. Since of wild polio virus type-2 in case of accidental/intended
then, there is a significant decline in the reported incidence leakage of the virus from a laboratory. To mitigate this risk,
of the vaccine preventable diseases as compared to their inactivated polio virus vaccine was introduced prior to the
incidence in 1987, as shown in Table 9. tOPV-bOPV switch in April 2016. As part of this Polio
Endgame Strategy, India has introduced Inactivated Polio
TABLE 9 Vaccine (IPV) from 30 November 2015. It is given as
Decline in reported vaccine preventable fractional IPV of 0.1 ml dose as intradermal injection at 6
diseases from year 1987 to 2020 and 14 weeks of life (45).
n-
Disease 1987 2020 INTRODUCTION OF MEASLES VACCINE SECOND
OPPORTUNITY
Poliomyelitis 28,257 0
In order to accelerate the reduction of measles related
Diphtheria 12,952 1,991
morbidity and mortality, second opportunity for measles
Pertussis 163,786 11,985 vaccination is being implemented. The National Technical
NNT 11,849 1,159 Advisory Group on immunization recommended introduction
Measles 247,519 12,081 of 2nd dose of measles vaccine to children between 9 months
and 10 years of age through supplementary immunization
To strengthen routine immunization, Government of India activity (SIA) for states where evaluated coverage of first dose
has planned the State Programme Implementation Plan (PIP) of measles vaccination is less than 80 per cent. In states, with
part C. It consists of : (a) Support for alternate vaccine coverage of measles vaccination more than 80 per cent, the
delivery from PHC to sub-centre and outreach sessions; second dose of vaccine will be given through routine
(b) Deploying retired manpower to carry out immunization immunization at 16-24 months (1).
activities in urban slums and underserved areas, where
INTRODUCTION OF PENTAVALENT VACCINE

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services are deficient; (c) Mobility support to district
immunization officer as per state plan for monitoring and (DPT + Hep B + Hib)
supportive supervision; (d) Review meeting at the state level The pentavalent vaccine contains five antigens i.e.,
with the districts at 6 monthly intervals; (e) Training of ANM, hepatitis B, diphtheria, pertusis, tetanus and haemophilus
cold chain handlers, mid-level managers, refrigerator influenza b (Hib) vaccine. Pentavalent vaccine is given at
mechanics etc.; (f) Support for mobilization of children to 6th, 10th and 14th weeks as primary dose. The vaccine has
immunization session sites by ASHA, women self-help groups replaced DPT and hepatitis B vaccines in the immunization
etc.; (g) Printing of immunization cards, monitoring sheet, schedule. However, birth dose of hepatitis B and two
cold chain chart vaccine inventory charts etc. booster doses of DPT will continue as before (45).
In addition, central government is supporting in supplies Initially, India introduced pentavalent vaccine in two
of auto-disable syringes, downsizing the BCG vial from 20 states - Kerala and Tamil Nadu. Presently it covers the
doses to 10 doses to ensure that BCG vaccine is available in whole country.
all immunization session sites, strengthening and
maintenance of the cold chain system in the states, and INTRODUCTION OF JAPANESE ENCEPHALITIS
supply of vaccines and vaccine van. VACCINE
PULSE POLIO IMMUNIZATION PROGRAMME The programme was introduced in 2006 to cover 104
endemic districts in phased manner, using SA 14-14-2 vaccine,
Pulse Polio Immunization Programme was launched in
imported from China. Single dose of JE vaccine was given to all
the country in the year 1995. Under this programme
children between 1 to 15 years of age through campaigns (3).
children under five years of age are given additional oral
polio drops in December and January every year on fixed The JE vaccine is being integrated into routine immunization in
days. From 1999-2000, house to house vaccination of the districts where campaign had already been conducted to
missed children was also introduced. The NIDs rounds cover immunize the new cohort of children by vaccinating with two
approximately 172 million children and SNIDs rounds cover doses at 9-12 months and 16-24 months (1).
40-80 million children. In addition, large scale multi-district 21 high burden districts have been identified in Assam,
mop-ups have been conducted (46). As a result only one Uttar Pradesh and West Bengal for adult JE vaccination in
case of polio was reported in 2011 in the month of January. the age group of 15-65 years. This will cut down deaths and
As on 25th Feb 2012, India was removed from the list of morbidity due to JE in adults as well (45).
polio endemic countries, and on 27th March 2014, India
was certified as polio-free country. Please see page 242 for INTRODUCTION OF ROTA VIRUS VACCINE
more details. Rota virus vaccine was introduced in 2016 in Odisha,
Himachal Pradesh, Haryana and Andhra Pradesh, and now
INTRODUCTION OF INACTIVATED POLIO VACCINE it covers the whole country. It is given under universal
(IPV) immunization programme as a 3 dose vaccine along with
The last global case due to WPV type-2 was reported at pentavalent 1st, 2nd and 3rd dose (45).
Aligarh in India in 1999. Most of the global cases due to
VDPVs (97%) as well as VAPP (40%) are due to type-2 RUBELLA VACCINE
virus. This necessitates the discontinuation of the use of To be initiated as Measles Rubella (MR) campaign

by R△J
 HEALTH PROGRAMMES IN INDIA
508
targeting 9 months to 15 years of age in a phased manner Questions about all vaccines (47)
over a period of three years. Subsequently, the Rubella Q. If the mother/caregiver permits administration of only
vaccine will be introduced as MR vaccine as two doses in the one injection during an infant's first visit at 9 months of
place of measles containing vaccine 1 and 2 at 9-12 months age, which vaccine should be given ?
and 16-24 months as per NTAGI recommendations (45).
A. At 9 months of age, the priority is to give measles
MISSION INDRADHANUSH vaccine with OPV and Vitamin-A.
The Ministry of Health & Family Welfare has launched Q. Which vaccines can be given to a child between
“Mission Indradhanush”, depicting seven colours of the 1-5 years of age, who has never been vaccinated ?
rainbow, in December 2014, to fully immunize 90 per cent A. The child should be given DPT1, OPV-1, measles and
of children who are either unvaccinated or partially 2 ml of vitamin A solution. It should then be given the
vaccinated; those that have not been covered during the second and third doses of DPT and OPV at one month
rounds of routine immunization for various reasons, by intervals. Measles second dose is also to be given as per the
2020. The target has now been pre-poned to 2018 (7). schedule. The booster dose of OPV/DPT can be given at a
Mission Indradhanush has completed six phases minimum of 6 months after administering OPV3/DPT3.
(from April 2015 to Dec. 2018) covering 681 districts wherein Q. Which vaccines can be given to a child between
3.39 crore children were reached; 81.79 lakh children were 5-7 years of age, who has never been vaccinated ?
immunized; and 87.18 lakh pregnant women were A. The child should be given first, second and third doses of
immunized. The first two phases of Mission Indradhanush DPT at one month intervals. The booster dose of DPT
have led to an increase of 6.7 per cent in full immunization can be given at a minimum of 6 months after
coverage in one year, as compared to 1 per cent in the past. administering DPT3 upto 7 years of age.
This increase was more in rural areas (7.9 per cent) as
compared to urban areas (3.1 per cent), hence shifting the Q. Should one re-start with the first dose of a vaccine if a
focus of the programme towards urban areas (11). child is brought late for a dose ?
Intensified Mission Indradhanush: A total of 190 districts/ A. Do not start the schedule all over again even if the child
urban areas across 24 states have been identified where is brought late for a dose. Pick up where the schedule
intensified mission indradhanush has started. It was was left off. For example: If a child who has received
BCG, HepB-1, DPT-1 and OPV-1 at 5 months of age,

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launched in Oct 2017. It involves intensive preparation,
implementation and integration of sessions into regular returns at 11 months of age, vaccinate the child with
DPT-2, HepB-2, OPV-2 and measles and do not start
immunization microplans. The focus is an urban slum areas
from DPT-1, HepB-1 again.
and districts with slowest progress and completion of due-list
of beneficiaries on the basis of head count surveys. As Q. Why it is not advisable to clean the injection site with a
on 15th Jan, 2018, number of children vaccinated were spirit swab before vaccination ?
49.30 lakh; number of children fully vaccinated was A. This is because some of the live components of the
12.02 lakh; and number of pregnant women vaccinated was vaccine are killed if they come in contact with spirit.
10.05 lakh (7).
DPT vaccine
MEASLES-RUBELLA (MR) VACCINE Q. If a child could not receive DPT1, 2, 3 and OPV 1, 2, 3
The WHO regional goal for. SEAR is measles elimination according to the schedule, upto what age can the
and rubella/congenital rubella syndrome control by 2020. vaccine be given ?
The MR vaccine is being introduced through campaign, A. The DPT vaccine can be given upto 7 years of age and
targeting around 41 crore children in the age group of OPV can be given upto 5 years of age. If a child has
9 months to 15 years in phased manner (covering l/3rd of received previous doses but not completed the schedule,
the total population of the country), followed by 2 doses in do not restart the schedule and instead administer the
routine immunization at 9-12 months and 16-24 months, remaining doses needed to complete the series.
replacing the measles vaccine (7).
Q. Why should there be a minimum gap of 4 weeks
MR campaign was launched in February 2017 from between two doses of DPT ?
5 States/UTs (Karnataka, Tamil Nadu, Goa, Lakshadweep and
A. This is because decreasing the interval between two doses
Puducherry) where 3.34 crore children were vaccinated
may not obtain optimal antibody production for protection.
against the target of 3.43 crore, with a coverage of 97 per cent.
Campaign has completed 33 states and immunized Q. Why give the DPT vaccine in the antero-lateral mid thigh
32.36 crore children (97.04 per cent of the target) (11) and not the gluteal region ?
A. DPT is given in the antero-lateral mid-thigh and not the
PNEUMOCOCCAL VACCINE (PCV) gluteal region to prevent damage to the sciatic nerve.
PCV was launched in May 2017 for reducing infant Moreover, the vaccine deposited in the fat of gluteal
mortality and morbidity caused by pneumococcal pneumonia. region does not invoke the appropriate immune response.
The vaccine was introduced in Himachal Pradesh, Q. What should one do if the child is found allergic to DPT
6 districts of Uttar Pradesh and 17 districts of Bihar, or develops encephalopathy after DPT ?
Madhya Pradesh, and Haryana, in 2021 it covers whole A. A child who is allergic to DPT or develops
country. Till September 2021, around 6.05 crore children were encephalopathy after DPT should be given the DTaP/DT
vaccinated (6). vaccine instead of DPT for the remaining doses, as it is
Very frequently queries come up about the vaccines and usually the P (whole cell Pertussis) component of the
the vaccination schedule. It is important to have the exact vaccine which causes the allergy/encephalopathy. It may
answer to these questions. be purchased with locally available resources.

by R△J
 UNIVERSAL IMMUNIZATION PROGRAMME 509
Q. Why DT is replaced by DPT vaccine for children above A. This is because the skin of newborns is thin and an intra­
2 years of age ? dermal injection of 0.1 ml may break the skin or
A. As pertussis cases were reported in higher age group penetrate into the deeper tissue and cause local abscess
children and the risk of AEFIs were not found to be more and enlarged axillary lymph nodes. Dose of 0.05 ml is
after DPT vaccine as compared to DT vaccine. sufficient to elicit adequate protection.
Q. Why is BCG given only upto one year of age ?
Measles vaccine A. Most children acquire natural clinical/sub-clinical
Q. Why give the measles vaccine only on the right upper tuberculosis infection by the age of one year. This too
arm ? protects against severe forms of childhood tuberculosis
A. The measles vaccine is given on the right upper arm to e.g. TB meningitis and miliary disease.
maintain uniformity and to help surveyors in verifying Q. If no scar appears after administering BCG, should one
the receipt of the vaccine. re-vaccinate the child ?
Q. If a child has received the measles vaccine before A. There is no need to re-vaccinate the child, even if there
9 months of age, is it necessary to repeat the vaccine is no scar.
later ?
OPV
A. Yes, the measles vaccine needs to be administered,
according to the National Immunization Schedule i.e. Q. Till what age can a child be given OPV ?
after the completion of 9 months until 12 months of age A. OPV can be given to children till 5 years of age.
and at 16-24 months. If not administered in the ideal Q. Can OPV and vitamin A be given together with DPT-
age for measles vaccine, it can be administered upto 5 booster dose ?
years of age. A. Yes.
Q. What is measles catch-up campaign ? Q. Can an infant be breast-fed immediately after OPV ?
A. A measles catch-up campaign is a special campaign to A. Yes.
vaccinate all children in a wide age group in a state or a
district with one dose of measles vaccine. The catch-up TT vaccine
campaign dose is given to all children, both immunized

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Q. If a girl has received all doses of DPT and TT as per the
and un-immunized, who belong to the target age group NIS till 16 years of age and she gets pregnant at 20 years,
of 9 months to 10 years. The goal of a catch-up should she get one dose of TT during pregnancy ?
campaign is to quickly make the population immune
from measles and reduce deaths from measles. A catch­ A. Give 2 doses of TT during the pregnancy as per the
up campaign must immunize nearly 100% of target age schedule.
group children. Q. Is TT at 10 years and 16 years meant only for girls ?
Q. Why 2nd dose of measles vaccine is introduced in the A. No, it is to be given to both boys and girls.
National Immunization Programme ? Q. Can TT be given in the first trimester of pregnancy ?
A. Measles is highly infectious disease causing illness and A. Yes, it should be given as soon as pregnancy is diagnosed.
death due to complications such as diarrhoea,
pneumonia or brain infection. One dose of measles Hepatitis B vaccine
vaccine at 9 months of age protects 85% of infants. With
2nd dose the aim is to protect all the children who Q. Up to what age can hepatitis B vaccine be given ?
remain unprotected after first dose. A. According to the National Immunization Schedule,
Q. If a child comes late for the first dose, then can it get the Hepatitis B vaccine should be given with the first, second
second dose ? and third doses of DPT till one year of age.
A. All efforts should be made to immunize the children at Q. Why give the birth dose of hepatitis B vaccine only
the right age i.e. first dose at completed 9 months to within 24 hours of birth ?
12 months and second dose at 16-24 months. However A. The birth dose of Hepatitis B vaccine is effective in
if a child comes late then give two doses of measles preventing perinatal transmission of Hepatitis B if given
vaccine at one month interval until 5 years of age. within the first 24 hours.
Q. If a child received one dose of measles vaccine during an JE vaccine
SIA campaign, should it receive the routine dose of
measles vaccine ? Q. If a child 16-24 months of age has been immunized with
JE vaccine during an SIA, can it receive the JE vaccine
A. Yes, the child should receive routine doses of measles again, as part of routine immunization ?
vaccine according to the Immunization Schedule
irrespective of the measles SIA dose. A. No, currently this is a single dose vaccine and should not
be repeated.
BCG vaccine Q. If a child above 2 years (24 months) of age has not
Q. Why give BCG vaccine only on the left upper arm ? received the JE vaccine through either RI or an SIA,
should she/he be given the JE vaccine ?
A. BCG is given on the left upper arm to maintain
uniformity and for helping surveyors in verifying the A. Yes, the child is eligible to receive a dose of the JE
receipt of the vaccine. vaccine, through RI, till the age of 15 years.
Q. Why do we give 0.05 ml dose of BCG to newborns Following are some Do’s and Don’ts during immunization
(below 1 month of age) ? sessions (47) :
by R△J
 HEALTH PROGRAMMES IN INDIA
------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Do’s and Don’ts during immunization sessions

Do’s Don’ts
Vaccination schedule
- It is safe and effective to give BCG, DPT, OPV and Measles vaccines at the - Withhold the vaccine in case of illness such as cold,
same time to a child who has completed 9 months and never been vaccinated cough, diarrhoea or fever.
Give BCG to infants less than 1 year of age
(never give BCG to children above 1 year of age).
- If a child is brought late for a dose, pick up where the schedule was left off.
For example, if a child left with DPT-2 and comes after 3 months give DPT-3

Cold chain
Check expiry date and VVM label of vaccine vial before - Leave vaccine carrier in sunlight: this spoils
immunizing every child vaccines that are sensitive to heat and light.
- Keep the vaccines and diluents in a plastic bag/zipper bag in the centre of - Leave the lid open, this can allow heat and light into
vaccine carrier with 4 conditioned ice-packs. Make sure that the diluents are the carrier, which can spoil vaccine.
also at +2 to +8 centigrade before reconstitution. - Drop or sit on the vaccine carrier: this can damage
Take one ice pack from vaccine carrier and keep reconstituted BCG & the carrier.
Measles vaccines only on the top of the ice pack. - Carry vaccines in handbag as this can spoil vaccines
that are sensitive to heat.
Keep the DPT, DT, TT and Hep. B vaccines on the
ice pack during the session.

Vaccine handling and administration

- Welcome beneficiaries. - Use un-sterile syringe or needle for immunization.
Wash hands before conducting the session. - Draw air into AD syringes.
Verify beneficiary's record and age of the child. - Touch any part of the needle
- Screen for contraindications - Recap the needle
- Check label of the vial and expiry date - Leave the needle inside the vial.

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- Lightly shake the vial of T-Series Vaccine before drawing the dose. -Ever inject in the buttock, never do that.
- Use a new AD syringe for each injection and new disposable syringe - Massage the vaccination site after vaccination.
for each reconstitution. - Use reconstituted measles and BCG vaccine after
- Use correct diluent for reconstitution of vaccine. 4hrs and JE after 2 hrs.
- Give appropriate vaccine. - Use vaccine with VVM in unusable stage or with
~ Inject vaccine using the correct site and route for the vaccine e.g. Intradermal in expiry date.
left arm for BCG; subcutaneous in right arm for Measles; intramuscular in
anterolateral aspect of mid thigh for DPT and Hepatitis B.
- Allow dose to self-disperse instead of massaging.
Explain potential adverse events following immunization and what to do.
- Discuss with beneficiaries/parents about next visit

Recording and reporting

- Fully document each immunization in the immunization card, tally sheet and - Turn away beneficiaries for not bringing the card.
immunization register. Ask parents/guardians to bring the card on next visit. Leave any cell blank in immunization card.
- Retain the counterfoil.

Adverse events following immunization (AEFI)

In case of serious AEFI refer the patient to appropriate health facility, - Report minor reaction following vaccination (mild
inform your supervisor immediately - document the type of vaccine(s), fever of less than three days, redness and pain).
batch number, expiry date, and full address of the child.
Report all serious AEFIs to the MOI/C.

Social mobilization
Use vaccination card to remind parents when to return with their child. Leave any community meeting without
Enlist community team like AWW, ASHA, NGOs and other community-based communicating about immunization session days.
workers to remind parents of the importance of full immunization.

Source : (47)

NATIONAL HEALTH MISSION Health Mission (NHM), with National Rural Health Mission
(NRHM) and National Urban Health Mission (NUHM) as its
The Ministry of Health and Family Welfare is implementing two sub-Missions. The National Health Mission was
various schemes and programmes and national initiatives to approved in May 2013. The main programmatic components
provide universal access to quality health care. The approach include health system strengthening in rural and urban areas;
is to increase access to the decentralized health system by Reproductive - Maternal - Newborn - Child and Adolescent
establishing new infrastructure in deficient areas and by Health (RMNCH+A); and control of communicable and non-
upgrading the infrastructure in existing institutions. As part of communicable diseases. An important achievement of NHM
the plan process, many different programmes have been has been considerable reduction in out of pocket expenses
brought together under the overarching umbrella of National from 72 per cent to 60 per cent (1).
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 NATIONAL HEALTH MISSION

The Government of India has introduced a series levels to reduce child morbidity and mortality: Setting up
of programmes over the past two decades to address of facilities for care of sick newborn such as Special New
maternal and newborn health. The major milestones so far Born Care Units (SNCUs), Newborn Stabilization Units
include (48) (NBSUs) and Newborn Care Corners (NBCCs) at
different levels is a thrust area under NHM.
a. 1992 - Child Survival and Safe Motherhood
Programme (CSSM) - Capacity building of health care providers: Various
trainings are being conducted under NHM to train
b. 1997 - RCHI doctors, nurses and ANMs for essential newborn care,
c. 2005 - RCH II early diagnosis and case management of common
d. 2005 - National Rural Health Mission ailments of children. These trainings are on Navjaat
Shishu Suraksha Karyakram (NSSK), Integrated
e. 2013 - RMNCH+A Strategy Management of Neonatal and Childhood Illnesses
f. 2013 - National Health Mission (IMNCI), Facility Based Newborn Care (FBNC). Infant
India Newborn Action Plan (INAP) and Young Child Feeding practices (IYCF), etc.
S- 2014 -
h. 2018 - Ayushman Bharat Programme - India Newborn Action Plan JINAPLhas been launched
with an aim to reduce neonatal mortality and stillbirths.
i. 2018 - Midwifery Initiative
- Newer interventions to reduce newborn mortality -
j. 2018 - RMNACH+N Strategy
vitamin K injection at birth, antenatal corticosteroids for
Linder NHM, health interventions/ initiatives are regularly preterm labour, kangaroo mother care and injection
designed and implemented to address the healthcare needs gentamicirTto young infants in cases of suspected sepsis.
of the country. A list of interventions currently being - Home Based New Born Care (HBNC>: Home based
implemented under NHM to reduce IMR and MMR is given newborn care through ASHAs has been initiated to
below (49): improve new born practices at the community level and
- (Promotion of institutional deliveries through Janani early detection and referral of sick new born babies.
Suraksha Yojana. - (Intensified Diarrhoea Control Fortnight (IDCF) to be

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- Capacity building of health care providers in basic and observed in July?\ugust focusing on ORS and Zinc
comprehensive obstetric care. distribution for management of diarrhoea and feeding
practices.
- Operationalization of sub-centres, primary health
centres, community health centres and district hospitals - (integrated Action Plan for Pneumonia and Diarrhoea
for providing 24 x 7 basic and comprehensive obstetric (IAPPD) launched in four states with highest infant
care services. mortality (Uttar Pradesh, Madhya Pradesh, Bihar and
Rajasthan).
- (^Narpe based web enabled tracking of pregnant women to
ensure antenatal, intranatal and postnatal care.j - (Management of malnutrition: Nutritional Rehabilitation
Centres (NRCs) have been established for management
- (Mother and child protection card in collaboration with
of severe acute malnutrition in children.
the Ministry of Women and Child Development to
monitor service delivery for mothers and children. - (Appropriate infant and young child feeding practices are
oeing promoted in convergence with Ministry of Woman
- (Antenatal, intranatal and postnatal care including iron
and Child Development^)
and folic acid supplementation to pregnant & lactating
women for prevention and treatment of_anaeml^i - ^ome programmes for control of communicable and
non-communicable diseases are now under NHM.J
- (Village health and nutrition days in rural areas as an
outreach activity, for provision of maternal and child - Universal Immunization Programme (UIP): Vaccination
health services. protects children against many life threatening diseases
such as tuberculosis, diptheria, pertussis, polio, tetanus,
- (Health and nutrition education to promote dietary
hepatitis B, Hib, measles and Japanese encephalitis in
diversification, inclusion of iron and folate rich food as
endemic districts.(infants are thus immunized against
well as food items that promote iron absorption.
nine vaccine preventable diseases every__year. The
- (Janani Shishu Suraksha Karyakram (JSSK) entitles all Government of India supports the vaccine programme
pregnant women delivering in public health institutions by supply of vaccines and syringes, cold chain
to absolutely free and no expense delivery including equipment and provision of operational costs)
caesarean section. The initiative stipulates TreeGlrugs,
- ((Mission Indradhanush has been launched in 528 high
diagnostics, blood and diet, besides free transport from
focus districts to reach more than 2.5 crore children who
home to institution, between facilities in case of a
are either unvaccinated or partially vaccinated; those
referral, and drop back home. Similar entitlements have
that have noFbeen covered during the rounds of routine
been put in place for all sick infants accessing public
immunization for various reasons. They will be fully
health institutions for treatment^
immunized against eight life-threatening but vaccine
- To sharpen the focus on the low performing districts, 184 preventable diseases which include diphtheria,
high priority districts have been prioritized for whooping cough, tetanus, polio, tuberculosis, measles,
Reproductive Maternal Newborn Child Health+ haemophilus influenza type B and hepatitis-B. In
Adolescent (RMNCH+A) interventions for achieving addition, vaccination against japanese encephalitis will
improved maternal and child health outcomes. be provided in selected districts/states of the country.
- Emphasis on facility based newborn care at different Pregnant women will also be immunized against tetanus.
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 HEALTH PROGRAMMES IN INDIA
512
-^Mother and Child Tracking System (MCTS): A name NUHM would cover all state capitals, district headquarters
based mother and child tracking system has been put in and about 779 other cities/towns with a population of
place which is web based to ensure registration and 50,000 and above (as per census 2011) in a phased manner.
tracking of all pregnant women and new born babies so Cities and towns below 50,000 population will be covered
that provision of regular and complete services to them by NRHM. The NUHM will focus on (39) :
can be ensured. 1. Urban poor population living in listed and unlisted
- Rashtriya Bal Swasthya Karyakram (RBSK) for health slums;
screening and early intervention services has been 2. All other vulnerable population such as homeless, rag­
launched to provide comprehensive care to all the pickers, street children, rickshaw pullers, construction
children in the age group of 0-18 years in the and brick and lime-kiln workers, sex workers and other
community. The purpose of these services is to improve temporary migrants;
the overall quality of life of children through early
detection of birth defeats, diseases, deficiencies, 3. Public health thrust on sanitation, clean drinking water,
development delays including disability. vector control etc.; and
- Under National Iron Plus Initiative (NIPI), through life 4. Strengthening public health capacity of urban local
cycle approach, age and dose specific IFA bodies.
supplementation programme is being implemented for The treatment of seven metropolitan cities, viz., Mumbai,
the prevention of anaemia among the vulnerable age New Delhi, Chennai, Kolkata, Hyderabad, Bengaluru and
groups like under-5 children, children of 6-10 years of Ahmedabad will be different. These cities are expected to
age group, adolescents, pregnant and lactating women manage NUHM through their Municipal Corporation
and women in reproductive age along with treatment of directly.
anaemic children and pregnant mothers at health The NUHM will provide flexibility to the states to choose
facilities. which model suits the needs and capacities of the states to
- Comprehensive primary health care through Ayushman best address the healthcare needs of the urban poor. Models
Bharat - Health and Wellness Centres : Launched in will be decided through community led action. All the
2018, Ayushman Bharat works a paradigm shift to move services delivered under the urban health delivery system

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from sectoral and selective approach of health service through the urban PHCs and urban CHCs will be universal
delivery to a comprehensive range of health care service. in nature, whereas the outreach services will be targetted to
Ayushman Bharat aims to cover preventive, promotive the target group (slum dwellers and other vulnerable
and ambulatory care at primary, secondary and tertiary groups). Outreach services will be provided through the
level by adopting a continuum of care approach. Since Female Health Workers (FHWs), essentially ANMs with an
the screening, prevention and management of chronic induction training of three to six months, who will be placed
illnesses including non-communicable diseases, at the Urban PHCs. These ANMs will report at the U-PHC
tuberculosis, and leprosy have been introduced at these and then move to their respective areas for outreach services
centres, training skill upgradation of the primary health on designated days. On other days, they will conduct
team in all functional Health and Wellness Centres on immunization and ANC clinics etc. at the U-PHC itself.
NCDs and use of information technology application is The NUHM would encourage the effective participation
being done. For details, please refer to page 547. of the community in planning and management of health
care services. It would promote a community health
The targets of National Health Mission volunteer - Accredited Social Health Activist (ASHA) or Link
The National Health Mission was launched with targets as Worker (LW) in urban poor settlement (one ASHA for
shown in Table 10 1000-2500 urban poor population covering about 200 to
TABLE 10 500 households); ensure the participation by creation of
Targets for NHM community based institutions like Mahila Arogya
Samiti (MAS) (50-100 households) and Rogi Kalyan
Targets (2012-17) Samitis. However, the states will have the flexibility to either
engage ASHA or entrust her responsibilities to MAS. In that
Reduce IMR to 25/1000 live births.
case, the incentives accruing to ASHA would accrue to
Reduce MMR to 1/1000 live births MAS (50). The NUHM would provide annual grant of
Reduce TFR to 2.1 Rs. 5000/- to MAS every year.
Reduce annual incidence and mortality from tuberculosis by half. Essential services to be rendered by the ASHA may be as
Reduce prevalence of leprosy to <1/10,000 population and follows (50):
incidence to zero in all districts.
(i) Active promoter of good health practices and enjoying
Annual malaria incidence to be <1/1000. community support.
Less than 1% microfilaria prevalence in all districts. (ii) Facilitate awareness on essential RCH services,
Kala-azar elimination by 2015, <1 case per 10,000 population in sexuality, gender equality, age at marriage/pregnancy;
all blocks. motivation on contraception adoption, medical
termination of pregnancy, sterilization, spacing
NATIONAL URBAN HEALTH MISSION methods. Early registration of pregnancies, pregnancy
care, clean and safe delivery, nutritional care during
NUHM seeks to improve the health status of the urban pregnancy, identification of danger signs during
population particularly slum dwellers and other vulnerable pregnancy; counselling on immunization, ANC, PNC
section by facilitating their access to quality health care. etc., act as a depot holder for essential provisions like
by R△J
 NATIONAL URBAN HEALTH MISSION

oral re-hydration therapy (ORS), Iron Folic Acid Tablet

(IFA), chloroquine, oral pills and condoms, etc.;
identification of target beneficiaries and support the
ANM in conducting regular monthly outreach sessions
and tracking service coverage.
(iii) Facilitate access to health related services available at
the Anganwadi/Primary Urban Health Centres/Urban
Local Body (ULBs) and other services being provided
by the ULB/State/Central Government.
(iv) Formation and promotion of Mahila Arogya Samitis in
her community.
(v) Arrange escort/accompany pregnant women and
children requiring treatment to the nearest Urban
Primary Health Centre, secondary/tertiary level health
care facility.
(vi) Reinforcement of community action for immunization,
prevention of water borne and other communicable
diseases like TB (DOTS), Malaria, Chikungunya and
Japanese Encephalitis.
(vii) Carrying out preventive and promotive health
activities with AWW/Mahila Arogya Samiti.
(viii) Maintenance of necessary information and records
about births and deaths, immunization, antenatal
services in her assigned locality as also about any
unusual health problem or disease outbreak in

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the slum, and share it with the ANM in charge of the
area.
In return for the services rendered, she would receive a
performance based incentive. For this purpose a revolving
fund would be kept with the ANM at the U-PHC (in the PHC
account), which would be replenished from time to time.
The urban health care facilities are as shown in Fig. 11

Urban Primary Health Centre

Functional for a population of around approximately
30,000-50,000, the U-PHC may be located preferably FIG. 11
within a slum or near a slum within half a kilometer radius,
Urban Health Care Facilities
catering to a slum population of approximately 25,000-
30,000, with provision for OPD. The cities, based upon the Source : (51)
local situation may establish a U-PHC for 75,000 for areas
with very high density and can also establish one for For the metro cities, the U-CHCs may be established for
around 5,000-10,000, slum population for isolated slum every 5 lakh population with 100 beds.
clusters.
For setting up the U-CHCs the Central Government
At the U-PHC level services provided will include OPD would provide only a one time capital cost, and the
(consultation), basic laboratory _ diagnosis, drug/ recurrent costs including the salary of the staff would be
contraceptive dispensing, apart from distribution of health borne by the respective state governments.
education material delivering RCH services and counselling
for all communicable and non-communicable diseases. In The U-CHC would provide medical care, minor surgical
order to ensure access to the urban slum population at facilities and facilities for institutional delivery.
convenient timings, the U-PHC may provide services from
Referral linkages
12 noon to 8 pm. It will not include in-patient care. The staff
pattern will be as shown in Fig. 11. Existing hospitals, including ULB maternity homes, state
government hospitals and medical colleges, apart from
Referral unit private hospitals will be empanelled/accredited to act as
referral points for different types of healthcare services like
Urban Community Health Centre (U-CHC) may be set up
as a satellite hospital for every 4-5 U-PHCs. The U-CHC maternal health, child health, diabetes, trauma care,
orthopaedic complications, dental surgeries, mental health,
would cater to a population of 2,50,000. It would provide
in-patient services and would be a 30-50 bedded facility. critical illness, deafness control, cancer management,
tobacco counselling/cessation, critical illness, surgical
U-CHCs would be set up in cities with a population of above
5 lakhs, wherever required. These facilities would be in cases etc.
addition to the existing facilities (SDH/DH) to cater to the The services provided at different levels are as shown in
urban population in the locality. Table 11 (51)
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 HEALTH PROGRAMMES IN INDIA
514
TABLE 11
Service norm by level of care facility

Services Levels of service delivery

Community First point of service Referral Centre - U-CHC
(Outreach) delivery (U-PHC) (specialist services)

A. Essential Health Services

Al. Maternal health Registration, ANC, identification of ANC, PNC, initial management of Delivery (normal and complicated),
danger signs, referral for institutional complicated delivery cases and management of complicated
delivery, follow-up counselling and referral, management of regular gynae/maternal health condition,
behaviour promotion. maternal health conditions, hospitalization and surgical
referral of complicated cases. interventions, including blood
transfusion.

A2. Family welfare Counselling, distribution of OCP/CC, Distribution of OCP/CC, IUD Sterilization operations, fertility
referral for sterilization, follow-up of insertion, referral for sterilization, treatment.
contraceptive related complications. management of contraceptive
related complications.

A3. Child health Immunization, identification of danger Diagnosis and treatment of Management of complicated
and nutrition signs, referral, follow-up, distribution childhood illnesses, referral of paediatric/neo-natal cases,
of ORS, paediatric cotrimoxazole, acute cases/chronic illness, hospitalization, surgical
post-natal visits/counselling for identification and referral of interventions, blood transfusion.
newborn care. neonatal sickness.

A4. RTI/STI referral, community level follow-up Symptomatic diagnosis and Management of complicated cases,
(including for ensuring adherence to treatment primary treatment and referral hospitalization (if needed).
HIV/AIDS) regime of cases undergoing treatment. of complicated cases.

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A5. Nutrition Height/weight measurement, Diagnosis and treatment of Management of acute deficiency
deficiency Hb testing, distribution of IFA tablets seriously deficient patients, cases, hospitalization, treatment
disorders promotion of iodized salt, nutrition referral of acute deficiency and rehabilitation of severe
supplements to children and cases. under-nutrition.
pregnant/lactating women,
promotion of breast feeding.

A6 Vector-borne Slide collection, testing using RDKs, Diagnosis and treatment, Management of terminally ill cases,
diseases DDT, counselling for practices for referral of terminally ill cases hospitalization
vector control and protection.

A7. Mental health - Initial screening and referral Psychiatric, neurological services

A7.1 Oral health - Diagnosis and referral Management of complicated cases.

A7.2 Hearing Management of complicated cases.

Impairment/
deafness

A8 Chest infections Symptomatic search and referral, Diagnosis and treatment, referral Management of complicated cases.
(TB/asthma) ensuring adherence to DOTS, of complicated cases.
other treatment

A9. Cardiovascular BP measurement, symptomatic Diagnosis and treatment and Management of emergency cases,
diseases search and referral, follow-up of referral during specialist visits. hospitalization and surgical
under-treatment patients. interventions (if needed).

A10. Diabetes Blood/urine sugar test (using Diagnosis and treatment, referral Management of complicated cases,
disposable kit), symptomatic of complicated cases. hospitalization (if needed).
search and referral.

All. Cancer Symptomatic search and referral, Identification and referral, Diagnosis and treatment,
follow-up of under-treatment follow-up of under-treatment hospitalization
patients. patients. (if and when needed).

Al2. Trauma care First aid and referral First-aid/emergency resuscitation, Case management and
(burns and documentation for medicolegal hospitalization, physiotherapy and
injuries) case (if applicable) and referral. rehabilitation.

A13. Other surgical Not applicable Identification and referral Hospitalization and surgical
interventions intervention.

B Other support services like IEC, BCC, counselling and personal and social hygiene
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 NATIONAL RURAL HEALTH MISSION

City level indicators

NATIONAL RURAL HEALTH MISSION
The city level indicators are as shown in Table 12.
Recognizing the importance of health in the process of
TABLE 12 economic and social development and to improve the quality
Process and input indicators in NUHM of life of its citizens, the government of India launched
"National Rural Health Mission" (NRHM) on 5th April, 2005,for
a period of 7 years (2005-2012) and recently extended upto
Community Processes year 2017. The mission seeks to improve rural health care
I. Number of Mahila Arogya Samiti (MAS) formed.* delivery system. It is operational in the whole country with
2 Number of MAS members trained. * special focus on 18 states viz. 8 Empowered Action Group
3. Number of Accredited Social Health Activists (ASHAs). states (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh,
selected and trained. Uttar Pradesh, Uttarakhand, Orissa and Rajasthan), 8 North
East states (Assam, Arunachal Pradesh, Manipur, Meghalaya,
Health Systems
Mizoram, Nagaland, Sikkim and Tripura), Himachal Pradesh
4. Number of ANMs recruited * and Jammu and Kashmir. By making necessary changes in the
5. No. of Special Outreach health camps organized in the basic health care delivery system the mission adopts a synergic
slum/HFAs * approach by relating health to determinants of good health viz.
6. No. of UHNDs organized in the slums and vulnerable areas.* of nutrition, sanitation, hygiene and safe drinking water. It also
7. Number of UPHCs made operational.* brings the Indian system of medicine (AYUSH) to the
8. Number of UCHCs made operational.* mainstream of health care (9).
9. No. of RKS created at UPHC and UCHC.*
10. OPD attendance in the UPHCs
The main aim of NRHM is to provide accessible,
II. No. of deliveries conducted in public health facilities.
affordable, accountable, effective and reliable primary
health care, and bridging the gap in rural health care
RCH Services through creation of a cadre of Accredited Social Health
Activist (ASHA). The mission is an instrument to integrate
12. ANC early registration in first trimester.
multiple vertical programmes alongwith their funds at the
13. Number of women who had ANC check-up in their first
district level. The programmes integrated into NRHM are

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trimester of pregnancy
14. TT (2nd dose) coverage among pregnant women. existing programmes of health and family welfare including
15. No. of children fully immunized RCH II; national vector borne disease control programmes
(through public health facilities) against malaria, filaria, kala-azar, dengue fever/DHF and
16. No. of Severely Acute Malnourished (SAM) children identified Japanese encephalitis; national leprosy eradication
and referred for treatment. programme; revised national tuberculosis control
programme; national programme for control of blindness;
Communicable Diseases iodine deficiency disorder control programme, and
17. No. of malaria cases detected through blood examination. integrated disease surveillance project (9).
18. No. of TB cases identified through chest symptomatic.
19. No. of suspected TB cases referred for sputum examination.
PLAN OF ACTION TO STRENGTHEN
20. No. of MDR-TB cases put under DOTS-plus. INFRASTRUCTURE
1. Creation of a cadre of Accredited Social Health
Hon-communicable Diseases Activist (ASHA).
21. No. of diabetes cases screened in the city 2. Strengthening sub-centres by : (a) Supply of essential
22. No. of cancer cases screened in the city. drugs both allopathic and AYUSH to the sub-centre;
23. No. of hypertension cases screened in the city. (b) In case of additional outlay, provision of
* Year 2013-14 being the baseline year, the indicators for these
multipurpose worker (male)/additional ANMs
NUHM components would be zero. For other indicators, the figure for wherever needed, sanction of new sub-centres and
2012-13 will be the base line. upgrading existing sub-centres; and (c) Strengthening
Source : (50) sub-centres with untied funds of Rs. 10,000 per
annum in all 18 states.
Impact level targets of NUHM are as follows : 3. Strengthening Primary Health Centres : Mission aims at
strengthening PHCs for quality preventive, promotive,
1. Reduce IMR by 40% (in urban areas) - National Urban IMR curative, supervisory and outreach services through
down to 20 per 1000 live births by 2017. (a) Adequate and regular supply of essential drugs and
40% reduction in U5MR and IMR. equipment to PHCs (including supply of auto-disabled
Achieve universal immunization in all urban areas. syringes for immunization); (b) Provision of 24 hours
service in at least 50 per cent PHCs by including an
2. Reduce MMR by 50%. AYUSH practitioner; (c) Following standard treatment
50% reduction in MMR (among urban population of the state/ guidelines; (d) Upgradation of all the PHCs for
country) 24 hours referral service and provision of second doctor
100% ANC coverage (in urban areas). at PHC level (one male and one female) on the basis of
3. Achieve universal access to reproductive health including felt need; strengthening the ongoing communicable
100% institutional delivery. disease control programmes and new programmes for
4. Achieve replacement level fertility (TFR 2.1). control of non-communicable diseases.
5. Achieve all targets of disease control programmes. 4. Strengthening Community Health Centres for First
Referral care by (a) Operating all existing CHCs
Source : (51) (30-50 beds) as 24 hours first referral units, including
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 HEALTH PROGRAMMES IN INDIA

posting of an anaesthetist; (b) Codification of new 2. Rogi Kalyan Samiti (Patient Welfare Committee/Hospital
“Indian Public Health Standards” (Refer to chapter 20 Management Society: It is a simple yet effective management
for more details) by setting up norms for structure. This committee is a registered society whose
infrastructure, staff, equipment, management etc. for members act as trustees to manage the affairs of the hospital
CHCs; (c) Promotion of “Rogi Kalyan Samiti” for and is responsible for upkeep of the facilities and ensure
hospital management; and (d) Developing standards provision of better facilities to the patients in the hospital.
of services and costs in hospital care. Financial assistance is provided to these Committees through
The NRHM infrastructure is as shown in Fig. 12. untied fund to undertake activities for patient welfare. 33,757
Rogi Kalyan Samities (RKS) have been set up involving the
community members in almost all District Hospitals (DHs),
Health manager
Sub-District Hospitals (SDHs), Community Health Centres
Chief Block Health Officer Accountant
(CHCs) and Primary Health Centres (PHCs) till June 2021.
Store keeper
Accredit private
3. The untied grants to sub-centres (SCs): The SCs are far
providers for 100,000 better equipped now with blood pressure measuring
population Block
public health 100 villages level
equipment, haemoglobin (Hb) measuring equipment,
goals
hospital Strengthen ambulance/ stethoscope, weighing machine etc. This has facilitated
transport services
Ambulance Increase availability of provision of quality antenatal care and other health care
Telephone nurses, provide telephones, services.
Obstetric/Surgical encourage fixed day clinics
Medical 4. The Village Health Sanitation and Nutrition Committee
emergencies 24 x 7 (VHSNC): It is an important tool of community
Round the
clock services; empowerment and participation at the grassroots level. The
villages / Cluster of GPs - PHC Level
VHSNC reflects the aspirations of the local community,
especially the poor households and children by year 2021,
3 Staff Nurses; 1 LHV
for 4-5 SHCs; 5.55 lakh VHSNCs have been set up across the country.
Ambulance/hired vehicle; Fixed day
MCH/Immunization Clinics;
5. Janani Suraksha Yojona (JSY): aims to reduce
Telephone; MO i/c; Ayush Doctor; maternal mortality among pregnant women by encouraging
Emergencies that can be handled by them to deliver in government health facilities. Under the

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nurses - 24 x 7; Round the clock services;
Drugs; TB / Malaria etc. tests scheme, cash assistance is provided to eligible pregnant
5-6 Gram Panchayat - Sub Health Centre Level
women for giving birth in a government health facility. Since
villages the inception of NRHM, 8.55 crore women have benefited
Skill up - gradation of educated RMPs / 2 ANMs,
1 male MPW For 5-6 Villages; Telephone link; under this scheme. For details please refer to page 521.
MCH/Immunization days; Drugs; MCH clinic 6. Janani Shishu Suraksha Karyakarm (JSSK): Launched
Village level - ASHA, AWW, on 1st June, 2011, JSSK entitles all pregnant women
Village health and sanitation committees
lation delivering in public health institutions to absolutely free and
1 ASHA, AWWs in every village; Village Health Day no expense delivery, including caesarean section. This
Drug kit, Referral chains
marks a shift to an entitlement based approach. Please refer
Fig. 12 to page 522 for details.
The NRHM infrastructure 7. National Mobile Medical Units (NMMUs): Support has
been provided by 1,634 MMUs under NHM in the country. To
District is the core unit of planning, budgeting and increase visibility, awareness and accountability, all Mobile
implementation of the programme. All vertical health and Medical Units have been repositioned as “National Mobile
family welfare programmes at district level have merged into Medical Unit Service” with universal colour and design.
one common “District Health Mission” and at state level into 8. National Ambulance Services: NRHM has supported
“State Health Mission”. There is provision of a “mobile free ambulance services to provide patients transport in
medical unit” at district level for improved outreach services. every nook and corner of the country connected with a toll
Since almost 75 per cent of health services are being free number. Currently, 35 states/UTs have the facility where
currently provided by the private sector, it is contemplated people can dial 108 or 102 telephone number for calling an
that involving the private sector as part of the RCH ambulance. Dial 108 is predominantly an emergency
initiatives will provide more effective health care delivery response system, primarily designed to attend to patients of
system. Thus setting up of “Public Private Partnership” critical care, trauma and accident victims etc. Dial 102
(PPP)” is to help to make the RCH II programme better, and services essentially consist of basic patient transport aimed
ensure availability of preventive and curative reproductive to cater the needs of pregnant women and children though
and child health services to the community. other categories are also taking benefit and are not
excluded. Janani Shishu Suraksha Karyakram (JSSK)
Major initiatives under NRHM entitlements e.g. free transport from home to facility, inter
1. Selection of ASHA: ASHA must be the resident of the facility transfer in case of referral and drop back for mother
village - a woman (married / widow / divorced) preferably in and children are the key focus of 102 service. This service
the age group of 25 to 45 years with formal education up to can be accessed through a toll free call to a Call Centre (6).
eighth class, having communication skills and leadership Presently as on June 2021, 11,879 Dial-108 and 10,716
qualities. Adequate representation from the disadvantaged Dial-102/104 Emergency Response Service Vehicles are
population group will ensure to serve such groups better. operational under NRHM, besides 5859 empaneled vehicles
The general norm of selection is one ASHA for 1000 are for transportation of patients, particularly pregnant
population. In tribal, hilly and desert areas the norm could women and sick infants from home to public health facilities
be relaxed to one ASHA per habitation. and back (6).
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 NATIONAL RURAL HEALTH MISSION
517
9. Web enabled Mother and Child Tracking System 12. Free drugs and free diagnostic service;
(MCTS): The name-based tracking of pregnant women and 13. National Iron4- Initiative is another new initiative
children has been initiated under NRHM with an intention to launched in 2013, to prevent and control iron deficiency
track every pregnant woman, infant and child upto the age of anaemia, a grave public health challenge in India.
three years by name, for ensuring delivery of services like Besides pregnant women and lactating mothers, it aims
timely antenatal care, institutional delivery and postnatal care to provide IFA supplementation for children, adolescents
for the mother, and immunization and other related services and women in reproductive age group. Weekly Iron and
for the child. The MCTs is to be fully updated for regular and Folic Acid Supplementation (WIFS) for adolescents is an
effective monitoring of service delivery, including tracking and important strategy under this initiative. WIFS (for 10-19
monitoring of severely anaemic women, low birth weight years age) has already been rolled out in 32 states and
babies and sick neonates. In the long run, it could be used for UTs under the National Iron Plus Initiative. WIFS covered
tracking the health status of the girl child and school health around 3 crore beneficiaries in December 2013 (1);
services. A more recent initiative is to link MCTS with 14. Reproductive, Maternal, Newborn, Child and Adolescent
AADHAR in order to track subsidies to eligible women (52). Health Services (RMNCH+A): A continuum of care
approach has now been adopted under NRHM with the
New initiatives (46)
articulation of strategic approach to Reproductive
The following are the major decisions of Mission Steering Maternal, Newborn, Child and Adolescent Health
Group; taken since 2011 : (RMNCH+A) in India. This approach brings focus on
1. Home delivery of contraceptives (condoms, oral adolescents as a critical life stage and linkages between
contraceptive pills, emergency contraceptive pills) by child survival, maternal health and family planning
ASHA; efforts. It aims to strengthen the referral linkages
2. Conducting District Level Household Survey (DLHS) - 4 between community and facility based health services
in 26 States/UTs where the Annual Health Survey (AHS) and between the various levels of health system itself.
is not being done; Please refer to page 530 for details;
3. Modifications in the scheme for promotion of menstrual 15. Delivery Points (DPs): Health facilities that have a high
hygiene covering 152 districts and nearly 1.5 crores of demand for services and performance above a certain
adolescent girls in 20 states; benchmark have been identified as “Delivery Points”
with the objective of providing comprehensive

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4. Differential financial approach for comprehensive health
care by which allocation of Untied Funds and Rogi reproductive, maternal, newborn, child and adolescent
Kalyan Samiti grants will be made based on the case health services (RMNCH+A) at these facilities. Funds
load and services provided by the health facility; have been allocated to strengthen these DPs in terms of
infrastructure, human resource, drugs, equipments etc.
5. Involving ASHA in Home Based Newborn Care;
Around 25,000 health facilities have been identified as
6. Revision in the criterion of allocation of funds to the states “Delivery Points” for focussed support under NRHM;
under NRHM based on the performance of the states
16. Universal Health Coverage (UHC): Moving towards
against the monitorable targets and implementation of
Universal Health Coverage (UHC) is a key goal of the
specific reform agenda in the health sector;
12th Five Year Plan. The National Health Mission is the
7. Expansion of Village Health and Sanitation Committees primary vehicle to move towards this goal;
to include nutrition in its mandate and renaming it as
17. Comprehensive primary healthcare: Nine areas for
Village Health, Sanitation and Nutrition Committee action to make primary healthcare comprehensive and
(VHSNC); universal are proposed. They are (45) :
8. Partial modification of the centrally sponsored scheme
a. Strengthen institutional structures and organization
for development of AYUSH hospitals and dispensaries
of primary healthcare services;
for mainstreaming of AYUSH under NRHM;
b. Improve access to technologies, drugs and
9. Rashtriya Bal Swasthya Karyakram (RBSK): This initiative diagnostics for comprehensive primary healthcare;
was launched in February 2013 and provides for Child
c. Increase utilization of Information, Communication
Health Screening and Early Intervention Services through
and Technology (ICT) - empowering patients and
early detection and management of 4 Ds i.e., Defects at
providers;
birth, Diseases, Deficiencies, Development delays
d. Promote continuity of care - making care patient centric;
including disability. For details please refer to page 529;
e. Enhance quality of care;
10. Rashtriya Kishor Swasthya Karyakram (RKSK): This is a
new initiative, launched in January 2014 to reach out to f. Focus on social determinants of health;
253 million adolescents in the country in their own spaces g. Emphasize community participation and address
and introduces peer-led interventions at the community equity concerns in health;
level, supported by augmentation of facility based services. h. Develop a human resource policy to support primary
This initiative broadens the focus of the adolescent health healthcare;
programme beyond reproductive and sexual health and i. Strengthen governance including financing,
brings in focus on life skills, nutrition, injuries and violence partnerships and accountability; and
(including gender based violence), non-communicable j. States are also offered support through the PIPs of
diseases, mental health and substance misuse (1); the NHM to strengthen existing sub-centres.
11 Mother and Child Health Wings (MCH Wings): 100/50/ 18. (Kilkari: Kilkari is an Interactive Voice Response (1VR)
30 bedded Maternal and Child Health (MCH) Wings based mobile service tFa: delivers ime- sensitive audio
have been sanctioned in public health facilities with high messages (voice call) about pregnancy and child health
bed occupancy to cater to the increased demand for directly to the mobile phones of pregnant women,
services. More than 32,000 additional beds have been mothers of young childrenancT their families. TTuFservice
sanctioned across 550 health facilities across 18 states; covers the critical time period- where the most maternal/

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518 HEALTH PROGRAMMES IN INDIA

infant deaths occur from the 4th month of pregnancy Interventions in all districts
until the child is one year old. Families whichjsuhs.cr.ibe - Child Survival interventions i.e. immunization, Vitamin
to the service receive one pre-recorded system generated A (to prevent blindness), oral rehydration therapy and
call per week. Each call will be 2 minutes in length and prevention of deaths due to pneumonia.
servers reminders for what the family should be doing
- Safe Motherhood interventions e.g. antenatal check up,
that week depending on woman’s stage of pregnancy or
immunization for tetanus, safe delivery, anaemia control
the child’s age? Kilkari services will be available to states
programme.
in regional dialect too (45);
- Implementation of Target Free Approach.
19. Launch ot Nationwide anti-TB drug resistance survey:
Drug resistance survey for 13 anti-tuberculosis drugs was - High quality training at all levels.
launched to estimate the burden of MDR-TB within the - IEC activities.
community. It is the biggest ever such survey in the - Specially designed RCH package for urban slums and
world; and tribal areas.
20. Kala- azar elimination plan: Kala- azar elimination plan - District sub-projects under Local Capacity
for Uttar Pradesh, Bihar, West Bengal and Jharkhand Enhancement.
was launched. It includes active search, new drug - RTI/STD Clinics at District Hospitals (where not
regimen, coordinated indoor residual spray and use of available)
non-invasive diagnostic kit. - (Facility for safe abortions at________ PHCs by providing
21. ANM0L: ANMOL is a tablet-based application which equipment, contractual doctors etc.
helps ANMs in carrying out their day to day work - Enhanced community participation through Panchayats,
efficiently and effectively by entering and updating service Women’s Groups and NGOs.
records of beneficiaries on real time basis, provides them - Adolescent health and reproductive hygiene.
with readily available information. It was launched on 7th
April, 2016, and is operational in 24 States/UTs. It is being Interventions in selected States/Distts.
used by more than 97,883 ANMs since its launch (6).
- Screening and treatment of RTI/STD at sub-divisional
REPRODUCTIVE AND CHILD HEALTH level.
___ PROGRAMME ___ - Emergency obstetric care at selected FRUs by providing

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drugs.
Reproductive and child health approach has been defined - Essential obstetric care by providing drugs and PHN/
as “people have the ability to reproduce *nd regulate their Staff Nurse at PHCs.
fertility, women are able to go through pregnancy and child - Additional ANM at sub-centres in the weak districts for
birth safely, the outcome of pregnancies is successful in terms ensuring MCH care.
of maternal and infant survival and well being, and couples - Improved delivery services and emergency care by
are able to have sexual relations, free of fear of pregnancy providing equipment kits, IUD insertions and ANM kits
and of contracting disease (53). at sub-centres.
The concept is in keeping with the evolution of an integrated - Facility of referral transport for pregnant women during
approach to the programme aimed at improving the health emergency to the nearest referral centre through
status of young women and young children which has been Panchayat in weak districts.
going on in the country namely family welfare programme,
universal immunization programme, oral rehydration therapy, The major interventions under RCH - Phase I
child survival and safe motherhood programme and acute
respiratory infection control etc. It is obviously sensible that Essential obstetric care (54)
integrated RCH programme would help in reducing the cost Essential obstetric care intends to provide the basic
inputs to some extent because overlapping of expenditure maternity services to all pregnant women through (1) early
would not be necessary and integrated implementation would registration of pregnancy {[within 12-16 weeks) J
optimise outcomes at field level. (2) provision of minimum three antenatal check ups by ANM
The RCH phase-I programme incorporated the or medical officer to monitor progress of the pregnancy and
components relating child survival and safe motherhood and to detect any risk/complication so that appropriate care
included two additional components, one relating to including referral could be taken in time. (3) provision of
sexually transmitted disease (STD) and other relating to safe delivery at home or in an institution, and (4) provision
reproductive tract infection (RTI). of three postnatal check ups to monitor the postnatal
The RCH programme was based on a differential recovery and to detect complications.
approach. Inputs in all the districts were not kept uniform.
While the care components was same for all districts, the Emergency obstetric care
weaker districts got more support and sophisticated facilities ((Complications associated with pregnancy are not always
were proposed for relatively advanced districts. lOn the basis predictable, hence, emergency obstetric care is an important
of crude birth rate and female literacy rate, all the districts intervention to prevent maternal morbidity and mortality
were^cllvicled into three categories. Category A having Under the CSSM_ programme 1748 Referral Units were
58 districts, category B having 184 districts and category C identified and supported with equipment kit E to kit P Under
having 265 districts. All the districts were covered in a the RCH programme the FRUs were strengthened through
phased manner over a period of three years. The supply of__emerqency obstetricUkit, equipment kit and
programme was formally launched on 15th October 1997. provision of skilled manpower on contract basis etc.
RCH phase-I interventions at district level were as traditional Birth Attendant still plays an important role
follows : during deliveries in our society.

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 REPRODUCTIVE AND CHILD HEALTH PROGRAMME
519
24-Hour delivery services at PHCs/CHCs Prevention and control of vitamin A
(To promote institutional deliveries, provision has been deficiency in children
made to give additional honorarium to the staff to It is estimated that large number of children suffer from
encourage round the clock delivery facilities at health sub-clinical deficiency of vitamin A. Under the programme,
centres. doses of vitamin A are given to all children under 5 years of
age. The first dose (1 lakh units) is given at nine months of
Medical Termination of Pregnancy age along with measles vaccination. The second dose
MTP is a reproductive health measure that enables a (2 lakh units) is given after 9 months. Subsequent doses
woman to opt out of an unwanted or unintended pregnancy (2 lakh units each) are given at six months intervals upto
in certain specified circumstances without endangering her 5 years of age (3). All cases of severe malnutrition to be
life, through MTP Act 1971. The aim is to reduce maternal given one additional dose of vitamin A.
morbidity and mortality from unsafe abortions. The
assistance from the Central Government is in the form of Prevention and control of anaemia in children
training of^manpower, supply of MTPequipment.and Iron deficiency anaemia is widely prevalent in young
provision for engaging doctors trained in MTP to visit PHCs children. To manage anaemia, the policy has been revised.
on fixed dates to perform MTP Infants from the age of 6 months onwards upto the age of
5 years are to receive iron supplements in liquid formulation
Control of reproductive tract infections (RTI) and in doses of 20 mg elemental iron and 100 mcg folic acid per
sexually transmitted diseases (STD) day for 100 days in a year/Children 6 to 10 years of age will
Under the RCH programme, the component of RTI/STD receive iron in the dose of 30 mg elemental iron and
control is linked to HIV_and AIDS control. It has been 250 mcg folic acid for 100 days in a year. Children above
planned and implemented in close collaboration with this age group would receive iron supplement in the adult
National AIDS Control Organization (NACO). NACO dose (3).
provides assistance for setting up RTI/STD clinics upto the
district level. The assistance from the Central Government is Training of dais
in the form of training of the manpower and drug kits A scheme for training of dais was initiated during

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including disposable equipment. Each district is assisted by 2001-02. The scheme is being implemented in 156 districts
two laboratory technicians on contract basis for testing in 18 states/UTs of the country. The districts have been
blood, urine and RTI/STD tests. selected on the basis of the safe delivery, rates being less
than 30 per cent. The scheme was extended to all the
Immunization districts of EAG states. The aim was to train at least one Dai
ThdjJniversal Immunization Programme (UIP) became a in every village, with the objective of making deliveries safe.
part of CSSM programme in 1992, RCH programme in
1997, and currently of National Health Mission. A Empowered Action Group (EAG)
An Empowered Action Group has been constituted inlhe
Ministry of Health and Family Welfare, with Union Minister
^The primary^goal of essential newborn care is to reduce for Health and Family Welfare as chairman on 20th March
perinatal and neonatal mo_rtaljty. The main components are 2001. As 55 per cent of the increase in the population of
resuscitation of newborn with asphyxia, prevention of India is anticipated in the states of Uttar Pradesh, Bihar,
hypothermia, prevention of infection, exclusive breast Madhya Pradesh, Rajasthan, Odisha, Chhattisgarh,
feeding and referral of sick newborn. The strategies are to Jharkhand and Uttarakhand, these states are perceived to be
train medical and other health personnel in essential most deficient in critical socio-demographic indices.
newborn care, provide basic facilities for care of low birth Through EAG, these states will get focussed attention for
weight and sick new boms in FRU and district hospitals etc. different health and family welfare programmes.

Diarrhoeal disease control District Surveys

(In the districts not implementing Integrated Management There is no regular source of data to indicate the
of Neonatal and Childhood Illness, the vertical programme reproductive health status of women. fThe RCH programme
for control of diarrhoeal disease will continue. India is the conducts district based rapid household survey to assess
first country in the world to introduce the low osmolarity the reproductive health status of women. The key indicators
Oral Rehydration Solution. Zinc is to be used as an adjunct are :
to ORS for the management of diarrhoea. Addition of Zinc a. Percentage of pregnant women with full ANC;
would result in reduction of the number and severity, of
episodes and the duration of diarrhoea. De-worming b. Percentage of institutional deliveries and home
guidelines have been formulated. The incidence of deliveries;
diarrhoea is reduced by provision of safe drinking water. c. Percentage of home deliveries by trained birth
attendant;
Acute respiratory disease control d. Current contraceptive prevalence rate;
The standard case management of ARI and prevention of e. Percentage of children fully immunized;
deaths due to pneumonia is now an integral part of RCH
programme. Peripheral health workers are being trained to f. Percentage of unmet need for family planning; and
recognize and treat pneumonia. Cotrimoxazole is being g. Percentage of household reported visits by health
supplied to the health workers through the drug kit. worker in previous 3 months.

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520 HEALTH PROGRAMMES IN INDIA

RCH - PHASE II RCH.The minimum services to be provided by a fully

functional FRU are (56) :
(RCH-phase II began from 1st April, 2005. The focus of 1. (24 hours delivery services including normal and
the programme is to reduce maternal and child morbidity assisted deliveries; }
and mortality with emphasis on rural health care. 2. ^Emergency obstetric care including surgical
The major strategies under the second phase of RCH interventions like_caesarean sections;
are (55) : 3. New-born care;
♦ Essential obstetric care 4. Emergency care of sick children;
a. Institutional delivery. 5. Full range of family planning services including
b. Skilled attendance at delivery. laproscopic services;
6. Safe abortion services;
♦ Emergency obstetric care 7. Treatment of STI/RTI;
a. Operationalizing First Referral Units. 8. Blood storage facility;
b. Operationalizing PHCs and CHCs for round the clock 9. Essential laboratory services; and
delivery services. 10. Referral (transport) services.
♦ Strengthening referral system There are three critical determinants of a facility being
The Government of India has given some broad 'declare? as a FRU. They are : availability of surgical
guidelines and strategies for achieving the reduction in interventions, new-born care and blood storage aci ity on a
maternal mortality rate and infant mortality rate. The 24 hoursTSasis.
initiatives which have been planned are : To be able to perform the full range of FRU function,
a health facility must have the following facilities :
Essential obstetric care (a) Ajpinimum bed strength of 20-30. However, in difficult
a. Institutional delivery - To promote institutional area's, as the North-East states and the underserved areas of
deliverer in K(JH Phase II, it was envisaged that fifty EAG states, this could initially be relaxedjo 10-12 beds:
percent of the PHCs and all the CHCs would be made (b) A fully functional operation theatre; (c) A fully functional
operational as 24-hour delivery centres, in a phased labour room; (d) An area earmarked and equipped for new-

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manner, by the year 2010. These centres would be born care in the labour room, and in the ward; (e) A
responsible for providing basic emergency obstetric funcffonal laboratory: (f) Blood storage facility; (g) 24 hour
care and essential newborn care and basic newborn water supply and electricity supply; and (h) Arrangements
resuscitation services round the clock. The experience for waste dis osal; and (i) Ambulance facility.
of RCH phase-I indicates that giving incentive to
health workers for providing round the clock services Strengthening referral system
did not function well in most of the states. On the During RCH phase-I, funds were given to the Panchayat
contrary there is the experience from government of for providing assitance to poor people in the case of
Andhra Pradesh and Tamil Nadu, where round the obstetric emergencies. Feedback from the states indicate that
clock delivery and new born care services could be there was no active involvement of Panchayats in running
ensured by providing 3 to 4 staff nurses/ANM at the the scheme. Based on these experiences different states
PHCs. have proposed different modes of referral linkage in RCH
b. (Skilled attendance at delivery - It is now recognized Phase II. Some of them have indicated to involve local self
globally that the countries which have been successful help groups, NGOs and women groups, whereas few others
in bringing down maternal mortality are the ones have indicated to outsource it.
where the provision of skilled attendance at every
birth and its linkage with appropriate referral services (jNeu) initiatives
for complicated cases have been ensured. The WHO 1. Training of MBBS doctors in life saving anaesthetic skills
has also emphasized that skilled attendance at every for emergency obstetric care : Provision of adequate and
birth is essential to reduce the maternal mortality in timely emergency obstetric care (EmOC) has been
any country. Guidelines for normaT delivery and recognized as the most important intervention for saving
management of obstetric complications at PHC/CHC lives of pregnant women who may develop complications
for medical officers and for ANC and skilled during pregnancy or childbirth. The operationalisation of
attendance at birth for ANM/LHVs have been First Referral Unit at sub-district/CHC level for providing
formulated and disseminated to the states. EmOC to pregnant women is a crucial strategy of RCH-II,
c. The policy decisions : ANMs I LHVs / SNs have now which needs focussed attention. The training _of MBBS
been permitted to use drugs in specific emergency doctors will be undertaken for only such numbers who
situations to reduce maternal mortality. They have are required for the functioning of_ERUs and CHCs, and
also been permitted to carry out certain emergency shall be limited to the requirement of tackling emergency
interventions when the life of the mother is at stake. obstetric situations only. It is not the replacement_o£the
specialist anaesthetist. Government of India is also
Emergency obstetric care introducing training of MBBS doctors in obstetric
((Operationalization of FRUs and skilled attendance at management skills. ^Federation of Obstetric—and
birth are the two activities which go hand in hand. In view of Gynaecology Society oTIndia has prepared a training
this, simultaneous steps have been taken to ensure tackling plan for 16 weeks in all obstetric management ^skills,
obstetric emergencies. It has been decided that all the First including caesarean section operation.
Referral Units be made operational for providing emergency 2. Setting up of blood storage centres at FRUs according to
and essential obstetric care during the second phase of government of India guidelines.

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 n
JANANI SURAKSHA YOJANA
521
JANANI SURAKSHA YOJANA 2. In high jjerforming states the benefit is only upto 2 live
births^__
The National Maternity Benefit scheme has been
ASHA package is available in all low performing states,
modified into a new Scheme caTTed Janani Suraksha Yojana
North-East states and in tribal districts of all states and UTs.
(JSY). It was launched on 12th April 2005-.-The objectives
In rural areas it includes the following components :
of the scheme are - reducing maternal mortality and
neonatal mortality through encouraging delivery at health (a) Cash assistance for referral transport for pregnant
institutions, and focusing at institutional care among women women to go to the nearest health centre for delivery
in below poverty line families. (should not be less than Rs. 250/-); (b) Cash incentive : This
should not be less than Rs. 200/- per delivery. ASHA should
The salient features of Janani Suraksha Yojana are as get her money after her post-natal visit to the beneficiary,
follows (7) : and when the child has been immunized for BCG; and
a. It is a JOO per cent centrally sponsored^chemeJ (c) Balance amount to be paid to ASHA in lieu of her
b. Under National Rural Health Mission, it integrates the services rendered by her. The payment should be made at
benefit of cash assistance with institutional care during the hospital/health institution itself.
antenatal, delivery and immediate post-partum care; <The Yojana subsidizes the cost of caesarean section and
This benefit will be given to all women, both rural and for management of obstejric complications, upto Rs. 1500
urban, belonging to below poverty line household. per delivery to the government institutions, where
However, with a view to give special focus in 10 low government specialists are not in position/)
performing states (states having low institutional In low performing and high performing states, all below
delivery rate), namely Uttar Pradesh, Uttarakhand, poverty line pregnant women preferring to deliver at home,
Madhya Pradesh, Jharkhand, Bihar, Rajasthan. are entitled to cash assistance of Rs. 500 per deliver .,
Chhattisgarh, Odisha, Assam and Jammu & Kashmir, regard'ess of age and number of children (1).
the benefit will be extended upto the third child if the
mother, of her own accord, chooses to undergo Direct benefit transfer under JSY: Payments under the
sterilization in the health facility where she delivered, JSY are being made through direct benefit transfer mode.
immediately after delivery. The other states are called Under this initiative, eligible pregnant women are entitled to
high performing states. The Accredited Social Health get JSY benefit directly into their Aadhar linked bank
Activist (ASHA) would work as a link health worker account/electronic fund transfer (7).

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between the poor pregnant women and public sector The year 2006-07 was declared as the year for
health insitution in the low performing states. ASHA institutional deliveries. During the year scope of the scheme
would be responsible for making available institutional was extended to the urban areas of high performing states
antenatal as well as postnatal care. She would also be and restriction of age and birth order were removed in the
responsible for escorting the pregnant women to the low performing states. The benefits of the scheme was also
health centre. The scale of assistance under the extended to all women belonging to SC/ST families for
scheme from 2012-13 would be as follows : institutional deliveries.
Rural Area Urban Area During the year 2018-19, about 100.41 lakh pregnant
women were benefitted from the scheme (11).
Category Mother's ASHA’s Total Mother's ASHA’s Total
package package* Rs. package package** Rs. (^Vandemataram scheme
LPS 1400 600 2000 1000 400 1400 This is a voluntary scheme wherein any obstetric and
HPS 700 600 1300 600 400 1000 gynaec specialist, maternity home, nursing home, lady
doctor/MBBS doctor can volunteer themselves for providing
LPS : Low performing states, HPS : High performing states sale motherhood services. The enrolled doctors will dispFay
* ASHA incentive of Rs. 600/- in rural areas includes Rs. 300/- for
ANC component and Rs. 300/- for accompanying pregnant ‘Vandemataram logo’ at their clinic. Iron and Folic Acid
woman for institutional delivery. tablets, oral pills, TT injections etc, will be provided by the
** ASHA incentive of Rs. 400/- in urban area includes Rs. 200/- for respective District Medical Officers to the ‘Vandemataram
ANC component and Rs. 200/- for accompanying pregnant doctors, clinics’ for free distribution to beneficiaries. The
woman for institutional delivery. cases needing special care and treatment can be referred to
Source : (6) the government hospitals, who have been advised to take
The eligibility of cash assistance is as follows (6) : due care of the patients coming with Vandemataram cards.
1. In low performing states (LPS) : All women, including Safe abortion services
those from SC__apd ST families, delivering in In India, abortion is a major cause of maternal mortality
government health centres like sub-centre, primary and morbidity and accounts for nearly 8.9 per cent maternal
health centre, community health centre, first referral deaths. Majority of abortions take place outside authorized
unit, general wards of district and state hospitals or health services and/or by unauthorized and unskilled
accredited private institutions} persons. Whether spontaneous or induced, abortion is a
2. In high performing states (HPS) : Below poverty line matter of concern as it may lead to complications. Under
women, and the SC and ST piegnant women delivering RCH phase II following facilities are provided :
in Govt, health centres or accredited private institutes!
a. Medical method of abortion : Termination of early
The limitation of cash assistance for institutional delivery pregnancy with two TTrugs - Mifepristone (RU 486)
is as follows : followed by Misoprostol. They are considered safe
1. In low performing states : All births, delivered in under supervision, with” appropriate counselling.
health centre, government or accredited private health Currently its usp in India is recommended upto
institutions will get the benefit. \ 7 weeks (49 days) .of amenorrhoea in a facility with

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 522 HEALTH PROGRAMMES IN INDIA

provision for safe abortion services and blood PRADHAN MANTRISURAKSHIT MATRITVA
transfusion. Termination of pregnancy with RU 486 ABHIYAN (PMSMA)
and Misoprostol is offered to women under the
preview of the MTP Act, 1971. The iPradhan Mantri Surakshit Matritva Abhivan (PMSMA)
has been launched by the Ministry in June, 2016. Under
b. Manual Vacuum Aspiration (MVA) : The department PMSMA, all pregnant women m the country are provided
of family welfare has introduced Manual Vacuum fixed da., free of cost assured and quality antenatal care. As
Aspiration (MVA) technique in the family welfare part of the campaign, a minimum package of antenatal, care
programme.(Manual Vacuum Aspiration is a safe and services (including investigations and drugs) is being
simple technique for termination of early pregnancy, provided to the beneficiaries on the 9th day of every month.
makes it feasible to be used in prirnary_heaLth centres The Abhiyan also involves private sector’s health care
or comparable Jacili.ties, thereby increasing j^cess to providers as volunteers to provide specialist care in
safe abortion services. The project of introducing the government facilities. About 2.20 crore ANC check-ups were
MVAjecTinique has been piloted in coordination with conducted by about 6,000 volunteers in more than 17,000
FOGSjk WHO and respective state governments government facilities. Also, more than 11.66 lakh high risk
before being accepted for implementation by the pregnancy cases were identified across the country (11).
ministry of health and family welfare.
SUMAN (Surakshit Matritva Aashwasan)
Village Health and Nutrition Dai;
Ministry has launched a new initiative namely “SUMAN-
(Organizing Village Health and Nutrition Day once a Surakshit Matritva Aashwasan” on 10th October 2019 with an
month at anganwadi centre to provide antenatal/post- alm to provide assured, dignified,Respectful and quality
partum care for pregnant women, promote institutional healthcare at no cost and zero tolerance for denial of services
delivery, health education, immunization, family planning for every woman and newborn visiting the public health facility
and nutrition services_etc. in order to end all preventable maternal and newborn deaths
Maternal death review and morbidities and provide a positive birthing experience.
The expected outcome of this new initiative is ‘‘Zero
Maternal death review as a strategy has been spelt_out
preventable maternal and newborn deaths and high quality
clearly in the RCH-II. Maternal death audit, both facility and of maternity care delivered with dignity and respect” (11).
community based, is an important strategy to improve the

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quality of obstetric care and reduce maternal mortality and LAQSHYA PROGRAMME (11)
morbidity. Guidelines and tools for initiating maternal death
review have been formulated (3). MOHFW launched “LaQshya program” to improve
quality of care in labour room and maternity OTs in public
Pregnancy tracking health facilities in 2017. The LaQshya programme is
evidence based approach to improve quality of maternal
?JThe link between pregnancy-related care and maternal and newborn care and provide respectful care, particularly
mortality is well established. RCH-II stresses the need for during the intrapartum and postpartum periods, which are
universaT screening of pregnant women and providing the most vulnerable periods for a woman and contribute to a
essential and emergency obstetric care. Focussed antenatal significant proportion of maternal deaths?
care, birth preparedness and complication readiness, skilled
attendance at birth, care within the first seven days etc. are Its implementation involves improving infrastructure
the factors that can reduce the maternal mortality (3). upgradation, ensuring availability of essential equipment,
providin adequate human resources, capacity building of
* JANANI-SHISHU SURAKSHA KARYAKRAM (JSSK) health care workers, and adherence to clinical guidelines and
improving quality processes in labour room and maternity OT.
Government of India launched the Janani-Shishu LaQshya program is being implemented at District Hospital
Suraksha Karyakram (JSSK) on 1st June 2011, a new (DH), Sub district Hospital (SDH), high case load Community
national initiative, to make available better health facitlies Health Centre (CHC) and First Referral Units (FRUs), and
for women and child. The new initiatives provide the medical colleges..[2,445 public health facilities including
following facilities to the pregnant women (57) : 193 medical colleges have been identified under LaQshya. Out
- All pregnant women delivering in public health of these, 441 labour rooms and 392 OTs have achieved state
institutions to have absolutely free and no expense certification. National certification for LaQshya has been
delivery, including caesarean section. The entitlements achieved by 447 labour rooms and 365 OTs till Dec. 2021 (6).
include free drugs and consumables, free diet upto 3 days Regional trainings of trainers have been completed for all
during normal delivery and upto 7 days for C-section, States/UTs across country to build a critical mass of trainers
free diagnostics, and tree blood wherever required. This who took this training cascade further. State orientation and
initiative would also provide for free transport from home baseline assessment have been conducted for all State/UTs.
to institution, between facilities in case of a referral and Based on the gaps, the States Tave prepared gap closure
drop back home. Similar entitlements have been put in plan. Onsite mentoring is being conducted in 24 identified
place tor all sick newborns accessing public health medical colleges to accelerate process of certification in
institutions for treatment till 30 days after birth. The medical colleges. LaQshya portal has been finalized and
scheme has now been extended to cover The operationalized. Data upload on LaQshya portal has been
complications during ANC, PNC~and also sick infants. 7~ initiated to aid digitization of all LaQshya related data,
- The scheme is estimated to benefit more-than 12 million readily available results and visualization through dashboard.
pregnant women who access government health facilities
for their delivery. Moreover, it will motivate those who ANAEMIA MUKT BHARAT PROGRAMME (AMB) (6)
still choose to deliver at their homes to opt for In 2018, Anaemia Mukt Bharat strategy was launched to
institutional deliveriesj achieve the envisaged target off5% reduction in anaemia

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 JSSK 523
prevalence every year under the POSHAN Abhiyaan. The The initiative aims to create a cadre of Nurse Practitioners
strategy recommends 6x6x6 strategy to reduce anaemia in Midwifery (NPMs) who are skilled in accordance to'
prevalence (nutritional and non-nutritional) in six age competencies prescribed by the International Confederation of
groups namely pre-school children (6-59 months), children Midwives (ICM) and are knowledgeable and capable of
(5_9 years), adolescent girls and boys (10-19 years)7 providing compassionate women-centred, reproductive,
pregnant women, lactating women and in women of maternal and newborn health care services. In order to create
reproductive age group (15—49 years) in programme mode a cadre of Nurse Practitioner Midwives, eighteen months
through life cycle approach. training would be provided to GNM/BSc nurses having 2 years
The six interventions under Anaemia Mukt Bharat experience in conducting deliveries. ^Training Curriculum
strategy are (prophylactic iron folic acid supplementation, would be based on the ‘Essential Competencies for Midwifery
periodic deworming, intensified year-round behaviour Practice’ defined by International Confederation of Midwife.
change communication campaign including delayed cord Midwifery practices intend to minimise unnecessary medical
clamping, testing and treatment of anaemia using digital interventions and promote physiological birthing by adoption
methods and point of care treatment, mandatory provision of alternate birthing positions during child birth (6).
of iron folic acid fortified foods in public health programmes 15 National Midwifery Training Centres are located in the
and addressing non-riutritional causes of anaemia in country. They are as follows : Telangana (2), one each in
endemic pockets, with special focus on malaria, Madhya Pradesh, Gujarat, Assam, Maharashtra, Uttar
haerfFogldbinopathies and fluorosis. The six institutional Pradesh, Rajasthan, West Bengal, Tamil Nadu, Karnataka,
mechanisms are inter-ministerial coordination, national Delhi, Punjab, Jammu & Kashmir and Andhra Pradesh (6).
Anemia Mukt Bharat unit, national, centre of excellence and Release of Scope of Practice : In July 2021, Gol released
advanced research on anaemia control, convergence with a “Scope of Practice document for Midwifery Educators
other ministries, strengthening supply chain and logistics, (ME) and Nurse Practitioner Midwife (NPM)” in
Anaemia *Mukt Bharat dashboard ancFcfigital portal-one-stop collaboration wifh the~Tndian Nursing Council (INC). It acts
shop for anaemia. as a guiding document for their education, regulation and
To address anaemia in children, bi-weekly IFA ongoing professional development.
supplements are provided to children aged 6-59 months Newer interventions to reduce newborn mortality have
through ASHAs and Weekly IFA supplements to children of also been implemented, including Vitamin-K injection at birth,
5-10 years and adolescents 10-19 years of age. (J 80 doses

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Antenatal corticosteroids in preterm labour, Kangaroo Mother
of IFA supplements are also being provided to pregnant and Care and empowering ANMs to provide Injection Gentamycin
lactating women during ANC and PNC period, respectively. to young infants for possible serious bacterial infection.
Bi-annual Vitamin-A supplementation is being done for all
children below five years of age. During FY 2021-22 (till (^Social Awareness and Actions to Neutralize Pneumonia
September, 2021), the achievements under IFA Successfully (SAANS) : SAANS (Social Awareness and
supplementation is as follows : Actions to Neutralize Pneumonia Successfully) Initiative was
launched on 16th November 2019 to accelerate action to
a. 2 crore children of age group 6-59 months were reduce deaths due to Childhood Pneumonia*- SAANS
provided 8-10 doses of Iron Folic Acid (IFA) Syrup every Campaign rolled out in the States/ UTs from 12th November
month. 2021-28th February 2022 with aims of accelerating action
b. 1.9 crore children of age group 5-9 years were provided against Childhood Pneumonia by generating awareness
4-5 IFA Pink tablets every month. around protect, prevent and treatment aspects of Childhood
c. 3 crore children of age group 10-19 years were provided Pneumonia and to enhance early identification and care
4-5 IFA Blue tablets every month. seeking behaviours among parents and caregivers (6).
d. 1.3 crore pregnant women and 0.6 crore lactating
women were provided 180 IFA Red tablets during ANC Child health components
and PNC respectively. The strategy for child health care, aims to reduce under-
MOTHER’S ABSOLUTE AFFECTION (MAA) five child mortality through interventions at every level of
service delivery and through improved child care practices
PROGRAMME :
and child nutrition.
Mother’s Absolute Affection (MAA) programme focuses
on promotion of optimum Infant and Young Child Feeding Nutritional rehabilitation centres (NRCs)
(1YCFT practices including early -initiation of breastfeeding Qgevere acute malnutrition is an important contributing
within one hour, exclusive breastfeedinc up to six months, factor for most deaths among children suffering from
age appropriate and adequate complementary feeding after common childhood illness such as diarrhoea and pneumonia.
six months and continuation of breastfeeding for two years Deaths among these malnourished children are preventable,
and beyond through capacity buildino of frontline health provided timely and appropriate actions are taken. NRCs are
workers and comprehensive IEC campaigns. As per NFHS-5 facility based units providing medical and nutritional care to
(2019-21), only 41.8 per cent newborns initiated on Severe Acute Malnutrition (SAM) children under 5 years of
breastfeed within one hour of birth while, 63.7 per cent age who have medical complications. In addition special
children breastfed exclusively till 6 months of age (6). focus is on improving the skill of mothers on child care arid
MIDWIFERY INITIATIVE : feeding practices so that the child continues to get adequate
care at home. The services provided at the NRCs include (1):
The Government of India has taken a landmark policy
decision to roll out midwifery services in the country in a. 24 hours care and monitoring of the child;
order to improve the quality of care and ensure respectful b. Treatment of medical complication;
care to pregnant women and newborns. The initiative was c. Therapeutic feeding;
launched in December 2018. d. Sensory stimulation and emotional care;

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524 HEALTH PROGRAMMES IN INDIA

e. Counselling on appropriate feed, care and hygiene; - At least the beginning of loss of oedema.
f. Demonstration and practice-by-doing on the preparation AND
of energy dense food using locally available, culturally - Return of appetite.
acceptable and affordable food items; AND
g. Social assessment of the family to identify and address - No nasogastric tube, infusions, no severe medical problems.
contributory factors; and AND
h. Follow up of the children discharged from the facility. - Is alert and active?
Management of medical complications in a The ONLY difference in management of the child in
child with SAM at health facility (58) transition phase is the change in type of diet. There is
A majority of the deaths in hospitals occur within 24 gradual transition from starter diet to catch up diet. The
hours of admission, many of these deaths can be prevented quantity of catch up diet given is equal to the quantity of
if the critically ill children are identified as soon as they are starter diet given in stabilization phase.
admitted and their treatment is started immediately. Rehabilitation Phase: Once children with SAM have
recovered their appetite and received treatment for medical
Triage complications they enter Rehabilitation Phase. The aim is to
Triage is the process of rapidly screening sick children. promote rapid weight gain, stimulate emotional and physical
Triage must be done for all paediatric patients coming to the development and prepare the child for normal feeding at
health facility. The first step is to check every child for home. The child progresses from transition phase to
emergency signs and provide emergency treatment as rehabilitation phase when:
necessary, keeping in mind the ABCD steps : Airway, - S/he has reasonable appetite; finishes > 90% of the feed
Breathing, Circulation, Coma, Convulsion and Dehydration. that is given, without a significant pause.
Assessment at admission (58) - Major reduction or loss of oedema.
- No other medical problem.
The child should be assessed by taking detailed history
and should be examined for the signs of under-nutrition. Micronutrient supplementation (58)
Principles of hospital-based management (58) Vitamin A: Give Vitamin A in a single dose to all SAM

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The principles of management of SAM are based on 3 children unless there is evidence that child has received
vitamin A dose in last 1 month.
phases: stabilization phase, transition phase and
rehabilitative phase. Recommended oral dose of Vitamin A according to
child’s age:
Stabilization Phase: Children with SAM without an adequate
appetite and/or a major medical complication are stabilized in Age Vit. A dose
an in-patient facility. This phase usually lasts for 1-2 days. <6 months 50,000 IU
The feeding formula used during this phase is Starter diet which
6-12 months or if weight <8 kg 100,000 IU
promotes recovery of normal metabolic function and nutrition
- electrolytic balance. All children must be carefully monitored >12 months 200,000 IU
for signs of overfeeding or over hydration in this phase. - Give same dose on Day 1, 2 and 14 if there is clinical
Transition Phase: This phase is the subsequent part of the evidence of vitamin A deficiency.
stabilization phase and usually lasts for 2-3 days. The - Children more than twelve months but having weight
transition phase is intended to ensure that the child is less than 8 kg should be given 100,000 ILJ orally
clinically stable and can tolerate an increased energy and irrespective of age.
protein intake. The child moves to the Transition Phase from - Oral treatment with vitamin A is preferred. For oral
Stabilization Phase when there is: administration, an oil-based formulation is preferred.

Take a history concerning On examination, look for

• Recent intake of food and fluids • Anthropometry- weight, height/length, mid arm circumference
• Usual diet (before the current • Oedema
illness) • Pulse, heart rate, respiratory rate.
• Breastfeeding • Signs of dehydration.
• Duration and frequency of • Shock (cold hands, slow capillary refill, weak and rapid pulse)
diarrhoea and vomiting • Palmar pallor.
• Type of diarrhoea (watery/ • Eye signs of vitamin A deficiency:
bloody)
- Dry conjunctiva or cornea,
• Chronic cough
- Bitot’s spots
• Loss of appetite
- Corneal ulceration
• Family circumstances (to
understand the child’s social - Keratomalacia
background) • Localizing signs of infection, including ear and throat infections, skin infection or pneumonia.
• Contact with tuberculosis • Mouth ulcers.
• Recent contact with measles • Skin changes of kwashiorkor:
• Known or suspected HIV - Hypo or hyperpigmentation
infection Desquamation
• Immunizations - Ulceration (spreading over limbs, thighs, genitalia, groin, and behind the ears).
- Exudative lesions (resembling severe burns) often with secondary infection (including Candida).

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 JSSK 525
- IM treatment should be used in children with severe master trainers at state and district level are paediatricians
anorexia, oedematous malnutrition, or septic shock. from tertiary hospitals and medical colleges (3).
Only water based formulations and half of oral dose
should be used. Facility based newborn care (59)
Other micronutrients should be given daily for at least As more sick children are screened at the peripheries
2 weeks: through IMNCI and referred to the health facilities, care of
- Multivitamin supplement (should contain vitamin A, C, the sick newborn and child at CHCs, FRUs, district hospitals
D, E and B12 and not just vitamin B complex): Twice and medical college hospitals assumes priority. Equipping
the facilities to provide the requisite level of care and
recommended daily allowance.
simultaneously enhancing the capacity of the medical
- Folic acid: 5 mg on day 1, then 1 mg/day. officers at these facilities to handle such cases thus becomes
- Elemental Zinc: 2 mg/kg/day. important. The setting up of SNCUs at district hospitals,
- Copper: 0.3 mg/kg/day (if separate preparation not stabilization units at CHCs, and newborn care corners at all
available use commercial preparation containing copper). facilities offering delivery facilities, is thus a key activity (3).
- Iron: Start daily iron supplementation after two days of the In the overall planning of facility based care it is
child being on catch up diet. Give elemental iron important to understand the level of care that is provided at
in the dose of 3 mg/kg/day in two divided doses, preferably the various facility levels. The newborn care facilities at
between meals. (DO not give iron in stabilization phase). different levels are as follows :
Follow-up of children discharged from NRC Health facility All newborns at birth Sick newborns
Close collaboration and information sharing between
Primary health centre Newborn care corner Prompt referral
NRC and community based care ( at PHC, sub-centre and (PHC)/Sub-centre (SC) in labor rooms.
AWC) are essential. The list of SAM children discharged identified as MCH level I
from NRC should be shared with area specific ANM and
1CDS supervisors. These children should be enrolled in the Community health centre Newborn care corner Newborn
anganwadi centre and given supplementary food as per the (CHC)/First referral unit in labor rooms and stabilization unit
(FRU) identified as in operation theatre (NBSU).
guidelines. The AWWs should prioritize these children for
MCH Level II
home visits, every week in the first 4 weeks and then once in

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2 weeks till the child is discharged from the programme. District hospital Newborn care corner Special newborn
During the home visits, AWW should observe feeding and identified as in labor rooms and care unit
provide appropriate counselling and support to the mother. MCH Level III in operation theatre (SNCU).
These children should be weighed every week at AWC. The
ASHA and AWW should ensure that these children should Newborn Care Corner (NBCC)
return for the scheduled follow-ups at the NRC (58). NBCC is a space within the delivery room in any health
Incentive of Rs 50 can be provided to ASHA for facility where immediate care is provided to all newborns at
accompanying the child to the NRC and motivating the birth. This area is MANDATORY for all health facilities
mother to stay at NRC for atleast 7 days till the child is where deliveries are conducted. About 20,337 NBCCs are
stabilized and has started to eat. Additional incentive of operational in the country (6).
Rs 50 may be given for each follow-up visit by the child,
upto a maximum of three visits (58). Newborn Stabilization Unit (NBSU)
Presently 1075 NRCs are functional across 17 states/UTs (11). NBSU is a facility within or in close proximity of the
maternity ward where sick and low birth weight newborns
Integrated Management of Neonatal and Childhood can be cared for during short periods. All FRUs/CHCs need
Illness (IMNCI) to have a neonatal stabilization unit, in addition to the
IMNCI strategy is one of the main intervention under the newborn care corner. It requires space for 4 bedded unit and
RCH II/ NRHM. The strategy encompasses a range of two beds in post-natal ward for rooming-in. About 2,579
interventions to prevent and manage the commonest major NBSUs are functional in the country.
childhood diseases.
Special Newborn Care Unit (SNCU)
Pre-service IMNCI SNCU is a neonatal unit in the vicinity of the labor room
Pre-service IMNCI has been accepted as an important which is to provide special care (all care except assisted
strategy to scale up IMNCI by Govt, of India and is being ventilation and major surgery) for sick newborns. Any
included in the curriculum of medical colleges of the facility with more than 3,000 deliveries per year should have
country. This will help in providing the much needed trained an SNCU (most district hospitals and some sub-district
IMNCI manpower in the public and private sector. hospitals would fulfil this criteria).
The minimum recommended number of beds for an
Facility based IMNCI (F-IMNCI) SNCU at a district hospital is 12. However, if the district
F-IMNCI is the integration of the facility based care hospital conducts more than 3,000 deliveries per year,
package with the IMNCI package, to empower the health 4 beds should be added for each 1,000 additional deliveries.
personnel with the skill to manage new born and childhood A 12 bedded unit will require 4 additional adult beds for the
illness at the community level as well as the health facility. It step down. 894 SNCUs are functional in the country.
focusses on providing appropriate in-patient management of
the major causes of neonatal and childhood mortality such Triage of sick newborns (59)
as asphyxia, sepsis, low birth weight, pneumonia, diarrhoea, Triage is sorting of neonates to rapidly screen sick neonates
malaria, meningitis and severe malnutrition in children. The for prioritizing management. Fig. 13 summarizes the process.

by R△J
 HEALTH PROGRAMMES IN INDIA

Newborns classified as “Emergency” require urgent intervention and emergency measures. All such newborns will be admitted to SNCU after
initial stabilization.

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Newborns classified as “Priority” are sick and need rapid assessment and admission to SNCU.
Newborns classified as non-urgent do not require urgent attention, but require further assessment and counselling.
FIG. 13
A. CRITERIA FOR ADMISSION TO NBSU (59) : I. Any newborn with following criteria should be
Newborn presenting with any of the following signs to a immediately admitted to the SNCU :
facility with neonatal stabilization unit requires admission for - Birth weight < 1800 g or gestation <34 weeks.
initial stabilization and transfer to SNCU : - Large baby (>4.0 kg).
- Perinatal asphyxia.
- Apnea or gasping. - Apnea or gasping.
- Respiratory distress (Rate>70/min with severe - Refusal to feed.
retractions/grunt). - Respiratory distress (rate > 60/min or grunt/retractions).
- Hypothermia <35.4°C - Severe jaundice (appears <24 hrs/stains palms and
- Hyperthermia (>37.5°C) soles/lasts>2 weeks).
- Central cyanosis. - Hypothermia <35.4°C, or hyperthermia (>37.5°C).
- Shock (cold periphery with capillary filling time (CFT) - Central cyanosis.
more than 3 seconds and weak and fast pulse). - Shock (cold periphery with CFT>3 seconds, and
- Significant bleeding that requires blood or component weak and fast pulse).
transfusion. - Coma, convulsions or encephalopathy.
Newborns, who after assessment and stabilization, can be - Abdominal distension.
managed at stabilization unit*. - Diarrhoea/dysentery. •
- Bleeding.
- Newborns with respiratory distress, having respiratory
- Major malformations.
rate 60-70/min without grunting or retractions (for
observation and oxygen therapy). II. Criteria for transfer from SNCU to the Step-Down :
- Newborns with gestation less than 34 weeks or weight - Newborn whose respiratory distress is improving and
does not require oxpgen supplementation to
<1800 g (for observation and assisted feeding).
maintain saturation.
- Newborns with hypothermia and hyperthermia who are - Newborn on antibiotics for completion of duration of
haemodynamically stable after initial stabilization. therapy.
- Newborns with jaundice requiring phototherapy. - Low birth weight newborn (less than 1800 g), who
- Neonates with sepsis who are haemodynamically stable, are otherwise stable (for adequate weight gain).
for observation and antibiotic therapy. - Newborn with jaundice requiring phototherapy but
* Others would require referral to an SNCU after stabilization, if otherwise stable.
an SNCU and appropriate referral is available in the district. - Newborn admitted for any condition, but are now
thermodynamically and hemodynamically stable.
B. CRITERIA FOR ADMISSION TO SNCU (59) : III. Criteria for discharge from SNCU :
Criteria for admission to SNCU and criteria for transfer to - Newborn is able to maintain temperature without
step-down unit and discharge are as follows : radiant warmer.
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 JSSK 527
- Newborn is haemodynamically stable (normal CFT, family is unable to go, ASHA should ensure that the
strong peripheral pulse). ANM visits sick newborn on a priority basis.
- Newborn accepting breast-feeds well. 6. Recognize postpartum complications in the mother and
- Newborn has documented weight gain for 3 refer appropriately.
consecutive days; and the weight is more than 1.5 kg. 7. Counsel the couple for family planning.
- Primary illness has resolved. 8. Provide immediate newborn care, in case of those
In addition to the above, mother should be confident of deliveries that do not occur in institutions (home deliveries
taking care of the newborn at home. and deliveries occurring on the way to the institution).

HOME BASED NEWBORN CARE (HBNC) (60) : ASHA will .make visits to all newborns according to
specified schedule upto 42 days of life. The schedule of visit
Home based newborn care is aimed at improving is as follows :
newborn survival. The strategy of universal access to home
based newborn care must complement the strategy of a. Six visits in the case of institutional delivery - Day 3, 7,
institutional delivery to achieve significant reduction in 14, 21, 28, and 42.
postpartum and neonatal mortality and morbidity. The b. Seven visits in the case of home delivery (Day 1, 3, 7,
providers of service include anganwadi workers, ANM, 14,21,28 and 42).
ASHA and the medical officer. However, ASHA is the main c. In cases of Caesarean section delivery, where the mother
person involved in home based newborn care. returns home after 5-6 days, ASHAs are entitled to full
incentive of Rs. 250 if she completes all five visits
The major objective of HBNC is to decrease neonatal starting from Day 7 to Day 42.
mortality and morbidity through :
d. In cases when a newborn is discharged from SNCU, ASHAs
1. The provision of essential newborn care to all newborns are eligible to full incentive amount 'of Rs. 250 for
and the prevention of complications. completing the remaining visits. In addition, ASHAs are
2. Early detection and special care of preterm and low birth also eligible for an incentive of Rs. 50 for monthly follow- up
weight newborns. of low birth weight babies and newborns discharged from
3. Early identification of illness in the newborn and SNCU (as approved by MSG of the National Health Mission
provision of appropriate care and referral. on 6th December 2013). The low birth weight are followed
4. Support the family for adoption of healthy practices and up for two years and SNCU discharged babies for one year.

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build confidence and skills of the mother to safeguard e. In cases where the woman delivers at her maternal
her health and that of the newborn. house and returns to her husband’s house, two ASHAs
The responsibilities of ASHA for home based newborn undertake the HBNC visits, i.e., one at maternal house
care are as follows (60) : immediately after delivery, and another one at
husband’s house when the new-born returns home or
1. Mobilize all pregnant mothers and ensure that they vice versa. In such cases the HBNC incentive of Rs. 250
receive the full package of antenatal care. can be divided into two parts in a way that each ASHA
2. Undertake birth planning and birth preparedness with who completes 3 visits or more is entitled to Rs. 125. In
the mother and family to ensure access to safe delivery. these instances, if an ASHA undertakes less than 3 visits,
3. Provide newborn care through a series of home visits she would not be entitled to HBNC incentive.
which include the skills for: f. In cases of twin or triples the incentive amount for ASHA
a. Weighing the newborn; would be two time of the regular HBNC incentive of
b. Measuring newborn temperature; Rs. 250/- (i.e., Rs. 500/-) or three times of Rs. 250/-
c. Ensuring warmth; (i.e., Rs. 750/-) respectively.
d. Supporting exclusive breast-feeding by teaching the The incentive money is paid to ASHA on 45th day
mother proper positioning and attachment for subject to the following :
initiating and maintaining breast-feeding;
e. Diagnosing and counselling in case of problems with a. Record of birth weight in the mother and child protection
breast-feeding; card;
f. Promoting hand-washing; b. Immunization of newborn with BCG, first dose of OPV,
g. Providing skin, cord and eye care; hep B and DPT/pentavalent vaccine and entry into the
h. Health promotion and counselling mothers and mother and child protection card;
families on key messages on newborn care which c. Registration of birth; and
includes discouraging unhealthy practices such as d. Both mother and newborn are safe until 42nd day of delivery.
early bathing, and bottle feeding; and
Home-Based Care for Young Child (HBYC)
i. Ensuring prompt identification of sepsis or other
illnesses. Under National Health Mission, Child Health division,
4. Assessing if the baby is high-risk (preterm or low birth MoHFW, GOI has rolled out Home-Based Cafe for Young
weight), through the use of protocols and managing such Child (HBYC) Programme , as an extension of the Home
LBW or preterm babies through : Based New Born Care (HBNC) programme to promote
evidence based interventions delivered in four key domains
a. Increasing the number of home visits;
namely nutrition, health, childhood development and WASH
b. Monitoring weight gain; and (Water, Sanitation and Hygiene). Under Home Based Care
c. Supporting and counselling the mother and family to of Young Child (HBYC) programme, the additional five
keep the baby warm and enabling frequent and home visits will be carried out by ASHA with support from
exclusive breast-feeding. Anganwadi workers. ASHA will provide home visits on 3rd,
5. Detect signs and symptoms of sepsis, provide first level 6th, 9th, 12th and 15th months to promote early initiation of
care and refer the baby to an appropriate centre. If the breast feeding, exclusive breast feeding till 6 months and

by R△J
 HEALTH PROGRAMMES IN INDIA

continued breast feeding till 2nd year of life along with programmes to look beyond the treatment of a single disease.
adequate complementary feeding, prevention of childhood This is cost effective and emphasizes prevention of disease
Pneumonia and Diarrhoea and to ensure age appropriate and promotion of child health and development besides
immunization and early childhood development. The provision of standard case management of childhood illness.
quarterly home visits schedule for low birth weight babies, In the Indian context this strategy is quite pertinent
SNCU & NRC discharges will now be harmonized with the considering the evidence from NFHS-III report highlighting
new HBYC schedule. ASHAs will be provided incentive of that ARI (17 per cent), diarrhoea (13 per cent), fever
Rs. 250 for completion of 5 home visits under HBYC for each (27 per cent) and under-nutrition (43 per cent) were the
young child (Rs. 50 per visit) as per the recommended commonest morbidities observed in the children aged under
schedule and additional commodities namely ORS packet 3 years. Coverage of measles vaccination in children
and Iron Folic Acid syrup will be provided in the kit. between 12-23 months was also low. An integrated
Strengthening facility based paediatric care approach to address these major childhood illnesses seems
to be an effective strategy to promote child health in this
Facility based care is complementary to community level country. The line of action is as shown in Fig. 14.
interventions in bringing down childhood morbidity and
mortality. Newborns and children referred from communities The Indian version of IMCI has been renamed as
and primary healthcare facilities are often seriously ill and at Integrated Management of Neonatal and Childhood Illness
high risk of dying. Those reaching health facilities need to be (IMNCI). It is the central pillar of child health interventions
managed appropriately and without delay in instituting care. under the RCH II strategy. The major highlights of the Indian
This objective can be achieved by establishing a well- adaptation are :
organised unit, adequate human resources, drugs, a. Inclusion of 0-7 days age in the programme;
equipment and other logistics that provides functional
quality of care consistent with clinical standards. OUT-PATIENT HEALTH FACILITY
The vision for paediatric care at District Hospital is to set up
a comprehensive unit comprising of the following sub-units : Check for danger signs
- Convulsions
1. Paediatric Outpatient Facility (including immunization - Lethargy/unconsciousness
and counselling services). - Inability to drink/breastfeed
2. Emergency Triage Assessment and Treatment (ETAT) Vomiting

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Facility.
3. Paediatric Inpatient Facility. Assess main symptoms
- Cough/difficulty breathing
a. High Dependency Unit.
- Diarrhoea
b. Paediatric Ward. - Fever
c. Diarrhoea Treatment Unit. - Ear problems
d. Isolation Room.
4. Ancillary (e.g. laboratory, imaging, pharmacy) & Assess nutrition and
Auxiliary Facilities (e.g. play area, hospital kitchen). immunization status and
potential feeding
The general paediatric care facility will function in close problems
coordination with specialised units that already have approved
guidelines for operationalization and include the following : Check for other problems
Newborn care facilities (Newborn Care Corners, Newborn
Stabilisation Unit, Special Newborn Care Unit); Nutrition
Classify conditions and
Rehabilitation Centre; and District Early Intervention Centre. identify treatment actions
Navjat Shishu Suraksha Karyakram (NSSK) According to
colour-coded treatment
NSSK is a programme aimed to train health personnel in —J
basic newborn care and resuscitation. It has been launched (Pink) (Yellow) (Green)
to address care at birth issue i.e. prevention of hypothermia, |
prevention of infection, early initiation of breast-feeding and ▼
Urgent referral
4___
Home management
basic newborn resuscitation. The objective of the new
initiative is to have a trained health person in basic newborn Out-patient Home
health facility Caretaker is
care and resuscitation unit at every delivery point (46). - Pre-referral counselled on
treatments how to
Integrated management of neonatal and - Advise parents - Give oral drugs
childhood illness (IMNCI) Refer child - Treat local
infections at
▼ home
Integrated management of childhood illness (IMCI) - Continue
Referral facility feeding
The extent of childhood morbidity and mortality caused - Emergency - When to return
by diarrhoea, ARI, malaria, measles and malnutrition is triage and immediately
substantial. Most sick children present with signs and treatment
(ETAT) - Follow-up
symptoms of more than one of these conditions. This overlap Diagnosis
means that a single diagnosis may not be possible or - Treatment
appropriate, and treatment may be complicated by the need - Monitoring and
follow-up
to combine for several conditions. An integrated approach to
manage sick children is, therefore, necessary. IMCI is a FIG. 14
strategy for an integrated approach to the management of The integrated case management process
childhood illness as it is important for child health Source : (61)

by R△J
 IMNCI

b. Incorporating national guidelines on malaria, TABLE 13

anaemia, vitamin-A supplementation and Identified health conditions for child health
immunization schedule; screening and early intervention services
c. Training of the health personnel begins with sick
Defects at Birth •
young infants upto 2 months; 1. Neural tube defect
d. Proportion of training time devoted to sick young 2. Down’s Syndrome
infant and sick child is almost equal; and 3. Cleft Lip and Palate / cleft palate alone
e. Is skill based ? 4 Talipes (club foot)
For more details please refer to chapter 9. 5. Developmental dysplasia of the Hip
6. Congenital cataract
IMNCI strategy is one of the main interventions under 7. Congenital deafness
RCH-II/NRHM. It focusses on preventive, promotive and 8. Congenital heart diseases
curative aspects of the programme. The objective is to 9. Retinopathy of prematurity
implement IMNCI package at the level of household, and Deficiencies.
through ANMs at sub-centre level; through medical officers, 10 Anaemia especially severe anaemia
nurses and LHVs at PHCs level. 11. Vitamin A deficiency (Bitot’s spots)
12. Vitamin D deficiency (Rickets)
Rashtriya Bal Swasthya Karyakram (RBSK) (62) 13. Severe acute malnutrition
RBSK is a new initiative launched in February 2013. It 14. Goitre
includes provision for Child Health Screening and Early Childhood Diseases:
Intervention Services through early detection and 15. Skin conditions (scabies, fungal infection and eczema)
management of 4 Ds, prevalent in children. These are defects 16. Otitis media
at birth, diseases in children, deficiency conditions and 17 Rheumatic Heart Disease
development delays including disabilities. An estimated 18. Reactive Airway Disease
27 crore children in the age group of 0-18 years are expected 19. Dental caries
to be covered across the country in a phased manner. 20. Convulsive disorders
Child Health Screening and Early Intervention Services Developmental delays and disabilities *
21. Vision impairment
under NRHM envisage to cover 30 identified health

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22 Hearing impairment
conditions for early detection, free treatment and
23. Neuro-motor impairment
management. Based on the high prevalence of diseases like 24. Motor delay
hypothyroidism, sickle cell anaemia and beta thalassaemia 25. Cognitive delay
in certain geographical pockets of some states/UTs, and 26. Language delay
availability of testing and specialized support facilities, these 27. Behaviour disorder (Autism)
states and UTs may incorporate them as part of this 28. Learning disorder
initiative. The health conditions are as shown in Table 13. 29 Attention Deficit Hyperactivity Disorder
30. Congenital Hypothyroidism, Sickle Cell Anaemia, Beta
Programme Implementation Thalassaemia (Optional)
1. For newborn : Source : (62)
- Facility based newborn screening at public health
birth defects. Further ASHAs will mobilise caregivers of
facilities, by existing health manpower.
children to attend the local Anganwadi Centres for screening
- Community based newborn screening at home by the dedicated Mobile Health Team. For performing the
through ASHAs for newborn till 6 weeks of age during above additional tasks, she would be equipped with a tool
home visits. kit consisting of a pictorial reference book having self-
2. For children 6 weeks to 6 years : explanatory pictures for identification of birth defects.
- Anganwadi centre based screening by dedicated Suitable performance based incentive may also be provided
Mobile Health Teams. to ASHAs. In order to ensure improved outcome of the
3. For children 6 years to 18 years : screening programme by Mobile Health Teams, ASHAs will
- Government and Government aided school based give priority to the children with low birth weight,
screening by dedicated Mobile Health Teams. underweight and children Jrom households known to have
any chronic illness (e.g., tuberculosis, HIV,
Facility based newborn screening haemoglobinopathy etc.). Line lists maintained by the ANMs
and AWWs would also be used to mobilise children.
This includes screening of birth defects in institutional
deliveries at public health facilities, especially at the Screening of children aged 6 weeks till 6 years
designated delivery points by ANMs, Medical Officers/
Gynaecologists. Existing health service providers at all attending Anganwadi Centres
designated delivery points will be trained to detect, register Children in the age group 6 weeks to 6 years of age will
report and refer birth defects to the District Early be examined in the Anganwadi Centres by dedicated Mobile
Intervention Centres in District Hospitals. Health Teams.
Community based newborn screening (age 0~6 weeks) Screening of children enrolled in Government and
for birth defects Government aided schools
Accredited Social Health Activists (ASHAs) during home For children in the age group 6 to 18 years, who will be
visits for newborn care will use the opportunity to screen the screened in Government and Government aided schools,
babies born at home and the institutions till 6 weeks of age. the block will be the hub of activity for the programme. At
ASHAs will be trained with simple tools for detecting gross least two dedicated Mobile Health Teams in each block will

by R△J
530 HEALTH PROGRAMMES IN INDIA

be engaged to conduct screening of children. Villages within UNFPA, NIPI and other development partners, the
the jurisdiction of the block would be distributed amongst Government of India has taken important steps to introduce
the mobile health teams. The number of teams may vary and support RMNCH+A implementation. This approach is
depending on the number of Anganwadi Centres, difficult to likely to succeed given that India already has a community
reach areas and children enrolled in the schools. The based programme with presence of 9.15 lakh ASHA workers,
screening of children in the Anganwadi Centres would be as well as the three tiered health system in place. These
conducted at least twice a year and at least once a year for provide a strong platform for delivery of services. This
school children to begin with. integrated strategy can potentially promote greater efficiency
In RCH Phase-II the other interventions of RCH Phase-I, while reducing duplication of resources and efforts in the
e.g., additional ANMs, public health nurses, private ongoing programme.
anaesthetists, safe motherhood consultants, 24 hours delivery The RMNCH+A strategy is based on provision of
services at PHCs and CHCs, referral transports, integrated comprehensive care through the five pillars, or thematic
financial envelop, RCH camps, training of Dais, border district areas, of reproductive, maternal, neonatal, child, and
cluster strategy, and intervention for newborn care and child adolescent health, and is guided by central tenets of equity,
health (immunization, control of ARI and diarrhoea, vitamin universal care, entitlement, and accountability. The “plus”
A and iron suplementation etc.) will continue. within the strategy focusses on :
The quality indicators used to monitor and evaluate RCH - ^Including adolescence for the first time as a distinct life
programme through monthly reports are (63) : stager
1. Number of antenatal cases registered - total and at - (Linking^maternal and child health to reproductive
less than 12 weeks; health, family planning, adolescent health, HIV, gender,
2. Number of pregnant women who had 3 antenatal preconception and prenatal diagnostic techniques;
check-ups; - CLinking home and community-based services to facility­
3. Number of high-risk pregnant women referred; based care; ancT^
4. Number of pregnant women who had two doses of
tetanus toxoid injection; - ^Ensuring linkages, referrals, and counter-referrals
5. Number of pregnant women under prophylaxis and between and among health facilities at primary (primary
treatment for anaemia; health centre), secondary (community health centre),
and tertiary levels (district hospitalFj

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6. Number of deliveries by trained and untrained birth
attendant; In developing the RMNCH+A strategy, the a[m is to
7. Number of cases with complications referred to PHC/ reach the maximum number of people in the remotest
FRU; corners oFthe country through a continuum of services,
8. Number of new born with birth weight recorded; constant innovation, and routine monitoring of
9. Number of women given 3 post natal check-ups; interventions! In rolling out the new strategy, the emphasis is
10. Number of RTI/STI cases detected, treated and referred; on high impact interventions in each of the five thematic
11. Number of children fully immunized; areas of reproductive, maternal, newborn, child, and
12. Number of adverse reactions reported after adolescent health, and then to focus its efforts, and those of
immunization; its development partners, on improving the coverage and
13. Number of cases of ARI and diarrhoea under 5 years quality of those interventions in 184 high-priority districts
treated, referred PHC/FRU and deaths; and (HPDs) across India. Guidelines and tools were developed
14. Number of cases motivated and followed up for and policies were adjusted.
contraception. 1. High-Priority Districts: The RMNCH+A strategy
addresses India’s inter-state and inter-district variations. The
districts with relatively weak performance against
REPRODUCTIVE, MATERNAL, NEWBORN, RMNCH+A indicators were identified. Uniform and clearly
CHILD AND ADOLESCENT HEALTH defined criteria were used to identify 184 high-priority
(RMNCH+A) STRATEGY districts across all 29 states. The RMNCH+A approach is a
conscious articulation of the GOI’s commitment to tailoring
In June 2012, the Government of India, Ethiopia, USA programmes to meet the needs of previously underserved
and the UNICEF convened the ^Global Child Survival Call groups, including adolescents, urban poor, and tribal
to Action : A Promise to Keep” summit in Washington, DC to populations.
energize the global fight to end preventable child deaths
through targeted interventions in effective, life-saving 2. Management tools and job aids: The RMNCH+A 5x5
interventions for children. More than 80 countries gathered matrix identifies five high-impact interventions across each
at the Call to Action to pledge to reduce child mortality to of the five thematic areas, five cross-cutting and health
< 20 child deaths per 1000 live births in every country by systems strengthening interventions, and the minimum
2035 (57). Eight months after the event, in February 2013, essential commodities. The 5x5 matrix as shown in Fig. 15,
the Government of India held its own historic Summit on the is an important tool for explaining the strategy in simple
Call to Action for Child Survival, where it launched “A terms, organizing technical support, and monitoring
Strategic Approach to Reproductive, Maternal, Newborn, progress with the states and high-priority districts.
Child, and Adolescent Health (RMNCH+A) in India.” Since
that time, RMNCH+A has become the heart of the Goals and targets (52)
Government of India’s flagship public health programme, Taking into account the progress made so far in maternal
the National Health Mission (64). and child health, it is pertinent to establish the goals and
With support from USAID and its Maternal Child Health targets for the implementation phase 2012-2017, after
Integrated Programme (MCHIP), as well as from UNICEF, considering the main reasons for mortality and interventions

by R△J
 RMNCH+A 531
Reproductive Health Maternal Health Newborn Health Child Health Adolescent Health
- Focus on spacing Use MCTS to ensure early Early initiation and - Complementary - Address teenage
methods, registration of pregnancy exclusive feeding, IFA pregnancy and
particularly PPIUCD and full ANC breast-feeding. supplementation increase
at high case load Detect high risk pregnancies - Home based and focus on contraceptive
facilities. and line list including newborn care nutrition. prevalence in
- Focus on interval severely anaemic mothers through ASHA. - Diarrhoea adolescents.
IUCD at all facilities and ensure appropriate - Essential Newborn management at - Introduce
including subcentres management. Care and community level community based
on fixed days. - Equip delivery points with resuscitation using ORS and services through
- Home delivery of highly trained HR and services at all Zinc. peer educators.
Contraceptives ensure equitable access to delivery points. - Management of - Strengthen ARSH
(HDC) and Ensuring EmOC services through - Special Newborn pneumonia. clinics.
Spacing at Birth FRUs, Add MCH wings as Care Units with - Full immunization - Roll out National
(ESB) through per need. highly trained coverage. Iron Plus Initiative
ASHAs. -CReview maternal, infant and human resource Rashtriya Bal including weekly
- Ensuring access to child deaths for corrective and other Swasthya IFA
Pregnancy Testing actions^- infrastructure. Karyakram supplementation
Kits (PTK “Nischay Identify villages with high - Community level (RBSK); screening Promote menstrual
Kits”) and numbers of home deliveries use of Gentamycin of children for 4Ds' hygiene.
strengthening and distribute Misoprostol to by ANM. (birth defects,
comprehensive selected women in 8th development
abortion care month of pregnancy for delays, deficiencies
services. consumption during 3rd and disease) and
Maintaining quality stage of labour; Incentivize its management.
sterilization services. ANMs for home deliveries.

Health Systems Strengthening Cross Cutting Interventions

Cases load based deployment of HR at all levels. Bring down out of pocket expenses by ensuring JSSK, RBSK and
- Ambulances, drugs, diagnostics, reproductive health other free entitlements.

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commodities. - ANMs & Nurses to provide specialized and quality care to
- Health education, demand promotion & behaviour change pregnant women and children.
communication. - Address social determinants of health through convergence.
Supportive supervision and use of data for monitoring and - Focus on un-served and underserved villages, urban slums and
review, including scorecards based on HMIS. blocks.
Public grievances redressal mechanism, client satisfaction and
patient safety through all round quality assurance. - Introduce difficult area and performance based incentives.

FIG. 15
5 x 5 matrix for high impact RMNCH+A interventions
To be Implemented with High Coverage and High Quality

proven to have an impact on them. The 12th Five Year Plan - Reduction in Maternal Mortality Ratio (MMR) to 100 per
has defined the national health outcomes and the three 100,000 live births by 2017.
goals that are relevant to RMNCH+A strategic approach are - Reduction in Total Fertility Rate (TFR) to 2.1 by 2017.
as follows : For achieving these goals, variable increase in the
- Reduction of Infant Mortality Rate (IMR) to 25 per 1.000 coverage level for key interventions are required. These are
live births by 2017. defined in the Table 14.
TABLE 14
Coverage targets for key RMNCH+A interventions for 2017
Increase facilities equipped for perinatal care (designated as ‘delivery points’) by 100%.
Increase proportion of all births in government and accredited private institutions at annual rate of 5.6% from the baseline of 61%
(SRS 2010).
Increase proportion of pregnant women receiving antenatal care at annual rate of 6% from the baseline of 53% (CES 2009)
Increase proportion of mothers and newborns receiving postnatal care at annual rate of 7.5% from the baseline of 45% (CES 2009)
Increase proportion of deliveries conducted by skilled birth attendants at annual rate of 2% from the baseline of 76% (CES 2009).
Increase exclusive breast-feeding rates at annual rate of 9.6% from the baseline of 35% (CES 2009).
Reduce prevalence of under-five children who are underweight at annual rate of 5.5% from the baseline of 45% (NFHS-3)
- Increase coverage of three doses of combined diphtheria-tetanus-pertussis (DTP3) (12-23 months) at annual rate of 3.5% from the
baseline of 7% (CES 2009).
- Increase ORS use in under-five children with diarrhoea at annual rate of 7.2% from the baseline of 43% (CES 2009).
- Reduce unmet need for family planning methods among eligible couples, married and unmarried, at annual rate of 8.8% from the
baseline of 21% (DLHS3).
- Increase met need for modern family planning methods among eligible couples at annual rate of 4.5% from the baseline of 47% (DLH 3).
Reduce anaemia m adolescent girls and boys (15-19 years) at annual rate of 6% from the baseline of 56% and 30%, respectively
(NFHS-3).
- Decrease the porportion of total fertility contributed by adolescents (15-19 years) at annual rate of 3.8% per year from the baseline of
16% (NFHS-3).
Raise child sex ratio in the 0-6 years age group at annual rate of 0.6% per year from the baseline of 914 (Census 2011)

by R△J
532 HEALTH PROGRAMMES IN INDIA

While the country aims to set one collective goal towards health needs, a comprehensive adolescent health strategy
reducing preventable maternal, newborn and child deaths has been developed. The priority under adolescent health
by 2017, it is increasingly becoming apparent that there is include nutrition, sexual and reproductive health, mental
varied and unequal rate of progress within the states and health, addressing gender-based violence, non-
districts. Therefore, state specific coverage targets should be communicable diseases and substance use. The strategy
established against existing baselines. The national and state proposes a set of interventions (health promotion,
‘scorecard’ is being introduced as a tool to increase prevention, diagnosis, treatment and referral) across levels of
transparency and track progress against reproductive and care. These interventions and approaches work towards
maternal health and child survival indicators related with building protective factors that can help adolescents and
intervention coverage. For more details about the score young people develop ’resilience’ to resist negative
cards please refer to page 534. behaviours and operate at four major levels: individual,
The implementation strategies of family, school and community by providing a comprehensive
RMNCH+A (52) package of information, commodities and services.
The key interventions of RMNCH+A as a “Continuum of The priority interventions are as follows :
Care” are as shown in Fig. 16. The set of interventions are
those that have high impact on reducing mortality and 1. Adolescent nutrition; iron and folic acid
improving survival. Most of these interventions have been part supplementation.
of the previous phase of NRHM. The effectiveness of these will 2. Facility-based adolescent reproductive and sexual health
be determined by the coverage achieved among the affected services (ARSH) (Adolescent health clinics).
fraction of population as also the availability, accessibility, 3. Information and counselling on adolescent sexual
actual utilization of services and quality of services delivered. reproductive health and other health issues.
Adolescent Health Programme (1, 52) 4. Menstrual hygiene.
Taking cognisance of the diverse nature of adolescent 5. Preventive health check-ups.

Clinical

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Reproductive care Pregnancy and child birth care Newborn and childcare
- Comprehensive abortion care - Skilled obstetric care, immediate Essential newborn care
- RTI/STI case management, newborn care and resuscitation - Care of sick newborn (SNCU, NBSU)
Postpartum IUCD and - Emergency obstetric care - Facility-based care of childhood illnesses (IMNCI)
sterilization; interval - Preventing Parent-to-Child - Care of children with severe acute
IUCD procedures Transmission (PPTCT) of HIV malnutrition (NRC)
- Adolescent friendly Postpartum sterilization Immunization
health services

Outreach/Sub-centre

Reproductive health care Antenatal care Postnatal care Child health care
Family planning (including - Full antenatal care package Early detection and First level assessment and
IUCD insertion, OCP and - PPTCT management of illnesses care for newborn and
condoms) in mother and newborn. childhood illnesses
- Prevention and - Immunization - Immunization
management of STIs - Micro-nutrient
- Peri-conception folic acid supplementation
supplementation

Family & Community

- Weekly IFA supplementation Counselling and preparation for Home-based newborn care and prompt referral
Information and counselling newborn care, breast-feeding, (HBNC scheme)
on sexual reproductive birth preparedness. Antibiotic for suspected case of newborn sepsis.
health and family planning. Demand generation for Infant and Young Child Feeding (IYCF), including
- Community based promotion pregnancy care and exclusive breast-feeding and complementary feeding.
and delivery of institutional delivery Child health screening and early
contraceptives. (JSY, JSSK). intervention services (0-18 years)
- Menstrual hygiene Early childhood development
Danger sign recognition and care-seeking for illness
Use of ORS and Zinc in case of diarrhoea

Intersectoral : Water, sanitation, hygiene, nutrition, education, empowerment.

Adolescence/Pre-pregnancy Pregnancy Newborn/postnatal Childhood

FIG. 16
Continuum of care across life cycle and different levels of health system

by R△J
 RMNCH+A

A. Adolescent Reproductive and Sexual Health - Administration of supervised weekly iron-folic acid
programme (ARSH) supplements of 100 mg elemental iron and 500 pg folic
acid using a fixed day approach.
Adolescent Reproductive and Sexual Health programme
(ARSH) focusses on reorganizing the existing public health - Screening of target groups for moderate/severe anaemia
system in order to meet service needs of adolescents. Steps and referring these cases to an appropriate health
are being taken to ensure improved service delivery for facility.
adolescents during routine sub-centre clinics and also to - Biannual de-worming (Albendazole 400 mg), six months
ensure service availability on fixed days and timings at the apart, for control of helminths infestation.
Primary Health Centre, Community Health Centre and - Information and counselling for improving dietary intake
District Hospital levels. Core package of services includes and for taking actions for prevention of intestinal worm
promotive, preventive, curative and counselling services infestation.
being made available for all adolescents - married and
unmarried, girls and boys through adolescent friendly health C. Menstrual Hygiene Scheme (1)
clinics. ARSH programme envisages creating an enabling The Ministry of Health and Family Welfare has launched
environment for adolescents to seek health care services scheme for promotion of menstrual hygiene among
through a spectrum of programmatic approaches : adolescent girls in the age group of 10-19 years in rural
- Facility based health services-Adolescent Friendly areas. This programme aims at ensuring that girls have
Health Clinics; adequate knowledge and information about menstrual
hygiene and have access to high quality sanitary napkins
- Counselling-Dedicated ARSH and ICTC counselling; along with safe disposal mechanisms. Key activities under
- Community based interventions-Outreach activities; and the scheme include :
- Capacity building for service providers. - Community based health education and outreach in the
i. Adolescent Friendly Health Clinics (AFHC): Through target population to promote menstrual health;
Adolescent Friendly Health Clinics, routine check-up - Ensuring regular availability of sanitary napkins to the
at primary, secondary and tertiary levels of care is adolescents;
provided on fixed day clinics. At present 6,302 - Sourcing and procurement of sanitary napkins;
AFHCs are functional across the country providing
- Storage and distribution of sanitary napkins to the

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services, information and commodities to more than
2.5 million adolescents for varied health related adolescent girls;
needs such as contraceptives provision, management - Training of ASHA and nodal teachers in menstrual
of menstrual problems, RTI/STI management, health; and
antenatal care and anaemia. - Safe disposal of sanitary napkins.
ii. Facility based counselling services: Counselling
services for adolescents on important issues such as CARE DURING PREGNANCY AND CHILDBIRTH (52)
nutrition, puberty, RTI/STI prevention and Pregnancy and childbirth are physiological events in the
contraception, delaying marriage and childbearing, life of a woman. Though most pregnancies result in normal
and concerns related to contraception, abortion birth, it is estimated that about 15 per cent may develop
services, pre-marital concerns, substance misuse, complications, which cannot be predicted. Most of these
sexual abuse and mental health problems are being complications can be averted by preventive care, skilled care
provided through recruitment and training of at birth, early detection of risk, appropriate and timely
dedicated counsellors. At present 881 dedicated management of obstetric complications and postnatal care.
ARSH counsellors are providing comprehensive The delivery of services during pregnancy and childbirth
counselling services to adolescents across the requires a strong element of continuum of care from
country. In 23 States/UTs, 1439 ICTC counsellors community to facility level and vice versa. While the
have been enrolled to provide sexual and antenatal package, counselling and preparation for newborn
reproductive health counselling to adolescents. care, breast-feeding, birth and emergency preparedness will
iii. Outreach activities: Outreach activities are being mainly be delivered through community outreach; skilled
conducted in schools, colleges, teen clubs, vocational birth attendance are to be provided at health facilities,
training centres, during Village Health Nutrition Day primarily 24x7 PHC and FRU. These facilities are most likely
(VHND), health melas and in collaboration with self to be the one that have been designated as “delivery points”
help groups to provide adequate and appropriate and therefore have provision for full complement of RMNCH
information to adolescents in spaces where they services. Following discharge from the health facilities,
normally congregate. mothers and newborns will be provided postnatal care
through home visits. Most of these services are already in
B. Weekly Iron and Folic Acid Supplementation (WIFS) place.
Ministry of Health and Family Welfare has launched the The priority interventions are as follows (52) :
Weekly Iron and Folic Acid Supplementation (WIFS) 1. Delivery of antenatal care package and tracking of
Programme to meet the challenge of high prevalence and high-risk pregnancies.
incidence of anaemia amongst adolescent girls and boys.
2. Skilled obstetric care.
The long term goal is to break the intergenerational cycle of
anaemia, the short term benefit is of a nutritionally 3. Immediate essential newborn care and resuscitation.
improved human capital. The programme, implemented 4. Emergency obstetric and newborn care.
across the country, both in rural and urban areas, will cover 5. Postpartum care for mother and newborn.
10.25 crore adolescents. The key interventions under this 6. Postpartum IUCD and sterilization.
programme are as follows : 7. Implementation of PC & PNDT Act.

by R△J
534 HEALTH PROGRAMMES IN INDIA

NEWBORN AND CHILD CARE Services. This should be supported by a referral transport
system that reaches the patient within 30 minutes of
The interventions in this phase of life mainly focus on
children under 5 years of age. Given below are the priority receiving a call and the health facility within the next
child health interventions that are already in place under 30 minutes. The long-term goal should be to establish and
operationalize Basic Emergency Obstetric Care and
NRHM.
Comprehensive Emergency Obstetric Care Centres as per
Priority Interventions (52) : the expected delivery load in the state and district.
1. Home-based newborn care and prompt referral. Maternal and Child Health (MCH) Wing (52)
2. Facility-based care of the sick newborn. Most health facilities, especially those at secondary and
3. Integrated management of common childhood tertiary level are having high case load of pregnant women
illnesses (diarrhoea, pneumonia and malaria). and newborn due to increase in institutional deliveries
4. Child nutrition and essential micronutrients following launch of JSY and JSSK. Therefore, it has been
supplementation. decided that dedicated Maternal and Child Health Wings
5. Immunization will be established in high case load facilities with adequate
6. Early detection and management of defects at birth, provision of beds. The new MCH wings will be
deficiencies, diseases and disability in children comprehensive units (30/50/100 bedded) with antenatal
0-18 years of age (Rashtriya Bal Swasthya Karyakram). waiting rooms, labour wing, essential newborn care room,
SNCU, operation theatre, blood storage units and a
CARE THROUGH THE REPRODUCTIVE YEARS postnatal ward and an academic wing. This will ensure
provision of emergency maternal and newborn care services
Reproductive health needs to exist across the as well as 48 hours stay, i.e., quality postnatal care to
reproductive years and therefore access to these services is mothers and newborns (52).
required in various life stages starting from the adolescence
phase. Reproductive health services include the provision SCORE CARD (52)
for contraceptives, access to comprehensive and safe
abortion services, diagnosis and management of sexually A. Health Management Information System - based
transmitted infections, including HIV. dashboard monitoring system:

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A new strategic direction has been developed for the The choice of indicators for dashboard monitoring system
family planning programme, wherein it has been are based on life cycle approach, and are as shown in
repositioned to not only achieve population stabilisation but Fig. 17.
also to reduce maternal mortality as also infant and child 1. Steps underway to include proportion:
mortality. A target-free approach based on unmet needs for - Pregnant women <19 yrs old to total women
contraception; equal emphasis on spacing and limiting registered for ANC.
methods; and promoting 'children by choice' in the context
- Home Based New born Care (HBNC) visit by ASHA
of reproductive health are the key approaches to be adopted
to planned visits.
for the promotion of family planning and improving
reproductive health. - Children 9-11 months fully immunized to children
9-11 months due for immunization.
These services will be delivered at home, through - Children with diarrhoea who were treated with ORS to
community outreach and at all levels of health facilities and children reported with diarrhoea.
include adolescents and adults in the reproductive age group.
- Children with diarrhoea who were treated with ORS
Priority interventions (52) and Zinc to children reported with diarrhoea.
- Children discharged live from SNCUs to number of
1. Community-based promotion and delivery of admissions in SNCUs.
contraceptives. - Children with ARI who received treatment to children
2. Promotion of spacing methods (interval IUCD). reported with ARI.
3: Sterilization services (vasectomies and tubectomies). 2. All India average for each indicator will be taken as the
4. Comprehensive abortion care (includes MTP Act). reference point.
5. Prevention and management of sexually transmitted 3. States scores will be determined on the basis of the
and reproductive infections (STI/RTI). national average :
- Positive scores from 1 to 4 for those above the
Delivery Points (52) national average (for positive indicators) and for those
The provision of services for delivery care in a health below the national average (for negative indicators).
facility generally serves as an important indicator to assess - Negative scores -1 to -4 for those below national
whether the facility is optimally functional or not. The average (for positive indicators) and for those above
concept of 'delivery point' emerges from this presumption. national average (for negative indicators).
Among the health facilities designated as LI, L2 and L3, 4. All the indicator scores for each state will be consolidated
there are some facilities which are conducting deliveries as state score (all indicators have the same weightage).
above a minimum bench mark (minimum 3 normal 5. States have been classified into four categories based on
deliveries per month at LI; minimum 10 deliveries per the state scores.
month, including management of complications, at L2; and
minimum 20-50 deliveries per month including C-section B. Survey based score card (52)
at L3). These are designated as delivery points. According to 19 survey based outcome and coverage indicators related
the government mandate, these facilities should be the first to health, nutrition and sanitation will be used for the score
to be strengthened for providing comprehensive RMNCH card. The indicators are as shown in Table 15.

by R△J
 SCORE CARD

Proportion of.
- 1st Trimester registration to total ANC registration.
- Pregnant women recieved 3 ANC to total ANC registration.
- Pregnant women given 100 IFA to total ANC registration.
- Cases of pregnant women with obstetric complications and attended to reported deliveries.
- Pregnant women receiving TT2 or Booster to total ANC registration.

Proportion of:
- Postpartum sterilization to
total female sterilization.
- Male sterilization to Proportion of.
total sterilization.
SBA attended home
IUD insertions in public plus
private accredited institutions deliveries to total
to all family planning methods reported home deliveries.
(IUD plus permanent). - Institutional deliveries to
total ANC registration.
Proportion of: C-Section to reported
- Newborns breast-fed within 1 hour to deliveries.
total live births. Postnatal material
- Women discharged in less than & Newborn care
48 hours of delivery in public institutions to total
number of deliveries in public institutions.
- Newborns weighing less than 2.5 kg to newborns weighed at birth.
- Newborns visited within 24 hrs of home delivery to total reported home deliveries.
Infants 0 to 11 months old who received measles vaccine to reported live births.
FIG. 17
Choice of indicators for dash board

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TABLE 15 Facility Survey, National Family Health Survey, Census,
Indicators for survey based score card Annual Health Survey.
Mortality Under-five mortality rate All India average for each indicator will be taken as a
Infant mortality rate reference point. States will be colour coded based on :
- Neonatal mortality rate
Maternal mortality ratio - Mortality indicators, nutrition, fertility: Green - less than
(per 100,000 live births) 20% of the national average, Yellow - 20% below and
Fertility Total fertility rate above national average, Red - more than 20% of the
- Births to women during age 15-19 national average.
out of total births. - Remaining Indicators: Green - more than 20% of the national
Nutrition - Children with birth weight less than 2.5 kg average, Yellow - 20% below and above the national
Children under 3 years who are underweight average, Red - less than 20% of the national average.
Gender - Child sex ratio 0-6
The score card will be updated as and when (every 1-2
Cross-cutting - Full Immunization
Children (12-23 months) receiving
years) new survey data is available.
1 dose BCG, 3 doses of Pentavelent/OPV/
1 dose IPV each and 2 measles vaccine. REPRODUCTIVE, MATERNAL, NEWBORN,
- Household having access to toilet facility
Couple using spacing method for more
CHILD, ADOLESCENT HEALTH “PLUS”
than 6 months. NUTRITION STRATEGY (RMNCAH+N)
Diarrhoea ORT or increased fluids for diarrhoea
(among children <2 years of age Due to the importance of nutrition across all life stages,
who had diarrhoea in preceding the strategy now includes nutrition as one of its important
2 weeks) pillars. RMNCAH+N strategy thus covers Reproductive,
Pneumonia - Care seeking for ARI in any health facility Maternal, Newborn, Child and Adolescent Health and the
(Among children <2 years of age who “plus” within it focuses on Nutrition, as well as important
had ARI in preceding 2 weeks). linkages between these services and with other components
Service Delivery - Woman who received 4 + ANC like family planning, adolescent health, HIV, gender, and
- Skilled Birth Attendance (delivery by preconception and prenatal diagnostic techniques. It also
doctor, ANM/Nurse/LHV). focuses on linkages between community-based services and
Mothers who recieved postnatal care from a facility-based services and ensures referrals, and counter­
doctor/nurse/LHV/ANM/other health
personnel within 2 days of delivery for referrals between various levels of health care system to
their last birth (%). create a continuous care pathway.
- Early initiation of breast-feeding (< 1 hr) The life course approach determines equal care and
- Exclusive breast-feeding for 6 months interventions to address both men and women in the
(among 6-9 months children)
community addressing the gender disparity in health seeking
Latest available data from national surveys will be taken behaviour and health education and promotion at all levels.
into consideration including Sample Registration System, The interlinkages between different life stages are
Coverage Evaluation Survey, District Level Household and summarized in Fig. 18.

by R△J
536 HEALTH PROGRAMMES IN INDIA

Both support Becomes

each other pregnant
1 not before 20
years of age
____________ i___________ OR
HEALTHY ADULT MAN HEALTHY ADULT WOMAN 2. at least 2 HEALTHY PREGNANT WOMAN
years after
• Maintains good nutritional Maintains good nutritional previous • Takes essential ANC services
status status childbirth OR • Receives essential care at home,
• Free from STI/RTI/HIV Free from anaemia 3. at least 6 birth preparedness
• Has knowledge about Free from STI/RTI/HIV months after • Takes nutritious diet, IFA and
contraception Aware about contraception an abortion calcium supplementation
• Plans with partner about when Plans with partner about when • Recognize danger signs
to become a parent to become a parent • Has knowledge about healthy
spacing and contraception

HEALTHY ADOLESCENT BOY/GIRL

• Have normal growth with good
nutritional status
• Free from anaemia
J RMNCAH+N:
Life cycle
k •
HEALTHY MOTHER (POST PARTUM)
Receives PNC care at home
• Aware of body changes, functions & approach • Takes nutritious diet

F
menstrual hygiene • Free from complications
• Aware about risks involved in teenage • Initiates breastfeeding immediately
pregnancy and how to prevent it after delivery
• Aware about prevention of RTIs/STIs/HIV • Adopts contraception during or just
& is free from these infections after postpartum period

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FIG. 18
Interlinkages between different life stages
Source : (65)

In India, Newborn Action Plan (INAP) developed in

INDIA NEWBORN ACTION PLAN (INAP) response to the global Every Newborn Action Plan (ENAP),
In the past two decades, there has been remarkable was launched in June 2014. The plan outlines a targetted
progress in the survival of mother and children beyond the strategy for accelerating the reduction of preventable
newborn period. Presently, the newborn health has captured newborn deaths and stillbirths in the country. INAP defines
the attention of the policy makers and two important the latest evidence on effective interventions which will not
milestones in this direction have been the National Rural only help in reducing the burden of stillbirths and neonatal
Health Mission and the Reproductive, Maternal, Newborn, mortality, but also maternal deaths. The goal is to attain
Child and Adolescent Health Strategy (RMNCH+A “Single Digit Neonatal Mortality Rate by 2030” and “Single
Strategy), NRHM has provided unprecedented attention and Digit Stillbirth Rate by 2030”.
resources for newborn health. By adopting RMNCH+A The INAP will be implemented within the existing
strategy in 2013, the country observed a paradigm shift in RMNCH+A framework, and guided by the principles of
its approach towards health care. Newborn health occupies integration, equity, gender, quality of care, convergence,
centre stage in the overall strategy as all the inter-linkages accountability and partnerships. Its strength is built on its six
between various components have the greatest impact on pillars of intervention packages impacting stillbirths
the mortality and morbidity rates of the newborn. and newborn health, which includes : (a) Pre-conception

by R△J
 INDIA NEWBORN ACTION PLAN (INAP)

and antenatal care; (b) Care during labour and childbirth; b. Situational [S], implementation dependent on
(c) Immediate newborn care; (d) Care of the healthy epidemiological context; and
newborn; (e) Care of small and sick newborn; and (f) Care c. Advanced [A], implementation based on health­
beyond newborn survival. For effective implementation, a system capacity of the state/district.
systematic plan of monitoring and evaluation has been
The states are urged to develop their own action plans
developed with a list of dashboard indicators (48).
based on the six packages described below :
The interventions under the National Health Mission
focussing on newborns are shown in Table 16. 1. Pre-conception and antenatal care
Health interventions must start well before conception
Strategic Intervention Packages (48) and their impact on the neonatal and stillbirth outcome
The interventions are grouped in six packages, requires equivalent consideration. The importance of
corresponding to the various life stages of the newborn. It is antenatal care for improved neonatal and perinatal outcome
estimated that high coverage of available intervention is well established; however, coverage of a few salient
packages can prevent almost three-quarters of the newborn interventions needs increased attention (e.g., use of long
deaths, one-third of stillbirths and half of the maternal lasting insecticide treated nets and intermittent preventive
deaths by 2025. treatment of malaria, antenatal syphilis screening combined
with treatment and increased emphasis on early detection,
The interventions have been categorized as : and prompt treatment of complications in pregnancy such as
a. Essential [E], to be implemented universally; pre-eclampsia, type-2 diabetes).

TABLE 16
Interventions under National Health Mission focussing on newborns

Programme (Year) Objectives Status

Janani Suraksha Yojana Safe motherhood intervention to increase Implemented in all states and union territories (UTs).
(JSY) (2005). institutional delivery through demand-side Special focus on low-performing states.

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financing and conditional cash transfer.
Integrated Management of Standard case management of major causes Operationalised in more than 500 districts
Neonatal and Childhood of neonatal and childhood morbidity 5.9 lakhs health and other functionaries, including
Illnesses (IMNCI) at the and mortality. physicians, nurses, AWWs, and ASHAs trained
community level and F-IMNCI under IMNCI.
at health facilities (2007). 26,800 medical officers and specialists placed at the
CHCs/FRUs trained under F-IMNCI.
Navjat Shishu Suraksha Basic newborn care and resuscitation - 1.3 lakh health providers trained to-date.
Karyakram (NSSK) (2009). training programme.
Janani Shishu Suraksha Zero out-of-pocket expenditure for maternal - Implemented in all states and UTs.
Karyakram (JSSK) and infant health services through free - Assured service package benefits extended to sick
(2011). healthcare and referral transport entitlements. children upto age one
Facility Based Newborn Newborn care facilities at various levels of - 20,337 NBCCs established at delivery points to
Care (FBNC) public health services that includes Newborn provide essential newborn care.
(2011). Care Corners (NBCCs) at all points of - 2,579 NBSUs established at CHCs/FRUs
childbirth to provide immediate care, - 894 SNCUs established at district/sub-district
Newborn Stabilization Units (NBSUs) at hospitals or medical colleges.
CHC/FRUs for management of selected - More than 6,300 personnel provided FBNC training.
conditions and to stablize sick newborns - Online reporting system adapted and scaled up in
before referral to higher centres; and Special seven states with 245 SNCUs made online and
Newborn Care Unit (SNCUs) at district/ more than 2.5 lakhs newborns registered in
sub-district hospitals to care for sick newborns the data base.
(all types of care except assisted ventilation
and major surgeries).
Home Based Newborn Provision of essential newborn care to all - Implemented in all states and UTs
Care (HBNC) newborns, special care of preterm and - Most of the ASHAs trained in newborn care.
(2011). low-birth-weight newborns; early detection - ASHAs visited more than 12 lakhs newborns in 2013.
of illness followed by referral; and support to
family for adoption of healthy practices,
by ASHA worker.
Rashtriya Bal Swasthya Screening of children with birth defects, ~ All children, ages 0 to 18 years targeted.
Karyakram (RBSK) diseases, deficiencies, and developmental - More than 8 crore children screened and more than
(2013). delays (including disabilities). 10 lakhs children identified for tertiary care in 2013.

Source : (48)

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538 HEALTH PROGRAMMES IN INDIA

The strategic interventions for pre-conception and The strategic interventions for care during labour and
antenatal care for newborns are given below. child birth are given below :
Pre-conception and antenatal care interventions package Care during labour and childbirth
Family and community Family and community

1 Reproductive health & family planning [E] 1. Skilled birth attendance [E]
- Adolescent reproductive health 2. Clean birth practices [E]
Delaying age of marriage and first pregnancy
Birth spacing Outreach/Sub-centre
2. Nutrition related interventions [E] . 3. Identification of complications and timely referral [E]
- Balanced energy protein supplementation
4 Pre-referral dose by ANM [EJ .
Peri-conceptional folic acid - Antenatal corticosteriods in preterm labour
- Maternal calcium supplementation - Antibiotics for premature rupture of membranes
Multiple micronutrient supplementation
(Iron, folic acid and iodine) Health facility
- Nutrition counselling
5. Emergency obstetric care [E]
3 Counselling and birth preparedness [E]
- Basic and comprehensive
4 Prevention against malaria [S]
6 Management of preterm labour [E]
Outreach/Sub-centre - Antenatal corticosteroids in preterm labour
- Antibiotics for premature rupture of membranes
5. Antenatal screening for anaemia and hypertensive disorders
of pregnancy (PIH, preeclampsia, eclampsia) [E]
6 Antenatal screening for malaria [S] 3. Immediate newborn care
7. Prevention and management of mild to moderate anaemia [E] Immediate care is the basic right of every newborn baby.
8. Maternal tetanus immunization [E] This package includes interventions such as immediate

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9. Adolescent friendly health services (nutrition and reproductive drying and stimulation, provision of warmth, hygienic care,
health counselling) [E] early initiation of breast-feeding, and administration of
10. Interval IUCD insertion [E] vitamin K. For babies who do not breathe at birth, neonatal
resuscitation is a crucial life-saving intervention.
Health facility Resuscitation training of providers in facilities reduces
intrapartum-related neonatal deaths and early neonatal
11. Antenatal screening and management of severe anaemia, deaths substantially. Hypothermia is a risk factor for
hypertensive disorders of pregnancy (PIH, preeclampsia, neonatal mortality, especially in cases of preterm and low
eclampsia), gestational diabetes, syphilis [E]
birth weight babies. All steps should be taken to prevent arid
12. Antenatal screening and management of hypothyroidism, manage hypothermia, and rooming-in of babies with mother
hepatitis B, HIV, malaria [S]
must be universally practiced. Delayed cord clamping in
13. Adolescent friendly health clinics (as per RKSK guidelines) [E] newborns, including pre-term babies is associated with
14. Postpartum family planning services including decreased risk of anaemia and intraventricular
PP1UCD insertion [E] haemorrhage. Administration of vitamin K at birth prevents
15. Prevention of Rh disease using anti D immunoglobulin [S] haemorrhagic disease of newborn.
The strategic interventions for immediate newborn care
2. Care during labour and childbirth are given below :
Intra-partum complications and preterm births remain a Immediate newborn care
challenge to the neonatal survival. Care during labour and
childbirth have the potential to reduce stillbirths by a third. It Family and community
is important to emphasize that BEmOC can reduce intra-
partum-related neonatal deaths by 40% and CEmOC can 1. Delayed cord clamping [E]
also reduce newborn mortality by 40%, whereas skilled 2 Interventions to prevent hypothermia [E] :
attendance at birth alone without access to the emergency - Immediate drying
component has a smaller effect at 25%. Care at childbirth - Head covering
also has additional benefits on child survival, improved Skin-to-skm care
growth, reduced disability and non-communicable diseases.
- Delayed bathing
Antenatal corticosteroids use to manage preterm labour 3. Early initiation and exclusive breast-feeding [E]
not only reduces neonatal deaths by 31%, but this 4 Hygiene to prevent infection [E]
intervention is also associated with reduced need of
specialized care for newborns, such as ventilators, etc. Outreach/Sub-centre
Antibiotics administration for pre-mature rupture of
5. Vitamin K at birth [E]
membranes (PROM) reduces early-onset postnatal sepsis.
Clean birth practices especially hand-washing with soap and 6. Neonatal resuscitation [E]
water by birth attendant has been found to reduce mortality Health facility
due to sepsis in births at home (15%), facilities (27%), and
during postnatal period (40%). 7. Advanced neonatal resuscitation [E]

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 INDIA NEWBORN ACTION PLAN (INAP) 539
4. Care of healthy newborn 5. Care of small and sick newborn
Evidence shows that community-based interventions can Specific interventions for small and sick newborns
significantly improve child survival. A large number of include Kangaroo mother care (KMC). KMC involves
ASHAs have been trained to perform various preventive and package of early and continuous skin-to-skin contact,
promotive health activities, such as counselling of mothers breast-feeding support, and supportive care in stable
on breast-feeding, complementary feeding, immunization, newborns weighing less than 2000 gm. KMC can be
care-seeking, promoting nutrition, sanitation, and safe practiced even at home, thus improving chances of
drinking water, etc. Despite the significant increase in newborn survival.
institutional deliveries, home deliveries persist to about 25%
to 40% in pockets across states. Even in cases of institutional Strategic interventions for care of small and sick newborn
deliveries, most women tend to return home within a few include :
hours after delivery. For women who stay at the institution
for 48 hours or more, it is also important to provide care to Care of small and sick newborn
the neonate at home for the remaining critical days of the
first week and upto the 42nd day of life. Home visitation by
ASHAs can contribute significantly to delivery of Family and community
interventions with focus on the newborn period. Regular
and timed contacts with the newborn are essential for 1. Thermal care and feeding support (for home deliveries) [E]
ensuring continued exclusive breast-feeding, appropriate Outreach! Sub-centre
immunization, and care-seeking of children with danger
signs. 2. Integrated management using IMNCI and use of oral
The interventions for care of healthy newborn are given antibiotics [E]
below : 3. Injectable Gentamicin by ANMs for sepsis [E] .
- Pre -referral
Care of healthy newborn
- Completion of antibiotic course in case referral is refused/
not possible "OR" as advised by treating physician.
Family and community

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Health facility
1. Home visits till six weeks by trained ASHA [E]
- Counselling 4. Kangaroo mother care at facility [E]
- Prevention of hypothermia, cord care 5. Full supportive care at block and district level [E] :
- Early identification of danger signs - NBSU at block level
Prompt and appropriate referral - SNCU at district level
2 Exclusive breast-feeding [E] 6. Intensive care services (NICU) at regional level [A] for -
3. Clean postnatal practices [E] - Assisted ventilation
- Surfactant use
Outreach! Sub-centre
- Surgery
4. Immunization [E] :
- BCG
6. Care beyond newborn survival
- OPV
- Hepatitis B This is a new package considering the burden of birth
Pentavalent vaccine defects and development delays in newborns. It is of
particular significance for SGA and preterm newborns, as
Health facility well as newborns discharged from SNCUs.
All the interventions (except home visits) The table below lists the interventions to care for
newborns beyond their survival.

Care beyond newborn survival

Family and community Outreach!Sub-centre Health facility

1. Screening for birth defects, failure to 3. As before 4. Newborn screening [A]

thrive and developmental delays [E]
5 Management of birth defects [E]:
2. Follow-up visits of [E] :
- Diagnosis
SNCU discharged babies till
1 year of age Treatment, including surgery

-- Small and low birth weight babies 6. Follow-up of high-risk infants

till 2 years of age (discharged from SNCUs and small
newborns) for -
- Developmental delay
- Appropriate management

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540 HEALTH PROGRAMMES IN INDIA

Monitoring and evaluation (48) with ENAP - i.e., 2025, 2030, and 2035.
A comphrehensive assessment of targets would be done Following core indicators (dashboard indicators) have
in 2020, which will help plan course corrections, if any, in been selected for monitoring, based on direct relevance to
on-going interventions. Further, from the year 2020, the the action plan framework, targets, goals, and review of
milestones will be reviewed every five years keeping in sync current data availability.

Dashboard indicators for INAP

Level and focus areas Indicators

Impact level indicators - Birth registration
- Stillbirth rate
— Early neonatal mortality rate
Neonatal mortality rate
Percentage of neonatal deaths to under-5 deaths
- Survival rate of newborns discharged from SNCU/NICU at one year of age
- Cause-specific neonatal mortality
Pre-conception & antenatal care - Births to women aged 15-19 years out of total births (teenage pregnancy)
Percentage of pregnant women who received full ANC
- Percentage of pregnant women detected and treated with severe anaemia
- Percentage of pregnant women detected and treated with PIH
Care during labour and child birth - Percentage of safe deliveries (institutional 4- home deliveries by SBA)
- Percentage of preterm births
- Caesarean section rate
- Percentage of women with preterm labour (< 34 weeks) receiving at least one dose of
antenatal corticosteroid
- Intra-partum stillbirth rate

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Immediate newborn care - Percentage of newborns breast-fed within one hour of birth
- Percentage of newborns delivered at health facility receiving vitamin K at birth
- Percentage of labour room staff trained in Navjat Shishu Suraksha Karyakram
- Percentage of newborns weighed at birth
- Percentage of low birth weight babies
Care of healthy newborn - Percentage of newborns received complete schedule of home visits under HBNC by ASHAs
- Percentage of sick newborns identified during home visits by ASHAs
- Exclusive breast-feeding rate
Percentage of mothers stayed for 48 hrs in the facility
- Percentage of newborn received birth dose of Hepatitis B, OPV and BCG
Care of small and sick newborn - Percentage of district hospitals with functional SNCU
Percentage of facilities with SNCUs having functional KMC units
- Percentage of female admissions in SNCU
- Mortality rate in newborns with admission weight < 1800 gm
- Percentage of newborn deaths due to birth asphyxia
- Percentage of newborns with suspected sepsis receiving pre-referral dose of gentamicin by ANM
Care beyond survival - Percentage of newborns screened for birth defects (facility 4- community)
- Percentage of newborns with any defect seen as birth
- Percentage of newborns discharged from SNCU followed up till one year of age
- Percentage of districts with functional District Early Intervention Centre (DEIC)

development for geriatric services, medical rehabilitation

NATIONAL PROGRAMME FOR HEALTHCARE I and therapeutic intervention and Information Education &
OF THE ELDERLY (NPHCE) (45) | Communication (IEC) are some of the strategies envisaged
Government of India has launched the “National in the NPHCE.
Programme for Health Care of the Elderly” (NPHCE) to It is expected to cover other districts in a phased manner.
address health related problems of elderly people, in 100 12 regional geriatric centres in selected medical colleges of
identified districts of 21 states during the 11th Plan period. the country are expected to be developed under the
8 regional geriatrics centres as referral units have also been programme. In addition, 2 National Centre of Ageing (NCA)
developed in different regions of the country under the are being established at AIIMS, New Delhi and Madras
programme. Medical College, Chennai, the core functions of which are
The basic aim of the NPHCE Programme is to provide training of health professionals, research activity and
separate, specialized and comprehensive healthcare to the healthcare delivery in the field of geriatrics.
senior citizens at various level of state healthcare delivery The details of the geriatric setup and activities
system including outreach services. Preventive and undertaken so far under the programme at various
promotive care, management of illness, health manpower healthcare levels are as below (7) :
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 NPCDCS

Department of Geriatric at 20 Super Specialized under the programme. During 12th Five Year Plan, the
Institutions : Geriatric Departments are being developed at 8 programme has covered all the districts of the country in a
identified medical institution located in various regions of phased manner (7).
the country with 30 bedded in-patient facility. Apart from
providing referral treatment, research and manpower A. Diabetes, Cardiovascular Disease and Stroke
development, these institutions are involved in developing (DCS) Component under NPCDCS
and updating training materials for various levels of health The programme focuses on the health promotion,
functionaries, developing IEC material, guidelines, etc. capacity building including human resource development,
Funds have been provided for manpower, equipments, early diagnosis and management of these diseases with
medicines, construction of building, training etc. integration with the primary health care system.
Geriatric unit at district hospitals: The programme is The major objectives of the programme are as
approved for implementation in 2017-2018 in 520 districts, follows (7) :
covering 35 states. There is provision for establishing 10 - Prevent and control common NCDs through behaviour
bedded geriatric wards and dedicated OPD services and lifestyle changes.
exclusively for geriatric patients. The grant-in-aid has been - Provide early diagnosis and management of common
provided for contractual manpower, equipments, medicines, NCDs.
construction of building, training etc.
- Build capacity at various levels of health care for
Rehabilitation Units at CHCs falling under identified prevention, diagnosis and treatment of common NCDs.
districts : There is provision for dedicated health clinics for - Train human resource within the public health set-up
the elderly persons twice a week. A rehabilitation unit is viz doctors, paramedics and nursing staff to cope with
being set up at all the CHCs falling under identified the increasing burden of NCDs, and
districts.The grant-in-aid has been provided for manpower,
- Establish and develop capacity for palliative &
equipments, training. The rehabilitation worker is supposed
rehabilitative care.
to provide physiotherapy to the needy elderly persons.
Activity at PHCs under identified districts: Weekly The programme is to be implemented in 20,000
geriatric clinics are arranged at the identified PHCs by a sub-centres and 700 community health centres (CHCs) in
trained Medical Officer. For diseases needing further 100 districts across 21 States/UTs and the strategies include
investigation and treatment, persons will be referred to the promoting healthy lifestyle through massive health

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first referral unit i.e. the Community Health Centre or education and mass media efforts at country level,
District Hospital as per need. One-time grant is given to opportunistic screening of persons above the age of
PHCs for procurement of equipment. 30 years, establishment of Non-Communicable Disease
(NCD) Clinic at Community Health Centre (CHC) and
Activity at Sub-centre under districts: The ANMs/Male District level, development of trained manpower and
Health Workers posted in sub-centre will make domiciliary strengthening of tertiary level health facilities. For long-term
visits to the elderly persons in area under their jurisdiction. sustainability of the programme, service delivery will be
She/he will arrange suitable calipers and supportive devices through existing public health infrastructure and systems.
from the PHC and provide the same to the elderly disabled The various approaches such as mass media, community
persons to make them ambulatory. Also, there will be a education and interpersonal communication will be used for
provision for treatment of minor ailments and rehabilitation behavioural change focusing on the following messages :
equipment at the identified sub centers.
- Increased intake of healthy foods
The tertiary component of the programme has been - Increased physical activity
renamed as “Rashtriya Varishth Jan Swasthya Yojana”
- Avoidance of tobacco and alcohol
(RVJSY).
- Stress management.
NATIONAL PROGRAMME FOR PREVENTION Activities at Sub-Centre
AND CONTROL OF CANCER, DIABETES, Health promotion for behaviour and lifestyle change will
CARDIOVASCULAR DISEASES AND be carried out by organizing various camps, interpersonal
STROKE (NPCDCS) communications, posters, banners, etc. Opportunistic
screening of population above 30 years will be carried out
India is experiencing a rapid health transition with large using BP measurement and blood glucose by strip method.
and rising burden of chronic non-communicable diseases The suspected cases of diabetes and hypertension will be
(NCDs) especially cardiovascular disease, diabetes mellitus, referred to CHCs of higher health facility for further
cancer, stroke, and chronic lung diseases. It is estimated that diagnosis and management. For screening of diabetes,
in 2016 NCDs accounted for 60 per cent of deaths. glucometer optium xceed, optium test strips and auto
Considering the fact that NCDs are surpassing the burden of disabled lancets are being procured at central level and
communicable diseases in India and the existing health provided to the concerned states as per their requirements
system is mainly focussed on communicable diseases, need from time to time.
for National Programme on Prevention and Control of
Diabetes, Cardiovascular Diseases and Stroke was Activities at CHC
envisaged. Later on this programme was integrated with NCD clinic at CHC shall do the diagnosis by required
National Cancer Control Programme, and National investigations/test like blood sugar measurement, lipid
Programme for Prevention and Control of Cancer, Diabetes, profile, ultrasound, X-ray and ECG etc., management and
Cardiovascular Diseases and Stroke (NPCDCS) came into stabilization of common CVD, diabetes and stroke cases
existence. During the 11th Five Year Plan period, (out-patient as well as in-patients). One of the nurses
100 identified districts in 21 states have been covered appointed under the programme shall undertake home visits

by R△J
 HEALTH PROGRAMMES IN INDIA

for bedridden cases, supervise the work of health workers national strategy for management of TB and diabetes
and attend monthly clinics being held in the villages on a comorbidities in India.
random basis. Complicated cases of diabetes, high blood
pressure etc. shall be referred from CHC to the district Guidelines for referral and treatment (66)
hospital for further investigations and management. Government of India has developed operational
guidelines (2016) for prevention, screening and control of
Activities at district hospital common non-communicable diseases. The guidelines for
NCD clinic at district hospital shall screen persons above referral, treatment and for ensuring the continuity of care
the age of 30 years for diabetes, hypertension, are as follows :
cardiovascular diseases etc. to identify individuals who are 1. Those with a systolic blood pressure of over 140 and a
at a high-risk of developing diabetes, hypertension and diastolic blood pressure of over 90 mm of Hg, or random
CVDs warranting further investigation/action. Detailed blood sugar of 140 mg/dl and above would be referred to
investigation will be done in respect of persons those who a medical officer, at the nearest facility, for confirmation,
are at high-risk of developing NCDs on screening and those conducting relevant laboratory investigations and
who are referred from CHCs. They shall provide regular initiation of treatment.
management and annual assessment of persons suffering
from cancer, diabetes and hypertension. People with 2. Those who are found positive for cancer/precancerous
established cardiovascular diseases shall also be managed at lesions will be referred by ANM/Staff Nurse in specified
district hospital. They shall provide home based palliative screening sites to the appropriate PHC/CHC/District
care for chronic, debilitating and progressive patients. Apart Hospital for confirmation and treatment by trained
from clinical services, district hospital shall be involved in specialist, as per the operational frame work developed
promotion of healthy lifestyle through health education and for cancer screening and management.
counselling to the patients and their attendants. 3. Once the diagnosis of Hypertension/diabetes is
established, the patient must receive at least a month’s
Urban health check-up scheme for diabetes and high supply of drugs from the PHC. Once the condition is
blood pressure stable, the state could also decide to provide the patient
with a three-month supply, with the ANM/ASHA visiting
The scheme has the following objectives : the patient each month for ensuring compliance, checking
1. To screen urban slum population for diabetes and high on diet and life style modification, and measuring the

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blood pressure. blood pressure/blood glucose. Alternatively, a three-
2. To create database for prevalence of diabetes and high month drug supply could be stocked with the ANM at sub­
blood pressure in urban slums. centre, to be given each month. Either way, sufficient drug
3. To sensitize the urban slum population about healthy supplies need to be made available at the PHC.
lifestyle. 4. The patient will need to go to the PHC for the first follow
up at the end of the first three months after diagnosis, and
The blood sugar and blood pressure will be checked for
all > 30 years and all pregnant women of all age. sooner if required. An annual specialist consultation at the
nearest nodal CHC with NCD clinic, is also recommended,
The NCD cells at the centre, state and district will based on the decision of the MO at the PHC.
implement and monitor the National Programme for 5. For those individuals who are already on treatment
Prevention and Control of Cancer, Diabetes, CVD and under the care of a private practitioner, they could be
Stroke (NPCDCS) in various states. The national NCD cell offered the choice of taking drugs from the public health
has been established at the centre. system, after appropriate confirmation. However, these
Achievements under the programme individuals would be visited regularly by the frontline
workers, monitored for compliance with treatment/
As on 31st March 2021, the programme is under lifestyle changes and recorded in the health card.
implementation in all 36 states/UTs. The facilities available
6. Community Follow up of these individuals would be by
are as shown in Table 17.
the ASHA making visits to enable positive behaviour
TABLE 17 modifications, treatment compliance, and encouraging
Comparative progress in achievements 2014-2021 patients to go the sub-centre for regular check-up of BP/
Facilities As on 31st As on 31st blood glucose. Some states have also provided the
March, 2014 March, 2021 ASHA with BP apparatus and glucometers to undertake
regular examinations at the village level. The ASHA will
State NCD Cells 21 36 prioritize those households where there are treatment
District NCD Cells 96 684 defaulters or those who experience complications. The
District NCD Clinics 95 640 aim is to minimize treatment defaulters and to achieve
District CCD facilities 51 194 hypertension and glycaemic control at an individual and
District Day Care Centres 38 239 population level. The ANM would also conduct regular
CHC NCD Clinics 204 5148 home visits.
Source : (6) WHO has developed a comprehensive global monitoring
New initiatives under the programme framework for prevention and control of NCDs (2013—
2020), which was endorsed by World Health Assembly in
1. Intervention for prevention and control of Rheumatic May 2013. This includes nine voluntary targets to monitor
Heart Disease under NPCDCS and Rashtriya Bal the progress made in the implementation of the programme.
Swasthya Karyakram (RBSK). India is committed to implementation of the action plan and
2. Integration of AYUSH with NPCDCS. take necessary steps to meet the objectives. The indicators
3. Integration of RNTCP with NPCDCS to articulate a and targets are as shown in Table 18 (67).

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 NPCDCS

TABLE 18
Indicators and targets for NCD prevention and control in India
Targets
Framework element
Outcome 2020 2025
Premature mortality Relative reduction in overall mortality from cardiovascular
10% 25%
from NCDs disease, cancer, diabetes, or chronic respiratory disease
Alcohol use Relative reduction in alcohol use 5% 10%
Obesity and diabetes Halt the rise of obesity and diabetes No mid-term Halt the rise in obesity
prevalence target set and diabetes prevalence

Physical inactivity Relative reduction in prevalence of insufficient physical activity 5% 10%

Raised blood pressure Relative reduction in prevalence of raised blood pressure 10% 25%
Salt/sodium intake Relative reduction in mean population intake of salt,
with aim of achieving recommended level of 20% 30%
less than 5 gms per day
Tobacco use Relative reduction in prevalence of current tobacco use 15% 30%
Drug therapy to Eligible people receiving drug therapy and counselling
prevent heart attacks (including glycaemic control) to prevent heart attacks 30% 50%
and strokes and strokes
Essential NCD medicines Availability and affordability of quality, safe and efficacious
and basic technologies to essential NCD medicines including generics, and basic 60% 80%
treat major NCDs technologies in both public and private facilities
Household indoor Relative reduction in household use of solid fuels as a
air pollution primary source of energy for cooking 25% 50%

Source : (67)

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B. Cancer component under NPCDCS gaps in the availability of cancer treatment facilities in the
Cancer is an important public health problem in India, country. Central assistance is provided for purchase of
with nearly 10 lakh new cases occurring every year in the equipment, which include a cobalt unit besides other
country. It is estimated that there are 2.8 million cases of equipment. A part of the grant can be used for the civil work
cancer in the country at any given point of time. With the but the manpower is to be provided by the concerned state
objectives of prevention, early diagnosis and treatment, the government/institution. The quantum of central assistance is
national cancer control programme was launched in Rs. 3 crores per institution under the scheme.
1975-76. In view of the magnitude of the problem and gaps 3. Decentralized NGO scheme
in the availability of cancer treatment facilities across the
country, the programme was revised in 1984-85 and This scheme is meant for 1EC activities and early
subsequently in December 2004. During 2010, the detection of cancer. The scheme is operated by the nodal
programme was integrated with National Programme on agencies and the NGOs are given financial assistance for
Prevention and Control of Diabetes, Cardiovascular Disease undertaking health education and early detection activities
and Stroke. The objectives of the programme are : of cancer.
a. Primary prevention of cancers by health education; 4. IEC activities at central level
b. Secondary prevention i.e. early detection and IEC activities at the central level are to be initiated in
diagnosis of common cancer such as cancer of cervix, order to give wider publicity about the Anti-Tobacco
mouth, breast and tobacco related cancer by Legislation for discouraging consumption of cigarettes and
screening/self examination method; and other tobacco related products, and for creating awareness
c. Tertiary prevention i.e. strengthening of the existing among masses about the ill effects of consumption of
institutions of comprehensive therapy including tobacco and tobacco related products. Under this scheme
palliative care. wider publicity would also be given about the rules being
The schemes under the revised programme are : formulated for implementation of various provisions of the
anti-tobacco legislation. November 7th is observed as
1. Regional Cancer Centre Scheme National Cancer Awareness Day in the country.
The existing regional cancer centres are being further 5. Research and training
strengthened to act as referral centres for complicated and
Training programmes, monitoring and research activities
difficult cases at the tertiary level. One time assistance of
will be organized at the central level under this scheme.
Rs. 3 crores during the plan period is provided to Regional
Following training manuals have been developed under the
Cancer Centres except TMH, Mumbai and IRCH (AIIMS) for
NCCP for capacity building in cancer control at district level:
strengthening and to the CNCI, Kolkata on the approved
pattern of funding. a. Manual for health professionals
b. Manual for cytology
2. Oncology Wing Development Scheme c. Manual for palliative care
This scheme had been initiated to fill up the geographic d. Manual for tobacco cessation

by R△J
 HEALTH PROGRAMMES IN INDIA

Cancer services under national programme for prevention On 24th September 2015, Government of India notified
and control of cancer, diabetes, CVD and stroke (46) : that the rules on “tobacco pack pictorial warnings” would
1. Common diagnostic services, basic surgery, come into effect from 1st April 2016. These rules mandate
chemotherapy and palliative care for cancer cases is display of pictorial health warnings on 85 per cent of the
being made available at 100 district hospitals. principle display area of tobacco product pack on both sides
2. Each district is being supported with Rs. 1.66 crores per (60 per cent of the picture and 25 per cent of the text).
annum for the following : National Tobacco Control Programme (3) : In order
- Chemotherapy drugs are provided for 100 patients at to facilitate the implementation of the Tobacco Control
each district hospital. Laws, to bring about greater awareness about the harmful
- Day care chemotherapy facilities is being established effects of tobacco, and to fulfill the obligations under the
at 100 district hospitals. WHO-Framework convention on tobacco control, Govt, of
- Facility for laboratory investigations including India has launched a new National Tobacco Control
mammography is being provided at 100 district Programme in the 11th Five Year Plan. Pilot phase was
hospitals and if not available, this can be outsourced launched in 16 districts covering 9 states in 2007-08. It now
at government rates. covers 108 districts in 31 states in the country. The main
components of the programme are :
3. Home based palliative care is being provided for chronic,
debilitating and progressive cancer patients at 100 districts. 1. Public awareness/mass media campaigns for awareness
4. Support is being provided for contractual manpower building and for behavioural change;
through 1 Medical Oncologist, 1 Cytopathologist, 2. Establishment of tobacco product testing laboratories, to
1 Cytopathology technician, 2 Nurses for day care. build regulatory capacity, as required under COTPA,
5. State Cancer Institutes will provide comprehensive cancer 2003;
diagnosis, treatment and care services. SCI will be apex 3. Mainstreaming the programme components as a part of
institution in the state for cancer treatment activities. the health delivery mechanism under the NRHM
framework;
6. 45 centres were to be strengthened as Tertiary Cancer
Centres (TCCs) to provide comprehensive cancer care 4. Mainstream research and training on alternate crops and
services at a cost of Rs. 6.00 crore each during 2011-12. livelihood, with other nodal ministries;
5. Monitoring and evaluation, including surveillance, e.g.
adult tobacco survey;

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NATIONAL TOBACCO
CONTROLPROGRAMME 6. Dedicated tobacco control cells for effective
implementation and monitoring of anti-tobacco initiatives;
A comprehensive tobacco control legislation titled “The 7. Training of health and social workers, NGOs school
Cigarettes and other Tobacco Products (Prohibition of teachers etc;
Advertisement and Regulation of Trade and Commerce, 8. School programme; and
Production, Supply and Distribution) Act, 2003” was passed 9. Provision of tobacco cessation facilities.
by the parliament in April, 2003 and notified in Gazette of
India on 25th Feb, 2004. The important provisons of the Act NATIONAL MENTAL HEALTH PROGRAMME
are :
a. Prohibition of smoking in public places; The National Mental Health Programme was launched
b. Prohibition of direct and indirect advertisement of during 1982 with a view to ensure availability of Mental
cigarette and other products; Health Care Services for all, especially the community at risk
and underprivileged section of the population, to encourage
c. Prohibition of sale of cigarette and other tobacco
application of mental health knowledge in general health
products to a person below the age of 18 years,
care and social development. A National Advisory Group on
d. Prohibition of sale of tobacco products near the mental health was constituted under the Chairmanship of
educational institutions; the Secretary, Ministry of Health and Family Welfare for the
e. Mandatory depiction of statutory warnings (including effective implementation of the National Health Programme.
pictorial warnings) on tobacco packs; and Eleven institutions have been identified for imparting
f. Mandatory depiction of tar and nicotine contents training in basic knowledge and skills in the field of mental
alongwith maximum permissible limits on tobacco health to the primary health care physicians and para­
packs. medical personnel. At present this programme covers
The rules related to prohibition of smoking in public 517 districts in 36 states.
places came into force from the 2nd October, 2008. As per The aims of the NMHP are : (a) Prevention and treatment
rules, it is mandatory to display smoke free signages at all of mental and neurological disorders and their associated
public places. Labelling and packaging rules mandating the disabilities; (b) Use of mental health technology to improve
depiction of specified health warnings on all tobacco general health services; and (c) Application of mental health
product packs came into force from 31st May, 2009. principles in total national development to improve quality
On account of sustained efforts on the part of Ministry of of life (68).
Health and Family Welfare, 34 States/UTs have issued The objectives of the programme are :
orders for implementation of the Food Safety Regulations
banning manufacture, sale and storage of gutka and pan 1. To ensure availability and accessibility of minimum
masala containing tobacco or nicotine in the year 2014-15. mental health care for all in the foreseeable future,
Besides several states/UTs have banned all forms of particularly to the most vulnerable and
smokeless tobacco products such as chewing tobacco, zarda, underprivileged sections of population.
khaini and other flavoured and processed tobacco 2. To encourage application of mental health knowledge
irrespective of name and form (45). in general health care and in the social development.

by R△J
 NATIONAL MENTAL HEALTH PROGRAMME

3. To promote community participation in the mental The Mental Healthcare Bill, 2013 was introduced in the
health services development, and to stimulate efforts Parliament in order to protect and promote the rights of
towards self-help in the community. persons with mental illness during the delivery of health care
The programme strategies are : in institutions and in the community and to ensure health
care, treatment and rehabilitation of persons with mental
1. Integration of mental health with primary health care illness, is provided in the least restrictive environment
through the NMHP; possible. Further, to regulate the public and private mental
2. Provision of tertiary care institutions for treatment of health sectors within rights framework, to achieve the
mental disorders; greatest public health good and to promote principles of
3. Eradicating stigmatization of mentally ill patients and equity, efficiency and active participation of all stakeholders
protecting their rights through regulatory institutions in decision making. Suicide has been decriminalized under
like the Central Mental Health Authority, and State the Act. The bill received assent of the Hon’ble President of
Mental Health Authority. India on 07.04.2017. The Ministry has constituted a
District Mental Health Programme components are : committee of experts for formulating rules and regulations
(a) Training programmes of all workers in the mental health under the Act.
team at the identified nodal institute in the state; (b) Public
education in mental health to increase awareness and to INTEGRATED DISEASE SURVEILLANCE
reduce stigma; (c) For early detection and treatment, the __ _____PROJECT _______ ________
OPD and indoor services are provided; and (d) Providing
valuable data and experience at the level of community to Integrated disease surveillance project is a decentralized
the state and centre for future planning, improvement in state based surveillance system in the country. This project is
service and research. intended to detect early warning signals of impending
outbreaks and help initiate an effective response in a timely
District Mental Health Programme has now incorporated manner in urban and rural areas. It will also provide
promotive and preventive activities for positive mental essential data to monitor progress of ongoing disease control
health which includes : programme and help allocate health resources more
- School mental health services : Life skills education in efficiently. The project was launched in Nov. 2004. It was a
schools, counselling services. 5 year project up to March 2010. The project was

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- College counselling services : Through trained teachers/ restructured and extended up to March 2012. It continues in
councellors. the 12th Five Year Plan with domestic budget as integrated
- Work place stress management : Formal & Informal Disease Surveillance Programme under National Health
sectors, including farmers, women etc. Mission for all states.
- Suicide prevention services : Counselling center at A Central Surveillance Unit (CSU) established and
district level, sensitization workshops, IEC, help lines etc. integrated in the National Centre for Disease Control, Delhi,
State Surveillance Units (SSU) at all State/UT head quarters
The National Human Rights Commission also monitors
and District Surveillance Units (DSU) at all districts in the
the conditions in the mental hospitals along with the
country have been established. IT network connecting 776
government of India, and the states are acting on the
sites in states/district head quarters and premier institutes has
recommendations of the joint studies conducted to ensure
been established with the help of National Information Centre
quality in delivery of mental care.
and ISRO (Indian Space Research Organization) for data
Thrust areas (46) entry, training, video conferencing and outbreak discussions.
1. District mental health programme in an enlarged and Under the project weekly disease surveillance data on
more effective form covering the entire country. epidemic prone diseases are being collected from reporting
2. Streamlining/modernization of mental hospitals in units such as sub-centres, PHCs, CHCs, hospitals including
government and private sector hospitals and medical
order to modify their present custodial role.
colleges. The data are being collected on ‘S’ syndromic; ‘P’
3. Upgrading department of psychiatry in medical probable; and ‘E laboratory formats using standard case
colleges and enhancing the psychiatric content of the definitions. Presently more than 90 per cent districts report
medical curriculum at the undergraduate as well as such weekly data through e-mail/portals. The weekly data
postgraduate level. are analysed by SSU/DSU for disease trends. Whenever
4. Strengthening the central and state mental health there is rising trend of illness, it is investigated by the Rapid
authorities with a permanent secretariat. Appointment Response Team to diagnose and control the outbreak. It is a
of medical officers at state headquarters in order to multi speciality team of an epidemiologist, a clinician, a
make the monitoring role more effective. microbiologist and other specialists as per requirement.
5. Research and training in the field of community The surveillance is needed to recognize cases or cluster of
mental health, substance abuse and child adolescent cases to initiate interventions to prevent transmission of
psychiatric clinics. disease or reduce morbidity and mortality; access the public
health impact of health events or determine and measure
The Mental Healthcare Act, 2017 (7) trends; demonstrate the need for public health intervention
The United Nations convention on the rights of persons programmes and resources and allocate resources during
with disabilities was ratified by the Government of India public health planning; monitor effectiveness of prevention
thus making it obligatory on the Government to align the and control measures; identify high-risk groups or
policies and laws of the country with the convention. There geographical areas to target interventions and guide analytic
was an increasing realization that persons with mental illness studies; and develop hypothesis that lead to analytic studies
constitute a vulnerable section of society and are subject to about risk factors for disease causation, propagation and
discrimination in our society. progression (69)

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546 HEALTH PROGRAMMES IN INDIA

In this project, different types of integration are proposed. Diarrhoea Cholera

These include : (a) Sharing of surveillance information of Jaundice Hepatitis, Laptospirosis,
disease control programmes; (b) Developing effective Dengue, Malaria,
partnership with health and non-health sectors in Yellow fever
surveillance; (c) Including non-communicable and Unusual syndromes Anthrax, Plague,
communicable diseases in the surveillance system; Emerging epidemics
(d) Effective partnership of private sector and NGOs in
surveillance activities; and (e) Bringing academic institutions The core conditions under surveillance in IDSP are as
and medical colleges into the primary public health activity follows (71) :
of disease surveillance. (i) Regular Surveillance:
The important information in disease surveillance are - Vector borne disease : Malaria
who gets the disease, how many get the disease, where did Water borne disease : Acute diarrhoeal
they get the disease, why did they get the disease, and what disease (cholera)
needs to be done as public health response. : Typhoid
The components of the surveillance activity are : Respiratory diseases : Tuberculosis
(a) Collection of data Vaccine preventable diseases : Measles
(b) Compilation of data Diseases under eradication : Polio
Other conditions : Road traffic accidents
(c) Analysis and interpretation (Link-up with police
(d) Follow-up action computers)
■(e) Feedback. Other international : Plague
commitments
The prerequisite of the effective surveillance are - use of
Unusual clinical syndromes : Meningoencephalitis /
standard case definition, ensure regularity of reports and the
(causing death/ Respiratory distress,
action on reports.
hospitalization) Haemorrhagic fevers,
The classification of surveillance in IDSP is as follows : other undiagnosed
a. Syndromic diagnosis - diagnosis is made on the basis conditions

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of clinical pattern by paramedical personnel and (ii) Sentinel Surveillance:
members of the community;
Sexually transmitted : H1V/HBV, HCV
b. Presumptive diagnosis - diagnosis made on typical diseases / blood borne
history and clinical examination by medical officer;
and Other conditions : Water quality
c. Confirmed diagnosis - clinical diagnosis by a medical monitoring
officer and or positive laboratory identification. : Outdoor air quality
(Large urban centres)
Syndromes under surveillance (69) : (Hi) Regular periodic surveys:
The paramedical health staff will undertake disease' NCD risk factors : Anthropometry,
surveillance based on broad categories of presentation. The Physical activity,
following clinical syndromes will be under surveillance in Blood pressure,
IDSP: Tobacco, Nutrition etc.
1. Fever: (iv) Additional state priorities:
a. Less than 7 days duration without any localizing signs Each state may identify upto five additional conditions
b. With rash for surveillance.
c. With altered sensorium or convulsions Outbreak
d. Bleeding from skin or mucus membrane In epidemiology, an outbreak is a sudden increase in
e. Fever more than 7 days with or without localizing occurrence of a disease in a particular time and place. A
signs single case of a communicable disease long absent from a
2. Cough more than 3 weeks duration population, or caused by an agent (e.g. bacterium or virus)
not previously recognized in that community or area, or
3. Acute flaccid paralysis emergence of a previously unknown disease, may also
4. Diarrhoea constitute an outbreak and should be reported and
5. Jaundice, and investigated.
6. Unusual events causing death or hospitalization. Warning signs of an impending outbreak are as
follows (70):
These syndromes are intended to pick up all priority
- Clustering of cases or deaths in time and/or space
diseases listed under regular surveillance at the level of the
community under the Integrated Disease Surveillance - Unusual increase in number of cases or deaths
Project. - Even a single case of measles, AFP, cholera, plague,
Fever with or without Malaria, Typhoid, dengue or JE
localizing signs JE, Dengue, Measles - Acute febrile illness of unknown aetiology
Cough more than 3 weeks Tuberculosis - Occurrence of two or more epidemiologically linked
Acute flaccid paralysis Polio cases of meningitis, measles

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 INTEGRATED DISEASE SURVEILLANCE PROJECT

- Unusual isolate
- Shifting in age distribution of cases AVUSHMAN BHARAT PROGRAMME
- Sudden increase/high vector density In February 2018, the Govt, of India announced two
- Natural disasters major initiatives in health sector, with aim to cover
preventive and health promotive interventions at primary,
Summary of outbreak syndromes and trigger events for secondary and tertiary care system. They are as follows (72):
investigation (70)
1. Health and Wellness Centre: The National Health Policy,
Syndrome Trigger event 2017 has envisioned Health and Wellness Centres as the
foundation of India’s health system. Under this 1.5 lakh
Acute watery - A single case of severe centres will bring health care system closer to homes of
stools dehydration/death in a patient people. The health centres will provide comprehensive
> 5 years of age with diarrhoea. health care, including maternal and child health services,
- More than 10 houses having at Communicable Diseases services, and services related to
least one case of loose stools Non-Communicable Diseases. To begin with, the
irrespective of age, per village or common NCDs such as hypertension, diabetes and 3
an urban ward. common cancers of oral, breast and cervix. It is also
envisaged to incrementally add primary healthcare
Fever < 7 days services for mental health, ENT, opthalmology, oral
duration health, geriatric and palliative health care and trauma
(a) Only fever 5 cases in 1000 population. care, as well as health promotion and wellness activities
(b) With rash Two similar cases in a village like Yoga. A few States/UTs have already started rolling
(Measles I (1000 population). out these additional packages of services in a phased
Dengue) manner. The centres will also provide free essential drugs
and diagnostic services.
(c) Altered Two cases of fever with altered
consciousness consciousness in the village/1000 2. The second component is the Ayushman Bharat -
population. Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) which
provides health coverage upto Rs. 5.00 lakh per family

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(d) Fever with Two cases of fever with bleeding in a per year to about 10.74 crore poor and vulnerable
bleeding village or 1000 population. families identified on the basis of Socio Economic Caste
Fever with Two cases of fever with convulsions Census data.
convulsions in a village or 1000 population.
The first Health and Wellness Centre was inaugurated on
Fever more More than 2 cases in a village or 1000 14th April 2018 in Bijapur district of Chhattisgarh. So far,
than 7 days population. 77,786 centres are operational in the country as on 16th
Jaundice More than 2 cases in a village or in Sep. 2021.
1000 population. Primary healthcare team at the Sub Health Centre level
Unusual event More than 2 deaths or AB-HWCs is headed by Community Health Officer (CHO)
hospitalization. who is a BSc/GNM Nurse or an Ayurveda Practitioner trained
in primary care and public health skills, and certified in a six
The reporting units for disease surveillance are : months certificate programme in community health. Other
members of the team being multi-purpose workers (Male and
Public Health Sector Private Health Sector Female) and Accredited Social Health Activists (ASHAs).
Rural CHCs, District Sentinel private The training programme is being carried out with support
hospitals practitioners, and from IGNOU and state specific Public/Health Universities. 282
Sentinel hospitals. 1GNOU Programme Study Centres (PSCs) have been notified
Urban Urban hospitals, Sentinel private so far, and another 111 PSCs have been notified under the
ESI / Railway / nursing homes, state specific certificate programme in the state of
Medical college hospitals, sentinel hospitals, Maharashtra, Tamil Nadu, Gujarat and West Bengal, taking the
Medical colleges, total of programme study centres to 393 across the country.
Private and Since the screening, prevention and management of
NGO laboratories chronic illnesses including NCDs, TB and Leprosy have
1. Sub-centre-health worker/ANM reports all patients been introduced at AB-HWCs, training and skill upgradation
fulfilling the clinical syndrome from PHC, private of the primary health team in all the functional AB-HWCs on
clinic, hospital etc. NCDs and use of IT application is being done.
2. PHC/CHC medical officers report as probable cases of To promote wellness and healthy lifestyle, orientation of
interest, where this cannot be confirmed by laboratory the public on wellness activities for lifestyle modification like
tests at the peripheral reporting units, and as increased physical activity (cyclathons and marathons),
confirmed when the laboratory information is eating RIGHT and SAFE, cessation of tobacco and drugs,
available as in case of blood smear +ve malaria and meditation, laughter clubs, open gyms, etc. is being done.
sputum AFB +ve tuberculosis. Beside these, Yoga sessions are being conducted at these
3. Sentinel private practitioners, district hospitals, centres on regular basis. Through annual health calendar,
municipal hospitals, medical colleges, sentinel planned activities at these centres on the health condition of
hospitals, NGOs - medical officers report as probable the day are resulting in increased awareness and preventive
cases of interest. measures to be adopted by the public.

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548 HEALTH PROGRAMMES IN INDIA

The telemedicine guidelines have also been provided to Government Hospitals along the Golden Quadrilateral
the States to initiate specialist consultations from the highway corridor as well as North-South & East-West
PHCs to the Hub Hospitals and the pilot of the application is Corridors wherein 116 TCFs were approved in 17 States on
being conducted in Andhra Pradesh, Tamil Nadu and these corridors on 100% Central assistance. The scheme
Maharashtra. was further extended during 12th FYP as “Capacity Building
Expanded service packages planned to be provided at for Developing Trauma Care Facilities in Govt. Hospitals on
functional AB-HWCs are as follows : National Highways” wherein 80 Hospitals/Medical Colleges
were approved for financial assistance in addition to other
1. Care in pregnancy and child birth. interventions. The scheme is being extended since then.
2. Neonatal and infant health care services.
Objectives of the programme are as follows :
3. Childhood and adolescent health care services.
- To establish a network of Trauma Care Facilities on
4. Family planning, contraceptive services and other
National/State Highways in order to reduce the incidence
reproductive health care services.
of preventable deaths and disabilities due to road traffic
5. Management of communicable diseases : National accidents by observing golden hour principle.
Health programmes.
- To develop Surveillance, Trauma Registry and Capacity
6. General out-patient care for acute simple illnesses and Building Centre for collection, compilation, analysis and
minor ailments. dissemination of information for policy formulation and
7. Screening, prevention, control and management of non- preventive interventions.
communicable diseases and chronic communicable - To improve the awareness about trauma care among the
diseases like tuberculosis and leprosy. general masses and vulnerable groups by developing
8. Basic oral health care. and disseminating IEC material.
9. Screening and basic management of mental health
ailments. B. Burn Injuries component (6) :
10. Care for common ophthalmic and ENT problem. India has one of the largest burdens of burns with an
11. Elderly and palliative health care services. estimated 7,000,000 burn injuries per year, and an
12. Emergency medical services including burns and trauma. estimated 1.4 lakh deaths and 2.4 lakh disabilities, making
burn injuries the second largest group of injuries after road

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Expected outcome (6) accidents. These figures translate to a mortality rate of over
8.3/100,000 population, disfigurement and permanent
- Increasing the trust of people on the service provision by
disability in 250,000 people annually, and a loss of 5 million
public healthcare facilities through health system
disability-adjusted life years (DALYs).
strengthening and improvement.
- Availability of assured healthcare services to ensure This high incidence has been attributed to illiteracy,
continuum of care. poverty, and low safety consciousness in the population.
The epidemiology of mortality after burns is unique in India;
- Reduction in out of pocket expenditure of the common
most burn injuries are in young adults and deaths are more
people.
common in women than men, contrasting trends observed
- Increased awareness among the people about preventive in other low-and middle-income countries. Burns survivors
and promotive healthcare. are also known to be financially distressed, vocationally
- Benefits of healthy lifestyle including Yoga, and eat right challenged and socially excluded. Death and disability due
& eat safe etc. to burn injury are preventable to a great extent provided
- Enabling environment to increase the health seeking timely and appropriate treatment is provided by trained
behaviour of the poor people. healthcare professionals.
For further details please refer to chapter 9 for school Keeping in view the magnitude of the problem, a pilot
health programme and chapter 10 for Health and Wellness programme on burn care was initiated in the year 2010 by
Centres. Ministry of Health & Family Welfare in the name of “Pilot
Programme for Prevention of Burn Injuries” (PPPBI). This
was initiated in three Medical Colleges and six Districts
NATIONAL PROGRAMME FOR PREVENTION Hospitals. The goal of PPPBI was to ensure prevention of
AND MANAGEMENT OF TRAUMA AND BURN Burn Injuries, provide timely and adequate treatment in
___ ___ INJURIES (NPPMTBI)_________ case of burn injuries, so as to reduce mortality,
complications and ensuing disabilities and to provide
A. Trauma Care component (6) : effective rehabilitative interventions if disability has set in.
The pilot project continued as full-fledged programme for
In India, road traffic crashes are one of the major causes
of disability, morbidity and mortality. As per the Road tertiary care level during the 12th Five Year Plan period. The
Accident Report for 2019, a total number of 4,49,002 financial assistance towards District Hospital component was
accidents took place in the country during the calendar year undertaken under National Health Mission (NHM). The
2019 leading to 1,51,113 deaths and 4,51,361 injuries. scheme is being extended since then.
The programme for trauma care started during 9th and NATIONAL GUINEAWORM
10th Five Year Plans as “Pilot Project for Strengthening ERADICATION PROGRAMME
Emergency Facilities along the Highways”. During the 11th
FYP, the programme was approved as “Assistance for India launched its National Guineaworm Eradication
Capacity Building for Developing Trauma Care Facilities in Programme in 1984 with technical assistance from WHO.
Government Hospitals on National Highways” for From the very beginning the programme was integrated into
developing a network of trauma care facilities (TCFs) in the the national health system at village level. With well defined

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 NATIONAL GUINEAWORM ERADICATION PROGRAMME

strategies, an efficient information and evaluation system, 6. Prevention and control of occupational health hazards
intersectoral coordination at all levels and close collaboration among salt workers in the remote desert areas of
with WHO and UNICEF, India was able to significantly reduce Gujarat and Western Rajasthan.
the disease in affected areas. The country has reported zero
cases since August 1996. In February 2000, the International NUTRITIONAL PROGRAMME
Commission for the Certification of Dracunculiasis
Eradication recommended that India be certified free of Please refer to chapter 11, for details.
dracunculiasis transmission (71).
The following activities are continuing as per NATIONAL FAMILY WELFARE PROGRAMME
recommendations of International Certification Team of See chapter 8 for details.
International Commission for Certification of Dracunculiasis
Eradication, Geneva :
NATIONAL WATER SUPPLY AND
a. Health education activities with special emphasis on SANITATION PROGRAMME
school children and women in rural areas;
b. Rumour registration and rumour investigation; The National Water Supply and Sanitation Programme
c. Maintenance of guinea-worm disease on list of was initiated in 1954 with the object of providing safe water
notifiable disease and continuation of surveillance in supply and adequate drainage facilities for the entire urban
previously infected areas; and and rural population of the country. In 1972 a special
d. Careful supervision of the functioning of hand pumps programme known as the Accelerated Rural Water
and other sources of safe drinking water, and Supply Programme was started as a supplement to the
provision of additional units, wherever necessary. national water supply and sanitation programme. Inspite of
increased financial outlay during the successive Five Year
YAWS ERADICATION PROGRAMME (9) Plans, only a small dent was made on the overall problem.
During the Fifth Plan, rural water supply was included in the
The disease has been reported in India from the tribal Minimum Needs Programme of the State Plans. The Central
communities living in hilly forest and difficult to reach areas Government is supporting the efforts of the States in
in 49 districts of 10 states, namely Andhra Pradesh, Assam, identifying problem villages through assistance under

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Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Accelerated Rural Water Supply Programme. A “problem
Maharashtra, Orissa, Tamil Nadu and Uttar Pradesh. village” has been defined as one where no source of safe
National Institute of Communicable Diseases is the nodal water is available within a distance of 1.6 km, or where
agency for planning, guidance, coordination, monitoring water is available at a depth of more than 15 metres, or
and evaluation of the programme. The programme is where water source has excess salinity, iron, fluorides and
implemented by the State Health Directorates of Yaws other toxic elements, or where water is exposed to the risk of
endemic states utilizing existing health care delivery system cholera.
with the coordination and collaboration of department of
The stipulated norm of water supply is 40 litres of
tribal welfare and other related institutions.
safe water per capita per day, and at least one hand
The number of reported cases has come down from more pump/spot-source for every 250 persons. Information,
than 3,500 to Nil during the period from 1996 to 2004, education and communication is an integral part of rural
since then no new case has been reported. sanitation programme to adopt proper environmental
sanitation practices including disposal of garbage, refuse
NATIONAL PROGRAMME FOR CONTROL AND and waste water, and to convert all existing dry latrines into
TREATMENT OF OCCUPATIONAL DISEASES low cost sanitary latrines. The priority is to evolve financially
viable sewerage systems in big cities and important
Government of India launched a scheme called “National pilgrimage and tourist centres and recycling of treated
Programme for Control and Treatment of Occupational effluents for horticulture, irrigation and other non-domestic
Diseases” in 1998-99. The National Institute of purposes (74).
Occupational Health, Ahmedabad (ICMR) has been
identified as the nodal agency for this programme. The programme was subsequently renamed as the
Rajiv Gandhi National Drinking Water Mission in 1991. In
The following research projects have been proposed by 1999-2000, Sector Reform Project was started to involve
the government (73) : the community in planning, implementation and
1. Prevention, control and treatment of silicosis and management of drinking water schemes which was in 2002
silico-tuberculosis in agate industry; scaled up as the Swajaldhara Programme.
2. Occupational health problems of tobacco harvesters
and their prevention; Swajaldhara (75)
3. Hazardous process and chemicals, database Swajaldhara was launched on 25th December 2002.
generation, documentation, and information Swajaldhara has certain fundamental reform principles,
dissemination; which need to be adhered to by the state governments and
the implementing agencies. Swajaldhara is a community led
4. Capacity building to promote research, education, participatory programme, which aims at providing safe
and training at National Institute of Occupational drinking water in rural areas, with full ownership of the
Disease; community, building awareness among the village
5. Health Risk Assessment and development of community on the management of drinking water projects,
intervention programme in cottage industries with including better hygiene practices and encouraging water
high risk of silicosis; and conservation practices along with rainwater harvesting.

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 HEALTH PROGRAMMES IN INDIA

Swajaldhara has two components : Swajaldhara I (First Swachh Bharat Mission Gramin (SBM-G) (77)
Dhara) is for a gram panchayat or a group of panchayats (at
The Mission in rural India will mean improving the level
block / tahsil level) and Swajaldhara II (Second Dhara) has
of cleanliness in rural areas through solid and liquid waste
district as the project area. District water and sanitation
management and making gram panchayats free of open
mission sanctions swajaldhara I. The panchayats and
defecation, clean and sanitized. The programme includes
communities have the power to plan, implement, operate,
the key components of earlier sanitation schemes.
maintain and manage all water supply and sanitation
schemes. There is an integrated service delivery mechanism, The key objectives of the programme are as follows:
taking up conservation measures through rain water (a) Bring about an improvement in the general quality of life
harvesting and ground water recharge systems for sustained in the rural areas, by promoting cleanliness, hygiene and
drinking water supply and shifting the role of government eliminating open defecation;
from direct service delivery to that of planning, policy
formulation, monitoring and evaluation and partial financial (b) Accelerate sanitation coverage in rural area to achieve
support. On completion of the project, gram panchayat the vision of Swachh Bharat by 2nd October 2019;
or village water and sanitation committee manages the (c) Motivate Communities and Panchayati Raj Institutions to
project. adopt sustainable sanitation practices and facilities
The programme was revised from 1st April 2009 and through awareness creation and health education;
named as National Rural Drinking Water Programme (60). It (d) Encourage cost effective and appropriate technologies
is now a component of Bharat Nirman which focuses on the for ecologically safe and sustainable sanitation; and
creation of rural infrastructure. (e) Develop wherever required, community managed
sanitation systems focusing on scientific solid &. liquid
Bharat Nirman waste management systems for overall cleanliness in the
Bharat Nirman was launched by the Government of India rural areas.
in 2005 as a programme to build rural infrastructure. While
The key components of SBM-G include, start up activities
phase-I was implemented in the period of 2005-06 to
2008-09, the phase-II was implemented from 2009-10 to including preparation of state plan; construction of
2011-12. At the beginning of phase-I period, priority was household toilets; construction of community sanitary
given to cover water quality problem and other complexes; and capacity building of functionaries etc. Under

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contaminants, e.g., arsenic and fluoride affected habitations the programme, construction of toilets in government
followed by iron, salinity, nitrate. schools and anganwadi centres will be done by the Ministry
of Human Resource Development and Ministry of Women
New initiatives in 12th Five Year Plan and Child Development respectively. Rural School sanitation
focusing on separate toilets for girls and boys is a major
1. In order to raise coverage of piped water supply, toilet intervention which shall be implemented under the
coverage and strengthening of institutions and systems in programmes of the Department of School Education.
rural drinking water and rural sanitation sectors the
Ministry has proposed a Rural Water Supply and A duly completed household sanitary toilet shall comprise
Sanitation Project for low income states; of toilet unit including a substructure which is sanitary (that
2. Enhancement of service levels for rural water supply safely confines human faeces and eliminates the need of
from the norm of 40 Ipcd to 55 lpcd for designing of human handling before it is fully decomposed), a super
system. The target being at least 50 per cent of rural structure, with water facility and hand wash unit for cleaning
population in the country to have access to water within and hand washing. The Mission aims that all rural families
their household premises or within 100 metres radius, have access to toilets. Incentives for construction of
with at least 30 per cent having individual household household toilets will be available for below poverty line
connections, as against 13 per cent today (76) households, and above poverty line households restricted to
SCs/STs, small and marginal farmers, landless labourers,
Rural Sanitation Programme (76) physically handicapped and women headed families.
Nirmal Bharat Abhiyan (NBA) Swachh Bharat Mission-Urban (78)
In 2012, a paradigm shift was made in the Total Swachh Bharat Mission-Urban (SBM-U) is being
Sanitation Campaign, by launching the Nirmal Bharat implemented by Ministry of Urban Development. The main
Abhiyan, in the 12th Five Year Plan. The objective of NBA is objectives of the mission are as follows:
to achieve sustainable behavioural change with provision of
1. Elimination of open defecation;
sanitary facilities in entire communities in a phased manner,
saturation mode with “Nirmal Grams” as outcomes. 2. Eradication of manual scavenging;
3. Modern and scientific municipal solid waste
Swachh Bharat Mission management;
Swachh Bharat Abhiyan or Swachh Bharat Mission is a 4. To effect behavioural change regarding healthy
national campaign by the government of India to clean sanitation practices;
streets, roads and infrastructure of the country. The 5. Generate awareness about sanitation and its linkage with
campaign was officially launched by Prime Minister of India public health;
on 2nd Oct, 2014, at Rajghat, New D&lhi. It aims to
eradicate open defecation by year 2019, by constructing 6. Capacity augmentation for ULB's; and
12 million toilets in rural India. Mission has two sub­ 7. To create an enabling environment for private sector
missions, namely, Swachh Bharat Mission Urban, and participation in Capex (capital expenditure) and Opex
Swachh Bharat Mission Gramin. (operation and maintenance).

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 NATIONAL WATER SUPPLY AND SANITATION PROGRAMME 551
Mission components households practicing open defecation will be catered by
The Mission has the following components: community toilets, due to constraints of space.
1. Household toilets, including conversion of insanitary Household toilets constructed under SBM (Urban) will
latrines into pour-flush latrines; have two main structures - the toilet superstructure
(including the pan and water closet), and the sub- structure,
2. Community toilets; either an on-site treatment system or a connection to
3. Public toilets; existing underground sewerage system.
4. Solid waste management; Solid waste management component of SBM-Urban
5. IEC & public awareness; and
Municipal Solid Waste Management (MSWM) refers to a
6. Capacity building and administrative & office expenses. systematic process that comprises of waste segregation and
By Public Toilets, it is implied that these are to be storage at source, primary collection, secondary storage,
provided for the floating population/ general public in places transportation, secondary segregation, resource recovery,
such as markets, train station, tourist places, near office processing, treatment, and final disposal of solid waste.
complexes, or other public areas where there are
considerable number of people passing by. PRADHAN MANTRI AWAS YOJNA (URBAN)
By Community Toilets, it is implied that a shared facility Ministry of Housing and Urban Affair (MOHUA) launched
provided by and for a group of residents or an entire the Pradhan Mantri Awas Yojna-Urban (PMAY-U) on 25th
settlement. Community toilet blocks are used primarily in June, 2015, as a flagship mission of Government of India. It
low-income and/or informal settlements / slums, where addresses urban housing shortage among the Economically
space and/or land are constraints in providing a household Weaker Section (EWS)/Low Income Group (LIG) category
toilet, These are for a more or less fixed user group. including slum dwellers by ensuring a pucca house to eligible
All statutory towns will be covered under the mission. The urban households. An eligible beneficiary family will
special focus group under the mission are as follows: comprise of a husband, wife, unmarried sons and /or
i. All manual scavengers in urban areas are identified, unmarried daughters. The beneficiary family should not own
insanitary toilets linked to their employment are a Pakka House (an all whether dwelling unit) either in his/ her
upgraded to sanitary toilets, and the manual scavengers name or in the name of any member of his/her family in any

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are adequately rehabilitated; part of India. An adult earning member (irrespective of
marital status) can be treated as separate household.
ii. In their efforts to streamline and formalize SWM systems
it shall be the endeavor of ULBs that the informal sector PMAY-U adopts a demand driven approach wherein the
workers in waste management (rag pickers) are given housing shortage is decided based on demand assessment
priority to upgrade their work conditions and are by States/Union territories (UTs). All houses built or acquired
enumerated and integrated into the formal system of or purchased under the mission have basic amenities like
SWM in cities; kitchen, water supply, electricity and toilet. The mission
iii. All temporary accommodation for migrants and the promotes woman empowerment by providing the ownership
homeless in urban areas have adequate provision for of houses in the name of female members or in joint name.
toilets either on the premises or linked to a public/ Preference is also given to women (with overriding
community toilet; preference to widows, single woman) persons belonging to
Scheduled Caste/Scheduled Tribes/Other Backward Classes,
iv. Mandating that construction labour in urban areas have
Minorities, Persons with disability and Transgender (80).
access to temporary toilets at all sites in urban areas,
buildings, parks and roads where construction /
maintenance work is taking place or where construction MINIMUM NEEDS PROGRAMME
labour is temporarily housed; and The Minimum Needs Programme (MNP) was introduced
v. Priority shall be accorded pro-actively to cover in the first year of the Fifth Five Year Plan (1974-78). The
households with vulnerable sections such as pensioners, objective of the programme is to provide certain basic
girl children, pregnant and lactating mothers. minimum needs and thereby improve the living standards of
the people. It is the expression of the commitment of the
Household toilet component of SBM-Urban government for the “social and economic development of
SBM (Urban) aims to ensure that - the community particularly the underprivileged and
(a) No households engage in the practice of open underserved population”. The programme includes the
defecation; following components :
(b) No new insanitary toilets are constructed during the a. Rural Health
mission period; and b. Rural Water Supply
(c) Pit latrines are converted to sanitary latrines. c. Rural Electrification
The target group for construction of household units of d. Elementary Education
toilets, thus, is: e. Adult Education
(i) 80% of urban households engaging in open defecation; f. Nutrition
(ii) All households with insanitary latrines; and 9- Environmental improvement of Urban Slums
(iii) All households with single-pit latrines. h. Houses for landless labourers
These will be targeted under this component for the There are two basic principles which are to be observed
construction of household toilets or individual household in the implementation of MNP : (a) the facilities under MNP
latrines during the mission period. The remaining 20% of are to be first provided to those areas which are at present

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552 HEALTH PROGRAMMES IN INDIA

underserved so as to remove disparities between different References

areas; (b) the facilities under MNP should be provided as a 1. Govt, of India (2014), Annual Report 2013-14, Ministry of Health
package to an area through intersectoral area projects, to and Family Welfare, New Delhi.
have a greater impact. 2. Govt, of India (2012), Strategic Action Plan for Malaria Control in
In the field of rural health, the objectives to be achieved India 2012-2017, Scaling up malaria control interventions with a
focus on high burden areas, Directorate of National Vector Borne
by the end of the Eighth Five Year Plan, under the minimum Disease Control Programme, DGHS, Ministry of Health and Family
needs programme were : one PHC for 30,000 population in Welfare, New Delhi.
plains and 20,000 population in tribal and hilly areas; one 3. Govt, of India (2010), Annual Report 2009-2010, DGHS, Ministry of
sub-centre for a population of 5,000 people in the plains Health and Family Welfare, New Delhi.
and for 3000 in tribal and hilly areas, and one community 4. Govt, of India (2016), Operational Manual for Malaria Elimination in
health centre (rural hospital) for a population of one lakh or India 2016 (Version 1), Directorate of NVBDCP, Ministry of Health
and Family Welfare, New Delhi.
one C.D. Block by the year 2000. The establishment of
5. Govt, of India (2016), National Framework for Malaria Elimination in
PHCs, sub-centres, upgradation of PHCs, and construction India (2016-2030), Directorate of NVBDCP, Ministry of Health and
of buildings thereof are all included in the State sector of the Family Welfare, New Delhi.
minimum needs programme. 6. Govt, of India (2022), Annual Report 2021-2022, Ministry of Health
In the field of nutrition, the objectives are: (a) to extend and Family Welfare, New Delhi.
nutrition support to 11 million eligible persons; (b) to expand 7. Govt, of India (2018), Annual Report 2017-2018, Ministry of Health
and Family Welfare, New Delhi.
“special nutrition programme” to all the ICDS projects; and 8. Govt, of India (2014), Press Information Bureau, 2nd Sept. 2014,
(c) to consolidate the mid-day meal programme and link it to Ministry of Health and Family Welfare, New Delhi.
health, potable water and sanitation. 9. Govt, of India (2006), Annual Report 2005-06, Ministry of Health
and Family Welfare, New Delhi.
20-POINT PROGRAMME 10. Rao, C.K. (1987). Ind. J. Lep., 59 (2) 203.
11. Govt, of India (2020), Annual Report 2019-2020, Ministry of Health
In addition to the Five Year Plans and Programmes, in and Family Welfare, New Delhi.
1975, the Govt, of India initiated a special activity. This was 12. Govt, of India (2012), Disability Prevention and Medical
Rehabilitation, Guidelines for Primary,secondary and tertiary level
the 20-Point programme - described as an agenda for care, NLEP, DGHS, Ministry of Health and Family Welfare, New
national action to promote social justice and economic Delhi.

telegram-@Cherry_2412
growth. 13. Govt, of India (2014), Programme Implementation Plan (PIP) for
12th Plan Period (2012-13 to 2016-17), Central Leprosy Division,
On August 20, 1986, and again in 2006, the existing 20- DGHS, Ministry of Health and Family Planning, New Delhi.
Point Programme was restructured. Its objectives are spelt 14. National Leprosy Eradication Programmme (2017), Annual Report
out by the Government as “eradication of poverty, raising for year 2016-2017.
productivity, reducing inequalities, removing social and 15. Govt, of India (2021), Nation Wide Implementation of Disease
economic disparities and improving the quality of life”. Eradication Programme, Press release page, 7th Dec. 2021.
16. Indian Journal of Leprosy, vol. 78, No. 1, Jan-March 2006.
The 20 points of twenty point programme 2006 are as
17. Govt, of India (2012), TB India 2012, RNTCP Status Report, Ministry
follows (79): of Health and Family Welfare, New Delhi.
1. Poverty eradication 18. Govt, of India (2020), Training Module (1-4) for programme
managers and medical officers, NTEP
2. Power to people
19. Govt, of India (2014), T.B. India 2014, RNTCP Annual Status Report,
3. Support to farmers Central TB Division, DGHS, Ministry of Health and Family Welfare,
4. Labour welfare New Delhi.
20. Govt, of India (2012), Notification dated 7th May 2012 regarding TB
5. Food security cases, Ministry of Health and Family Welfare, New Delhi.
6. Housing for all 21. Govt, of India (2021), Guidelines for Progrmmatic Management of
Drug Resistant Tuberculosis in India, March 2021, Central TB
7. Clean drinking water Division, Ministry of Health and Family Welfare, New Delhi.
8. Health for all 22. RNTCP (2017), Guidelines on Programmatic Management of Drug
Resistant Tuberculosis in India, Ministry of Health and Family
9. Education for all
Welfare, New Delhi.
10. Welfare of scheduled castes, scheduled tribes, minorities 23. Govt, of India (2016), Technical and Operational Guidelines for
and OBCs Tuberculosis Control in India 2016, RNTPC, Ministry of Health and
11. Women welfare Family Welfare, New Delhi.
23A. Govt, of India (2007), NACPIII, To Halt and Reverse the HIV Epidemic
12. Child welfare in India, NACO, Ministry of Health and Family Welfare, New Delhi.
13. Youth development 24. Govt, of India (2022), India TB Report 2022, Central TB Division,
Ministry of Health and Family Welfare, New Delhi.
14. Improvement of slums 25. Govt, of India (2013), T.B. India2013, RNTCP Annual Status Report,
15. Environment protection and afforestation Central TB Division, DGHS, Ministry of Health and Family Welfare,
16. Social security New Delhi.
26. RNTCP (2018), TB India 2018, Ministry of Health and Family
17. Rural roads Welfare, New Delhi.
18. Energization of rural area 27. Govt, of India (2013), National AIDS Control Programme Phase-IV
(2012-2017), Strategy Document, Dept of AIDS Control, Ministry of
19. Development of backward areas Health and Family Welfare, New Delhi.
20. IT enabled E-Governance 28. NACO (2017), National Strategic Plan for HIV/AIDS and STI 2017-
2024, Paving way for an AIDS Free India, Dec. 1.2017.
The restructured 20-Point Programme constitutes the 29. Govt, of India (2006), National AIDS Control Programme Phase III
Charter for the country’s socio-economic development. It has (2007-12), Strategy and Implementation Plan, NACO, Ministry of
been described as “the cutting edge of the plan for the poor”. Health and Family Welfare, New Delhi.

by R△J
 REFERENCES

Govt, of India (2008), HIV Sentinel Surveillance Round 2008, 58. Govt, of India (2011), Operational Guidelines on Facility Based
National Action Plan Sept 2008 - June 2009, NACO, Ministry of Management of children with Severe Acute Malnutrition, Ministry of
Health and Family Welfare, New Delhi. Health and Family Welfare, New Delhi.
NACO (2017), HIV Sentinary Surveillance 2016-2017, Technical 59. Govt, of India (2011), Facility Based Newborn Care Operational
Brief. Guide, Guidelines for Planning and Implementation, Ministry of
NACO (2014), Annual Report 2013-2014, Department of AIDS Health and Family Welfare, New Delhi.
Control, Ministry of Health and Family Welfare, New Delhi. 60. Govt, of India (2014), Home Based Newborn Care, Revised
Govt, of India (2013), National Framework for Joint HIV/TB Operational Guidelines, Ministry of Health and Family Welfare, New
Collaborative Activities, Nov. 2013, Central TB Division and NACO, Delhi.
Ministry of Health and Family Welfare, New Delhi. 61. WHO (2006), Working Together for Health, The World Health
Govt, of India (2021), National Guidelines for HIV Care and Treatment Report, 2006.
2021, NACO, Ministry of Health and Family Welfare, New Delhi. 62. Govt, of India (2013), Operational Guidelines, Rashtriya Bal
NACO Website, National AIDS Prevention and Control Policy. Swasthya Karyakram (RBSK), Child Health Screening and early
Govt, of India (2007), Operational Guidelines for Programme intervention service under NRHM, Feb. 2013, Ministry of Health and
Managers and Service Providers for Strengthening STI/RTI Services, Family Welfare, New Delhi.
NACO, Ministry of Health and Family Welfare, New Delhi. 63. S. Menon et al (2006), Health Programme Series 10, Reproductive
Govt, of India (2004), National Programme for Control of Blindness and Child Health Programme: Flagship Programme of National Rural
in India, Ministry of Health and Family Welfare, New Delhi. Health Mission, 2006.
WHO (2013), Universal Eye Health, A Global Action Plan 2014-2019. 64. USAID (2013), MCHIP (2014), India’s Reproductive Maternal,
Allan, D. (1987). World Health, Jan-Feb, 1987, p. 9. Newborn, Child and Adolescent (RMNCH+A) Strategy, July 2014.
Grant, J.P. (1987). World Health, Jan-Feb, 1987, p. 10. 65. Govt, of India (2021), Reference Manual for Integrated RMNCAH+N
Govt, of India (2017), Immunization Handbook for Medical Officers, Counselling, Ministry of Health and Family Welfare, New Delhi.
Ministry of Health and Family Welfare, New Delhi. 66. Govt, of India (2016), Operational Guidelines- Prevention,
Govt, of India (2005), Health Information 2005, Ministry of Health Screening and Control of Common Non-Communicable Diseases:
and Family Welfare, New Delhi. Hypertension, Diabetes, and Common Cancers (Oral, Breast,
Govt, of India (1987). Centre Calling, Nov. 1987. Cervix) (Part of Comprehensive Primary Health Care), Ministry of
Govt, of India (2011), National Health Profile 2011, DGHS, Ministry Health and Family Welfare, New Delhi.
of Health and Family Welfare, New Delhi. 67. Govt, of India (2013), National Action Plan and Monitoring
Govt, of India (2016), Annual Report 2015-2016, Ministry of Health Framework for Prevention and Control of Non-communicable
and Family Welfare, New Delhi. Diseases (NCDs) in India, Developed through the WHO- Government
Govt, of India (2012), Annual Report 2011-2012, Ministry of Health of India, 2012- 2013 Biennial Workplan, Ministry of Health and
and Family Welfare, New Delhi. Family Welfare, New Delhi.

telegram-@Cherry_2412
Govt, of India (2011), Immunization Hand Book for Health Workers, 68. National Institute of Health and Family Welfare, website, Legislations,
Ministry of Health and Family Welfare, New Delhi. National Mental Health Programme.
Govt, of India (2014), India Newborn Action Plan (INAP), Sept. 69. Govt, of India (2005), Integrated Disease Surveillance Project,
2014, Ministry of Health and Family Welfare, New Delhi. Training Manual for state and District Surveillance Officers, Ministry
Govt, of India (2015), Press Release, Ministry of Health and Family of Health and Family Welfare, New Delhi.
Welfare, New Delhi, 24th July 2015, Achievements under the
70. Govt, of India, Training Manual for State and District Surveillance
National Rural Health Mission.
Officers, Integrated Disease Surveillance Project, Module-8.
Govt, of India (2013), Guidelines for Preparing NUHM Programme
Implementation Plan (PIP) for 2013-14, July 2013, Urban Health 71. WHO (2000), Weekly Epidemiological Record, No.22, 2nd June
Division, Department of Health and Family Welfare, New Delhi. 2000.
Govt, of India (2013), National Urban Health Mission, Framework for 72. Ministry of Finance Press release 2018.
Implementation, May 2013, Ministry of Health and Family Welfare, 73. National Institute of Health and Family Welfare, website, Legislations,
New Delhi. National Programme for Control and Treatment of Occupational
Govt, of India (2013), For Healthy Mother and Child, A Strategic Diseases.
Approach to Reproductive, Maternal, Newborn, Child and 74. Bookhive’s, 8th Five Year Plan (1992-97) by E. Chandran, Issues of
Adolescent Health (RMNCH+A) in India, January 2013, Ministry of Current Interest, Series No. 4.
Health and Family Welfare, New Delhi. 75. Swajaldhara, Deptt of drinking water supply, Ministry of Rural
Govt, of India (1997), Reproductive and Child Health Programme, Development, GOI, website http://ddws.nic.in / swajaldhara / html I
Schemes for Implementation October 1997, Department of Family faq.htm.
Welfare, Ministry of Health and Family Welfare, New Delhi. 76. Govt, of India (2014), Annual Report 2013-14, Ministry of Drinking
Govt, of India (2000), Annual Report 1999-2000, Ministry of Health Water and Sanitation, New Delhi.
and Family Welfare, New Delhi.
77. Govt, of India (2014), Swachh Bharat Mission (Gramin) Guidelines,
Govt, of India (2004), Annual Report 2003-2004, Ministry of Health Ministry of Drinking Water and Sanitation, New Delhi.
and Family Welfare, New Delhi.
78. Govt, of India (2014), Guidelines for Swachh Bharat Mission,
Govt, of India (2004), Guidelines for Operationalising First Referral
Units, Maternal Division, Ministry of Health and Family Welfare, New Ministry of Urban Development, New Delhi.
Delhi. 79. Govt, of India (2016), Twenty Point Programme-2006, Progress
Govt, of India (2018), Guidelines for community based events (CBE), Report for the period of April 2016-June 2016.
Poshan Abhiyan, Ministry of Women and Child Development, New 80. Govt, of India (2022), Years ofPradhan Mantri Awas Yojana-Urban,
Delhi. 2015-2022, Ministry of Housing and Urban Affairs, New Delhi.

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 Demography and
Family Planning
"Delay the first, postpone the second and prevent the third"

Demography, as understood today, is the scientific study (5) FIFTH STAGE : (Declining)
of human population. It focuses its attention on three readily
The population begins to decline because birth rate is
observable human phenomena : (a) changes in population
lower than the death rate. Some East European countries,
size (growth or decline); (b) the composition of the
notably Germany and Hungary are experiencing this stage.
population; and (c) the distribution of population in space. It
deals with five “demographic processes”, namely fertility,
mortality, marriage, migration and social mobility. These WORLD POPULATION TRENDS
five processes are continuously at work within a population At the beginning of the Christian era, nearly 2,000 years
determining size, composition and distribution. ago, world population was estimated to be around
(Community medicine is vitally concerned with population, 250 million. Subsequent estimates of the world population,
because health in the group depends upon the dynamic and rates of increase are given in Table 1.

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relationship between the numbers of people, the space which
they occupy and the skill that they have acquired in providing TABLE 1
for their needs)The main sources of demographic statistics in World population
India are population censuses. National Sample Surveys,
registration of vital events, and adhoc demographic studies.
Demographic cycle
The history of world population since 1650 suggests that
there is a demographic cycle of 5 stages through which a
nation passes:
(1) FIRST STAGE (High stationary)
This stage is characterized by a (high birth ratg and a(high
death rat -, which cancel each other and the population
remains stationary. India was in this stage till 1920.
(2) SECOND STAGE (Early expanding)
The death rate begins to decline, while the birth rate
remains unchanged. Many countries in South Asia and
Africa are in this phase. Birth rates have increased in some
of these countries possibly as a result of improved health
conditions and shortening periods of breast-feeding (1).
(3) THIRD STAGE (Late expanding)
The death rate declines still further, and the birth rate
tends to fall. _The population continues to grow because
births exceed deaths. India has entered this phase. In a
number of developing countries (e.g., China, Singapore)
birth rates have declined rapidly. It required all the human history up to the year 1800 for
the world population to reach one billion. The second billion
(4) FOURTH STAGE (LouLstationary) came in 130 years (around 1930), the third billion in 30 years
This stage is characterized by a low birth and low death (around 1960), the fourth billion in 15 years (in 1974), the
rate with the result that the population becomes stationary. fifth billion in 12 years (in 1987), and the sixth billion in
C-Zero-, population growth has already been recorded in 12 years (1999). The 7th billion came by 31st Oct. 2011 (after
Austria during 198CH85. Growth rates as little as 0.1 were 15 years). It is projected to reach 8 billion on 15th Nov. 2022.
recorded in UK, Denmark, Sweden and Belgium during About three fourths of the world’s population lives in the
1980-85. In short, most industrialized countries have developing countries. The population of the ten most
undergone a demographic transition shifting from a high populous countries of the world and their relative share is
birth and high death rates to low birth and low death rates. shown in Fig. 1. Although, in terms of population USA ranks
by R△J
 WORLD POPULATION TRENDS 55
TABLE 3
U.S.A. Birth and death rates in selected developed and
335 developing countries in mid-2022
Country Birth rate Death rate
India 18.7 7 20
280 Bangladesh 18.6 5.50
Pakistan 21.6 7.00
Sri Lanka 14 8 6.60
Thailand 11.0 7.60
Myanmar 17.7 8.20
Nepal 19.1 640
China 12.1 7 10
Japan 8.0 10.40
231
Singapore 8.7 4 40
Brazil UK 12.0 9 40
216 USA 12.4 8 70
Source : (2)
Nigeria
218 The world’s birth rate fell below 30 for the first time
around 1975 and had declined to about 17.6 during
Bangladesh r mid-2022 (3).(in most of the world the decline reflected
171 Russia Mexico falling birth rates and a global trend towards smaller
146 132 families. The outstanding examples are^ Singapore and
Population in million Thailand. In Singapore, in 50 years, the birth rate fell from
23 per thousand in 1970 to 4.4 in 2022; and in Thailand
FIG. 1 from 37 per thousand to 7.6 during the same period.

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Ten most populated countries of the world (mid-2022)
TABLE 4
Source : (2)
Reduction in the birth and death rates in
selected countries, 1990 - mid-2022
third in the world after India, there is a yawning gap of
1076 million between the population of these two countries. Birth rate Death rate
Country
CThe United Nations has estimated that world’s population is 1990 2022 1990 mid-2022
growing at an annual rate of 1.1 per cent in the year 2022.
Bangladesh 35 18.6 10 55
Three countries of SEAR i.e. India (1412 million), Nepal 38 19.1 13 6.4
Indonesia (280 million), and Bangladesh_(171 million) are India 31 18.7 11 7.2
among the most populous ten countries of the world. At present Sri Lanka 21 14 8 7 6.6
India’s population is second to that of China. According to UN 11.0 8 76
Thailand 19
projections, India’s population will reach 1.53 billion by the
Singapore 18 8.7 5 4.4
year 2050, and will be the highest population country in the
China 23 12.1 8 10.4
world. The trend of population increase in South East Asia
Pakistan 40 21.6 11 7.0
Region countries is as shown in Table 2.
Source : (2)
TABLE 2
In all these countries, key factors in fertility decline
Trends in increase of population of SEAR countries included changes in government attitudes towards growth,
(in million) the spread of education, increased availability of
contraception and the extension of services offered through
family planning programmes, as well as the marked change
in marriage patterns. ^
Death rates have also declined worldwide over the last
decades. The global death rate declined from 11.0 (between
1975-1980) to 7.678 per thousand population during 2022,
a reduction of 30.2 per cent. The decline in the death rate of
the South-East Asia Region has been more marked, from
14.1 to 7.0 per 1000 population.
C In countries with a relative young population, crude
death rates are mainly affected by irifant and child mortality.
With improvement in maternal and child health services,
successful implementation of the expanded programme on
Source : (2) immunization, diarrhoeal disease and acute respiratory
infection control programmes, as well as with the, control .of
Birth and death rates other infectious diseases, there has been marked reduction
The glaring contrasts in birth and death rates in selected in infant and child mortality rates, which are reflected in the
countries are as shown in Table 3. declining crude death ratesj

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556 DEMOGRAPHY AND FAMILY PLANNING

Growth rates 5. <In_2018, for the first time in history, persons aged 65
Cwhen the crude death rate is substracted from the crude years or over, worldwide, outnumbered children under
birth rate, the net residual js the currgnt annual growth_rate. age 5 years.
exclusive of mig'ration.|The relation between the growth rate 6. It is estimated that ten countries are experiencing a net
and population increase is as shown in Table 5. outflow of more than 1 million migrants between 2010
and 2020. For many of these countries losses of
TABLE 5 population due to migration are dominated by
Relation between growth rate and population temporary labour movements.
Number of years 7. Ckife expectancy at birth for the world’s population reached
Annual rate of required for the 72.6 years in 2019. Life expectancy in under developed
Rating
growth % population to countries is 7.4 years behind global average, due largely to
double in size persistently high levels of child and maternal mortality,
and in some countries, to violence and conflict, or the
Stationary population No growth
Slow growth
continuing impact of the HIV epidemic, \
Less than 0.5 More than 139
Moderate growth 0.5 to 1.0 139-70 The rampant population growth has been viewed as the
Rapid growth 1.0 to 1.5 70-47 greatest obstacle to the economic and social advancement of
Very rapid growth 1.5 to 2.0 47-35 the majority of people in the underdeveloped world.
“Explosive” growth 2.0 to 2.5 35-28
2.5 to 3.0 28-23 DEMOGRAPHIC TRENDS IN INDIA
»
3.0 to 3.5 23-20
»
3.5 to 4.0 20-18
Demographic indicators
Source : (4) L Demographic characteristics provide an overview of its
It is said that population growth rates, like railway trains., are population size, composition, territorial distribution,
subject to momentum. They start slowly and gain momentum. changes therein and the components of changes such as
Once in motion, it takes time to bring the momentum under nativity, mortality and social mobility. Demographic
control. In case of the train the control factors are mass and indicators have been divided into two parts (population
inertia; in population, they are age distribution, marriage statistics and vital statistics!

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customs and numerous cultural, social and economic factors^ Population statistics include indicators that measure the
The world population growth rate was at, or near to its population size, sex ratio, density and dependency ratio.
peak, around 1970, when the human population grew by an {Vital statistics include indicators such as birth rate, death
estimated 1.92 per cent. The most recent data shows a slight rate, natural growth rate, life expectancy at birth, mortality
decline since then to 1.1 per cent in mid 2022. and fertility rates.
The growth rate is not uniform in the world. There are (These indicators help in identifying areas that need policy
many countries in the world (e.g., European countries) and programmed interventions, setting near and far-term
where the growth rate is less than 0.3 per cent per year. In goals and deciding priorities, besides understanding them in
developing countries, the growth rates are excessive - it is an integrated structure. J
around 2.6 per cent in Africa, 1.0 per cent in Latin America, With a population of 1,412 million in the year mid 2022,
0.3 per cent in Europe and industrialized countries, and India is the second most populous country in the world, next
0.9 per cent in Asia. A population growing at 0.5 per cent only to China, whereas seventh in land area. With only 2.4
per ear will double in about 140 years, a population per cent of the world’s land area, India is supporting about
growing at 3 per cent per year will double in about 20-25 17.5 per cent of the world’s population. The population of
years (Table 5). These differences in growth rates are largely India since 1901, averaged annual exponential growth rate
the result of fertility and mortality patterns. The salient (%), and the decadal growth of population (%) was as
features of population growth at a glance are as follows (5): shown in Table 6.
1. The world’s population continues to grow, albeit at a TABLE 6
slower pace than at any time since 1950, owing to Population of India, 1901-2011 (As per census)
reduced levels of fertility. From an estimated 7.7 billion
people worldwide in 2019 to around 8.5 billion in 2030, Total Average Decadal
9.7 billion in 2050 and 10.9 billion in 2100. population annual growth rate
Year
(in million) exponential (%)
2. Countries of Sub-Saharan Africa could account for more growth rate (%)
than half of the growth of the world’s population
between 2019 and 2050. 1901 238.4 - -
3. (More than half of the projected increase in global 1911 252.1 0.56 0.75
population will be concentrated in just nine countries: 1921 251.3 (-) 0.03 (-) 0.31
The Democratic Republic of the Congo, Egypt, Ethiopia, 1931 279.0 1.04 11.00
India, Indonesia, Nigeria, Pakistan, United Republic of 1941 318.7 1.33 14.22
Tanzania, and the USA. Jndia is projected to surpass 1951 361.1 1.25 13.31
China as world’s most populous country around 2027. 1961 439.2 1.96 21.64
1971 548.2 2.20 24.80
4. In most of Sub-Saharan Africa, as well as in parts of
1981 683.3 2.22 24.66
Asia, Latin America and Caribbean, recent reductions
1991 846.4 2.16 23.87
of fertility means that the population at working ages
2001 1,028.6 1.7 21.52
(25-64 years) is growing faster than in other age groups,
2011 1,210.1 1.64 17.64
providing an opportunity for accelerated economic
growth known as the “demographic dividend”. Source : (6)

by R△J
 DEMOGRAPHIC TRENDS IN INDIA

India’s population has been steadily increasing since cent to the nation-wide increase in population. Demographic
1921. The year 1921 is called the “big divide” because the outcomes in these states will determine the timing and size of
absolute number of people added to the population during population at which India achieves population stabilization.
each decade has been on the increase since 1921 (Table 6).
India’s population is currently increasing at the rate of Age and sex composition
16jxiillion each year. The age-sex composition of India’s population is as
s^Jndia’s population numbered 238 million in 1901, doubled shown in Table 8.Gn the age group 0-14 years male
in 60 years to 439 million (1961); doubled again, this time in population is about 1.1 per cent more than female, whereas
only 30 years to reach 846 million by 1991) It crossed in the age group 60 +, percentage of. i emale population is
1 billion mark on 11 May 2000, and is projected to reach 0.6 percent more than male population. The proportion of
1.53 billion by the year 2050. This will then make India the population in the age group 0-14 years is higher in rural
most populous country in the world, surpassing China^ areas (26.5 per cent) than in urban areas (21.5 per cent), for
With the division of some states the rank of most populous both male and female population (10).
states have changed. Table 7 shows the ten most populous (The proportion of population below 14 years of age is
states in the country by rank. It is seen that Uttar Pradesh showing decline, whereas the proportion of elderly in the
comes first with about 231.425 million people, Maharashtra country is increasing. This_trend_is_i£LContinue in the tirnelo
comes second with 128.711 million people and Bihar comes come. The increase in the elderly population will impose a
third with 108.377 million people. These ten states account greater burden on the already outstretchedhealth services in
for about 71 per cent of the total population of India (7). the countr
TABLE 7 TABLE 8
Ranking of most populous states Per cent distribution of estimated population
by projected population size 2020 by age and sex, India (2020)

Population Per cent to total Population percentage

Rank State 2020 population of India group Total Males Females
(000) 2020
0-4 7.5 7.7 7.4
1. Uttar Pradesh 231,425 16.7 5-9 8.3 8.4 8.1

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2. Maharashtra 128,711 9.0 10-14 9.0 9.2 8.9
3. Bihar 108,377 7.8 15-19 10.2 10.4 9.9
4. Andhra Pradesh 90,949 6.5 20-24 11.2 11.0 11.4
5. Madhya Pradesh 82,134 5.9 25-29 10.5 10.4 10 7
6. Rajasthan 76,759 5.5 30-34 8.8 8.8 8.7
7. Tamil Nadu 70,617 5.0 35-39 7.4 7.4 7.5
8. Gujarat 65,532 4.7 40-44 6.2 6.2 6.2
9 Karnataka 64,410 4.6 45-49 5.2 5.2 5.3
10. Odisha 43,732 3.1 50-54 4.2 4.2 4.1
55-59 3.4 3.3 3.5
Source : (8)
60-64 2.9 2.9 3.0
It has been estimated that with current trends, the 65-69 2.1 21 2.2
population in India will increase from_ 1.210 _ billion to 70-74 1.4 1.4 1.5
1.4 billion during the period 2011 to 2026. \ There is a 75-79 0.9 0.8 0.9
substantial difference in total fertility rate in between and within 80-84 0.5 0.4 0.5
states. At one end of spectrum are southern states like Kerala, 85+ 0.3 0.2 0.3
Tamil Nadu, Karnataka and Andhra Pradesh with total fertility
rate at or below replacement levels. At the other end are high Total 100.0 100 0 100.0
fertility states like Uttar Pradesh, Chhattisgarh, Uttarakhand,
Note : * Total may not add upto 100 due to rounding off.
Rajasthan, Jharkhand, Bihar, Madhya Pradesh and Orissa,
with an estimated total fertility rate of more than 2.2. Source : (10)
(/The Government of India has categorized states Population pyramid
according to total fertility rate (TFR) level into very high-
focus (more than or equal to 3.0), high-focus (more than 2.1 (^Population pyramid is also known as “Age and Sex”
and less than 3.0) and non-high focus (less than or equal pyramid. It is a graphical representation of the age and sex of a
to 2.1) categories. The states categorized as very high-focus population. It "shows the distribution of ages^ across 'a
and high focus are as follows (9): population divided down the center between male and female
members of The population. The graphic starts from the
TFR 2.2-3.0 - Assam-2.3, Dadra & Nagar youngest at the bottom to oldest at theTop. It is called a pyramid
Haveli-2.3, Mizoram-2.3, because when a population is growing (there are more babies
Chhattisgarh-2.5, Jharkhand-2.6, being born then there^are people dying) the graphic forms the
Manipur-2.6^ Rajasthan-2.7, shape of a triangle.(A population pyramid can be used to
Nagaland-2.7, Madhya Pradesh-2.8 compare difference between male and female population of an
TFR more than - Bihar-3.3, Uttar Pradesh-3.1 and area. They also show the numbeFdf dependents ancTgeneral
or equal to 3.0 Meghalaya-3.0 structure of the population at any given time (11).
It is matter of concern that these states will delay the Fig. 2 shows age and sex pyramid of India and
attainment of replacement level ofjfertilit in India. These Switzerland. The pyramid is typical of developing countries,
high fertility states are anticipated to contribute about 50 per with a broad base and a tapering top.

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 DEMOGRAPHY AND FAMILY PLANNING
558
INDIA SWITZERLAND
Population 1390 million (end-2020) Population 8.65 million (mid-2020)

100 + 100 +
95-99 Male Female 95-99 Female
90-94 90-94
85-89 85-89
80-84 80-84
75-79 75-79
70-74 70-74
65-69 65-69
60-64 60-64
55-59 55-59
50-54 50-54
45-49 45-49
40-44 40-44
35-39 35-39
30-34 30-34
25-29 25-29
20-24 20-24
15-19 15-19
10-14 10-14
5-9 5-9
0-4 0-4

4% 2% 2% 4% 6% 6% 4% 2% 2% 4% 6%
FIG. 2
Percentage distribution by age of the population of India and of the population of Switzerland.

Sex ratio Sex ratio at birth : The sex ratio at birth for the country
fSex ratio is defined as “the number of females per 1000. for the period 2018-20 (3-years average) has been
males”. One of the basic demographic characteristics of the estimated at 907. At National level, it is 907 in rural areas
population is the sex composition. In any study of and 910 in urban areas. Among the bigger States/CJTs, the

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population, analysis or the sex composition plays a vital sex ratio at birth varies from 974 in Kerala to 844 in
role. The sex composition of the population is affected by Uttarakhand. In the rural areas, the highest and the lowest
the differentials—in mortality conditions of males and sex ratio at birth are in the States of Kerala. (973) and
females, sex selective migration and sex ratio at birth. Uttarakhand (853) respectively. The sex ratio at birth in
^Female deficit syndrome” is considered adverse because^of urban areas varies from 975 in Kerala to 821 in
social implications. A low sex ratio indicates strong male- Uttarakhand. Table 10 shows the variation in sex ratio at
ch ild^preference and consequent gender inequities, neglect birth by residence among bigger States/UTs in the country.
qT the girl child resulting in higher mortality at younger age,
female infanticide, female foeticide, higher maternal TABLE 10
mortahty and male bias in enumeration of population.j Easy Sex Ratio (female per 1000 male) at birth by residence,
availability of the sex determination tests and abortion India and bigger states/UTs, 2018-2020
services may also be proving to be catalyst in the process, Bigger states Total Rural Urban
which may be further stimulated by preconception sex
selection facilities. Andhra Pradesh 926 930 919
Assam 923 923 930
The trends in the sex ratio in the country from 1901 Bihar 895 894 897
onwards are as shown in Table 9. Chhattisgarh 958 970 910
TABLE 9 Delhi 860 972 857
Sex ratio in India Gujarat 877 882 869
Haryana 870 868 874
Himachal Pradesh 950 952 920
Jammu & Kashmir 921 918 930
Jharkhand 914 915 910
Karnataka 942
Ro 00
S3 SJ

Kerala [974J 97
Madhya Pradesh 919 908 960
Maharashtra 876 881 870
Odisha 925 928 907
Punjab 897 874 932
Rajasthan 911 914 901
Tamil Nadu 917 902 930
Telangana 892 903 875
Source : (6) Uttar Pradesh 905 . 890 960
Uttaranchal f844J
The sex ratio in India has been generally adverse to West Bengal 936 941 920
women, i.e., the number of women per 1,000 men has
India 907 907 910
generally been less than 1,000. Apart from being adverse to
women, the sex ratio has also declined over the decades. Source : (10)

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 URBANIZATION 559
Child sex ratio (0-6 years) : Census 2011 marks a advantage is taken of the demographic transition with high
considerable fall in child sex ratio in the age group of 0-6 economic growth rates (13).
years and has reached an all time low of^914 since 1961. (The term “demographic burden” is used to connote the
The fall has been 13 points from 927 to 914 for the country increase in the total dependency ratio during^ any peTTocFof
during 2001 to 2011. In rural areas, the fall has been time, mostly causecTby increased old age dependency ratio?
significant - 15 points from 934 to 919 and in urban areas it This is an inevitable consequence of demographic transition,
has been 4 points from 906 to 902 over the decade (6). and the country has to face this problem~~sooner or
later (13).
Dependency ratio
The proportion of persons above 65 years of age and Density of population
children below 15 years of age are considered -to be One of the important indices of population concentration
dependant~rm- the economically productive age group is the density of population. It is the ratio between (total)
(15-64 years). The ratio of the combined age groups 0-14 population and surface (land) area. This ratio can he
years plus 65 years and above to the 15-65 years age group calculated for any territorial unit for any point in time,
is referred to as the total dependency ratio. It is also referred depending on the source of the population data (13). In the
to as the societal dependency ratio and reflects the.need Indian census, density is defined as the number of persons,
for a society to provide tor their younger and older living per square kilometre. The trends of the density in the
population groups. The dependency ratio can be subdivided country from 1901 onwards are as shown in Table 11. For
into youngage dependency ratio (0-14 years); and old the year 2020 the density of population per sq. km. in
age dependency ratio (65 years and more). These ratios India was 464.
areTTiowever, relatively crude, since they do not take into
consideration elderly or young persons who are employed TABLE 11
or working age persons who are unemployed. It is given by
the formula : Density of population in India 1901-2011

Children 0-14 years age +

lotal Population more than 65 years of age 1901 77
dependency = --------- —--- ---------- ——--- —-------------- x 1U0
rat:o Population of 15 to 64 years 1911 82

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1921 81
For India, the dependency ratio for the year mid-2020 is 1931 90
calculated as : 1941 103
% of population in 0-14 years age group - 26.2 per cent 1951 117
% of population above 65 years of age - 6.6 per cent 1961 142
% of population in 15-64 years age group - 67.3 per cent 1971 177
1981 216
Total 26.2 + 6.6 1991 267
dependency = x 100
ratio 67.3 2001 325
2011 382
48.736 per cent
The young age dependency ratio is 38.3 per cent, Source : (6)
and old age dependency ratio is 9.8 per cent for the year
Urbanization
mid 2020 (12).
By definition, urban population is the number of persons
For international comparison, the child, old and total
residing in urban localities. The definition of urban locality
dependency ratios are used to study the dependency burden
varies from country to country. In Indian context, the urban
of the population. ^The total dependency ratio tends to
areas are the “Towns (places with municipal corporation,
decrease in the earlier stages of development wherL_rapjd
municipal area committee, town committee, notified
decline in fertility reduces the child population more than
area committee or cantonment board); also, all places
the increase in the older persons, but subsequently the having 5,000 or more inhabitants, a density of not less than
increase in older persons far out-weighs the decline in the 1,000 persons per square mile or 390 per square kilometre,
child population. There is a shift from child^dependency to pronounced urban characteristics and at least three~~Tourths
old age dependency, as fertility declines and life expectancy of the adult male population employed in pursuits other
increases. than agriculture” \l3).
rapid decline in dependency ratios, especially the ..The population in India continues to be predominantly
child-dependency ratio, has been identified to be a key factor rural_ with agriculture as the main occupation for the
underlying rapid economic development. The term
a majority of the people.
demapraphic bonus” connotes the period when the
dependency ratio in a population declines because of decline As per population totals for the year 2019, the urban
in fertility, until it starts to rise again because of increasing population stands at 471.828 million (34.5 per cent).
longevity. This period depends on the pace of decline in Mumbai is the highest populous city with 126*9 million
fertility level of a population. If the switch to small families is followed by Delhi 10.927 million, Bengaluru comes third
fast, the demographic bonus can give a considerable push to with 5.104 million, Kolkata 4.631 million is fourth and
development. If investment in health care and education for Chennai (4.328 million) is fifth. Fig. 3 indicates the level of
skill development are made during this period, maximum urbanization in the country (14).

by R△J
 DEMOGRAPHY AND FAMILY PLANNING

The family size depends upon numerous factors, viz.

duration of marriage, education of the couple, the number
of live births and living children, preference of male
children, desired family size, etc.
The question of family size is undoubtedly important
from the demographic point of view. The family planning
programme’s campaign is currently basecfon the theme of a
“two-child” family norm, with a view to reach the long-term
demographic goal of NRR=1. Family planning involves both
decision regarding the “desired family size” and the effective,
limitationof fertility once that size has been reached.
Table 12 shows the total fertility rates (completed family
size) in India and selected countries. The decrease in family
size does not appear to be due to any reduction in fertility;
rather it appears to be due to the result of deliberate family
planning.
TABLE 12
Total fertility rates in selected developed and developing
countries : 1994 and 2020
Country 1994 2020
India 3.7 1.8
Bangladesh 3.9 2.1
Nepal 4.8 1.9
Sri Lanka 2.3 2.2
Myanmar 3.6 2.2
China 1.9 1.7

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Pakistan 5.5 3.6
UK 1.8 1.8
USA 2.0 1.8
Japan 1.5 1.4
Census year Switzerland 1.5 1.5

Source : (16, 17)

FIG. 3
INDIA - Growth of urban population 1901-2011 Literacy and education
kin 1948, the Declaration of Human Rights stated that
kJFheincrease in urban population has been attributed everyone has a right to education^ Yet, even today, this right
both to natural growth (through births) and migration from is being denied to millions of children. Education is a crucial
element in economic and social development. Without
villages because of employment opportunities, attraction of
education, development can neither be broad based nor
better living conditions and availability of social services
sustained. The benefits that accrue to a country by having a
such as education, health, transport, entertainment etc. The literate population are multidimensional. Spread of literacy
continuous migration of people from country side to urban is generally associated with modernization, urbanization,
areas jn India constitute a social crisis, the ramification of industrialization, communication and commerce. It forms an
which may eventually impair thequality of life. important input in the overall development of individuals
The urban-rural scenario in India is as follows (6) : enabling them to comprehend their social, political and
.^cultural environment better, and respond to it appropriately.
Administrative Units Census 2011 2020 Increase kHigher levels of education and literacy lead to a greater
No. of States/UTs 35 37 2
awareness and also contribute to improvement of economic
conditions, and is a pre-requisite for acquiring various skills
No. of Districts 640 741 101 and better use of health care facilities?)
No. of Sub-Districts 5,924 6,553 629
It was decided in 1991 census to use the term literacy rate
No. of Villages 640,867 664,369 23,502 for the population relating to seven years age and above.
A person is deemed as literate if he or she can read and write
Family size with understanding in any language. A person who can
While in common parlance, family size refers to the total merely read but cannot write is not considered literate. The
number of persons in a family, in demography, family size same concept has been continued in census 2001 and 2011
means the total number_of children a woman has borne alsoCThe literacy rate taking in account the totaljaopulation
at a point in time (15). The completed family size indicates in the denominator has now been termed as “crude literacy
the total number of children borne by a woman during her rale”, while the literacy rate calculated taking into account
child-bearing age, which is generally assumed to be between the 7 years and above population in the denominator is
15 and 45 years. The total fertility rate gives the called the effective, literacy rate. The formula for computing
approximate magnitude of the completed family size. crude literacy rate and effective literacy rate are as follows:

by R△J
 LITERACY AND EDUCATION 561
Number of literate persons x 100 TABLE 13
Crude literacy rate = ——-------------;—;--- ;------- ;------------
Total population in a given year State-wise literacy rate in India - 2011

State/ Literacy rate

Number of literate persons Union Territory* Total Males Females
Effective aged 7 and above x 100
literacy Jammu & Kashmir 68.74 7826 58.01
rate Population aged 7 and above
in a given year Himachal Pradesh 83.78 90.83 76.60
Punjab 76.68 81.48 71.34
A significant milestone reached in Census 2011 is that the
Chandigarh* 86.43 90.54 81.38
total number of illiterates has come down from
304.1 million in 2001 to 272.9 million in 2011 showing a Uttarakhand 79.63 88.33 70.70
decline of 31.1 million. The reverse trend was noted during Haryana 76.64 85.38 66.77
1991-2001 period. The decadal increase in the number of NCT of Delhi* 86.34 91.03 80.93
literates among males is of 31.9 per cent points and the Rajasthan 67.06 80.51 52.66
corresponding increase among females is of 49.1 per cent
Uttar Pradesh 69.72 79.24 59.26
points (6). These two changes are a clear indication that the
gender gap in literacy is shrinking in the country. It will have Bihar 63 82 73 39 53.33
far reaching consequence on the development of the society. Sikkim 82.20 87.29 76.43
Fig. 4 shows the literacy rates in India after independence. Arunachal Pradesh 66.95 73.69 59.57
Nagaland 80.11 83.29 76.69
Manipur 79.85 86.49 73.17
Mizoram 91.58 93.72 89.40
Tripura 87.75 92.18 83.15
Meghalaya 75.48 77.17 73.78
Assam 73.18 78.81 67.27
West Bengal 77.08 82.67 71.16

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Jharkhand 67.63 78.45 56.21
Odisha 73.45 82.40 64.36
Chhattisgarh 71.04 81.45 60.59
Madhya Pradesh 70.63 80.53 60.02
Gujarat 79.31 87.23 70.73
Daman & Diu* 87.07 91.48 79.59
Dadra & Nagar Haveli* 77.65 86.46 65.93
Maharashtra 82.91 89.82 75.48
Andhra Pradesh 67.66 75.56 59.74
Karnataka 75.60 82.85 68.13
Goa 87.40 92.81 81.84
Lakshadweep* 92.28 96.11 88.25
Kerala 93.91 96.02 91.98
Tamil Nadu 80.33 86.81 73.86
Puducherry* 86.55 92.12 81.22
FIG. 4 Andaman & Nicobar Islands* 86.27 90.11 81.84
Literacy rates in India 1951-2011 INDIA 74.04 82.14 65.46
Source : (18)
Source : (6)
The national average of literacy rate is misleading as wide
variations exist between the states. Table 13 shows the Government of India has made education compulsory up
literacy rates in different states in India. The national to the age of 14 years in the country. Though considerable
percentage of literates in the population above 7 years of progress has been made in expanding primary education, a
age is about 74.04 with literate males about 82.14 per cent major concern is high drop out rates in the first few years of
and females lagging behind with about 65.46 per cent. schooling.
Table 13 shows that Kerala continues to occupy the top
rank in the country with about 93.91 per cent literates. Life expectancy
Mizoram (91.58 per cent, and Lakshadweep (92.28 per
cent) closely follow Kerala. On the other end is Bihar and t Life expectancy - or expectation of life ~ at a given age is
Arunachal Pradesh with literacy rate of only 63.82 and 66.9 the average number of years which a person of that age may
per cent respectively. The states which have literacy rates expect to live, according to the mortality pattern prevalent in
below the national average are Arunachal Pradesh, Andhra that country. Demographers consider it as one of the best
Pradesh, Bihar and Jharkhand, Jammu & Kashmir, Uttar indicators of a country’s level of development and of the
Pradesh, Madhya Pradesh, Rajasthan and Odisha etc. overall health status of its population. /

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 DEMOGRAPHY AND FAMILY PLANNING

' Life expectancy at birth has continued to increase 15 and living till 45 with her husband is exposed to the risk
globally over the years. For 1950-1955, the combined life of pregnancy for 30 years, and may give birtFFjo
expectancy at birth for both sexes was 46.5 years. Five 15 children, but this maximum is rarely achieved, y
decades later by 2008, it was 69 years - an increase of 22.5 ( Fertility depends upon several factors. The higher fertility
years. The increase has been more marked in less developed in Indians attributed to universality of marriage, lower age at
regions of the world than in the developed regions (16). marriage, low level of literacy, poor leveTof living, limited
Most countries in the world exhibit a sex differential in use of contraceptives_and traditional ways of life. National
mortality favouring women - females live longer than males Family Health Survey-5 conducted in India during
as shown in Table 14 and 15. 2019-2021 provides some detailed information of fertility
trends, as shown in Table 16.
(Trends in life expectancy show that people are living
longer, and they have a right to a long life in good health, TABLE 16
rather than one of pain and disability. Health policy makers
Total fertility rate by selected background characteristics
thus need to recognize this changing demographic pattern (2019-21)
and plan for prevention and control of diseases associated National Family Health Survey-5
with old age. |
Tables 14 and 15 present life expectancy at birth in India
and those in selected countries. Japan leads in life
expectancy for both males and females, 81 and 87 years
respectively for the year 2020.

TABLE 14
Expectation of life at birth, years in India
Year Males Females

1901 23.63 23.96

1911 22.59 23.31

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1921 1942 20.91
1931 26.91 26.56
1941 32.09 31.37
1951 32.45 31.66
1961 41.89 40.55
1971 46.40 44.70
1981 54.10 54.70
1991 59.70 60.90
2001 63.90 66.90
2011 64.00 67 00

Source : (6)

TABLE 15
Expectation of life at birth, years, in selected countries 2020
Developing 2020 Developed 2020
countries Male Female countries Male Female
Nepal 67 70 UK 79 83
Bangladesh 71 74 USA 76 81
Myanmar 64 69 Sweden 81 85 Source : (20)
India 68 70 Switzerland 82 85
Some of the factors which have engaged attention of
Sri Lanka 74 80 Russian Federation 68 78 demographers since long are discussed below.
Thailand 73 80 Japan 81 87
Pakistan 67 71 Singapore 81 85 J^JVge at marriage
The age at which a female marries and enters the
Source : (19)
reproductive period of life has a great impact on her fertility.
The Registrar General of India collected data on fertility on a
FERTILITY national scale and found that females who marry before the
age of 18 gave birth to a larger number of children than
(j3y fertility is meant the actual bearing of children. Some those who married after (21). In India some demographers^
demographers prefer to use the word natality in place of have estimated that if marriages were postponed from the
fertility. A woman’s reproductive period is roughly from age of 16 to 20-21, the number of births would decrease by
15 to 45 years - a period of 30 years. A woman married at 20-3jlp_erxent (21).

by R△J
 FERTILITY 563
Early marriage is a long-established custom in India. As JLJEafnily planning
early as 1929, the Sarada Act was enacted forbidding the
Family planning is another important factor in fertility
practice of child marriage. The census data reveals that prior
to 1951, the average age at marriage for girls in India was reduction. In a number of developing countries, family
13 years. There is however, a gradual rise in the age at planning has been a key factor in declining fertility (Table 4).
marriage in the country.^The_Child Marriage Restraint Act of Family planning programmes can be initiated rapidly and
1978 raises the legal age at marriage from 15 to 18 years for require only limited resources, as compared to other factors.
girls, and from 18 to 21 years for boys. Studies indicate that
in many States, the mean age at marriage for girls has jhjOt-her factors
already moved upto 20 years in 2006, and many others are Fertility is affected by a number of physical, biological,
very close to this. For the year 2020, the national average for social and cultural factors such as place of women in society,
effective marriage is 22.7 years. The exceptions are the rural value of children in society, widow remarriage, breast­
areas, where a substantial proportion of marriages continue feeding customs and beliefs, industrialization ^and
to take place when the girl is around 16 years of age (10). urbanization. better health conditions, housing,
opportunities for women and local community involvement.
jLJ>uration of married life Attention to these factors requires long-term government
Studies indicate that 10-25 per cent of all births occur programmes and vast sums of money.
within 1-5 years of married life; 50-55 per cent of all births
within 5-15 years of married life. Births after 25 years of FERTILITY RELATED STATISTICS
married life are very few (21). This suggests that family
planning efforts should be concentrated in the first few years Fertility may be measured by a number of indicators, as
of married life in order to achieve tangible results^ given below. Stillbirths, foetal deaths and abortions,
however, are not included in the measurement of fertility in
3^£ipacing of children a population (22).
Studies have shown that when all births are postponed by
one year, in each age group, there was a decline in total 1. girth Rate
fertility. It follows that spacing of children may have a Birth rate is the simplest indicator of fertility and is

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significant impact on the general reduction in the fertility defined as “the number of live births per 1000 estimated
rates. \
mid-year population, in a given year”. It is given by the
^JEducation formula :
There is an inverse association between fertility and it Number of live births during the year
educational status. Education provides knowledge; ‘Hn Birth Rate = ------ ---------- ------ ---------------- ------------- X 1000
Estimated mid-year population
increased exposure to information and media; builds skill for
gainful employment; increases female participation in family The birth rate is an unsatisfactory measure of fertility
decision making; and raises the opportunity costs of because the total population is not exposed to child bearing.
women’s time. The National Family Health Survey-5 shows Therefore it does not give a true idea of the fertility of a
that the total fertility rate is 1.02 children higher for illiterate population.
women than for women with at least a high school education
(Table 16). 2. General Fertility Rate (GFR)
Qlt is the “number of live births per 1000 women in the
conomic status reproductive age-group (15-44 or 49 years) in a given
Operational Research studies support the hypothesis that year”.\
.economic status bears an inverse relationship with fertility.
Number of live births in an area
The total number of children born declines with an increase during the year
in per capita expenditure of the household. The World GFR --- ----------------------------------------------------- X1000
Population Conference at Bucharest in fact stressed that Mid-year female population age 15-44
economic development is thejjest contraceptive. It will take (or 49) in the same area in same year
care^oTpopulation growth and bring about reductions in
fertility. ^general fertility rate is a better measure of fertility than
the crude birth rate because the denominator is restricted to
6^Caste and religion the number of women in the child-bearing age, rather than
Muslims have a higher fertility than Hindus. The National the whole population. The major weakness of this rate is
Family Health Survey-5 reported a total fertility rate of 2.36 that not all women in the denominator are exposed to the
among Muslims as compared to among Hindus. The risk of childbirth.
total fertility rate among Christians was found to be 1.88.
Among Hindus, the lower castes seem to have a higher 3. General Marital Fertility Rate (GMFR)
fertility rate than the higher castes (20). ^Jfjsjhe—^number of live births per 1000 marned_women
in the reproductive age group (15-44 or 49) in-a~given
7^-Nutrition year”.
There appears to be some relationship between Number of live births in a year
nutritional status and fertility levels. Virtually, all well-fed GMFR -- ------------------------------------------------------X 1000
societies have low fertility, and poorly-fed societies high Mid-year married female population in
fertility. The effect of nutrition on fertility is largely indirect. the age-group 15-49 years

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564 DEMOGRAPHY AND FAMILY PLANNING

4. Age-specific Fertility Rate (ASFR) less than 1, then the reproductive performance of the
population is said to be below replacement level.
A more precise measure of fertility is age-specific fertility
rate, defined as the “number of live births in a year to 1000 10. Child-woman Ratio
women in any specified age-group”. The age-specific
fertility rates throw light on the fertility pattern. They are It is the number of children 0-4 years of age per 1000
also sensitive indicators of family planning achievement. women of child-bearing age, usually defined as 15-44 or
49 years of age. This ratio is used where birth registration
Number of live births in a
particular age group statistics either do not exist or are inadequate. It is estimated
^ASFR = -------------------------------------------------------- X 1000 through data derived from censuses (6).
Mid-year female population
of the same age-group 11. Pregnancy Rate
It is the ratio of number of pregnancies in a year to
5. Age-specific Marital Fertility Rate (ASMFR)
married women in the ages 15-44 (or 49) years. The
It is the number of live births in a year to 1000 married “number of pregnancies” includes all pregnancies, whether
women in any specified age group. these had terminated as live births, stillbirths or abortions or
Number of live births in a had not yet terminated.
particular age group
-------------------------------------------------- X1000 12. Abortion Rate
Mid-year married female population
The annual number of all types of abortions, usually
of the same age group
per 1000 women of child-bearing age (usually defined as
6. Total Fertility Rate (TFR) age 15-44) (25).
QbtaMertility rate represents the average number of
13. Abortion Ratio
cmldrena woman would have if she were to pass through
her reproductive years bearing children at the same rates as This is calculated by dividing the number of abortions
the women now in each age group (23). It is computed by performed during a particular time period by the number of
summing the age-specific fertility rates for all ages; if 5-year live births over the same period (26).

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age groups are used, the sum of the rates is multiplied by 5.
This measure gives the approximate magnitude of 14. Marriage Rate
“completed family size”. It is the number of marriages in the year per 1000
45-49 population :
5x SASFR Crude Number of marriages in the year
15-19 Marriage = ------------- ——--------------- ------------------ X 1000
TFR = -------------------------- Mid-year population
1000
Demographers consider this a very unsatisfactory rate,
7. Total Marital Fertility Rate (TMFR) because the denominator is comprised primarily of
Average number of children that would be born to a population that is not eligible to marry. A more sensitive rate
married woman if she experiences the current fertility is the general marriage rate :
pattern throughout her reproductive span. General Number of marriages within one year
45-49 Marriage = ----------------------------------------------------------- X 1000
Dafp Number of unmarried persons age
5x 2 ASMFR 15-49 years
15-19
TMFR = ------------------------- This rate is more accurate when computed for women
1000 than for men because more men than women marry at the
older ages (6).
8. Gross Reproduction Rate (GRR)
Average number of girls that would be born to a woman if Fertility trends
she experiences the current fertility pattern throughout her (^Researches indicate that the level of fertility in India is
reproductive span (15-44 or 49 years), assuming no beginning to decline. The crude birth rate which was about
mortality. (49 per thousand population during 1901-11 has declined to
45-49 about 25.0 per thousand population in. 2002, and was
5 X y ASFR for female live births 20 4 per, thousand population in 2016. The rural urban
15-19 differential has narrowed. However, the crude birth rate has
GRR =--------------- --------------------------------------- continued to^be higher in rural areas as compared to urban
1000 areas in the last 3 decades.»
9. Net Reproduction Rate (NRR) $ f The Total fertility rate has declined from 3.6 in 1991 to
2.0 in 2020. The TFR in rural areas has declined fromJL4dn
(^et Reproduction Rate (NRR) is defined as the number of 1971 to 2.2 in 2020, whereas the corresponding decline in
daughters a newborn _gjrl_will bear during hgr lifetime urban areas has been from 4.1 to 1.6 during the same
assuming fixed age-specific fertility and mortality rates (24). period. There are considerable inter-state variations in total
NRR is a demographic indicator. NRR of 1 is equivalent fertility rate as shown in Fig. 5. In bigger states it varies from
to attaining approximately the 2-child norm. If the NRR is 1.4 in West Bengal and Tamil Nadu to 3.0 in Bihar (7)

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 FERTILITY RELATED STATISTICS 565
Birth and death rates
The birth and death rates are important components of
population growth. The birth and death rates in India are
shown in Table 18. A look at Table 18 shows that whereas
the death rate has considerably declined from 27.4 in 1951
to an estimated 7.2 per thousand population in 2020, the
birth rate has declined niggardly from 39.9 in 1951 to an
estimated 18.7 per thousand in 2020.
(The Fifth Five Year (1974-79) Plan’s objective was to
reduce the birth rate from 35 per thousand at the beginning of
the Plan to 30 per thousand by 1978-79. During 1979-84, the
birth rate was stagnating around 33 per thousand with no
obvious decline. During 1990, however, the birth rate showed
a slight decline, to an estimated 30.2, further declining to 26.4
by the year 1998. The current picture indicates that birth and
death rates are both declining in India.
TABLE 18
Birth and death rates in India
Year Birth rate Death rate
1941-1950 39.9 27.4
1951-1960 41.7 22.8
1961-1970 41.2 19.0
1971-1980 37.2 15.0
1981 33.9 12.5
1991 29.5 9.8

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1995 28.3 9.0
1998 26.8 9.0
1999 26.1 8.7
2002 25.0 8.1
2004 24.1 7.5
2006 23.5 7.5
2008 22.8 7.4
2010 22.1 7.2
2012 21.6 7.0
Crude birth rate (2020) and Total fertility rate (2020) 2015 20.0 7.0
for major states 2016 20.4 6.4
Source : (10) 2018 20.0 6.2
2022 18.7 72
Recent estimates of the fertility indicators and age­ Source : (7)
specific fertility rates in India are given in Table 17.
HIGH BIRTH RATE : India like other developing
TABLE 17 countries is faced with the dilemma of a high birth rate and a
Fertility indicators of India, 2020 declining death rate. This is a vicious circle, not easy to
break. Thekcauses of high birth rate are (1) Universality of
marriage : Marriages arp universal and sacramental.
Everyone, sooner or later (usually sooner) gets married and
participates in reproduction. The individual’s economic
security or emotional maturity are seldom a pre-requisite to
marriage. (2) Early marriage : Marriages are performed
early. Data indicate that about 60 per cent of the girls aged
15-19 years are already married. (3) Early puberty : Indian
girls attain puberty early, between 12 and 14 years. (4)_Law,
standard of living : Where standards of living are low, birth
rates are high". (5)(Low level of literacy : The 2011 census
showed that only 74.04 per ^ent of the population was
literate. The female literacy is still lower, especially in the
rural areas. (6) [Traditional customs and habits : Customs
dictate that every woman must marry and every man must
have a son. Children are considered a gift of God and their
birth should not be obstructed. (7) [Absence of family
planning habit : Family planning is oT~recent origin.
It has not yet become part of the marital mores of the people.
DECLININGDEATH RATE : The declining death rate has
been attributed to : Hl) absence of natural checks, e.g..
Source : (10) famines and large scale epidemics, (2) mass control of
by R△J
 X—* *<_ KJ <A 'i—’ '-A-KJC,/ \

demography and family planning

diseases, e.g., smallpox, plaque, cholera, malaria etc., education, and means to do so”. The World Conference of the
(3) advances in medical science, e.g., extensive use of International Women’s Year in 1975 also declared “the right
chemotherapeutics, antibiotics, and insecticides, (4) better of women to decide freely and responsibly on the number and
health facilities, e.g., establishment of primary health spacing of their children and to have access to the information
centres and more treatment centres, (5) impact of and means to enable them to exercise that right” (30). Thus
national health programmes, (6) improvements in food during the past few decades, family_planning has emerged
supply, (7) international aid in several directions, and from whispers in private quarters to the focus of international
(8Pdevelopment of social consciousness among the masses. concern as~a~basic human right, and a component of family
Demographers opine that further rapid decline in India’s health and sociaFwelfare.
death rate may not continue in future. The reason is that
most of the “easy” conquest of mortality has been Scope of family planning services
accomplished through the widespread use of vaccines, Family planning is not synonymous with birth control; it
antibiotics, insecticides, and other life-saving measures. The is more than mere birth control. A WHO Expert Committee
tasks that remain now are the most difficult ones such as (1970) has stated that family planning includes in its
improvements in environmental sanitation and nutrition; purview:- (1) the proper spacing and limitation of births,
and control of non-communicable and genetic diseases^ (2) advice on sterility, (3) education for parenthood, (4) sex
education, (5) screening for pathological conditions relatecT
Growth rate toThereproductive system (e.g., cervical cancer), (6) genetic
The population growth rates in India are presented in counselling, (7) premarital consultation and examination,
Table 6. Prior to 1921, the population of India grew at a slow (8) carrying out pregnancy tests, (9) marriage counselling,
rate. This was due to the operation of natural checks (10) the preparation of couples for the arrival of their first
(e.g., famines and epidemics) which took a heavy toll of child, (11) providing services for unmarried mothers,
human life. After 1921, the “great divide”, the occurrence of (12) -'(teaching home economics and nutrition, and
famines and epidemics was effectively controlled through (13) providing adoption services (29). These activities vary
better nutrition and improved health care services, with the from country to country according to national objectives
result that the death rate declined more steeply than the birth and policies with regard to family planning. This is the
rate. Consequently, there was a net gain in births over deaths, modern concept of family planning.

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leading to rapid growth in population, which rose from
1.25 per cent in 1951 to 1.96 in 1961, 2.20 in 1971, 2.22 in Health aspects of family planning (31, 32, 33)
1981, 2.16 in 1991, 1.7 in 2001 and 1.64 in 2011 (Table 6). Family planning and health have a two-way relationship.
India is now the second most populous country in the The principal health outcomes of family planning were listed
world, adding 17.5 million every year to her 1210 million at and discussed by a WHO Scientific Group on the Health
the time of 2011 census. However, the most recent data Aspects of Family Planning (31). These can be summarized
indicates a decline in India’s population growth rate. The under the following headings.
estimates for the year 2020 is 1.2.
Women’s health
FAMILY PLANNING maternal mortality, morbidity of women of child-
bearing age, nutritional status (weight changes,
Definition haemoglobin level, etc.) preventable complications of
There are several definitions of family planning. An Expert pregnancy and abortion.
Committee (1971) of the WHO defined family planning as “a
way of thinking and living that is adopted voluntarily, upon Foetal health
the basis of knowledge, attitudes and responsible decisions Cfoetal mortality (early and late foetal death);
by individuals and couples, in order to promote the health abnormal development.
and welfare of the family group and thus contribute
effectively to the social development of a country” (27). Infant and child-health
Another Expert Committee (28) defined and described (neonatal, infant_and pre:school mortality,
family planning as follows : (Family planning refers to practices nealth of theTnfant at birth (birth weight),
that help individuals or couples to attain certain objectives vulnerability to diseases.
(a) to avoid unwanted births;
(b) to bring about wanted births; (a) WOMEN’S HEALTH : Pregnancy can mean serious
problems for many women. It may damage the mother’s
(c) to regulate the intervals between pregnancies; health or even endanger her life. In developing countries,
(d) to control the time at which births occur in relation to the risk of dying as a result of pregnancy is much greater
the ages of the parent: and than in developed countries. The risk increases as the
(e) to determine the number of children in thefamily. mother grows older and after she has had 3 or 4 children.
Family planning by intervening in the reproductive cycle of
Basic human rights women, helps them to control the number, interval and
The United Nations Conference on Human Rights at timing of pregnancies and births, and thereby reduces
Tehran in 1968 recognized family planning as a basic human materna moria’ity and morbidity and im: roves health. The
right. The Bucharest Conference (29) on the World Population health impact of family planning occurs primarily through :
held in August 1974 endorsed the same view and stated in its (i) the avoidance of unwanted pregnancies; (ii) limiting the
\Plan_of Action’ that “all couples^and individuals have the number of births and proper spacing, and (iii) timing the
basichuman right to decide freelymid responsibly the number births, particularly the first and last, in relation to the age of
and spacing of thpjr children and to have the information. the mother. It is estimated that guaranteeing access to family
by R△J
 FAMILY PLANNING
567
planning alone could reduce the number of maternal deaths The concept of welfare is very comprehensive and is
by 25 per cent; and child mortality by 20 per cent (13). basically related to quality of life. The Family Welfare
(i) 'Unwanted pregnancies . The essential aim of family Programme aims at achieving a higher end - that is, to
planning is to prevent the unwanted pregnancies. An improve the quality of life of the people.
unwanted pregnancy rpayjead to an induced abortion.
From the point of view of health, abortion outside the Small-family norm
medical setting (criminal abortion) i', Zw of the most (J5mall differences in the family size will make big
dangerous consequence of unwanted pregnancy. Particular differences in the birth rate. The difference of only ope child
mention must be made of the unmarried mother who faces per family over a decade will have a tremendous impact on
significantly higher health risks. There is also evidence of the population growth. \
higher incidence of mental disturbances among mothers The gbiectiyeuof the Family Welfare Programme in India is
who have had unwanted pregnancies. that people should adopt the “small family norm” to stabilize
(ii) Limiting the number of births and proper spacing : the country’s population at the level of some 1,533 million by
Repeated pregnancies increase the risk of maternal mortality the year 2050 AD. Symbolized by the inverted red triangle, the
and morbidity. These risks rise with each pregnancy beyond programme initially adopted the model of the 3-child family.
the third, and increase significantly with each pregnancy In the 1970s, the slogan was the famous Do Ya Teen Bas. In
beyond the fifth. The incide_nce of rupture of the uterus jand view of the seriousness of the situation, the 1980s campaign
uterine atony increases with parity as does the incidence of has advocated the 2-child norm. The current emphasis is on
toxaemia, eclampsia and placenta previa. Anaemia is a three themes : “Sons or Daughters - two will do”: “Second
common problem in mothers with many children and the rate child after 3 years”, and “Universal Immunization”.
of stillbirths tends to increase significantly with high_parity. A significant achievement of the Family Welfare
The somatic consequences of repeated pregnancies may. also Programme in India has been the decline in the fertility rate
be exemplified in the clear association between the incidence from 6.4 in the 1950s to 2,2 in 2018. The national target
of cancer of the cervix and high parity. Family planning is the was to achieve a Net Reproduction Rate of ‘1’ by the year
only way to limit the size and control the interval between 2006, which is equivalent to attaining approximately the
births with a view to improving the health of the mother. 2-child norm, which could not be attained. All efforts are
(iii) CTiminq of births : Generally mothers face greater risk being made through mass communication that the concept

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of dying below the age of 20 and above the age of 30-35. In of small family norm is accepted, adopted and woven into
many countries, complications of pregnancy and delivery lifestyle of the people.
show the same pattern of risk, with the highest rate below
20 and over 35 years of age. Eligible couples
(b) FOETAL HEALTH : A number of congenital (f^An “eligible couple” refers to a currently married couple
anomalies (e.g., Down’s syndrome) are associated with wherein the wife is in the reproductive age_, which is
advancing maternal age. Such congenital anomalies can be generally assumed to lie between the ages of_L5 and45.
avoided by timing the births in relation to the mother’s age. There will be aF least ,150 to 180 such couples per 1000
Further, the “quality” of population can be improved only population in India. These couples arc in n^ed of family
by avoiding completely unwanted births. In the present state planning services. About 20 per cent of eligible couples are
of our knowledge, it is very difficult to weigh the overall found in fhe "age group ,15-24 years. On an average
genetic effects of family_planning. 2.5 million couples are joining the reproductive group every
(c) CHILD HEALTH : Issues relating to family planning year. The “Eligible Couple Register” is a basic document for
are highly relevant to paediatrics. It would seem that family organizing family planning work. It is regularly updated by
size and birth spacing, if practised by all, will yield each functionary of the family planning programme for the
substantial child health benefits. These are : (a) _ Child area falling within his jurisdiction?^
mortality : It is well known that child mortality increases
when pregnancies occur in rapid succession. A birth interval Target couples
of 2 to 3 years is considered desirable to reduce THild In order to pin-point the .couples who are a priority group
mortality. Family planning is, therefore, an important means within the broad definition of “eligible couples”, the^term
of ensuring the survival of all children in a family, (b) Child “target couple” was coined. Hitherto, the term target couple
growth, development and nutrition : Birth spacing and was applied to couples who have had 2-3 living children,
family size are important factors in child growth and and family planning was largely directed to~such_cc>uples.
development. The child is likely to receive his full share of The definition of a target couple has been gradually
love and care, including nutrition he needs, when the family enlarged to include families with one child or even newly
size is small and births are properly spaced. Family planning, married couples (34) with a view to develop acceptance of
in other words is effective prevention against malnutrition. the idea of family planning from the earliest possible stage.
(c)Qn/ech'ousdiseases^) Children living in large-sized families In effect, the term target couple has lost its original meaning.
have an increase^ in infection, especially infectious The term eligible couple is now more widely used and has
gastroenteritis, respiratory and skin infections. come to stay.
The welfare concept Couple protection rate (CPR)
Family planning is associated with numerous (^Couple protection rate J CPR) is an indicator of the
misconceptions - one of them is its strong association in the prevalence of contraceptive practice in the community. It is
minds of people with sterilization. Others equate it with birth defined as the per cpnt of eligible, couples effectively
control. The recognition of its welfare concept came only a protected against childbirth by one or the other_approved
decade and half after its inception, when it was named methods of family planning, viz, sterilization, JUD, condom
Family Welfare Programme. or oral pillsTSterilization accounts for over 60 per cent of
by R△J
 * PefOOiKL taodtoco 'G, tinaoss
— MoJl^_ £ fercd&l GdO<^o<t> S>KocjliioA' (JMid
56g__________DEMOGRAPHY AND FAMILY PLANNING_____________________________

effectively protected couples (35){Demographers are of the (7) Achieve 80 per cent institutional deliveries and
view that the demographic goal of NRR=1 can be achieved 100 per cent deliveries by trained persons.
only if the CPR exceeds 60 per cent. (8) (Achieve universal access to information/coupselling,
(^Couple protection rate is based on the observation that ancTservices for fertility, regulation and contraception
50 to 60 per cent of births in a year are of birth order 3 or with a wide basket of choices)
more. Thus attaining a 60 per cent CPR will be equivalent to (9) (Achigve 100 per cent registration of births, deaths,
cutting off almost all third or higher order births, leaving 2 or marriage and pregnancy. 1 .>
less surviving children per couple (35). Therefore, in India, (10) ^Contain the spread of Acquired .Immunodeficiency
the previous National Population Policy was to attain a CPR Syndrome_(AIDS), and promote greater integration
of 42 per cent by 1990 (end of Seventh Five Year Plan), and between the management of reproductive tract
60 per cent by the year 2000. In short CPR is a dominant infections (RTI) and sexually transmitted infections
factor in the reduction of net reproduction rate.I (STI) and the National AIDS Control Organization.
(11) Prevent and control communicable diseases.
NATIONAL POPULATION POLICY 2000 & (12) ^Integrate Indian Systems of Medicine (ISM) in the
provision of reproductive and child health services,
Population policy in general refers to policies intended to
and in reaching out to households. (
decrease the birth rate or growth rate. Statement of goals,
objectives and targets are inherent in the population policy. (13) ^Promote vigorously the small family norm to achieve
replacement levels of TFR. J
In April^l976jlndia formed its first - “National Population
(14) (^Bring about convergence in implementation of related
Policy”. It called for an increase in the legal minimum age of
social sector programmes so that family welfare welfare
marriage from 15 to 18 for females, and from 18 to 21 years
becomes a people centred programme. I e
for males. However, for the most part, the 1976 statement _J
became irrelevant and the policy was modified in 1977. New If the NPP 2000 was fully implemented, it was
policy statement reiterated the importance of the small anticipated that in the year 2010 the population may be
family norm without compulsion and changed the 1107 million instead of 1162 million projected by the
programme title to ^family welfare programme”. The Technical Group of Population Projections. However, the
National Health Policy approved by the parliament in 1983 provisional population (1210 million) in 2011 is higher by

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had set the long-term demographic goals of achieving a Net about 110 million compared to the target set for the year
Reproductive Rate (NRR) of one by the year 2000 (which 2010. Efforts at population stabilization will be effective only
was not achieved). if an integrated package of essential services is directed at
village and household levels. Inadequacies in the existing
(“National Population Policy 2000” is the latest in this
health infrastructure have led to a unmet need of 28 per cent
series. It reaffirms the commitment of the government
of contraception services and obvious gap in coverage and
towards target free approach in administering family
outreach. The NPP 2000 is to be largely implemented and
pjanning services. It gives informed choice to the people to managed at panchayat and nagar palika levels in
voluntarily avail the reproductive health care services.^
coordination with the concerned state/UT administration.
The new NPP 2000 is more than just a matter of fertility
and mortality rates. It deals with women education; CONTRACEPTIVE METHODS
empowering women for improved health and nutrition; child (Fertility Regulating Methods)
survival and health: the unmet needs for family welfare
services; health care for the under-served population groups Q^ontraceptive methods are, by definition, preventive
like urban slums, tribal community, hill areajpopulation and methods to help women avoid unwanted pregnancies. They
displaced and migrant population; adolescent’s health and include all temporary and permanent measures to prevent
education; increased participation of men in planned pregnancy resulting from coitus)
parenthood; and collaboration with NGOs. ; The last few years have witnessed a contraceptive
(^T?ie objective of _NP£L 2000 is to bring the TFR to revolution, that is, man trying to interfere with the ovulation
replacement level by Thp long term objective is to cycle.
achieve requirements of suitable economic growth, social It is now generally recognized that there can never be an
development and environment protection. ideal contraceptive - that is, contraceptive that is safe,
The National Socio-Demographic Goals to be achieved effective, acceptable, inexpensive, reversible, simple to
by the year 2010 were as follows (36): administer, independent of coitus, long-lasting enough to
obviate frequent administration and requiring little or no
(1) (Address the unmet needs for basic reproductive_and meJica^supervision. Further, a method which may be quite
child health services, supplies and infrastructure. smtaFHFfor one group may be unsuitable for another
(2) Make school education upto the age 14 free and because of different cultural patterns, religious beliefs and
compulsory, and reduce drop-outs at primary and socio-economic milieu. As there is no single method likely to
secondary school levels to below 20 per cent for both meet the social, cultural, aesthetic and service needs of all
boys and girls. individuals and communities, the search for an “ideal
(3) Reduce infant mortality rate to below 30 per 1000 live contraceptive” has been given up. The present approach in
births. family planning programmes is to provide a “cafeteria
(4) (Bed uce maternal mortality ratio to below 100 per choice” that is to offer all methods from which an individual
100/300 live births. can choose according to his needs and wishes and to
(5) Achieve universal immunization of childrenjagainst all promote family planning as a way of life.
vaccine preventable diseases^ The term conventional contraceptives is used to denote
(6) IProynote delayed marriage for girls, not earlier than those methods that require action at the time of sexual
age 18 and preferably after 20 years of age. intercourse, e.g., condoms, spermicides, etc. Each
by R△J
 maliL £ -4^ H W y
* N>o . oP Go O nooflid Ped gyroloj&jQo ir> barrier methods 569
— g— 1
contraceptive method has its unique advantages and Condoms can be a hignly ghly e effective method of
disadvantages. The success of any contraceptive method contraception, if they are used correctly at every coitus.
depends not only on its effectiveness in preventing Failure rates for the condom vary enormously.Cgurveys have
pregnancy but on the rate of continuation of its proper use. reported pregnancy rates varying from 2-3 per 100 women-
The contraceptive methods may be broadly grouped into years to more than 14 in typical users (40). Most failures are
two classes - spacing methods and terminal methods, as due to incorrect use.
shown below : The ADVANTAGES of condom are : (a) they are easily
available (b) safe and inexpensive (c) easy to use; do not
I. ^Spacing methods require medical supervision (d) no side effects (e) light,
1. Barrier lhethods compact and disposable, and (f) provides protection not only
against pregnancy but also agajnst STD. The STD.
(a) Physical methods
DISADVANTAGES are : ( (a) it may slip off or tear during
(b) Chemical methods coitus due to incorrect use, and (b) /U\ interferes.......
with4-U-sex
(c) Corpl^ined methods sensation locally about which some complain while others get
2. Intra-uterine devices used to it. The main limitation of condoms is that many men
3. Hormonal methods do not use them regularly or carefully, even when the risk of
unwanted pregnancy or sexually transmitted disease is high. -
4. Post-conceptional methods
Condoms are manufactured in India by the Hindusthan
5. Miscellaneous.
Latex in Trivandrum, London Rubber Industries in Chennai
II[Terminal methods ] and others. Besides commercial outlets, condoms are
supplied under Social marketing programme?)
1 Male sterilization
2 Female sterilization.
Female condom
Clhe_female condom is a pouch made of polyurethane, -§ o
BARRIER METHODS which lines the vagina. Anjnternal ring in the close end of the ‘
pouch covers the cervix and an externa! ring remains outside '
A variety of barrier or “occlusive” methods, suitable for the vagina. It is prelubricated with silicon, and a spermicide Q

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both men and women are available. The aim of these need not be used. It is an effective barrier to STD infection. J?
methods is to prevent live sperm from meeting the ovum. However, high cost and acceptability are major problems. The
Barrier methods have increased in popularity quite recently failure rates during the first year use vary from 5 per 100^
because of certain contraceptive and non-contraceptive women-years pregnancy rate to about 21 in typical users (4lT. £
advantages. The main contraceptive advantage is the a
absence of side-effects associated with the “pill” and IUD. 2. Diaphragm < CWiSaJbK) ------
The non-contraceptive advantages include .some protection Cjhe diaphragm is a vaginal barrier. It was invented by a
from sexually transmitted diseases, a reduction in the German physician in 1882. Also known as “Dutch cap”, the
incidence of pelvic inflammatory disease and possibly some diaphragm is a- shallow cup made of <ynthP.tic rubber ,
protection from the risk of cervical cancer (37). Barrier or plastic material. It ranges in diameter from 5-10 cm S'
methods require a high degree of motivation on the part of (2-4 inches). It has a flexible rim made of spring or metal. It is
the user. In general they are less effective than either the pill important that a woman be fitted with a diaphragm of the
or the loop. They are only effective if they are used proper size. It is held in position partly by the spring tension and
consistently and carefully. partly by the vaginal muscle tone. This means, for successful
use, the vaginal tone must be reasonable. Otherwise, in the
a. PHYSICAL METHODS case of a severe degree of cystocele, the rim may slip down.
1. Condom (38, 39) Cthe diaphragm is inserted before sexual intercourse and B
must remain in place for not less than 6 hours after sexual
fCondom is the most widely known and used barrier intercourse. A spermicidal jelly is always userLakmglwith the
device by the males around the world. In India, it is better diaphragm. The diaphragm_holds the spermicide over the
known by its trade name NIRQDH, a Sanskrit word, meaning cervix. Side-effects are practically nil. Failure rate for the
prevention. Condom is receiving new attention today as an diaphragm with spermicide vary between 6 to 12 per 9
effective, simple “spacing” method of contraception, without 100 wompn-uparq (40). V)
side effects/ In _addition to preventing pregnancy, condom
protects both men and women from sexually transmitted ADVANTAGES : The primary advantage of the
diseases .j diaphragm is the almost total absence of risks and medical O
contraindications. DISADVANTAGES : Initially a physician
The condom is fitted on the erect penis before or other trained person will be needed to demonstrate the
intercourse. The air must be expelled from the teat end to technique of inserting the diaphragm into the vagina and to 5
make room for the ejaculate. The condom must be held ensure a proper fit.(After delivery, it can hg used only affay
carefully when withdrawing it from the vagina to avoid involution of the uterus is completed. Practice at insertion,
spiking seminal fluid into the vagina after intercourse. A new privacy for this to be carried out and facilities for washing
condom should be used for each sexual act. and storing the diaphragm precludes its use in most Indian
Condom prevents the semen from being deposited in families, particularly in the rural areas. Therefore, the extent
vagina. ;The effectiveness of a condom may be increased by of its use has never been great.
using it in coni unction witTi a spermicidal jeily insertedrTgto % Clf diaphragm is left in the vagina for an extended
the vagina before intercourse. The spermicide serves as period, there is a remote possibility of a toxic shock
additional protection in the unlikely event that the condom syndrome, which is a state of peripheral shock requiring
should slip off or tear. resuscitation (42l_ __
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570 DEMOGRAPHY AND FAMILY PLANNING

/^Variations of the diaphragm include the cervical cap,

vault cap and the vimule cap. These devices are not
recommended in the National Family Welfare Programme.
3. Vaginal sponge^ QMoD OXUfW I
Another barrier
barrierdevice
deviceemployed
employed
for forTiundreds
hundreds of years
of years
is — is
the sponge soaked in vinegar or olive oil, but it is only
recently one has been commercially marketed in USA under
the trade name|TODAY for the sole purpose of preventing
Lippes loop Cu-T-200B
conception. It is a small polyurethane foam sponge
measuring 5 cm x 2.5 cm, saturated with the spermicide,
nonoxynol-9. The sponge is far less effective than the
diaphragm, but it is betterthan nothing (43). The failure rate
in parous women is between 20 to 40 per 100 women-years
and in nulliparous women about 9 to 20 per 100 women-
years (41). 'fnoVoxtbSO ;
b. CHEMICAL METHODS
In the 1960s, before the advent of IUDs and oral
contraceptives, spermicides (vaginal chemical contraceptives) Copper 7
were used widely. They comprise four categories (44):
a) Foams : foam tablets, foam aerosols
b) Creams, jellies and pastes - squeezed from a tube
c) Suppositories - inserted manually, and
d) Soluble films - C-film inserted manually.

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The spermicides contain a base into which a spermicide
is incorporated. The Commonly used modern spermicides
are (“surface-active aqents’J which attach themselves to
spermatozoa and inhibit oxygen uptake and kill sperms (45). Multiload 375 Progestasert Levonorgestrel IUD
The main drawbacks of spermicides are : (a) they have a FIG. 6
high failure rate (b) they must be used almost immediately
Types of IUDs
before intercourse and repeated before each sex act (c) they
must be introduced into those regions of the vagina where
sperms are likely to be deposited, and (d) they may cause
mild burning or irritation, besides messiness. The spermicide $ FIRST GENERATION IUDsi
should be dree from potential systemic toxicity. It should not The first generation IUDs comprise the(mert)or non­
have an inflammatory or carcinogenic e fleet on the vaginal medicated devices, usually made of polyethylene, or other
skin oFcervix. No spermicide which is safe to use has yet polymers. They appeared in different shapes and sizes -
been found to be really effective in preventing pregnancy loops, spirals, coils, rings, and bows. Of all the models, the
when used alone (44). Therefore, spermicides are not ^Lippes Loop is the best known and commonly used device
recommended by professional advisers. (They are best used in the developing countries^
in conjunction with barrier methods. Recently there has
been some concern about possible teratogenic effects on (Lippes Loop)^
foetuses, following their use. However, this risk is yet to be Lippes Loop is (double7“S” shaped device made of
confirmed (42). polyethylene, a plastic material that is non-toxic, non-tissue
reactive and extremely durable ’ ^contains a small amountof
INTRA UTERINE DEVICES barium sulphate to allow X-ray observation. The Loop has
attached threads.or ‘Tail” made of fine nylon, which project
Types of IUD into the vagina after insertion. The tail can be easily felt and
There are two basic types of ILJD {non-medicated and is a reassurance to the user that the Loop is in its place. The
medicated. Both are usually made of polyethylene or other tail also makes it easy to remove the Loop when desired.
polymers^ in addition, the medicated or bioactive IUDs The Lippes Loop exists in four sizes A,B,C, and D, the
release either metal ions (copper) or hormones latter being the largest. A larger sized device usuallyJnas a
(progestagens). greater anti-fertility effect and a lower expulsion rate but a
(The non-medicated or inert IUDs are often referred to as higher :removal rate because of side-effects such as pain and
first generation IUDs. The copper IUDs comprise the bleeding. The larger Loops (C and D) are more suitable for
second and the hormone-releasing IUDs the third multiparous women.
generation IUDs. The medicated IUDs were developed to
reduce the incidence oF side-effects and to increase the ^SECOND GENERATION IUDs £
contraceptive^ eHecriveness? However, they are more It occurred to a number of research workers that the ideal
expensive and must be changed after a certain time to IUD can never be developed simply as a result of obtaining
maintain their effectiveness (46). Fig. 6 shows different types changes in the usual shape or size (43). A new approach was
of IUDs currently in use. tried in the 1970s by adding copper to the IUD. It was found
by R△J
 IUDs -571
that metallic (copper^ad a strong anti-fertility effect (47). Mechanism of action of IUDs
The addition ol copper has made it possible to develop
At present, the most widely accepted view is that the IUD
smaller devices which are easier to fit, even in nulliparous causes a foreign body reaction in the uterus causing cellular
women. A number of copper bearing devices are now ancTnochemical changes in the endometrium and uterine
commercially available : fluids, and it is believed that these changes impair the
Earlier devices : viability of the gamete and thus reduce its chances of
- Copper-7 fertilization, ratherthan its implantation.
- Copper T-200^ Medicated IUDs produce other local .^effects that may
contfibutediQ.. their contraceptive action. Copper seems to
Newer devices: enhance the cellular response in the endometrium (48). It
- Variants of the T device also affects the enzymes Ln the uterus. By altering the
(i) Cu-T 220 C biochemical composition of cervial mucus, copper ions may
(ii) Cu-T 380 A or Ag affect sperm motility, capacitation and survival (48).
- Nova T_ (^Hormone-releasing devices increase the viscosity of the
- Multiload devices cervical mucus arid thereby prevent sperm from entering the
(i) ML-Cu-250 cervix. They also maintain high levels of prngp.stpronejn the
\ii) ML-Cu-375 endometrium and thus, relatively low levels of oestrogen,
thereby sustaining an endometrium. unfavourable to
The numbers included in the names of the devices refer implantation (48).
to the surface area (in sq. mm) of the copper on the device.
Nova T and Cu-T 380 Ag are distinguished by a silver core Effectiveness
over which die copper wire is wrapped.
The IUD is one of the most effective reversible
QThe newer copper devices are significantly more effective contraceptive methods. The “theoretical effectiveness” of
in preventing pregnancy than the earlier copper ones or the IUD is less than that of oral and injectable hormonal
inert IUDs. The newer copper IUDs - Multiload devices and contraceptives. But since IUDs have longer continuation
variants of the T device - offer the further advantage of rates than the hormonal pills or injections, the overall
having an effective life of at least 5 years. They can be left in

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effectiveness of IUDs and oral contraceptives are about the
place safely for the time, unless specific medical or personal same in family planning programmes (49).
reasons call for earlier removals
Table 19 shows the rates of pregnancy, expulsion and
Advantages of copper devices removal of some of the IUDs. It can be seen from Table 19
- Low expulsion rate that copper devices are more effective than the Lippes Loop
in preventing pregnancy, with fewer expulsions. Studies
- Lower__incidence of side-effects, e.g., pain and have shown that the effectiveness of copper devices is
bleeding directly related to the amount of copper surface area
- easier to fit even in nulliparous women (usually this is 200 or 220 sq. mm.)
- better tolerated by nullipara
- increased contraceptive effectiveness TABLE 19
- ^effective as post-coital contraceptives, if inserted First year clinical trial experience in parous women
within 3-5 days of unprotected intercourse
Pregnancy Explusion Removal
Device rate (%)
THIRD GENERATION IUDs # rate (%) rate (%)

A third generation of IUDs based on still another Lippes Loop 12-20 12-15
principle, i.e., release of a hormone have become available Cu-7 2-3 6 11
on a limited scale. The most widely used hormonal device is TCu-200 8 11
progestasert, which is a T-shaned device filled with 38 mg TCu-380A 0.5-0.8 5 14
of progp^prnnp the natural hormone. The hormone is Progesterone IUD 1.3-1.6 2.7_ 9.3
released slowly in the uterus at the rate of Levonorgestrel IUD 0.2 6 17
bS-meg-daily. It has a direct local effect-on the uterine lining,
on the cervial mucus and possibly on the sperms. Because Source : (41)
the hormone supply is gradually depleted, ^regular
replacement of the device is necessary. _____________ Change of IUD
Another hormonal device LNG-20 (Mirena) is a Clnert IUDs such as Lippes Loop may be left in place as
T-shaped IUD releasing 20 mcg of levonorgestrel (a potent long as required, if there are no side-effects. Copper devices
synthetic_steroid); it has a low pregnancy rate (0.2 per 100 cannot be used indefinitely because copper corrodes and
women) and less number of ectopic pregnancies (41). mineral deposits build up on the copper affecting the release
"Long-term clinical experience with levonorgestrel releasing of copper ions. They have to be replaced periodically. The
IUD has shown to be assbciaTed with lower menstrual blood same applies to the hormone-releasing devices. This is an
Joss and fewer days of bleeding than the copper devices. The inherent disadvantage of medicated devices when they are
levonorgestrel releasing IUD has an effective life of 10 years used in large national family planning programmes.
(41). The hormonal devices would be particularly valuable kJChe^ Cu-T 380A is approved for use for 10 years.
for women in developing countries Tn whom excess blood However, the Cu-T 380A has been demonstrated to
loss caused by inert devices have been shown to result in maintain its efficacy over at least 12 years of use. The
significant anaemia. But these devices are more expensive, C^T-200 is approved for 4 years and the Nova T for
to be introduced on a wide scale. 5 years. The progesterone-releasing IUD must be replaced
by R△J
 572 DEMOGRAPHY AND FAMILY PLANNING

every year because the reservoir of progesterone is depleted during menstruation or within 10 days of the beginning of a
in 12-18 months. The levonorgestrel IUD can be usedfor at menstruaLperiod (43). During this ~penbd~Iihsertion is
least 7 years, and probably 10 years. The progesterone IUD technically easy because the diamejterof the cervical canal is
has a slightly higher failure rate, but the levonorgestrel greater at this time than during the secretory phase. The
device that releases 15-20 pg levonorgestrel per day is as uterus tsYelaxed and myometrial contractions which might
effective as the new copper IUDs (41). tend to cause expulsion are at a minimum (45). In addition,
the risk that a woman is pregnant is remote at this time.
Advantages
The IUD insertion can also be taken up durinq the first
The IUD has many advantages : (a) simplicity, i.e., no week after delivery before the woman leaves the hospital
complex procedures are involved in insertion; no ("immediate postpartum insertion”). Special care is required
hospitalization is required (b) insertion takes only a few with insertions during the first week after delivery because of
minutes (c) once inserted IUD stays in place as long as the greater risk of perforation during this time. Furtherrnore,
required (d) inexpensive (e) contraceptive effect is reversible immediate postpartum insertion is associated with a high
by removal of IUD (f) virtually free of systemic metabolic expulsibn rate. A convenient time for loop insertion is
side-effects associated with hormonal pills (g) highest 6-8 weeks after delivery (“post-puerperal insertion”). Post-
continuation rate, and (h) there is no need for the continual puerperal insertion of an IUD has several advantages. It can
motivation required to take a pill daily or to use a barrier be combined with the follow-up examination of the women
method consistently: only a single act of motivation is and her child. IUD insertion can also be taken up
required. However, as with most contraceptive methods, the immediately after a legally induced first trimester abortion,
IUD can produce side-effects such as heavy menstruation i But IUD insertion immediately after a, second trimester
and/or pain. | abortion is not recommended (46). Since there isTTrisk of
infection, most physicians still do not approve, of an IUD
Contraindications insertion after an illegal abortion (46).
ABSOLUTE : (a) (^suspected pregnancy (b) [pelvic
inflammatory disease (c) vaginal bleeding of undiagnosecL Follow-up
aetiology (d) cancer of the cervix, uterus or adnexia and An important aspect of IUD insertion is follow-up which is
other pelvic tumours (e) previous ectopic pYegnancy (50). sadly neglected. The objectives of the follow-up examination

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RELATIVE : (a) anaemia (b) menorrhagia (c) history of are : (a) to provide motivation and emotional support for the
PIP since, last pregnancy (d) purulent cervical discharge woman (b) to confirm the presence of the~ IUD, and
(c) diagnose an-’ treat any side-effecFor complication (51).
malformations, fibroids (f) unmotivated person (46). The JUD wearer should be examined after her first menstrual
period, for the chances of loop expulsion are high during this
The ideal IUD candidate period; and again after the thirds menstrual periocT to
evaluate the problems of pain and bleeding; and thereafter
The Planned Parenthood Federation of Ameiica (PPFA) at six-month or one-year intervals depending uport the
has described the ideal IUD candidate as a woman : ’ facilities and the convenience of the patient.,
- who has borne at least one child The IUD wearer should be given the following
- has no history of pelvic disease instructions : (a) she should regularly check the threads or
- has normal menstrual periods “tail” to be sure that the IUD is in the uterus; if she Jails to
- is willing to check the IUD tail locate the threads, she must consult the doctor (b)_she
should visit the clinicjwhenever she experiences any side­
- has access to follow-up and treatment of potential effects such as fever._pelvic pain and bleeding, and (c) if she
problems, and . misses a period, she must consult the doctor. _
- is in a monogamous relationship.
The federation does not, however, rule out women who SIDE-EFFECTS AND COMPLICATIONS
do not conform to this profile (51). 1. Bleeding\^^
An important finding that has recently emerged is that the The commonest complaint of women fitted with an IUD
C lUD_is not a method of first choice for nulliparous women. (inert or medicated) is increased vaginal bleeding. It
They have more problems with IUD such as expulsions, low accounts for 10-20 per cent of all IUD removals (51). The
abdominal _pain and pelvic infection, than other women. bleeding may take one or more of the following forms :
IUDs such as copper-T, which are smaller and more pliable greater volume of blood loss during menstruation, longer
are better suited to the small uterus of the nulliparous menstrual periods or mid-cycle bleeding (48). From the
women, if they cannot use or accept alternative methods of woman’s point of view, irregular bleeding constitutes a
contraception. source of personal inconvenience; from a medical point of
In 1985, the American College of Obstetricians and view, the concern is iron-deficiency anaemia. Usually
Gynaecologists stated that IUDs are “not recommended bleeding or spotting between periods settles within
for women jwho have not had children or who have 1-2 months (49). The patient who is experiencing the
multiple partners, because of the risk of PIP and possible bleeding episodes should receive iron tablets (ferrous
infertility” (51). sulphate 200 mg, three times daily).
Studies have shown that the greatest blood loss is_caused by
Timing of insertion the larger non-medicated devices. Copper devices seem to
Although the loop can be inserted at almost anytime cause less average blood loss. Menstrual blood loss is
during a woman’s reproductive years (except during consistently lower when hormone-releasing devices are
pregnancy), the most propitious time for loop insertion is used (46).
by R△J
 IUDs 573
If the bleeding is heavy or persistent or if the patient 4. Uterine perforation
develops anaemia despite the iron supplement, the IUD Many workers have reported uterine perforation by the
should be removed. Since there is often a direct relationship IUD (57). The reported incidence ranges from J: 150 to
between the bleeding and the size and configuration of the 1: 9000 insertions (57), depending upon the time of insertion,
IUD (50), a change of IUD from the Lippes Loop to one of design of the IUD, technique of insertion and operator’s
copper devices is advised. In most women, removal of the experience. In the hands of trained physicians, it should not be
device is rapidly followed by a return to the normal higher than 0.3 per cent (58). The device may migrate intcythe
menstrual pattern. If an abnormal pattern persists, a full peritoneal cavity causing serious .complications such as
gynaecological examination is required to ensure that there intestinal obstruction. Copper devices produce an intense
is no pelvic pathology (46). tissue reaction leading to peritoneal adhesions. Perforations
occur more frequently when insertions are performed
between 48 hours and 6 weeks postpartum. Interestingly, the
Pain is the second major_side-effect leading to IUD perforation may be completely asymptomatic and discovered
removal. WHO estimates that 15-40 per cent of IUD only when searching for a missing IUD. The conclusive
removals appear to be for pain only (46). Pain may be diagnosis of perforation is usually made by a pelvic X-ray.
experienced during IUD insertion and for a few days GEvidence.suggests that any IUD thathasjperforated the uterus
thereafter, as well as during_menstruation (51). It may should be removed because the risks of intra-abdpminal
manifest itself in low backache, cramps in the lower inflammatory response leading to adhesions_or perforatiortof
abdomen and occasionally pain down the thighs. These organs within the abdominal cavity outweigh the risks
symptoms, usually disappear by the third month (49). associated with re mov^KSl):
If during insertion, the pain is particularly severe, it is
possible that the device may have been incorrectly placed in 5. Pregnancy
the uterus or there is a disparity in size between the device Considering all IUDs together, the actual use failure rate
and the uterine cavity. Severe pain can also indicate a in the first year is approximately.3 per cent (41). It differs, in
uterine perforation (46). Pain could also be due to infection. different types of IUDs. About 50 per cent of uterine
Pain is more commonly observed in nullipara and those who pregnancies occurring with the device in situ end in a
have not had a child for a number of years (52, 53). spontaneous abortion f51). (Removal of the IUD in early
Slight pain during insertion can be controlled by pregnancy has been found to reduce this abortion rate by

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analgesics such as aspirin and codein. If pain is intolerable, halfj In women who continue the pregnancy with the device
the IUD should be removed. In place of a Lippes Loop, a in situ, a 4-fold increase in the occurrence of premature
copper device_can be tried. If the_woman decidesmot to births compared with other women has been reported (46).
have an IUD, another method of contraception should be The earlier teaching that pregnancy with an IUD in situ is
prescribed. not unsafe is no longer accepted. Pregnancy with an IUD
should be regarded as a potential medical complication with
3. Pelvic infection
the dangers of infection and spontaneous abortion. The
Pelvic inflammatory disease (PID]js_a_cpllectivetenri that options left open are (45) :
includes acute, subacute _and chronic conditions of the
(a) yf the woman requests an induced abortion, this is
ovaries, tubes, uterus, connective tissue and pelvic
legally available. J
peritoneum_and is usually the result of infection (50).
Studies suggest that IUD users are about 2 to 8 times more (b) '\If the woman wishes to continue with the
likely to develop PIP than non-contraceptors (54). Risk pregnancy and the threads are visible, the_d£vice
associated with IUD use is greater among women who have should be removed by gently pulling the threads^
a number of sexual partners (55) possibly because of greater (c) Mf the woman wishes to continue with_jthe
potential for exposure to STDs. The greater risk of PID with pregnancy and the threads are not visible, there
IUD use may be due to introduction of bacteria into the should be careful examination for possible
uterus during IUD insertion. Recent work has focused on complications. If there are any signs of
PiD as being caused by organisms ascending the IUD tail intrauterine infection and sepsis, evacuation of
from the lower genital tract to uterus .and tubes (56). The the uterus un ie: broad-spectrum antibiotic cover
organisms include Gardnerella. Anaerobic streptococci. is mandatory.
Bacteroides, Coliform bacilli and Actinomyces. The risk of If the woman becomes pregnant with the IUD, she should
PID appears to be the highest in the first few months after be advised that only 25 per cent of pregnancies will have a
IUD insertion. successful outcome if the IUD is left in place.
The clinical manifestations of PID are vaginal discharge.
pelvic pain and tenderness, abnormal bleeding, chills and 6. Ectopic pregnancy
feven In many cases, the infection may be asymptomatic or The possibility of ectopic pregnancy must be considered
low grade. Even one or two episodes of PID can cause when an IUD user becomes pregnant. The ectopic
infertility permanently blocking the fallopian tubes. pregnancy rate per 1000 women year in levonorgestrel IUD
Therefore, young womefTsHould be fully counselled on the and Cu-T 380A is about 0.2 as compared to non­
risks of PID before choosing anJUD. contraceptive users, where it is about 3-4.5. With
When PID is diagnosed, it should be treated promptly progesteron IUD it is higher-about 6.8, because its action is
with broad-spectrum antibiotics. Most clinicians recommend limited to a local effect on endometriuml With levonorgestrel
removing IUD if infection does not respond to antibiotics IUD the chances of ectopic pregnancy are less, because it is
within 24-48 hours (48). The risk of PID calls for proper associated with a partial suppression of gonadotrophins with
selection of cases for IUD insertion, better sterilization and subsequent disruption of normal follicular growth and
insertion techniques, and modified devices without tails. inhibition of ovulation in significant number of cycles (41).

by R△J
■jDOM&fJbooal Wocfe, uaVulb QucjpM cuJffi&o ct± W ftW o¥ gcxuzd lAtetfe^
.iMPI DEMOGRAPHY AND FAMILY PLANNING ^5' J<aJa%
Women using IUDs should be taught to recognize the HORMONAL CONTRACEPTIVES
symptoms of ectopic pregnancy - lower abdominal pain,
dark and scanty vaginal bleeding or amenorrhoea. Women ^Hormonal contraceptives when properly used are the
at high risk of ectopic pregnancy - because of previous_EID, most effective spacing methods of contraception. Oral
tubal pregnancy or other ectopic pregnancy - should not use contraceptives of the combined type are almost 100 per cent
an IUD if other methods are feasible (51). effective in preventing pregnancy. They provide the best
means of ensuring spacing between one childbirth and
7. Expulsion another. More than 65 million in the world are estimated to
be taking the “pill” of which about 9.52 million are
Expulsion rates vary between 12-20 per cent (Table 19). estimated to be in India.
Expulsion can be partial or complete. Partial expulsion is
diagnosed on speculum examination by observing the stem Gonadal steroids
of the IUD__protruding through the cervix. Clin icaTsk ill,
To physicians in general medicine, the term “steroid” refers
timing of insertion and the age and parity of the user all
to adrenocortical hormones, while to those in gynaecology, it
influence the likelihood of expulsion.
implies gonadal steroids, i.e., oestrogens and progestogens.
An expulsion usually occurs during the first few weeks
a. Synthetic oestrogens : Two synthetic oestrogens are
following insertion or during menstruation. Expulsion is
used in oral contraceptives. These are ethinylestradiol and
most common among young women, nulliparous women
mestranoE Both are effective. In fact, mestranol is inactive
and women who have a postpartum insertion. Expulsion
until converted into ethinylestradiol in the liver (59).
rates are somewhat lower for copper than for inert devices.
As many as 20 per cent of all expulsions go undetected. In b. Synthetic progestogens : These are classified into three
general, expulsion in itself is not a serious problem, but if groups - pregnanes, oestrones and tonanes. (i) Pregnanes :
expulsion is unnoticed, pregnancy may occur. These include megestrol, chlormadmone'and medroxy­
progesterone acetate. The pregnane progestogens are now
8. Fertility after removal not recommended in oral contraceptives because of doubts
raised by the occurrence.of breast tumours in beagle dags,
G^tility does not seem to be impaired after removal of a (ii) Oestrones : These are also known as l^nortestosterones,
device provided there has been no episode of PIP, whilst the e.g., norethisterone, norethisterone acetate, lynestrenol,
device was in situ (48). Over 70 per cent of previous IUD ethynodiol diacetate and norethynodrel. These are all
users conceive within one year of stopping use (51). It is

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metabolized to norethisterone before becoming active.
now established that PID is a threat to woman’s fertility. For some women, oestranes are more acceptable than
There is no meaningful data available on the long-term use gonanes. (iii) Gonanes: The most favoured gonane is
of IUD on subsequent fertility (46). levonorgestrel (59).
9. Cancer and teratogenesis Classification
There is no evidence to date that IUD use increases Hormonal contraceptives currently in use and/or under
cancer risks. Nor is there any evidence of developmental study may be classified as follows :
abnormality or congenital malformations among the
offspring of either former users of IUDs or those who A. Oral pills
conceive with an IUD in situ (46). 1. Combined pill
2. Progestogen only pill (POP)
10. Mortality 3. Post-coital pill
4. Once-a-month (long-acting) pill
Mortality associated with IUD use is extremely rare and 5. Male pill
has been estimated to be one death per 100,000 woman-
years of use, the deaths usually following complications such B. Depot (slow release) formulations
as septic spontaneous abortion or ectopic pregnancy (46). In 1. Injectables
fact, IUD is safer than oral contraceptives in this regard, 2. Subcutaneous implants
particularly in older or high-risk patients (46). 3. Vaginal rings
Of all the available spacing methods of contraception, A. ORAL PILLS
IUDs are among the most effective, with an average
pregnancy rate after one year of about 3-5 per 100 typical 1. Combined pill
users (51). In comparison with other methods, the IUD is a
relatively inexpensive form of contraception, because of its The combined pill is one of the major spacing methods of
long life. Unlike use of barrier methods, IUD use is contraception. The “original pill” which entered into the
independent of the time of intercourse. I IUDs have a market in the early 1960s contained 100-200 mcg of a
relatively high continuation rates. Inert devices, as well as synthetic oestrogen and 10 mg of a progestogen. Since then,
those with copper lack the systemic metabolic effects ajaumber of improvements have been made to reduce the
associated with oral pills. Women who cannot tolerate the undesirable side-effects of the pill by reducing the dose of
adverse effects of oral pills may find the IUD an acceptable both the oestrogen and progestogen. At the present time,
alternative. XltjJoes not interfere with lactation^ However, most formulations of the combined pill contain no more
because of expulsion and possible side-effects like menstrual than 30-35 mcg of a synthetic oestrogen, and 0.5 to 1.0 mg
irregularities, IUDs should preferably.be used in settings of a progestogen. The debate continues about the minimum
where follow-up facilities are available. Evidence to date effective dose of the progestogen in the pill which will
shows that for a fully informed woman, the IUD can provide produce the least metabolic disturbances.
a satisfactory, highly effective, relatively low-risk method of (The pill is given orally for 21 consecutive days beginning
contraception. on the 5th day of the menstrual cycle (for a few preparations

by R△J
 HORMONAL CONTRACEPTIVES 575
20 or 22 days are advised), followed by a break of 7 days 2. Progestogen-only pill (POP)
during which period menstruation occurs. When the
This pill is commonly referred to as “minipilF or
bleeding occurs, this is considered the first day of the next
“micropill”. It contains only progestogen, which is given in
cycle. The bleeding which occurs is not like normal
small doses’ throughout the cycle. The commonly used
menstruation, but is an episode of uterine bleeding from an
progestogens are norethisterone and levonorgestrel.
incompletely formed endometrium caused by the withdrawal
of exogenous hormones. Therefore it is called “withdrawal The progestogen-only pills never gainecTwi de spread use
bleeding” rather than menstruation. Further, the loss oF because of poor cycle control and an increased pregnancy
blood which occurs is about half that occurring in a woman rate (60). However, they have a definite~place~in modern-
having ovulatory cycle. If bleeding does not occur, the day” contraception. \[hey could be prescribed to older
woman is instructed to start _the second cycle_one week after women for whom the combined pill is contraindicated
the preceding one. Ordinarily, the woman ‘^menstruates” because of cardiovascular risk^. They may also be
after the second course of pill intake .j considered in young women with risk factors for
The pill should be taken everyday at a fixed time, neoplasia (61). The evidence that the progestogens
preferably before going to bed at night. The first course may lower the high-density lipoproteins may be of some
should be started strictly on the 5th day of the menstrual concern.
period^as any deviation ih^this respect may not_prevent
pregnancy, If the user forgets to take a pill, she should take it 3. Post-coital contraception
as soon aS she remembers, and that she should take the next Post-coital (or “morning after”) contraception is
day’s pill at the usual time J recommended within 72 hours of an unprotected
intercourse. Two methods are available :
Types of pills
(a) IUD : The simplest technique is to insert an ILJD, if
The Department of Family Welfare, in the Ministry of acceptable, especially a copper device within 5 days.
Health and Family Welfare, Government of India has made
available 2 types of low-dose oral pills under the brand (b) Hormonal : More often a hormonal method may be
names of^MALA-N Vmd ,MALA-D. It contains Levonorgestrel preferable. In India Levonorgestrel 0.75 mg tablet is
0.15 mg and Ethinyl estradiol 0.03 mg. Mala-D in a package approved for emergency contraception. It is used as one
of 28 pills (21 of oral contraceptive pills and 7 brown film tablet of 0.75 mg within 72 hours of unprotected sex and the
2nd tablet after 12 hours of 1st dose.

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coated 60 mg ferrous fumarate tablets) is made available to
the consumer under^ocial marketing at a price of Rs. 3 per or
packet: Mala-N is supplied free of cost through all PHCs, Two oral contraceptive pills containing 5CLnicg^of ethinyl
urban family welfare centres, etc. Some of the combined estradiol within 72 hours after intercourse, and the same
pills are as shown in Table 20. dose after 12 hours.
TABLE 20 or
Some combination oral contraceptives
Four oral contraceptive pills containing 30 or 35 mcg of
ethinyl estradiol within 72 hours and 4 tablets after 12
hours.
or
Mifepristone 10 mg once within 72 hours.
Post-coital contraception is advocated as an emergency
method; for example, after unprotected intercourse, rancor
contraceptive failure. Opinion is divided about the effect on
foetus, should the method fail. Although the failure rate for
post-coital contraception is less than 1 per cent, some
experts think a woman should not use the hormonal method
unless she intends to have an abortion, if the method fails.
There is no evidence that foetal abnormalities will occur. But
some doubts remain (62).

4. Once-a-month (long-acting) pill

Experiments with once-a-month oral pill in which
quinestrol, a long-acting oestrogen is given in combination
with a short-acting progestogen, have been disappointing
(63). The pregnancy rate is too high to be acceptable. In
addition, bleeding tends to be irregular.

5. Male pill
The search for a male contraceptive began in 1950 (64)
Research is following 4 main lines of approach
(a) preventing spermatogenesis (b) interfering with sperm
storage and maturation (c) preventing sperm transport in the
vas, and (d) affecting constituents of the seminal fluid. Most

by R△J
576 DEMOGRAPHY AND FAMILY PLANNING

of the research concentrated on interference with maintain contraceptive effect. In spite of this reduction, it
spermatogenesis. (An ideal male contraceptive would became clear by 1980 that some of the untoward vascular
decrease sperm ^ount while leaving_testosterone at normal effects (e.g., hypertension) persisted, in addition to
levels. But hormones that suppress sperm"-production tend metabolic effects which are attributed to the progestogen
to lowerjtestosterone and affect potency and libido. \ content of the pill. It became clear that progestogen
levels must also be minimal to avoid the complications of pill
A male pill made of gossypol - a derivative of cotton-seed
use.
oil, has been very much in the news. It is effective in
producing azoospermia or severe oligospermia, but as many
2. Carcinogenesis
as 10 per cent of men may be~permanently azoospermic
after taking it for 6 months. Further gossypol could be toxic. A review prepared by WHO (72) concluded that there
Animal studies show a narrow margin between effective and was no clear evidence of a relationship, either, positive or
toxic doses. At present it does not seem that gossypol will negative between the use of combined pill and the risk of
ever be widely used as a male contraceptive (65). any form of cancer. However, the WHO Multicentre case­
control study on the possible association between the use of
MODE OF ACTION OF ORAL PILLS hormonal contraceptives and neoplasia indicated a trend
towards increased risk of cervical cancer with increasing
The mechanism of action of the combined oral pill is to duration of use of oral contraceptives; this finding is being
prevent the release of the ovum from the ovary. This is further explored (73).
achieved by blocking the pituitary secretion of gonadotropin
that is necessary for ovulation to occur. Progestogen-only 3. Metabolic effects
preparations render the cervical mucus thick and scanty and
thereby inhibjt sperm penetration. Progestagens also inhibit A great deal of attention has been focused recently on the
tubal motility, and delay the transport of the sperm and of metabolic effects induced by oral contraceptives. These
the ovumjtoJhejiteriniL cavity (63). have included the elevation of blood pressure, the alteration
in serum lipids with a particular effect on decreasing
EFFECTIVENESS high-density lipoproteins, blood plotting and the ability to
modify carbohydrate metabolism with the resultant
Taken according to the prescribed regimen, oral elevations of blood glucose and plasma insulin (74JTTKese
contraceptives of the combined type are almost 100 per cent

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effects are positively related to the dose of tFF progestogen
effective in preventing pregnancy (50). Some women do not component (75). Family planning specialists have voiced a
take the pill regularly, so the actual rate is lower. In growing concern that the adverse effects associated with
developed countries, the annual pregnancy rate is less than oral contraceptives could be a potential long-range
1 per cent but in many other countries, the pregnancy rate is problem for the users in that they may accelerate
considerably higher (63). atherogenesis and result in clinical problems such as
Under clinical trial conditions, the effectiveness of myocardial infarction and stroke.
progestogen-only pills is almost as good as that of the
combination products. However, in large family planning 4. Other adverse effects
programmes, the effectiveness and^gontinuation rates are (i) Liver disorders : The use of the pill may lead to
usually lower than in clinical trials .(The effectiveness may hepatocellular adenoma and gall bladder disease.
also be affected by certain drugs such as rifampicin, Cholestatic jaundice can occur in some pill users,
phenobarbital and ajnpicillin (63) (ii) jactation : Preparations containing a relatively high
amount of oestrogen adversely affect the quantity and
RISKS AND BENEFITS constituents of breast milk (73), and less frequently cause
premature cessation of lactation. In a WHO study (73) users
a. Adverse effects of the combined pill experienced a 42 per cent decline in
milk volume after 18 weeks, compared with a decline of
1. Cardiovascular effects^/''" 12 per cent for users of progestogen-only minipills and
0.16 per cent for controls using non-hormonal preparations.
Data from the earlier case control studies (66, 67) and the
Women taking oral contraceptives, no matter what type,
Oral Contraceptive Study of the RCGP (68) and the Oxford
excrete small quantities of hormones in their breast milk, but
Study in UK (68, 69) provided conclusive evidence that the
little is known about the long-term impact, if any, on the
use of the combined pill was associated with an excess
child (71). (iii) Subsequent fertility: In general, oral
mortality. Women who had used the pill were reported to
contraceptive use seems to be followed by a slight delay in
have a 40 per cent higher death rate than women who had
conception (76). The proportion of women becoming
never taken the pill. Virtually, all the excess mortality
pregnant within 2 months of discontinuing the pill may
was due to cardiovascular causes, that is myocardial
range from 15-35 per cent (77). It is not known whether the
infarction, cerebral thrombosis and venous thrombosis, with
prolonged use of the pill beyond 5-10 years affects
or without pulmonary embolus (70, 71). The risk increased
subsequent fertility. (iv)QEctopic pregnancies : These are
substantially with age and cigarette smoking. The evidence
more likely to occur in women taking progestogen-only pills-,
was convincing that the cardiovascular complications
were positively associated with the oestrogen content of the but not in those taking combined pills, (v) (jFoetal
pill. development : Several reports have suggested that oral pills
taTen inadvertently during (or even just before) pregnancy
(The above findings led to the progressive reduction. oLthe might increase the incidence of birth defects_of the foetus,
oestrogen content to the minimum levels necessary to but this is not yet substantiated (78).

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 HORMONAL CONTRACEPTIVES 577
5. Common unwanted effects^- TABLE 21
(i) Breast tenderness : Breast tenderness, fullness and Check-list for prescription of oral contraceptives
discomfort have been observed in women taking oral pills.
Check the following by
Breast engorgement and fullness are said to be dependent history and examination Yes No
on progestogen; pain and tenderness are attributed to
oestrogen, (ii) Weight gain : About 25 per cent of users Above 40 years of age
complain of weight gain. It is usually less than 2 kg, and Above 35 years of age
occurs during the first 6 months of use. This is attributed to and a heavy smoker
water retention, in which case restriction of salt intake is Seizures
usually effective, (iii) Headache and migraine : Migraine Severe pain in the calves
may be aggravated or triggered by the pill. Women, whose or thighs
migraine requires treatment with vasoconstrictors such as Symptomatic varicose veins
ergotamine, should not take oral pills, (iv) Bleeding in the legs
disturbances : A small minority of women using oral Severe chest pains
contraceptives may complain of break-through bleeding or Unusual shortness of breath
spotting in the early cycles. A few”women may not have a after examination
withdrawal bleeding at the end of a cycle. Women should be Severe headaches and/or
visual disturbances
forewarned of these possibilities.
Lactating (yes = for less than
6 months)
b. Beneficial effects
Intermenstrual bleeding and/
The single most significant benefit of the pill is its almost or bleeding after sexual
100 per cent effectiveness in preventing pregnancy and intercourse
thereby removing anxiety about the risk of unplanned Amenorrhoea
pregnancy. Apart from this, the pill has a number of non­ Abnormally yellow skin, eyes
contraceptive health benefits (79). Both the Royal College of Blood pressure (yes = above 140 mm
General Practitioners’ and the Oxford Family Planning Hg systolic and/or
Association’s long-term prospective studies of pill use in 90 mm Hg diastolic)

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Britain have shown that using the pill may give protection Mass in the breast
against at least 6 diseases: benign breast disorders including Swollen legs (oedema)
fibrocystic disease and fibroadenoma, ovarian cysts, iron- Instructions : If all the above are negative, the woman may be
deficiency anaemia, pelvic inflammatory disease, ectopic given oral contraceptives. If any are positive, she must first be
pregnancy and ovarian cancer. seen by a doctor

Source : (71)
Contraindications
B. DEPOT FORMULATIONS
(a) Absolute : (Qancer of the breast and genitals; liver
disease; previous or present history of thromboembolism; The need for depot formulations which are highly
cardiac abnormalities; congenital hyperlipidaemia; effective, reversible, long-acting and oestrogen-free for
undiagnosed abnormal uterine bleeding. spacing pregnancies in which a single administration suffices
for several months or years cannot be stressed. The
(b) Special problems requiring medical surveillance : Age injectable contraceptives, subdermal implants and vaginal
over 40 years; smoking and age over 35 years; mild rings come in this category.
hypertension; chronic ren^l disease; epilepsy; migraine;
nursing mothers in the first~6 months; diabetes mellitus; 1. Injectable contraceptives
gall bladder disease; history of infrequent bleeding, There are two types of injectable contraceptives.
amenorrhoea, etc. (63). Progestogen-only injectables and the newer once-a-month
combined injectables. The formulation and injection
Duration of use schedules of injectable contraceptives are as shown in
The pill should be used primarily for spacing pregnancies Table 22.
in younger women. Those over 35 years should go in for A. PROGESTOGEN-ONLY INJECTABLES
other forms of contraception. Beyond 40 years of age, the
pill is not to be prescribed or continued because of the Thus far, only two injectable hormonal contraceptives -
sharp increase in the risk of cardiovascular both based on progestogen - have been found suitable.
complications (63). They offer more reliable protection against unwanted
pregnancies than the older barrier techniques. These are :
Medical supervision (80) a. DMPA (Depot-medroxyprogesterone acetate)
Women taking oral contraceptives should be advised b. NET-EN (Norethisterone enantate)
annual medical examinations. An examination before c. DMPA-SC
prescribing oral pills is required (a) to identify those with
contraindications, and (b) those with special problems that a. DMPA (81)
require medical intervention or supervision. A check-list ^Depot-medroxyprogesterone acetate (DMPA or Depo-
(Table 21) has been developed for screening women who provera) has been in use since 1960s. The standard dose is
can be given oral pills by the health workers. an intramuscular injection of 150 mg every 3 months. It

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 DEMOGRAPHY AND FAMILY PLANNING
573
TABLE 22
Formulations and injection schedules of injectable contraceptives

Common trade names Formulation Injection type and schedule

Progestin - Only Injectables

Depo-Provera®, Megestron®, Depot medroxyprogesterone One intramuscular (IM) injection

Contracep®, Depo-Prodasone® acetate (DMPA) 150 mg every 3 months
depo-subQ provera 104® (DMPA-SC) DMPA 104 mg One subcutaneous injection
every 3 months
Noristerat®, Norigest®, Doryxas® Norethisterone enanthate (NET-EN) 200 mg One IM injection every 2 months
Combined Injectable (progestin + estrogen)1
Cyclofem®, Ciclofeminina®, Lunelle®2 Medroxyprogesterone acetate 25 mg One IM injection every month
4- Estradiol cypionate 5 mg (MPA/E2C)
Mesigyna®, Norigynon® NET-EN 50 mg + Estradiol valerate One IM injection every month
5 mg (NET-EN/E2V)
Deladroxale®, Perlutal®, Dihydroxyprogesterone (algestone) One IM injection every month
Topasel®, Patectro®, acetophenide 150 mg +
Deproxone®, Nomagest® Estradiol enanthate 10 mg
Anafertin®, Yectames® Dihydroxyprogesterone (algestone) acetophenide One IM injection every month
75 mg + Estradiol enanthate 5 mg
Chinese Injectable No. 1® 17a-hydroxyprogesterone caproate 250 mg + One IM injection every month,
Estradiol valerate 5 mg except 2 injections in first month

1 Also called monthly injectables.

2 The U.S. Food and Drug Administration approved Lunelle, but it is currently not available in the United States.
Source : (81)

gives protection from pregnancy in 99 per cent of women for c. DMPA-SC 104 mg (81)

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at least 3 months. It exerts its contraceptive effect primarily A new lower-dose formulation of DMPA, depo-subQ
by suppression of ovulation. However, it also has an indirect pipvera J 04 (also called DMPA-SC), isjnjected under the
effect on the endometrium and direct action on_the fallopian skin rather than in the muscle. It contains 104 mg of DMPA
tubes and on the production of cervical mucus, all of which rather Than the 150 mg in the intramuscular formulation.
may play a role in reducing fertility. DMPA has been found Like the intramuscular formulation, DMPA-SC is given at
to be a safe, effective and acceptable contraceptive which 3-month intervals.
requires a minimum of motivation or none at all. Another
advantage is that it does not affect lactation. Therefore in DMPA-SC is just as effective as the formulation injected
the experience of several countries^ ^DMPA has proved into the muscle, and the patterns of bleeding changes and
acceptable during the postpartum period as a means of amount of weight gain are similar.
spacing pregnancies. However, the side-effects of DMPA Injections of DMPA-SC are given in the upper thigh or
(viz. weight increase, irregular menstrual bleeding and abdomen. DMPA-SC should not be injected intramuscularly,
prolonged infertility after its use) are disadvantages limiting and the intramuscular formulation should not be injected
the age groups for which the drug could regularly be used. subcutaneously. The intramuscular formulation cannot be
QAs_jlow practiced in a number of countries, this diluted to make the lower-dose subcutaneous formulation.
contraceptive should find good use among multiparae of aye
over 35 years who have already completed their familie^. Side-effects
Both DMPA and NET-EN have similar side effects, the
b. NET-EN most common being ^disruption of the normal menstrual
(^Norethisterone enantate (NET-EN) has been in use as_a cycle, manifested by episodes of unpredictable bleeding, at
contraceptive since 1966. However, it has been less times prolonged and at other times excessive. In addition,
extensively"used than DMPA. It is given intramuscularly in a many women using DMPA or NET-EN may become
dose of 200 mg every 60 days. Contraceptive action appears amenorrhoeic. The unpredictable bleeding may be very
to include inhibition of ovulation, and progestogenic effects inconvenient to the user; and amenorrhoea can be
on cervicaljnucus. A slightlyT higher (0.4) pregnancy rate alarming, causing anxiety. Studies showed that women
(failure rate) has been reported as compared to DMPA. discontinuing DMPA became pregnant some 5.5 months
(average) after the treatment period. At 2 years, more than
Administration 90 per cent of previous users became pregnant (82). A study
The initial injection of both .DMPA and NET-EN should be is in progress in India to examine the return of fertility
given during the first 5 days of the menstrual period. This among women who discontinued NET-EN. The potential
timing is very important to rule out the possibility of long-term effects of DMPA and NET-EN are not yet known.
pregnancy. Both are given by deep intramuscular injection
Contraindications
into the gluteus maximus. The injection site should never be
massaged following injections. (82). Although compliance These include cancer of the breast; all genital_c^ncers;
with regular injection intervals should be encouraged, both (^Undiagnosed abnormal uterine bleeding; and a suspected
DMPA and Net-EN may be given two weeks early or two malignancy. Women usually' "should not start using a
weeks late (83). progestin-only injectable if they have high blood pressure

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 HORMONAL CONTRACEPTIVES 579
(systolic > 160 mm Hg or diastolic > 100), certain conditions the first three months it is taken biweekly and from 4th
of the heart, blood vessels, or liver including history of month onwards, once weekly. It can be initiated anytime
stroke or heart attack and current deep vein thrombosis. during the menstrual cycle if it is reasonably certain that the
Also, a woman breast-feeding a baby less than 6 weeks~old woman is not pregnant.
should not use progestin-only injectables (81). However, the following timing of initiation can be opted
(Jhe particular advantage of DMPA and MELLEN is that by the women to start the package after proper screening by
they are highly effective, long-lasting and reversible health-care provider: f
contraceptives; Checklists hSve been developed for - on first day of period
auxiliarfesprimarily for the screening of women who can be - on the day of abortion itself
given injectable contraceptives without being examinedjby
the physician; they can also be utilized in follow-up visits. - within 4 weeks after childbirth, whether breastfeeding or
not
B. COMBINED INJECTABLE CONTRACEPTIVES To start with, take one pill at the correct time (mentioned
These injectables contain a progestogen and an above) and take another pill three days later (2 pills in a
oestrogen. They are given at monthly intervals, plus or week). Then the schedule of these 2 pills per week to be
minus three_days. Combined injectable contraceptives act followed for three months. From fourth month onwards,
mainly by suppression oLovulation. The cervical mucus is only one pill per week to be taken (the first pill day to be
repeated every_week) This weekly regime to be continued,
affected! mainly by progestogen, and becomes an obstacle
regardless of menstrual cycle, till protection from pregnancy
to sperm penetration^ Changes are also produced in
is needed (86).
endometrium which makes it unfavourable for implantation
if fertilization occurs, which is extremely unlikely. )
POST-CONCEPTIONAL METHODS
In clinical trials, Cyclofem/Cycloprovera and Mesigyna (Termination of pregnancy)
have both been found to be highly effective’with 12 month
failure rates of 0.2 per cent or less for Cyclofem/
Menstrual regulation
Cycloprovera and 0.4 per cent for Mesigyna. The side-effects
are similar to progestogen only injectables, but are much A relatively simple method of birth control is “menstrual
less. Data on return to ovulation and fertility are limited. regulation”. It consists of aspiration of the uterine contents 6
to 14 days of a missed period, but before most pregnancy tests

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The contraindications are confirmed or suspected can accurately determine whether or not a woman is pregnant
pregnancy; past or present evidence of thromboembolic (45/TCervical dilatation is indicated only in nullipara or in
disorders; cerebrovascular or coronary artery disease; focal apprehensive subjects. No after-care is necessary as a rule.
migraine; malignancy of the breast; and diabetes with
vascular complications. Combined injectables are not The immediate complications are uterine perforation and
suitable for women who are fully breast feeding until trauma. Late complications (after 6 weeks) include a
6 rnonthsjsostpartum It is less suitable for women with risk tendency to abortion or premature labour, infertility,
factors for oestrogen. menstrual disorders, increase in ectopic pregnancies and
Rh-immunization (87).
2. Subdermal implants Some regard menstrual regulation as very early abortion,
The Population Council, New York has developed a others view it as a treatment for delayed periods. Menstrual
subdermal implant known as CNorplant for long-term regulation differs from abortion in 3 respects (88) : (a) the
contraception. It consists of 6 silastic (silicone rubber) lack of certainty if a pregnancy is being terminated.
capsules containing 35 mg (eacli) of levonorgestrel (84). Microscopic examination of the aspirated material can
More recent devices comprise fabrication of levonorgestrel confirm pregnancy post fete: , but it is not obligatory (b) the
into_2_smallxpds, Norplant (R)-2, which are comparatively lack of legal restrictions, and (c) the increased safety of the
easier to insert and remove. The silastic capsules or rods are early procedure.
implanted beneath the skin of the forearm or upper arm.
Effective contraception is provided for over 5 years. The Menstrual induction
contraceptive effect of Norplant is reversible on removal of This is based on disturbingJhe normal progesterone-
capsules. A large multicentre trial conducted by prostaglandin balance by intrauterine application of 1-5 mg
International Committee for Contraception Research (ICCR) solution (or 2.5-5 mg pellet) of prostaglandin F2. Wjthin_a
reported a 3-year pregnancy rate of 0.7. The main few minutes of the prostaglandinjmpact, performed_under
disadvantages, however, appear to be irregularities of sedation, the uterus responds with a sustained con ii action
menstrual bleeding and surgicaLprocedures necessary to lasting about ~7~ minutes, followed by cyclic contractions
insert and remove implants^ continuing for 3-4 hours. The bleeding starts and continues
for 7-8 days (87).
3. Vaginal rings
(^Vaginal rings containing levonorgestrel have been found Oral abortifacient
to be effective. The hormone is slowly absorbed through the CMifepristone (RU 486) in combination with misoprostol is
vaginal mucosa, permitting most of it to bypass the digestive 95 per cent successful in terminating pregnancies of upto
system and liver, and allowing ^potentially lower dose. The 9 week’s duration with minimum com plications. The
ring is worn in the vagina for 3 weeks of the cycle and commonly used regimen is mifepristone 200 mg orally on
removed for the fourth (85). * day 1, followed by misoprostol 800 mcg vaginallv either
immediately or within 6-8 hours. Commercially it comes as
4. Centchroman non-hormonal pill (Chhaya) : MDELkit having combipack tablets of mifepristone 200 mg
Centchroman is commonly known as weekly pill as for one tablet and misoprostol 200 mcg 4 tablets (800 mcg).

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580_______ DEMOGRAPHY AND FAMILY PLANNING____________
The other regimen is a dose of mifepristone 600 mg on day different for medical abortion (which is performed by drugs
one, followed by 400 mcg orally of misoprostol on day three. alone and/or surgical abortion) and that which is performed
The patient should return for a follow-up visit with a manual or electric aspirator. In developed regions it is
approximately 14 days after the administration of estimated that 30 women die for every 100,000 unsafe
mifepristone to confirm by clinical examination or ultra­ abortions. This number rises to 220 deaths, per 100,000
sonographic scan that a complete termination of pregnancy unsafe abortions in developing regions and 520 deaths in
has occurred. Patients who have an ongoing pregnancy at sub-Saharan Africa (91).
this visit have a risk of foetal malformation resulting from the In India an ICMR study documented that the rates of safe
treatment. Surgical termination is recommended to manage (legal) and unsafe (illegal) abortion were 6.1 and 13.5 per
medical abortion treatment failures. 1000 pregnancies respectively. It is evident that perhaps two
thirds of all abortions take place outside authorized health
Contraindications service by unauthorized and often unskilled persons (92).
Administration of mifepristone and misoprostol is The EARLY COMPLICATIONS of abortion include
contraindicated in following conditions : (1) History of allergy haemorrhage, shock, sepsis; uterine perforation, cervical
or known hypersensitivity to mifepristone, misoprostol or injury, thromboembolism and anaesthetic and psychiatric
other prostaglandin; (2) Confirmed or suspected ectopic complications. The LATE SEQUELAE include infertility,
pregnancy or undiagnosed adnexal mass; (3) IUD in place; ectopic gestation, increased risk of spontaneous abortion
(4) Chronic adrenal failure; (5) Haemorrhagic disorder or
concurrent" anticoagulant therapy; (6) Inherited porphyria; Data indicates that the seventh and eighth week of
and (7) If a patient does not have adequate access to medical gestation is the optimal time for termination of pregnancy
facilities equipped to provide emergency treatment of (93). Studies indicate that the risk of death is /.times higher
incomplete abortion and blood transfusion. for women who wait until the second trimester to terminate
pregnancy. The Indian Law (MTP Act. 1971) allowed
ABORTION abortion only upto 20 weeks of pregnancy. In the year,2020_
the MTP Bill was amended, to increase the duration of
Abortion is theoretically defined as termination of pregnancy upto 24 weeks.
pregnancy before the foetus becomes viable (capable of
living independently). This has been fixed administratively Legalization of abortion

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at 28 weeks, when the foetus weighs approximately 1000 g. During the last 25 years there have been gradual
Abortion is sought by women for a variety of reasons liberalization of abortion laws throughout the world. Until
including birth control. In fact, in some countries (e.g., 1971, abortions in India were governed exclusively by the
Hungary) the legal abortions exceed live births\ Indian Penal Code 1860 and the Code of Criminal Procedure
(^Abortions are usually categorized as spontaneous and 1898, and were considered a crime except when performed to
induced. Spontaneous abortions occur once in every save the life of a pregnant woman. Jhe Medical Termination
15 pregnancies (89). They may be considered “Nature’s, of Pregnancy Act was passed by the Indian Parliameniin 1971
method of J)irth_ control”. Induced abortions, on the other and came into force from April 1, 1972 (except in Jammu and
hand? are deliberately induced - they may be legal or illegal. Kashmir, where it came into effect from November 1, 1976).
Illegal abortions are hazardous; they are usually the last Implementing rules and regulations initially written in 1971
resort of women determined to end their pregnancies at the were revised again in 1992 (94)\[he Medical Termination of
risk of their own livesj Pregnancy Act is a health care measure which helps to reduce
maternal morbidity and mortality resulting from_ illegal
Abortion hazards abortions. It also affords an opportunity for motivating such
On an average, 73 million induced (safe and unsafe) women to adopt some form of contraception. \
abortions take place worldwide each year. About 61 per
cent of all unintended pregnancies and 29 per cent of all THE MEDICAL TERMINATION OF
pregnancies, end in induced abortion (90). The rate of PREGNANCY ACT 1971
abortion was higher in developing regions than in developed
world. About 45 per cent unsafe abortions were estimated to The Medical Termination of Pregnancy Act, 1971 lays
have taken place worldwide each year, almost all in down :
developing world. Among these, 8 million were carried out 1. The conditions under which a pregnancy can be
in the least safe or dangerous conditions. Over half of all terminated.
estimated unsafe abortions globally were in Asia. 3 out of 4 2. The person or persons who can perform such
abortions that occurred Fn Africa"and Latin America were Terminations, and
unsafe^Eacbyyear between 4.7 per cent to 13.2 per cent of 3. TFhe place where such terminations can be performed.
maternal deaths can be attributed to unsafe abortions
Around 7 million women are hospitalized every year in 1. The conditions under which a pregnancy can be
developing countries'as a result of unsafe abortion^ terminated under the MTP Act. 1971 :
Abortions are safe if they are done with a method There are 5 conditions that have been identified in the
recommended by WHO that is appropriate to the pregnancy Act :
duration and if the person providing abortion is trained. a. [Medical - where continuation of the pregnancy might
Unsafe abortion occurs when a pregnancy is terminated endanger the mother’s life or cause grave injury to her
either by a person lacking the necessary skills or in an physical or mentaThealth.-
environment that does not conform to minimal medical b. Eugenic - where there is substantial risk of the child
-Standards, or both. The people, skills and medical standards being born with serious handicaps due to physical or
considered safe in the provision of induced abortion are mental abnormalities.

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 ABORTION
531
c. Humanitarian - where pregnancyjs the result of rape. (c) 3 years of practice in OBG for those doctors registered
d. Socio-economic - where actual or reasonably before the 1971 MTP Act was passed.
foreseeable environments (whether social or (d) 1 year of practice in OBG for those doctors registered
economic) could lead to risk of injury to the health of on or after the date of commencement of the Act. j
the mother, and
3. The place where abortion is performed
e. Failure of contraceptive devices - The anguish caused
by an unwanted pregnancy resulting from a failure of (Under the new rules, non-governmental institutions may
any contraceptive device or method can be presumed also take up abortions provided they obtain a licence from
to constitute a grave mental injury to the health of the the Chief Medical Officer of the district, thus eliminating the
mother. This condition is a unique feature of the requirement of private clinics obtaining a Board licence.j
Indian law and virtually allows abortion on request, in Impact of liberalization of abortion
view of the difficulty of proving that a pregnancy was
not caused by failure of contraception?^ Although abortion has been greatly liberalized, the
annual number of legal abortions are about 1000
The written consent of the guardian is necessary before
pregnancies, whereas the illegal abortions performed in the
performing abortion in women under 18 years of age, and
country are about 13.5 per 1000 pregnancies. In other
in lunatics even if they are older than 18 years.
words, illegal abortions are still rife although it is now more
than 45 years since MTP Act was promulgated.
2. The person or persons who can perform abortion
An amendment to the MTP Act in the year 2003jncludes
(fhe Act provides safeguards to the mother by authorizing
decentralization of power for approval of places as MTP
only a Registered Medical Practitioner having experience in
centres, from state to district level with the aim of enlarging
gynaecology and obstetrics to perform abortion where the
the network of safe MTP centres, and - MTP servicg
length of pregnancy does not exceed 12 weeks. However,
providers. The strategy at thef-community levellis : (a) .spread
where jhe pregnancy exceeds 12 weeks and is not more than
awareness regarding safe MTP in the community and the
20 weeks^ tTie opinion of two Registered Medical
availability of services thereof ; (b) Enhance access to
Practitioners is necessary to terminate the pregnancy. \
confidential counselling for safe MTP: train ANMs, AWWs,

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3. Where abortion can be done and link workers/ASHAs to provide such counselling; and
(c) Promote post-abortion care through ANMs, AWWs, link
The Act stipulates that no termination of pregnancy shall workers/ASHAs while maintaining confidentiality. At the
be made at any place other than a hospital established or 'facility level the strategy is : (1) To provide manual Vaccum
maintained by Government or a place approved for the Aspiration facility at all CHCs and at least 50 per cent of
purpose of this Act by Government. PHCs that are being strengthened for 24 hour deliveries;
(Abortion services are provided in hospitals in strict (2) Provide comprehensive and high quality MTP services at
confidence. The name of the abortion seeker is kept all FRUs; and (3) Encourage private and NGO sectors to
confidential, since abortion has been treated statutorily as a establish quality MTP services (98).
personal matter, According to the new Oct. 2022 ruling of Supreme Court,
(Rule 3B allows abortion between 20 and 24 weeks of
MTP RULES (1975) pregnancy if there is a change in marital status during
Rules and Regulations framed initially were altered in pregnancy including widowhood or divorce. The Supreme
October 1975 to eliminate time-consuming procedures Court declared that rule 3B must also extend to unmarried
involved in MTP and to make services more readily women who experience a change in their relationship (even
available. These changes have occurred in 3 administrative if not married) status, whether due to separation from,
areas (95, 96). desertion by or death of their partners (97).
Repeated abortion is not conducive to the health of the
1. Approval by Board mother. It has to be ensured that abortion does not replace
CUnder the new rules, the Chief Medical Officer of the the traditional methods of birth control. The numerous
district is empowered to certify that a doctor has Jhe abortion hazards which are inherent should serve as a
necessary training in gynaecology and obstetrics to do warning that abortions under the best of circumstances can
abortions. The procedure of doctors applying to never be as safe as efficient contraception, k
Certification Boards was removed ]
MISCELLANEOUS
2. Qualification required to do abortion
The new rules allow for registered medical practitioners to 1. Abstinence
qualify through on the spot training :
The only method of birth control which is completely
C‘If he has assisted a RMP in the performance of effective is complete sexual abstinence. It is sound in theory;
25 cases of medical termination of pregnancy in an in practice, an oversimplification. It amounts to repression of
approved institution’ll a natural force and is liable to manifest itself in other
The doctor may also qualify to do MTPs under the new directions such as temperamental changes and even nervous
rules if he has one or more of the following qualifications breakdown. Therefore, it can hardly be considered as a
which are similar to the old rules : method of contraception to be advocated to the masses.
(a) < ■ months housemanship in_obstetrics and gynaecology. 2. Coitus interruptus
(b) a postgraduate qualification in OBG. This is the oldest method of voluntary fertility control.
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582 DEMOGRAPHY AND FAMILY PLANNING

It involves no cost or appliances. It continues to be a widely cycles are irregular, it is difficult to predict the safe period
practised method. The male withdraws before ejaculation, (b) it is only possible for this method to be used by educated
and thereby tries to prevent deposition of semen into the and responsible couples with a high degree of motivation
vagina. Some couples are able to practise this method and cooperation (c) compulsory abstinence of sexual
successfully, while others find it difficult to manage jThe intercourse Jor nearly one half of every month - whatrnay
chief drawback of this method is that the precoital secretion be called “programmed sex” (d) this method is not
of the male may contain sperm, and even a drop of semen is applicable during the postnatal period, and (e) a high failure
sufficient Jo cause pregnancy. Further, the slightest mistake rate of 9_oer 100 woman-years (40). The failures are due to
in timing the withdrawal may lead to the deposition of a wrong calculations, inability to follow calculations, irregular
certain amount of semen.pTherefore, the failure rate with this use and “taking chances”.
method may be as high as 25 per cent. Two medical complications have been reported to result
Hitherto, the alleged side-effects (e.g., pelvic congestion, from the use of safe period; ectopic pregnancies and
vaginismus, anxietyjieurosis) were highly magnified. Today, embryonic abnormalities. Ectopic pregnancies may Jollow
expert opinion is changing in this respect. If the couple conception late in the menstrual cycle and displacement of
prefers it, there should be no objection to its use. It is better the ovum; {embryonic abnormalities may result from
than using no family planning method at all.Ut is conceded conception involving either an over-aged sperm or over­
that coitus interruptus along with abstinence and abortion aged ovum. If this is correct, the safe period may not be an
played a major role in reducing birth rates in the developed absolutely safe period (99).
world during the 18th and 19th centuries (45).
4. Natural family planning methods
3. Safe period (rhythm method)_______________
The term “natural family planning” is applied to three
This is also known as the ^calendar method^ first methods: (a) basal body temperature (BBT) method
described by Ogino in 1930. The method is based on the (b) cervical mucus method, and (c) symptothermic method.
fact th at (ovulation occurs from 12 to 16 days before the The principle is the same as in the calendar method, but
onset of menstruation (see Fig. 7). The days on which here the woman employs self-recognition of certain
conception is likely to occur are calculated as follows : physiological signs and symptoms associated with ovulation
as an aid to ascertain when the fertile period begins. For

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avoiding pregnancy, couples abstain from sexual intercourse
during the fertile phase of the menstrual cycle; they totally
desist from using drugs and contraceptive devices. This is
the essence of natural family planning.
(a) Basal body temperature method (BBT)
(JL- BBT method depends upon the identification of a
specific physiological event - the rise of BBT at the time of
ovulation, as a result of an increase in the production of
progesterone. The rise of temperature is very small, 0.3 to
0.5 degree C. When no ovulation occurs (e.g., as after
menarche, during lactation) the body temperature does not
rise. Cjhe temperature is measured preferably before
getting out oF~5e3 in the morning. The BBT method is
reliable if intercourse is restricted to the post-ovulatory
infertile period, commencing 3 days after I he ovulatory
temperature rise and continuing up to the beginning of
menstruation. <£he major drawback of this method is that
abstinence is necessary for the entire pre-ovulatory period.
Therefore, few couples now use the temperature method
alone (100).
FIG. 7
Safe period in a 28-day cycle (b) Cervical mucus method
This is also known as “billings method” or “ovulation
6jhe shortest cycle minus 18 days gives the first day of the
method”. This method is based on the observation of
fertdejieried. The longest cycle minus 10 days gives the last
changes in the characteristics of cervical mucus. At the time
day of the fertile period. For example, if a woman’s
of ovulation, cervical mucus becomes watery clear
menstrual cycle varies from 26 to 31 days, the fertile period
resembling raw egg white, smooth, slipper and profuse.
during which she should not have intercourse would be from
After ovulation, under the influence of progesterone Jthe
the(8th_day to the 21st day of the menstrual cycle, counting
mucus thickens and lessens in quantity. It is recommended
day one as the first day of the menstrual period. Fig. 7 shows
that the woman uses a tissue paper to wipe the inside of
the fertile period and the safe period in a 28-day cycle.
vagina to assess the quantity and characteristics of mucus.
However, where such calculations are not possible, the To practice this method the woman should be able to
couple can be advised to avoid intercourse from the Xth tg. distinguish between different types of mucus. This method
the 22ndjiay of the menstrual cycle, counting from the first requires a high degree of motivation than most other
day ot the menstrual period (94). methods. The appeal and appropriateness of this method in
The drawbacks of the calendar method are : (a) a developing countries such as India, especially among lay
woman’s menstrual cycles are not always regular. If the people, is dubious.
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 FAMILY PLANNING 583

(c) Symptothermic method Government institutions. Guidelines have been issued from
This method combines the temperature, cervical mucus time to time by the Government covering various aspects of
and calendar techniques for identifying the fertile period?lf sterilization. These are (108, 109):
the woman cannot clearly interpret one sign, she can a. i The jage of the husband should not ordinarily be less
“double check” her interpretation with another. Therefore, than 25 years nor should it be over 50 years.
this method is more effective than the “Billings method”. b. Clhe age of the wife should not be less than 20 years or
To sum up, natural family planning demands discipline more than 45 years. >
and understanding of sexuality. It is not meant for c. ( The motivated couple must have 2 living children at
everybody. C[he educational component is more important the time of operation. \
with this approach than with other methods., The opinion of
the Advisory Group to WHO’s Special Programme of d.^Jf the couple has 3 or more living children, the lower
Research in Human Reproduction is that the current natural limit of age of the husband or wife may be relaxed at
family planning methods have very little application the discretion of the operating surgeon, and
particularly in developing countries (101). e£ It is sufficient if the acceptor declares having obtained
the consent of his/her spouse to undergo sterilization
5. Breast-feeding operation without outside pressure, inducement or
Field and laboratory investigations have confirmed the coercion, and that he/she knows that for all practical
traditional belief that lactation prolongs postpartum purposes, the operation is irreversible, and also that
amenorrhoea and provides some degree of protection the spouse has not been sterilized earlier. |
against pregnancy (102). No more than 5-10 per cent of
women conceive during lactational amenorrhoea. and even Male sterilization (110, 111)
this risk exists only during the month preceding the (^Male sterilization or vasectomy being a comparatively
resumption of menstruation (103). However, once simple operation can be performed even in primary health
menstruation returns, continued lactation no longer offers centres by trained doctors under local anaesthesia. When
any protection against pregnancy (104). By and large, by 6 carried out under strict aseptic technique, it should have no
months after childbirth, about 20-50 per cent of women are risk of mortality. In vasectomy, it is customary to remove a

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menstruating and are in need of contraception (105). piece of vas at least 1 cm after clamping. The ends are
ligated and then folded back on themselves and sutured into
6. Birth control vaccine position, so that the cut ends face away from each other.
Several immunological approaches for men and women This will reduce the risk of recanalization at a later date. It is
are being investigated. t[he most advanced research involves important to stress that the acceptor is not immediately
immunization with a vaccine prepared from hpfa sub-unit n£ sterile after the operation, usually until approximately
human chorionic gonadotropin (hCG)7a hormone produced 30 ejaculations have taken place (45). During this
in early pregnancy. Immunization with hCG would block intermediate period, another method of contraception must
continuation of the pregnancy. Antibodies appeared in be used. If properly performed, vasectomies are almost
about 4-6 weeks and reached maximum after about 100 per cent effective.
5 months and slowly declined reaching zero levels after a
period ranging from 6-11 months. The immunity can be Following vasectomy, sperm production and Jiormone
boosted by a second injection. Two types of pregnancy output are not affected. The sperm produced are destroyed
vaccines employing variants of the beta sub-unit of hCG are intraluminally by phagocytosis. This is a normal process in
now about to go into clinical trial (51). Research on the male genital tract, but the rate of destruction is greatly
birth control vaccines continues. The uncertainties are increased after vasectomyWasectomy is a simpler, faster and
great (85). less expensive operation than tubectomy in terms of
instruments, hospitalization and doctor’s training. Co$twis_e,
TERMINAL METHODS the ratio is about 5 vasectomies to one tubal ligation.^
(Sterilization)
COMPLICATIONS
Cvpluntary sterilization is a well-established contraceptive The very few complications that may arise are :
procedure for couples desiring no more children. Currently
female sterilizations account for about 85 per cent and i s ale (а) Operative : The early complications include pain,
sterilizations for 10-15 per cent of all sterilizations in India scrotal haematoma and local infection. Wound infection is
(106), in spite of the fact that male sterilization is-simpler, reported to occur in about 3 per cent of patients. Good
safer and cheaper than female sterilization. haemostasis and administration of antibiotics will reduce the
Sterilization offers many advantages over other risk of these complications.
contraceptive methods - it is a one-time method; it does not (б) \§perm granules : Caused by accumulation of sperm,
require sustained motivation of the user for its effectiveness: these are a common and troublesome local complication of
provides the most effective protection against pregnancy; vasectomy. They appear in 10-14 days after the operation.
the risk of complications is small if the procedure is The most frequent symptoms are pain and swelling.
performed according to accepted medical standards; and it Clinically the mass is_ hard and the average size
is most cost-effective. It has been estimated that each approximately 7 mm. Sperm granules may provide a
procedure averts 1.5 to 2.5 births per woman (107). medium through which re-anastomosis of the severed vas
can occur. The sperm granules eventually subside. It has
Guidelines for sterilization been reported that using metal clips to close the vas may
Sterilization services are provided free of charge in reduce or eliminate this problem;1
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584 DEMOGRAPHY AND FAMILY PLANNING

(c) CSpontaneous recanalization : Most epithelial tubes will 4. <To wear a T-bandage or scrotal support (langot) for
recanaiize after damage, and the vas is no exception. The 15 days : and to keep the site clean and dry.
incidence of recanalization is variously placed between 5. CTo2avoid cycling or lifting heavy weights for 15 days;
Qto 6 per cent. Its occurrence is serious. Therefore, the there is, however, no need for complete bed rest.
surgeon should explain the possibility of this complication to
every acceptor prior to the operation, and have written 6 (jo have the stitches removed on the 5th day after the
consent acknowledging this fact. In a study, the wives of opeiation,___ -
6 out of 14,047 men who had vasectomies in the UK
became pregnant between 16 months and 3 years later No scalpel vasectomy
(112). Therefore, the patient should be urged to report for a CNo scalpel vasectomy is a new technique that is safe,
regular follow-up, may be up to 3 years) convenient and acceptable to males. This new method is
(d) (Autoimmune response : Vasectomy is said to cause an now being canvassed for men as a special project, on a
autoimmune response to sperm. Blocking of the vas causes voluntary basis under the family welfare programme. Under
reabsorption of spermatozoa and subsequent development the project, medical personnel all over the country are to be
of antibodies against sperm in the blood. Normally 2 per trained. Availability of this new technique at the peripheral
cent of fertile men have circulating antibodies against their level will increase the acceptance of male sterilization in the
own sperm. In men who have had vasectomies, the figure country. The project is being funded by the UNFPA (98).]
can be as high as 54 per cent. There is no reason to believe
that such antibodies are harmful to physical health. It is Female sterilization
likely that the circulating antibodies can cause a reduction in Female sterilization can be done as an interval procedure,
subsequent fertility despite successful reanastomosis of the postpartum or at the time of abortion. Two procedures have
vas (44). become most common, namely laparoscopy and
(e) [Psychological : Some men may complain of minilaparotomy.
diminution of sexual vigour, impotence, headache, fatigue,
etc. Such adverse psychologicafeffects are seen in men who (a) Laparoscopy
have undergone vasectomy under emotional pressure. That This is a technique of female sterilization through
is why it is important to explain to each acceptor the basis abdominal approach with a specialized instrument called

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of the operation and give him sufficient time to make up “laparoscope”. The abdomen is inflated with gas (carbon
his mind voluntarily and seriously to have the operation dioxide, nitrous oxide or air) and the instrument is
done.__ introduced into the abdominal cavity to visualize the Tubes.
Once the tubes are accessible, the Falope rings^or clips) are
Causes of failure (111)
applied to occlude the tubes. This operation should be
The failure rate of vasectomy is generally low, 0.15 per undertaken only in those centres where specialist
100 person-years. The most common cause of failure is due obstetrician-gynaecologists are available. The short
to the mistaken identification of the vas. That is, instead of operating time, shorter stay in hospital and a small scar are
the vas, some other structure in the spermatic cord such as some of the attractive features of this operation.
thrombosed vein or thickened lymphatic has been taken.
Histological confirmation has, therefore, been ( Patient selection : Laparoscopy is not advisable for
recommended on all vasectomy specimens by some authors pbstpartum patients for 6 weeks following delivery;
in developed countries. In developing countries, histological however, it can be done as a concurrent procedure to MTP
confirmation is ruled out because of lack of facilities for sucE Haemoglobin per cent should not be less than 8. There
an examination. A simpler method has been recommended, should be no associated medical disorders such as heart
that is, microscopic examination of a smear prepared by disease, respiratory disease, diabetes and hypertension. It is
gentle squeezing of the vas on a glass slide and staining with recommended that the patient be kept in hospital for a
Wright’s_siain. The vas can be identified by the presence of minimum of 48 hours after the operation.
columnar epithelial cells that line the lumen of the vas. In The cases are required to be followed-up by health
some cases, failure may be due to spontaneous workers (F) LHVs in their respective areas once between
recanalisation of-vas. Sometimes there may be more than 7-10 days after the operation, ancL once again between
one vas on onejide. Pregnancy could also result from sexual 12 and 18 months after the operation.)
intercourse before the disappearance of sperms from the Complications : Although complications are uncommon,
reproductive tract. I when they do occur they may be of a serious nature
Post-operative advice requiring experienced surgical intervention. Puncture of
large blood vessels and other potential complications have
To ensure normal healing of the wound and to ensure the been reported as major hazards of laparoscopy.
success of the operation, the patient should be given the
following advice : operations
1. (£he patient should be told that he is nof sterile Minilaparotomy is a modification of abdominal
immediately after the operation; at least tubectomy. It is a much simpler procedure requiring a
30 ejaculations may be necessary before the seminal smaller abdominal incisiop of only 2.5 to 3 cm conducted
examination is negative (45). under local anaesthesia.y he minilap/Pomerov technique is
2. tfo use contraceptives until aspermia has been considered a revolutionary procedure for female
established, j sterilization. It is also found to be a suitable procedure at the
3. IJo-avoid taking bath for at least 24 hours after the primary health centre level and in mass campaigns. It has
operation. the advantage over other methods with regard to safety,
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 TERMINAL METHODS 585
efficiency and ease in dealing with complications. Minilap based technical guidance : Up-to-date service delivery
operation is suitable for postpartum tubal sterilization. guidelines, tools, and job aids can help translate research
findings into better practice; (5) Commimicai^eff^ciively :
Evaluation of contraceptive methods Communication grounded in behaviour theory and sensitive
Contraceptive efficacy is generally assessed by measuring to local norms motivates clients to seek services and helps
the number of unplanned pregnancies that occur during a them make good family planning choices; (6) Assure
specified period of exposure and use of a contraceptive contraceptive security : A strong logistics system and a long­
method. The two methods that have been used to measure term plan for contraceptive security ensure that a variety of
contraceptive efficacy are the Pearl index and life-table methods, and the supplies and equipment to provide them,
analysis. are always available; (7) Work for, supportive policies :
Showing how family planning contributes to development
The Pearl index is defined as the number of “failures per goals makes the case for continued support for family
100 woman-years of exposure (HWY).” This rate is given by planning programme; (8) Coordinate : When governments,
the formula : donor agencies, and implementing partners work together,
they streamline efforts and avoid duplication; (9) Build a
Total accidental pregnancies \
rate per HWY = ------------------------------------------------ X 1200 1 high-performing staff : Programme can keep workers
Total months of exposure motivated and on the job by creating a good working
environment, matching skills with tasks, and rewarding a job
In applying the above formula, the total accidental well done; (10) Secure adequate budget, use it well :
pregnancies shown in the numerator must include every Spending wisely, doing more with less, and finding ways to
known conception, whatever its outcome, whether this had recover costs can help ensure financial sustainability;
terminated as live births, still-births or abortions or had not (11) Base decisions on evidence : Research, monitoring, and
' yet terminated. (The factor 1200 is the number of monthsJn evaluation yield important information to guide decision­
100 years. The total months of exposure in the denominator making, and they need not be expensive: (12) Lead strongly,
is obtained by deducting from the period under review of manage well: Strong leadership helps programmes navigate
10 months for a full-term pregnancy, and 4 months for an change. Good management solves operational problems;
abortion (99). and (13) Integrate services appropriately : Programmes
can address a wider range of health needs by integrating
A failure rate of 10 per HWY would mean that in the

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services where appropriate and offering referrals where
lifetime of the average woman about one-fourth or
it is not.
2.5 accidental pregnancies would result, since the average
fertile period of a woman is about 25 years (99).
Unmet need for family planning (113)^
In designing and interpreting a use-effectiveness trial,
a minimum of 600 months of exposure is usually ( Many women who are sexually active would prefer to
considered necessary before any firm conclusion can be avoid becoming pregnant, but nevertheless are not using
reached (99). any method of contraception (including use by their
partner). These women are considered to have an_“unmet
With most methods of contraception, failure rates decline need” for family planning. The concept is usually applied to
with duration of iisp. IThe Pearl index is usually based on a married women. However, it can apply to sexually active
specific exposure (usually one year) and2 therefore, fails to fecund women and perhaps to men, but its measurement
accuratgly compare methods at various durations of has been limited to married women only. Unmet need can
exposure. This limitation is overcome by using the method be a powerful concept for family planning. It poses a
of life-table analysis J challenge to family planning programme - to reach and
(jjfe-table analysis : Life-table analysis calculates a failure serve millions of women whose reproductive attitude
rate for each month of use. A cumulative failure rate can resembles those of contraceptive user - but who are, for
then.compare methods for any specific length of exposure. some reason or combination of reasons, not using
Women who leave a study for any reason other than contraceptives.
unintended pregnancy are removed from the analysis, ^Among the most common reason foe unmet need are
contributing their exposure until the time of the exit. inconvenient or unsatisfactory services, lack of information,
fears about -contraceptive side-effects and opposition from
Element of success in family planning
husband or relatives. Unmet need is defined on the basis of
programme
women’s response to survey questions^
The main strategy of family planning programme is to
According to the National Family Health Survey-5, the
offer to client easy access to a wide range of affordable
unmet need for family planning is highest (28.0 per cent)
contraceptive method through multiple service delivery
among women between 15 to 24 years of age and is almost
channels in a good quality, reliable fashion. The key points
entirely for spacing the births rather than for limiting the
are as follows : (1) Make services accessible : Offering
births. The unmet need for contraception among women
services through a variety of delivery points makes methods
aged 30 years and above are mostly for limiting the births.
available to more potential users; (2) Make services
affordable : Partnerships between public and private-sector Unmet need for family planning is higher in ruiaLareas
services encourage clients to pay what they can, while public than in urban areas. It also varies by women’s education
programmes serve the poor for free or for low fees; (3) Offer (within range of 11-17 per cent) and religion (hindu and
client-centered care : Planning and providing services with Christian women have a lower unmet need than muslim
the clients in mind help to make sure their needs are met women). Table 23 shows some of the characteristics of
and their preferences are honoured; (4) Rely on evidence­ unmet need for family planning in India (20)

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 DEMOGRAPHY AND FAMILY PLANNING

TABLE 23 Contraception and adolescence (114)

Pprrpntaae of currently married women with unmet need for (Adolescence is the period between puberty and the end
family planning in India by selected background of physiological maturation, which occurs between ages
characteristics (NFHS-5, 2019-2021) 15-19 years. Pregnancy in adolescence constitutes about
11 per cent of all pregnancies in most developing countries
r-------- Unmet need for
family planning and in some developed countries such as the USA. For the
Background characteristics
For spacing For limiting Total year 2014, WHO puts the global adolescent birth rate at
49 per 1000 girls of that age, country rates range from one
1 Age to 229 births per 1000 girls. This indicates a marked
15-19 15.6 22 17.8 decrease since 1990 (115). These are often “at risk”
20-24 12.4 4.9 17.3 pregnancies. Many are undesired, and occur in unmarried
6.2 7.0 13 2 adolescents who then resort to legal or illegal abortion,
25-29
30-34 2.5 6.6 9.1 performed under unsatisfactory medical conditions. This has
35-39 0.9 5.5 6.3 serious health and even life-threatening consequences for
40-44 0.3 4.7 5.0 these young women - the ensuing mortality and morbidity
0.2 3.3 3.4 (especially secondary sterility) are quite considerable.
45-49
2 Residence Prevention of undesired pregnancies and of sexually
Urban 3.5 4.9 8.4
transmitted diseases in young people through educational
43 5.6 9.9
Rural programmes dealing with responsible sexual behaviour is a
3. Schooling major public health challenge. Adolescents are ambivalent
No schooling 20 5.3 7.3 about family planning : to request contraception is to “reveal”
<5 years complete 2.4 4.9 7.2 one’s sexuality. For this reason, adolescent girls sometimes
5-7 years complete 2.9 5.4 8.3 choose the risk of an undesired pregnancy and of an abortion.
8-9 years complete 4.7 5.5 10.3
5.1 9.9 BARRIER METHODS : Condoms make barrier method
10-11 years complete 4.8
6.9 5.6 12.5 worthwhile, because they protect those adolescents, with
12 or more years complete
occasional different sexual partners, against STD and AIDS.
4. Religion However, condoms must be properly used, and it depends
Hindu 3.9 5.2 9.0
on the man’s behaviour. Young men seem to be increasingly

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Muslim 5.0 6.8 11.8
10.4
aware of the importance of safeguarding their own health
Christian 5.5 4.8
9.5
and that of their partners. Cervical caps and diaphragms, on
Sikh 3.5 6.0
82 the other hand, are inappropriate for adolescents since they
Buddhist/Neo-Buddhist 3.9 4.3
7.5 require foreseeing of intercourse and complicated
Jain 4.8 2.7
6.1 10.7 manipulations, to which young people are loath.
Other 4.5
HORMONAL CONTRACEPTION: Hormonal methods are
5. Caste/tribe
4.0 5.2 9.2 perfectly suitable for adolescents, who generally do not suffer
Scheduled caste
4.5 4.7 9.2 from such problems as cardiovascular contraindications. In
Scheduled tribe
4.2 5.4 9.6 fact, these are probably the most adequate methods, since
Other backward class
3.7 5.7 9.4 they are completely reversible, and in no way modify the
Other
5.0 6.9 12.0 future fertility of these young women. In developed countries,
Don’t know pills are usually preferred, but trimestrial or monthly injections
6. Wealth index are also appropriate. Implants, with their five year term, cover
Lowest 4.5 6.9 11.4
too long a period for certain adolescents.
Second 4.1 5.6 9.7
3.9 48 8.6 IUD : IUD are theoretically contraindicated, because of
Middle
4.0 5.0 9.0 the risk of pelvic infection and of secondary sterility.
Fourth
3.7 4.8 86 However, an adolescent is better protected by an IUD than
Highest
by illegal repeated abortions. This method has the advantage
4.0 5.4 9.4 of being discrete and avoiding demanding routines.
Total
OTHER METHODS : Periodic abstinence is not easy
Source : (20) when cycles are irregular and intercourse is unforeseen, and
with new partners. In certain countries, however, they are
“Demand satisfied” by modern contraceptives practically the only method taught, for religious reasons, and
\Demand satisfied’ calculates the need satisfied by modern poor protection is preferable to no protection at all.
methods out of total demand in the community (includes the Similarly, withdrawal is not very suitable method, since
cohort using modern contraceptives and traditional methods, young men are usually not very skillful.
and having unmet need for contraception). India’s ‘demand Spermicides are not contraindicated, but have two
satisfied’ shows an increase from 72 per cent in NFHS-4 to disadvantages - they are costly, and are not effective against
74.2 per cent in NFHS-5 and modern contraceptive usage.
12 states show ‘demand satisfied’ of more than 75 per cent. STD and AIDS.
A major chunk of the world population is under 25 years
Cjhe National Family Health Survey-5 results show that
age group. An extremely large number of young people will,
although current use of contraception has increased, and the
therefore, be entering their reproductive years at that time.
extent of unmet need has declined in most of the states in
The demographic future of the world will depend on them,
India, there is a need for considerable improvement in the
coverage and quality of family planning services, especially in on how well informed they are, and on their sense of
the states of Uttar Pradesh, Bihar, Assam and Jharkhand etc. responsibilities.

by R△J
 DELIVERY SYSTEM 587
DELIVERY SYSTEM In 1979, the offices of the Family Welfare and National
Malaria Eradication Programme were merged into one office
Since family planning is essentially a component of the and named as Regional Office for Health and Family
health care system, the primary responsibility for the Welfare. These regional offices have been set up to maintain
delivery of services rests with the Government through its liaison with state governments and give technical assistance
health care system at the Centre and in the States. to them in connection with the implementation of the Family
At the Centre Welfare Programme and other important health
programmes. To co-ordinate the family welfare
The Family Welfare Programme is a centrally sponsored activities between the state governments and the central
scheme, and the states receive 100 per cent assistance from government, one Family Welfare Cell has been sanctioned
the central government. Since the entire cost is virtually for each State.
borne by the central government, the central government
controls the planning, and financial management of the At the district level
programme (e.g., establishment of clinics, pattern of staffing,
At the district level, the. set-up consists of a District Family
expenditure); training, research and evaluation, and most
Welfare Bureau consisting of 3 divisions - an administrative
important, the formulation of an overall policy for the
division headed by the District Family Welfare Officer; mass
programme. The current policy is to promote family
education and media division, in charge of District Mass
planning on the basis of voluntary and informed acceptance
Education and Media Officer, and an evaluation division, in
with full community participation. The emphasis is on a
2—child family. Recently there have been two major changes charge of a Statistical Officer. These are supported by 1,083
in the approach to delivery of family planning services : first, Urban Family welfare centres and 871 Urban Health Posts.
a greater emphasis on spacing methods, side by side with Presently there are 4 types of Urban Health Posts-type A for
terminal methods, and secondly to take the servicestogvery areas with population less than 5,000, type B for areas with
doorstep and motivate families to adopt the small family population between 5,000-10,000, type C for population
norm./ between 10,000-25,000, and type D for areas with
population between 25,000-50,000. If the population is
The administrative apparatus consists of a separate more than 50,000, then it is to be divided into sectors of
Department of Family Welfare, which was created in 1966 in 50,000 population and Health Posts provided. Type A, B
the Central Ministry of Health and Family Welfare. The and C Health Posts are attached to a hospital for providing

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Secretary to the Government of India in the Ministry of referral and supervisory services. Type D Health Post is
Health and Family Welfare is in over all charge of the attached to a hospital for sterilization, MTP and referral
Department of Family Welfare. He is assisted by a Special (115). Only type D health post have a post of medical
Secretary and Joint Secretaries. The special secretary officer.
supervises the programme implementation and coordinates
the various activities. There is now an Advisor (Mass Media The 10 city family welfare bureaus are entrusted with the
and Communication) - an officer of the rank of an responsibility of coordination, monitoring and supervision
Additional Secretary. The National Institute of Health and etc. of the family welfare services provided by various
Family Welfare acts as an apex technical institute for institutions in the city.
promoting health and family welfare in the country through Presently there are three types of Urban Family Welfare
education, training services, research and evaluation. There Centres. Type I is for population between 10,000-25,000,
is a Central Family Welfare Council consisting of all the State type II is for population between 25,000-50,000, and
Health Ministers to review the implementation of the type III is for above 50,000 population (115). These are
programme. A Population Advisory Council headed by the manned by 2 para-medical staff in type I and II centres and
Union Health Minister, Members of Parliament, and persons by 6 persons including medical officer in type III centres.
from the fields related to population control was set up in
1982. This body acts like a “think tank” to analyze the The Urban family welfare centres and health posts
implementation of the programme and advise the provide comprehensive integrated services of MCH and
government suitably. A cabinet sub-committee headed by family planning. The staff pattern is different for different
the Prime Minister has also been formed for periodic review types of health posts and urban family welfare centres.
of the progress of the family welfare programme. Family
planning is no longer viewed as the sole responsibility of the At the community health centre
Health Ministry, but will devolve on all ministries connected Community health centre is established and maintained
with human resources and development. This is an by the state governments. Presently it is manned by four
important breakthrough in current thinking. medical specialists i.e. surgeon, physician, gynaecologist
and paediatrician, supported by 21 paramedical and other
At the state level staff. It has 30 in-door beds with one OT, X-ray, labour room
Under the Indian constitution, the state governments are and laboratory facilities and serves as a referral centre for
responsible for the administration and implementation of the four PHCs. According to Indian Public Health Standards,
Family Welfare Programme. Since most of the crucial policy the community health centre is to be manned by 6 medical
decisions are made by the central government, the pattern specialists including an anaesthetist and an eye surgeon
of organization and many features of the delivery system are supported by 24 paramedical and other staff with inclusion
fairly well-standardized in the States. of two nurse midwives. It provides, apart from other
The organizational set-up at the State level consists of a emergency obstetric &are, full range of family planning
State Family Welfare Bureau, which is part of the State services including laproscopic services and safe abortion
Health and Family Welfare Directorate. At present, 25 State services. At present as of March 2021, 5,481 community
Family Welfare Bureaus are functioning in the country. health centres are functional\in the country.

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588 DEMOGRAPHY AND FAMILY PLANNING

At the primary health centre deaths can be averted. The focus of the programme is now
Since more than 65 per cent of India’s population lives in towards meeting the unmet need of contraception and
the rural areas an adequate network of service centres has increasing the use of modern contraceptive use, thereby
been extended to the rural areas. A Rural Family Welfare help in averting unintended and mistimed pregnancies,
Centre with a medical officer and supporting staff forms an achieve desired family size, and promote the health of the
mother and child.
integral part of the primary health centre. A total of 5,435
Rural Family Welfare Centres were established in the country Currently the family planning methods in India can be
at all block level PHCs sanctioned upto 1.4.1980. Most of broadly classified in two categories - spacing methods, and
the states have integrated these centres into their primary limiting permanent methods.
health care system and after this date family planning
services are being provided through integrated facilities at (A) Spacing methods/These are reversible methods which
PHCs. As of March 2021, 25,140 primary health centres can be adopted and discontinued as per an individual's
were functioning in the country. Each centre is supported by choice,
sub-centres. The total number of sub-centres functioning are (a) Oral contraceptives pills (combined oral
1,56,101. contraceptive pill (Mala N), Centchroman (Chhaya)
When fully staffed (by 3 medical officers including one (b) Condoms
lady doctor and supporting personnel) the PHC is expected (c) Intrauterine contraceptive devices (IUCD 380A -
to provide fairly comprehensive “essential health care” effective for 10 years, IUCD 375 - effective for
including family planning care. The medical officers are 5 years)
usually trained to provide MTP and sterilization services.
The programme of insertion of copper-T ILJDs has been (d) Contraceptive injectable MPA (Antara programme)
intensified. It is intended that laparoscopic services which (B) Permanent method zThese methods are irreversible in
have become very popular will be made more widely nature
available at the PHC.
(a) Female sterilization
The sub-centres are to provide the main thrust of the
programme. Each sub-centre is staffed by one male and one i. Minilap
female health worker. They are responsible for providing ii. Laparoscopic

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rudimentary health and MCH care; family planning (b) Male sterilization
motivation, supplies and services in spacing methods.
i. Conventional
Various studies conducted have highlighted that the
ii. Non scalpel vasectomy (no incision no stitches)
existing infrastructure is not being optimally utilized because
of its inadequacy to provide proper services. To improve (C) Emergency contraceptive pills
matters popular committees have been set up at all
During the year 2020-2021 the number of acceptors by
levels by some states to involve people in the programme
different methods was as follows (116):
and in exercising vigilance over the work of various
functionaries. Sterilization 26.8 lakh
Total IUCD 54.72 lakh
At the village level Post-partum IUCD 27.43 lakh
Two schemes are being implemented at the village level Injectable MPA 18.81 lakh
to improve the outreach of services and increase local
participation: (a) The Village Health Guides : An Centchroman 57.11 lakh
innovative approach has been the creation of a band of Post-abortion IUCD 80,165
village Health Guides (mostly women), one for each village
or a population of 1000. They are made responsible for Performance of social marketing programme in the sale
spreading knowledge and information to the eligible couples of contraceptives was :
and providing them with supplies of Nirodh and oral Condoms .... 459.51 million
pills. About 3.23 lakh health guides are in position, Oral pills ... 159.19 million cycles
(b) Trained dais : The national target is to provide one
trained dai per 1000 population. They conduct safe Saheli .... 77.52 lakh tablets
deliveries in rural areas. They also act as family planning
counsellors and motivators, supplementing the delivery New initiatives (117)
system, (c) ASHA : 9.39 lakh ASHAs have been selected so 1 Home Delivery of Contraceptives (HDC)
far and have been provided with drug kits. At present the a. A new scheme has been launched to utilize the
village health guides in some states only, trained dais and services of ASHA to deliver contraceptives at the
ASHAs are the lynchpins of the family planning delivery doorstep of beneficiaries. The scheme was launched
system in India. in 233 pilot districts of 17 States on 11th July 2011
Family planning has a significant role in mitigating the and is now expanded to the entire country from
impact of high population growth by helping women achieve 17th December 2012.
desired family size and avoid unintended and mistimed b. ASHA is charging a nominal amount from
pregnancies. Past few years have seen a paradigm shift in beneficiaries for her effort to deliver contraceptives at
family planning programme. Studies show that if the current doorstep i.e. Rs. 1 for a pack of 3 condoms. Rs.l for a
unmet need for family planning could be fulfilled over the cycle of OCPs and Rs. 2 for a pack of one tablet of
next 5 years, 35,000 maternal deaths and 1.2 million infant ECP.

by R△J
 DELIVERY SYSTEM 589
2. Ensuring spacing at birth (ESB) launched under NRHM in 2008 across the country. The
a. Under a new scheme launched by the Government of PTKs are being made available at sub-centres and to the
India, services of ASHAs to be utilized for counselling ASHAs to facilitate the early detection and decision making
newly ^arrj^Touplesl6~ensure spacing of 2~years for the outcomes of pregnaney.
after marriage and couples with 1 child to have 4. Mission Parivar Vikas (MPV)
spacing of 3 years after the birth of'TsFchitd. The A programme launched in 146 high total fertility rate
scheme” is operational in 18 States (EAG, North- districts to accelerate the use and awareness of family
Eastern and Gujarat and Haryana). ASHA would be planning methods. States and districts’ fact sheet highlight
paid following incentives under the scheme : the current indicators and trends in these districts and will
- Rs. 50-QZ- to ASHA for delaying first child birth by act as baseline and roadmap for future work in these
2 years after marriage. districts, A five pronged strategy has been developed under
- Rs. 500/- to ASHA for ensuring spacing of 3 years the mission parivar vikas. which comprise of (9):
after the birth of 1st child. a. Delivering assured services;
- Rs. 1000/- in case the couple opts for a permanent b. Building additional capacity/human resources
limiting method upto 2 children only. development for enhanced service delivery;
b. Ministry of Health & Family Welfare has introduced c. Ensuring commodity security;
short term IUCD (5 years effectively), Cu IUCD 375 d. Implementing new promotional schemes; and
under the National Family Planning programme.
Training of State level trainers has already been e. Creating an enabling environment.
completed and process is underway to train service 5. New contraceptive launch (9)
providers upto the sub-centre level.
The new contraceptive injectable MPA under “Antara
c. A new method of IUCD insertion (post-partum IUCD programme” and oral contraceptive pill centchmman
insertion) has been introduced by the Government. “chhaya^T have been added to the existing contraceptive
dCPromoting Post-partum Family Planning services at basket of choice thus providing the users with new options.
district hospitals by providing for placement of (The public sector provides a wide range of contraceptive
dedicated Family Planning Counsellors and training of

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services for limiting and spacing of births at various levels of
personnej.__ ) health system as described in Table 24.
3. Pregnancy Testing Kits t Government of India is promoting “Fixed Day Static
\Nischav-Home based pregnancy test kits (PTKs) was Services” (FDSJ approach in sterilization services within the

TABLE 24
Family planning services in public health sector
—
Family planning Service provider Service location Service strategy and
method promotional schemes

Spacing Methods
IUCD 380 A/IUCD 375 Trained & certified ANMs, LHVs, Sub-centre & higher levels • On demand
SNs and Doctors • Camp approach
• Revised Compensation Scheme
Oral contraceptive Trained ASHAs, ANMs, LHVs, At door step (in pilot • On demand
pills (OCPs) SNs and Doctors districts), Village level • Village Health Nutrition Days
Sub-centre & higher levels
Condoms Trained ASHAs, ANMs, LHVs, At door step (in pilot • On demand
SNs and Doctors districts), Village level • Village Health Nutrition Days
Sub-centre & higher levels
Injectable Trained doctors, SNs and ANMs Medical colleges and district
contraceptive MPA hospitals (in MPV districts
at all levels upto sub-centres)
Limiting Methods
Minilap Trained & certified MBBS PHC & higher levels • Fixed Day Static Approach
Doctors & Specialist Doctors • Camp approach
• Revised Compensation Scheme
Laparoscopic Trained & certified Specialist Doctors Usually CHC & higher levels • National Family Planning
sterilization (OBG & General Surgeons) Insurance Scheme
NSV (No Scalpel Trained & certified MBBS PHC & higher levels
Vasectomy) Doctors & Specialist Doctors
Emergency
Contraception
Emergency Trained ASHAs, ANMs, LHVs, At door step (in pilot • On demand
contraceptive pills SNs and Doctors districts) Village level, ♦ Village Health Nutrition Days
(ECPs) Sub-centre & higher levels

ANM : Auxiliary Nurse Midwife; LHV : Lady Health Visitor; SN : Staff Nurse; ASHA : Accredited Social Health Activist.
Source : (9)

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 •:c-

DEMOGRAPHY AND FAMILY PLANNING

public health system with the aim of increasing access to Involvement of private sector
sterilization services. States are being provided technical and The family planning programme, to be successful, will
financial support for the development of human resources have to be extended beyond the government delivery
and upgradation of health facilities for the functioning of
system to include the private sector. Grants-in-aid are
FDS. In the states with high unmet need for limiting methods,
provided to voluntary organizations and industrial
sterilization camps will continue till the time FDS is
organizations for running family welfare centres and
implemented effectively. The frequency of sterilization
services at different health facilities at FDS is as follows (98) : postpartum centres. The scheme for involvement of private
medical practitioners in the family welfare programme has
District hospital - twice a week been extended to practitioners of integrated medicine.
Sub-district hospital - weekly Government has also created nation-wide retail outlets for
selling subsidized condoms.
CHC/Block PHC - fortnightly
24x7 PHC/PHC - monthly Incentives
The use of incentives and disincentives to encourage
Community Needs Assessment Approach (118) couples to practise family planning has become a common
Till recently, the achievements of family welfare strategy in many developing countries. Financial
programme were assessed on the basis of the targets given compensation of individuals undergoing sterilization was
from the centre for individual contraceptives. This led to a first introduced in 1966; over the years, it has been
situation where the achievement of the contraceptive targets gradually increased. The acceptors now receive a one-time
had become the ends by themselves. Over the years it payment as shown in Table 25 (9):
became apparent that there were many drawbacks in the top
down target approach in which types and quantity of National Family Planning Indemnity Scheme
contraceptive need to be canvassed was decided by the (NFPIS)
higher authorities. Firstly, the user preference was not
reflected in the targets. If the contraceptive required in With effect from, 01.04.2013, it. has been decided that
accordance with the user was not available, the targets were States/UTs would process and make payment of claims to
not likely to be achieved. There was no authentic system of accepters of sterilization in the event of death/failures/

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feedback regarding which type of contraceptive was to be complications/indemnity cover to doctors/health facilities.
promoted in a particular area or among a particular age The States/UTs would make suitable budget provisions for
group. Secondly, the quality of the services became implementation of the scheme through their respective
secondary. For example, if in an attempt to fulfil targets for State/UT Programme Implementation Plans (PIPs) under the
the number of IUD insertions, the quality of care is National Rural Health Mission (NRHM) and the scheme is
compromised (especially while screening women for pre­ renamed as “Family Planning Indemnity Scheme”.
existing reproductive tract infections and sexually
transmitted diseases before IUD insertion) the acceptability Claims arising out of Amount (Rs.)
of IUD programme would receive a serious setback and sterilization operation
discontinuation rate will be high. Thirdly, people may be
tempted to resort to false reporting to claim fulfilment of the A Death at hospital/within seven 2,00,000
target. In other words, contraceptive targets and cash days of discharge
incentives resulted in the inflation of performance statistics B Death following sterilization 50,000
and deterioration in the quality of services. (8th-30th day from discharge)
Government of India deliberated objectively on the utility C Expense for treatment of 25,000
of retaining the practice of targets at national and state medical complications
levels. In the year 1995-96, one district in each of 18 states D Failure of Sterilization 30,000
(including a pilot project in Kerala and Tamil Nadu) were E Doctors/facilities covered for 2,00,000
made target free. Later on the practice of fixing up of targets litigations upto 4 cases per year (per case)
for individual contraceptive method was given up from April including defence cost
1996. This does not mean a licence to do no work. The
population goals remain the same as before. Health workers State government employees, who undergo sterilization
are expected to consult families and local community in the after two or three children are eligible for a special increment
beginning of the year in order to assess their needs and
(two increments after 2 children and one after 3 children).
preference and then work-out for themselves the programme
and workload for the coming year. The requirement for Central government employees get one increment after
each village needs to be worked out to arrive at sterilization. It is under the scheme introduced in Dec. 1979
the workload for the ANM, this becomes the target for the to promote small family norm, provided the employee is
ANM for the year. The workload of different ANMs under below 50 years of age and his spouse below 45 years. They
one PHC when added up would determine the workload get special leave (14 days for women and 7 days for men).
for the PHC. Similarly requirements at the district level No maternity leave is allowed after 3 children.
would be worked out by adding up the requirements at all The State Governments have been requested to : issue
the PHCs. Green Cards to individual acceptors of terminal methods
Later on it was found that due to complex calculations after two children as a mark of recognition and for priority
required the health workers were unable to fix the attention in schemes where preferential treatment was
performance norms for themselves. Therefore, it was feasible. Cash awards have been instituted for the best
decided to modify and rename the target free manual as performing states, the amount of which will be spent on
Community Needs Assessment Approach Manual. promoting family welfare activities (119).
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 DELIVERY SYSTEM 591
TABLE 25
Compensation scheme in public facilities and private accredited facilities
Compensation scheme in public facilities (Amount in Rs.)

Compensation scheme in private accredited facilities (Amount in Rs.)

States Type of operation Facility Others/Acceptor Total

11 High focus states (Uttar Pradesh, Bihar,

Vasectomy (All) 2000 1000 3000
Madhya Pradesh, Rajasthan, Chhattisgarh, Jharkhand,
Tubectomy (All) 2000 1000 3000
Odisha, Uttrakhand, Assam, Haryana, Gujarat)

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Vasectomy (All) 2500 1000 3500
Mission Parivar Vikas Districts Tubectomy (All) 2500 1000 3500
Post Partum Sterilization (PPS) 3000 1000 4000
Other High focus states Vasectomy (All) 1300 200 1500
(North-East States, J&K, Himachal Pradesh) Tubectomy (All) 1350 150 1500
Vasectomy (All) 1300 200 1500
Non-high focus states
Tubectomy (All) 1350 150 1500

Source: (9)

Family welfare linked health insurance was introduced in 1969. It is a hospital-based, maternity
scheme (98) centred approach to family planning. The primary objective
of the postpartum programme is to improve the health of the
Government of India has introduced a family planning
mother and children through MCH and Family Welfare
insurance scheme for acceptors of sterilization and
programme which includes antenatal, neonatal, and
indemnity cover for doctors performing sterilization
postnatal services; immunization services to children and
procedures in both government and accredited private/
mothers; and prophylaxis against anaemia and blindness.
NGO/corporate health facilities. The insurance scheme will
The programme is based on the following rationale :
be operated by the ICICI.
a. That women who have recently delivered are of proven
Compensation in the event of death : fertility, and are at risk to become pregnant again rapidly
In the event of death following sterilization (inclusive of b. At the time of delivery and during the lying-in period, they
death during process of sterilization operation) in hospital or are generally more receptive to adopt one or the other
within 7 days from the date of discharge from the hospital, family planning method.
the compensation available as stated above. The postpartum programme offers necessary facilities to
All the doctors and health facilities rendering family such women. It has proved to be an efficient way of
planning services, conducting such operations shall stand delivering family planning services. The programme now
indemnified against claims arising out of failure of covers 550 medical institutions at national, state and district
sterilization, death or medical complications resulting there­ levels inclusive of 100 medical colleges and 2 post-graduate
from up to a maximum amount of Rs 2 lacs per doctor/ institutions. A scheme of PAP smear test facilities has been
health facility per case. The cover would also include the sanctioned for all medical colleges.
legal costs and actual modality of defending the prosecuted With a view to provide MCH and family welfare services
doctor/ health facility in court, which would be borne by the in rural and semi-urban areas, as well as to improve the
insurance company within certain limits (120). health of mothers and children, the postpartum programme
has been extended to sub-divisional and sub-district
Postpartum Programme (121) hospitals. 1,012 such centres are functioning in the
An All India Hospital Postpartum Programme (AIHPP) country (122).
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 DEMOGRAPHY AND FAMILY PLANNING
59_2
Population education VOLUNTARY ORGANIZATIONS
Population education has been defined as “an Voluntary organizations have played a major role in
educational programme which provides for a study of the population control programmes since the beginning. They
population situation in the community, nation and world are involved in every possible way so as to complement
with the purpose of developing in the students rational and governmental efforts to promote Family Welfare
responsible attitudes and behaviour towards that situation” Programme. Apart from educational and motivational
(121). The content of population education programme is efforts, their activities include running of Family Welfare
influenced by the specific national situation as well as by Centres, post-partum centres, ANM training schools,
political and educational goals (123). population research centres and other innovative projects. c
In the Indian context, the concept of population Some of the well-known voluntary agencies in India are
education is designed to bring home to the students, both at the Family Planning Association of India, the Family
school and university level the consequences of Planning Foundation and the Population Council of India.
uncontrolled population growth; the benefits of a small Others include the Indian Red Cross, the Indian Medical
family norm; the economics, sociology and statistics of Association, Rotary Clubs, Lions Clubs, Citizens Forum,
population growth, its distribution and its relation to the Christian Missionaries and Private Hospitals.
levels of living. At the international level, the International Planned-
Parenthood Federation is the world’s largest private
SOCIOLOGY OF FAMILY PLANNING voluntary organization supporting family planning services
in developing countries. It is an international federation of
independent Family Planning Associations with
The institution of family is as old as man himself. It is the headquarters in London. Others with long experience in this
basic social cell. The need for its discipline has only recently field include the United Nations Fund for Population
dawned because of changing economic, social and cultural Activities (UNFPA), the US Agency for International
patterns in the world - and above all, because of concern of Development (USAID), the Population Council, Ford
what might be called “quality of life” criteria. Sociologists Foundation, the Pathfinder Fund and World Bank besides
and economists have shown that it will be difficult to raise WHO and UNICEF. The international agencies are assisting

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the living standards of the people while population growth in funding family planning research, services, training and
continues unchecked. The gains of the five year information programmes designed to reduce the family size.
developmental plans are being absorbed by the rapidly
growing population for basic consumption, e.g., food, NATIONAL FAMILY WELFARE PROGRAMME
shelter, clothing, education and medical care.
India launched a nation-wide family planning
Attitude surveys have shown that awareness of family programme in 1952, making it the first country in the world
planning is very widespread and over 60 per cent people to do so, though records show that birth control clinics have
have attitudes favourable to restricting or spacing births been functioning in the country since 1930. The early
(29). People are generally in favour of family planning, and beginnings of the programme were modest with the
there is no organized opposition to it. In spite of this, the establishment of a few clinics and distribution of educational
rate of contraceptive use by couples in the developing material, training and research. During the Third Five Year
countries is very low, This is the crux of the family planning Plan (1961-66), family planning was declared as “the very
problem. Studies have shown that the population problem is centre of planned development”. The emphasis was shifted
complicated by deep-rooted religious and other beliefs, from the purely “clinic approach” to the more vigorous
attitudes and practices favouring larger families (e.g., strong “extension education approach” for motivating the people
preference for male children). The common beliefs are - that for acceptance of the “small family norm”. The introduction
children are the gift of God; the number of children is of the Lippes Loop in 1965 necessitated a major structural
determined by God; children are a poor man’s wealth; reorganization of the programme, leading to the creation of
children are an asset to which parents can look forward in a separate Department of Family Planning in 1966 in the
periods of dependency caused by old age or misfortune, etc. Ministry of Health. During the years 1966-1969, the
Most of these beliefs stem from ignorance and lack of programme took firmer roots. The family planning
communication. infrastructure (e.g., primary health centres, sub-centres,
urban family planning centres, district and State bureaus)
The problem of family planning is, therefore, essentially was strengthened. During the Fourth Five Year Plan (1969-
the problem of social change. Contraceptive technology is 74), the Government of India gave “top priority” to the
no short cut to the problem. What is more important is to programme. The Programme was made an integral part of
stimulate social changes affecting fertility such as raising the MCH activities of PHCs and their sub-centres. In 1970, an
age of marriage, increasing the status of women, education All India Hospital Postpartum Programme and in 1972, the
and employment opportunities, old age security, compulsory Medical Termination of Pregnancy (MTP) Act were
education of children, accelerating economic changes introduced. During the Fifth Five Year Plan (1975-80) there
designed to increase the per capita income, etc. It is now have been major changes. In April 1976, the country framed
axiomatic that economic development is the best its first “National Population Policy”. The disastrous forcible
contraceptive. The experience of all countries which have sterilization campaign of 1976 led to the Congress defeat in
had a t successful population control show that the best the 1977 election. In June 1977, the new (Janata)
motivation is economic, a desire to improve standard of Government that came into power formulated a new
living. The solution to the problem is one of mass education population policy, ruling out compulsion and coercion for all
and communication, so that people may understand the times to come. The Ministry of Family Planning was
benefits of a small family. renamed “Family Welfare”.
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 NATIONAL FAMILY WELFARE PROGRAMME 593
Although the performance of the programme was low Action Plan (INAP) came with the goal to attain single digit
during 1977-78, it was a good year in as much as the neonatal mortality rate by 2030 and single digit stillbirth rate
programme moved into new healthier directions. The 42nd by 2030. In the year 2017, National Health Policy was
Amendment of the Constitution has made “Population launched.
control and Family Planning” a concurrent subject, and this Table . 26 shows the achievements of the Health and
provision has been made effective from January 1977. The Family Welfare Programme.
acceptance of the programme is now purely on voluntary
basis. The launching of the Rural Health Scheme in 1977 TABLE 26
and the involvement of the local people (e.g., Health Achievements of Health & Family Welfare Programme
Guides, trained Dais, Opinion leaders) in the family welfare
programme at the grass-root level were aimed at
accelerating the pace of progress of the programme. India
was a signatory to the Alma Ata Declaration in 1978. The
acceptance of the primary health care approach to the
achievement of HFA/2000 AD led to the formulation of a
National Health Policy in 1982. The National Health Policy
was approved by the Parliament in 1983. It laid down the
long-term demographic goal of NRR=1 by the year 2000 -
which implies a 2—child family norm - through the
attainment of a birth rate of 21 and a death rate of 9 per
thousand population, and a couple protection rate of 60 per
cent by the year 2000. The Sixth and Seventh Five Year
Plans were accordingly set to achieve these goals. The
National Health Policy also called for restructuring the
health care delivery system to achieve HFA/2000 AD, and
family planning has been accorded a central place in health
development.

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The Universal Immunization Programme aimed at
reduction in mortality and morbidity among infants and Source : (116)
younger children due to vaccine preventable diseases was
started in the year 1985-86. The oral rehydration therapy EVALUATION OF FAMILY PLANNING
was also started in view of the fact that diarrhoea was a
leading cause of death among children. Various other Evaluation is defined as a “process of making judgements
programmes under MCH were also implemented during the about selected objectives and events by comparing them
Seventh Five Year Plan. The objective of all these with specified value standards for the purpose of deciding
programmes were convergent and aimed at improving the alternative course of action”. The purpose of evaluation is to
health of the mothers and young children, and to provide improve the design and delivery of family planning services.
them facilities for prevention and treatment of major Five types of evaluation have been defined by a WHO
diseases. During 1992 these programmes were integrated Expert Committee in 1975 (32) on evaluation of family
under Child Survival and Safe Motherhood (CSSM) planning in health services :
Programme.
The process of integration of related programmes 1. Evaluation of need
initiated was taken a step further during 1994 when the That is, health, demographic and socio-economic needs
International Conference on Population and Development for family planning. For example, the current status of
in Cairo recommended implementation of Unified maternal mortality in a given area is an indicator of the need
Reproductive and Child Health Programme (RCH). It is for family planning.
obviously sensible that integrated RCH programme would
help in reducing cost of inputs to some extent because 2. Evaluation of plans
overlapping of expenditure would no longer be necessary That is, an assessment of the feasibility and adequacy of
and outcome will be better. Accordingly, during Ninth Five programme plans.
Year Plan the RCH Programme integrates all the related
programmes of the Eighth Five Year Plan. The concept of 3. Evaluation of performance
RCH is to provide need based, client oriented, demand (a) Services : Clinic services, mobile services, post­
driven, high quality integrated services. partum services, contraceptive distribution, follow
The Government of India evolved a more detailed up services, education and motivation activities;
and comprehensive National Population Policy 2000 (see (b) Response : Number of new acceptors, characteristics
page 568) to promote family welfare. of acceptors;
In the year 2005 Govt, of India launched National Rural (c) Cost analysis; and
Health Mission, initially for seven years (2005-2012) which
was extended for 5 years up to 2017. Then came National (d) Other activities : Administration, manpower, data
Urban Health Plan and merging both these plans as system, etc.
National Health Mission. In the year 2013, RMNCH+A
strategy was launched which was based on a continuum of 4. Evaluation of effects
care approach and defines integrated packages of services Changes in knowledge, attitudes, motivation and
for different stages of life. In the year 2014, India Newborn behaviour.
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jggggl DEMOGRAPHY AND FAMILY PLANNING

5. Evaluation of impact 28. WHO (1971). Tech. Rep. Ser., No. 476.
29. Department of Medical and Public Affairs. The George Washington
A WHO Study Group in 1976 (125) proposed the University Medical Centre, Washington DC (1974). Population
following indices for evaluating the impact : (a) Family size Reports, No. 1974.
(number of living children (b) desired number of additional 30. United Nations (1975). World Conference of the International
children (c) birth interval (d) age of the mother at birth of Women’s Year : World Plan of Action, Document E/Cof.66/5, 1975,
first child and last child (e) birth order, and (f) number of UN Secretariat.
31. WHO (1970). Techn. Rep. Ser., No.442.
abortions. To this may be added, changes in birth rate and
32. WHO (1975). Techn. Rep. Ser., No.569.
growth rate.
33. Siegel, E. et al (1974). Am. J. Ohs & Gyn, 118 : 995.
Evaluation is a technical activity that requires trained 34. Mukerji, S. (1987). J. Family Welfare, 33 (3) 14.
personnel, statistical facilities and adequate flow of data and 35. Mohan, M. (1985). J. Family Welfare, 31 (3) 3-12.
information. 36. Govt, of India (2000). National Population Policy 2000, Ministry of
Health and Family Welfare, New Delhi
The Family Welfare Programme in India has come a long
37. Skrine, R. (1984). The Practitioner, 229 : 441-446.
way and holds forth the promise that in the not very distant
38. Dalsimer, I. et al, eds (1973). Barrier Methods, Population Report
future it may be accepted as a way of life by most people. Series H : I.
Although birth control continues to occupy the same 39. Sherris, J.D. ed (1982). Barrier Methods, Population Report Series
important position in the programme as it used to be in the H:6.
earlier days the programme now aims at achieving a higher 40. WHO, USAID (1997). The Essentials of Contraceptive Technology,
end - and that is, to improve, in conjunction with Population Information programme. Ed. by Robert A. Hatcher et al.
other development programmes, the quality of life of the 41. Leon Speroff and Philip D. Darney, A Clinical Guide for
people (124). Contraception, 3rd Ed.
42. Hofmann, A.D. (1984). Bull WHO, 2 (2) 331-344.
References 43. Clive Wood (1975). Contraception Explained, Geneva, WHO.
44. Belsky Raymond, ed (1975). Barrier Methods, George Washington
1. International Planned Parenthood Federation (1981). People University Medical Centre (Population Report Series B : 3),
8 (2) 26. Washington, DC.
2. Macrotrends.net, World Population 1950-2022. 45. Hawkins, D.F. and Elder M.G. (1979). Human Fertility Control :
3. World Population review 2022, 2022 World Population by country. Theory and Practice, Butterworth, London.
4. Bogue, D.N. (1969). Principles of Demography, John Wiley. 46. WHO (1983). Offset Publication, No.75.

telegram-@Cherry_2412
5. UNO (2019), World Population Prospects, 2019, Highlights. 47. Zipper, J.A. et al (1969). Am. J. OBG, 105 :1275.
6. Govt, of India (2012). Census 2011, Provisional Population Report, 48. Gray, R.H. et al (1980). Manual for the Provision of IUDs, WHO,
Office of the Registrar General and Census Commissioner India, Geneva.
Ministry of Home Affairs, March 31st, 2011. 49. Liskin, L. ed (1982). Intra-Uterine Devices, The John Hopkins
7. Govt, of India (2019). Sample Registration System Statistical University (Population Report Series B : 4).
Report 2018, Office of the Registrar General and Census 50. WHO (1971). Techn. Rep. Ser., No.473.
Commissioner India, Ministry of Home Affairs, New Delhi.
51. Hutchings, J.E. et al (1985). International Family Planning
8. Govt, of India (2020), Population projections for India and States Perspectives, 11 (3) 77-85.
2011-2036, Report of the Technical Group on Population
Projections, July, 2020. 52. WHO (1966). Techn. Rep. Ser., No.322.
9. Govt, of India (2020), Annual Report, 2019-20, Ministry of Health 53. WHO (1968). Techn. Rep. Ser., No.397.
and Family welfare, New Delhi. 54. Vassey, M. et al (1982). Lancet, 1 : 841.
10. Govt, of India (2022), SRS Report for year 2020, Ministry of Home 55. Eschenbach, D.A. et al (1977). Am. J. OBG, 128 (8) 838.
Affairs, New Delhi. 56. Sparks, R.A. etal (1981). Brit. Med. J., 282 : 1189-91.
11. Population Pyramid, National Geographic Society, 2020. 57. Padma Rao, K. (1972). J. OBG of India, 22 : 268.
12. WHO (2020), State of World’s Population, 2020, Against my WILL 58. Snowden R. et al (1977). The IUD, A Practice Guide Croom Helm,
defying the practice that harm women and girls and undermine London.
equality. 59. V. Wynn, et al (1979). Lancet, 1 : 1045.
13. WHO (2008). Health Situation in the South-East Asia Region 2001- 60. Spellacy, W.N. (1982). Am. J. OBG, 142 : 717.
2007. 61. McEwan, J. (1985). The Practitioner, 229 : 415-423.
14. India Demographic’s, Population of India, 2020. 62. People (1983). 10(3)30.
15. Bhende, Asha A and Kanitkar, T. (1985). Principles of Population
63. WHO (1982). Offset Publication, No.64.
Studies, Himalaya Publ. House, Mumbai.
64. Ericsson, R. (1974). Control of Male Fertility, Harper and Row,
16. UNICEF (2009). State of the World’s Children 2009, Special Edition.
Hagerstown.
17. UNO (2020), Countries in the world by population, 2020.
65. Royal College of General practitioners (1974). Oral Contraceptives
18. Govt, of India (2011). Census of India 2011, Provisional Population and Health, London, Pitman Medical.
Totals, Paper - 1 of 2011.
66. Inman, W.H.W. and Vessey, M.P (1968). Brit. Med. J. 2 : 193.
19. Population Reference Bureau (2020), Population Data Sheet.
67. Mann, J.I. and Inman, WHW (1975). 2 : 245.
20. National Family Health Survey NFHS 5 India 2019-21, International
Institute for Population Sciences, Mumbai, India MEASURE DHS + 68. Vassey, M. et al (1976). Jr. Biosocial Science, 8 : 373.
ORC & MACRO. 69. Vassey, M. and Mann J.I. (1978). Br. Med. Bull, 34 : 157.
21. Agarwala, S.N. (1977). India’s Population Problems, 2nd Ed., Tata 70. Stradel, B.V. (1981). New Eng. J. Med., 305 : 612-618.
Me Graw Hill. 71. Kols, A. et al (1982). Oral Contraceptives, The Johns Hopkins
22. Last, J.M. (1983). A Dictionary of Epidemiology, Oxford Medical University (Population-Report Series A : 6).
Publications. 72. WHO (1978). Techn. Rep. Ser., No.619.
23. The John Hopkins University (1985). Population Reports, M.8, Sept- 73. WHO (1974). The Work of WHO, 1982-83.
Oct. 85, Baltimore, Maryland. 74. Knopp, R.H. et al (1982). Am. J. OBG, 142 : 725.
24. World Bank (1987). World Development Report, 1987, Oxford 75. Kay, C.R. (1982). Am. J. OBG, 142 : 762-765.
University Press, New Delhi. 76. Hull, M.G.R. et al (1981). Lancet, 1 : 1329.
25. John M. Last (2001). A Dictionary of Epidemiology, 4th ed. 77. WHO (1981). Techn. Rep. Ser., No. 657.
26. International Family Planning Perspectives (1983). 9 (3) 84, New 78. Ambani, L.M. et al (1977). Fertility and Sterility, 28 : 791.
York, USA.
79. Mishall, D.R. (1982). Am.J.OBG, 142 : 809.
27. WHO (1971). Techn. Rep. Ser., No. 483.

by R△J
 REFERENCES 595
80. Any Questions (1970). Brit. Med. J., 1 : 354. 106. Govt, of India (1984). Year Book—Family Welfare Programme in
81. Info Reports (2007). Injectable Contraceptives : Tool for Providers, India, 1983-84, Ministry of Health, New Delhi.
Jan-Feb, 2007, Johns Hopkins Bloomberg, Info Project centre for 107. Bhiwandiwala, R (1981). People 8 (4) 14.
communication programme. 108. Govt, of India (1978). Central Calling, March 1978. Dept, of Family
82. WHO (1982). Offset Publication No.65. Welfare.
83. IPPF Medical Bulletin (1996). Vol. 30, Number 2, April 1996. 109. Govt, of India (1978). Central Calling, Aug. 78, Dept, of Family
84. Fathalla, M. (1981). People, 8 (4) 12. Welfare.
85. WHO (1978). The Work of WHO 1976-77, Biennial Report. 110. Elstein, M. (1970). The Practitioner, 205 : 30.
86. Govt, of India (2021). Reference Manual for Integrated RMNCAH+N 111. Kanti Giri (1976). Bibliography on Human Reproduction, Family
Counselling, Ministry of Health and Family Welfare, New Delhi. Planning and Population Dynamics, WHO, SEARO New Delhi.
87. Robinson, P. (1975). An Aid to the Teaching of Human Reproduction, 112. Philip, T. et al (1984). Brit. Med. J. 289 : 77A9.
Family Planning and Population Dynamics, WHO, SEARO, New Delhi. 113. France Donnay (1991). Children in the Tropics, Controlling Fertility,
88. International Planned Parenthood Federation (1974). IPPF Medical 1991 No. 193-194.
Bulletin, Feb 1974. 114. P&P (1997). Population Report, Meeting Unmet Needs; New
89. Vlugt, T. et al (1973). Pregnancy Termination, The George Strategies, No. 43, Series J, June 1997.
Washington University (Population Report Series F : 3). 115. WHO (2014). Adolescent: Health Risks and Solutions, Fact Sheet
90. WHO (2021). Fact Sheet on Abortion, 25th Nov. 2021. No. 345, May 2014.
91. WHO (2018). Preventing unsafe abortions, 19th Feb. 2018. 116. Govt, of India (2022). Annual Report 2021 -2022, Ministry of Heatlh
92. Govt, of India (2012). Annual Report 2011-2012, Ministry of Health and Family Welfare, New Delhi.
and Family Welfare, New Delhi. 117. Govt, of India (2014). Annual Report 2013-14, Ministry of Health
93. WHO (1980). The Work of WHO 1978-79. and Family Welfare, New Delhi.
94. Govt, of India (1978). Manual for Health Worker, Female, Vol I, 118. Govt, of India (1985). Annual Report, 1984-85, Ministry of Health
Ministry of Health & Family welfare, New Delhi. and Family Welfare, New Delhi.
95. Grewal, S. (1976). J. Indian M.A., 66 : 269. 119. Veena Soni (1983). International Family Planning Perspectives,
96. Cook, R.J. (1976). IFPP Bulletin, April 1966. 9(2)35.
97. A New direction for Abortion Law in India, Courts have promises to 120. Govt, of India (2006). Annual Report 2005-06, DGHS, Ministry of
keep, 3rd Oct. 2022. Health and Family Welfare, New Delhi.
98. Govt, of India (2010). Annual Report 2009-2010, Ministry of Health 121. UNESCO. Regional Office for Education in Asia (1979). Regional
and Family Welfare, New Delhi. Workshop on Population and Family Education, Final Report, Sept/
99. Peel, John and Potts Malcom (1970). Textbook of Contraceptive Oct 1970, Bangkok, Thailand.
Practice, Cambridge University Press. 122. Govt, of India (2002). Bulletin on Rural Health Statistics in India,

telegram-@Cherry_2412
100. People (1981). 8 (4) 20. March 2002, Issued by Rural Health Division, DGHS, New Delhi.
101. People (1982). 9 (2) 47. 123. Sherris, J.D. (1982). Population Education in the Schools, The Johns
102. Population Reports (J) (1981). 24 : 525. Hopkins University, Maryland (Population Rep.Ser. M : 6).
103. Jain, A.K. et al (1981). Stud. Family Plan, 12:79. 124. Govt, of India (2004). Annual Report 2003-2004, Ministry of Health
104. ICMR Bulletin, Dec. 1983. and Family Welfare, New Delhi.
105. People (1982). 9 (2) 41. 125. WHO (1976). Techn. Rep. Ser., No. 587

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 ■■ Preventive Medicine in Obstetrics,
Paediatrics and Geriatrics
“The test of any civilization is the measure of consideration and
care which it gives to its weaker members”

In any community, mothers and children constitute a (2) child health is closely related to maternal health. A healthy
priority group. In sheer numbers, they comprise mofHer brings forth a healthy baby; there is less chance for a
approximately 71.14 per cent of the population of the premature birth, stillbirth or abortion; (3) certain diseases
developing countries. In India, women of the child-bearing and conditions of the mother during pregnancy (e.g., syphilis,
age (15 to 44 years) constitute 52.4 per cent of total female german measles, drug intake) are likely to have their effects
population, and children under 15 years of age about 26.5 upon the foetus; (4) after birth, the child is dependant upon
per cent of the total population. Together they constitute the mother. At least up to the age of 6 to 9 months, the child is
nearly 57.5 per cent of the total population. By virtue of completely dependant on the mother for feeding. The mental
their numbers, mothers and children are the major and social development of the child is also dependant upon
consumers of health services, of whatever form. the mother. If the mother dies, the child’s growth and

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Mothers and children not only constitute a large group, but development are affected (maternal deprivation syndrome):
(5) in the care cycle of women, there are few occasions when
they are also a “vulnerable” or special-risk group. The risk is
connected with child-bearing in the case of women; and service to the child is not simultaneously called for. For
instance, postpartum care is inseparable from neonatal care
growth, development and survival in the case of infants and
and family planning advice; and (6) the mother is also the first
children. Whereas 50 per cent of all deaths in the developed
teacher of the child. It is for these reasons, the mother and
world are occurring among people over 70, the same
child are treated as one unit.
proportion of deaths are occurring among children during the
first five years of life in the developing world. Global Obstetrics, Paediatrics and Preventive and
observations show that in developed regions maternal Social Medicine
mortality ratio averages at 12 per 100,000 live births; in
developing regions the figure is 232 for the same number of In the past, maternal and child health services were
live births (1). From commonly accepted indices, it is evident rather fragmented, and provided piecemeal “personal health
that infant, child and maternal mortality rates are high in services” by different agencies, in different ways and in
many developing countries. Further, much of the sickness and separate clinics. The current trend in many countries is to
deaths among mothers and children is largely preventable. By provide integrated MCH and family planning services as
improving the health of mothers and children, we contribute compact family welfare service. This implies a close
to the health of the general population. These considerations relationship of maternity health to child health, of maternal
have led to the formulation of special health services for and child health to the health of the family; and of family
mothers and children all over the world. health to the general health of the community. In providing
these services, specialists in obstetrics and child health
The problems affecting the health of mother and child are (paediatrics) have joined hands, and are now looking
multifactorial. Despite current efforts, the health of mother and beyond the four walls of hospitals into the community to
child still constitutes one of the most serious health problems meet the health needs of mothers and children aimed at
affecting the community, particularly in the developing positive health. In the process, they have linked themselves
countries. The present strategy is to provide mother and child to preventive and social medicine, and as a result, terms
health services as an integrated package of “essential health such as “social obstetrics”, “preventive paediatrics” and
care”, also known as primary health care which is based on “social paediatrics” have come into vogue.
the principles of equity, intersectoral coordination and
community participation. The primary health care approach OBSTETRICS
combines all elements in the local community necessary to Obstetrics is largely preventive medicine. The aim of
make a positive impact on the health status of the population, obstetrics and preventive medicine is the same, viz. to ensure
including the health of mothers and children. that throughout pregnancy and puerperium, the mother will
have good health and that every pregnancy may culminate in
Mother and child - one unit a healthy mother and a healthy baby. The age-old concept
Mother and child must be considered as one unit. It is that obstetrics is only antenatal, intranatal and postnatal care,
because: (1) during the antenatal period, the foetus is part of and is thus concerned mainly with technical skills, is now
the mother. Theperiod of development of foetus in mother is considered as a very narrow concept, and is being replaced
about 280 days. During this period, the foetus obtains all the by the concept of community obstetrics which combines
building materials and oxygen from the mother’s blood; obstetrical concerns with concepts of primary health care.
by R△J
 PREVENTIVE PAEDIATRICS 597
SOCIAL OBSTETRICS also with the influence of these factors on the organization,
The concept of social obstetrics has gained currency in delivery and utilization of child health care services. In other
recent years. It may be defined as the study of the interplay words, social paediatrics is concerned with the delivery of
of social and environmental factors and human reproduction comprehensive and continuous child health care services
going back to the preconceptional or even premarital period. and to bring these services within the reach of the total
The social and environmental factors which influence human community. Social paediatrics also covers the various social
reproduction are a legion, viz. age at marriage, child bearing, welfare measures - local, national and international - aimed
child spacing, family size fertility patterns, level of education, to meet the total health needs of a child.
economic status, customs and beliefs, role of women in Preventive and social medicine, with its involvement in
society, etc. A study of these factors is an important aspect of total community care, and expertise in epidemiology and in
social obstetrics. The social obstetric problems in India, differ the methodology of collection and utilization of data relating
from the social obstetric problems in the developed to the community and the environment, makes an
countries, because of various differing social, economic, indispensable contribution to social obstetrics and social
cultural and other factors. While accepting the influence of paediatrics in the :
environmental and social factors on human reproduction, 1. collection and interpretation of community statistics,
social obstetrics has yet another dimension, that is the delineating groups “at risk” for special care;
influence of these factors on the organization, delivery and
2. correlation of vital statistics (e.g., maternal and infant
utilization of obstetric services by the community. In other
morbidity and mortality rates, perinatal and child
words, social obstetrics is concerned with the delivery of
mortality rates) with social and biological characteristics
comprehensive maternity and child health care services
such as birth weight, parity, age, stature, employment
including family planning so that they can be brought within
etc. in the elucidation of aetiological relationships;
the reach of the total community (2).
3. study of cultural patterns, beliefs and practices relating
Preventive paediatrics to childbearing and childrearing, knowledge of which
Paediatrics which is synonymous with child health is that might be useful in promoting acceptance and
branch of medical science that deals with the care of utilization of obstetric and paediatric services by the
children from conception to adolescence, in health and community;
disease. Paediatrics is one of the first clinical subjects to link 4. to determine priorities and contribute to the planning
of MCH services and programmes; and

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itself to preventive medicine. Like obstetrics, paediatrics has
a large component of preventive and social medicine. There 5. for evaluating whether MCH services and programmes
is no other discipline so comprehensive as paediatrics that are accomplishing their objectives in terms of their
teaches the value of preventive medicine. Recent years have effectiveness and efficiency.
witnessed further specialization within the broad field of Hitherto, obstetrics, paediatrics and preventive and social
paediatrics viz. preventive paediatrics, social paediatrics, medicine were operating in watertight compartments. The
neonatology, perinatology, developmental paediatrics, emergence of social paediatrics, social obstetrics and their
paediatric surgery; paediatric neurology, and so on. association with preventive and social medicine are certainly
Preventive paediatrics, comprises efforts to avert rather new developments in contemporary medicine. In some
than cure disease and disabilities. It has been broadly divided Universities, a chair of social paediatrics has also been
into antenatal paediatrics and postnatal paediatrics. The aims established. The increasing coming together of these
of preventive paediatrics and preventive medicine are the disciplines augurs well for the provision of comprehensive
same: prevention of disease and promotion of physical, mother and child health care and family planning services as
mental and social well-being of children so that each child a compact family welfare service.
may achieve the genetic potential with which he/she is born.
To achieve these aims, hospitals for children have adopted Maternity cycle
the strategy of “primary health care” to improve child health The stages in maternity cycle are :
care through such activities as growth monitoring, oral (i) Fertilization;
rehydration, nutritional surveillance, promotion of breast­
feeding, immunization, community feeding, regular health (ii) Antenatal or prenatal period;
check-ups, etc. Primary health care with its potential for (iii) Intranatal period;
vastly increased coverage through an integrated system of (iv) Postnatal period; and
service delivery is increasingly looked upon as the best (v) Inter-concepticfnal period.
solution to reach millions of children, especially those who Fertilization takes place in the outer part of the fallopian
are most in need of preventive and curative services. tube. Segmentation of the fertilized ovum begins at once
and proceeds at a rapid rate. The fertilized ovum reaches
Social paediatrics the uterus in 8 to 10 days. Cell division proceeds at a rapid
The challenge of the time is to study child health in rate. By a process of cell division and differentiation, all the
relation to community, to social values and to social policy. organs and tissues of the body are formed. The periods of
This has given rise to the concept of social paediatrics. growth have been divided as follows :
Social paediatrics has been defined as “the application of
the principles of social medicine to paediatrics to obtain a 1. Prenatal period :
more complete understanding of the problems of children in (a) Ovum - 0 to 14 days
order to prevent and treat disease and promote their (b) Embryo - 14 days to 9 weeks
adequate growth and development, through an organized (c) Foetus - 9th week to birth
health structure (3)”. Social paediatrics, like social
obstetrics, covers a wide responsibility. It is concerned not 2. Premature infant - from 28 to 37 weeks
only with the social factors which influence child health but 3. Birth, full term - average 280 days.

by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS____________________

MCH problems mother is exposed to significantly higher risks. Many women

MCH problems cover a broad spectrum. At one extreme, are infected with HIV, hepatitis B, cytomegalo viruses,
the most advanced countries are concerned with problems herpes simplex virus or toxoplasma during pregnancy.
Furthermore, about 2 to 10 per cent pregnant women suffer
such as perinatal problems, congenital malformations,
from asymptomatic bacteriuria.
genetic and certain behavioural problems. At the other
extreme, in developing countries, the primary concern is As far as the baby is concerned, infection may begin with
reduction of maternal and child mortality and morbidity, labour and delivery and increase as the child grows older.
spacing of pregnancies, limitation of family size, prevention Children may be ill with debilitating diarrhoeal, respiratory
of communicable diseases, improvement of nutrition and and skin infections for as much as a third of their first year of
promoting acceptance of health practices. Currently, the life. In some regions, the situation is further aggravated by
main health problems affecting the health of the mother and such chronic infections as malaria and tuberculosis. The
the child in India, as in other developing countries, revolve occurrence of multiple and frequent infections may
round the triad of malnutrition, infection and the precipitate in the children a severe protein-energy
consequences of unregulated fertility (4). Associated with malnutrition and anaemia. When the child becomes ill,
these problems is the scarcity of health and other social traditions, beliefs and taboos enter into play; the indirect
services in vast areas of the country together with poor effect of infections may be more important than the direct
socio-economic conditions. one in traditional societies.
Prevention and treatment of infections in mother and
1. MALNUTRITION children is a major and important part of normal MCH care
Malnutrition is like an iceberg; most people in the activity. It is now widely recognized that children in
developing countries live under the burden of malnutrition. developing areas need to be immunized against nine
Pregnant women, nursing mothers and children are infections - tuberculosis, diphtheria, whooping cough,
particularly vulnerable to the effects of malnutrition. The tetanus, hepatitis B, haemophilus influenza type B,
adverse effects of maternal malnutrition have been well Japanese encephalitis in endemic states, measles and polio.
documented-maternal depletion, low birth weight, Many countries, including India, have adopted the WHO
anaemia, toxemias of pregnancy, postpartum haemorrhage, Expanded Programme on Immunization as part of everyday
all leading to high mortality and morbidity. The effects of MCH care. Tetanus toxoid application during pregnancy has
malnutrition are also frequently more serious during the also been taken up. Education of mothers in medical

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formative years of life. Previously it was thought that measures such as oral rehydration in diarrhoea and febrile
malnutrition was largely concentrated in school age diseases. In addition, a good knowledge and practice of
children, and in toddlers. Now it is realized that the personal hygiene and appropriate sanitation measures,
intrauterine period of life is a very important period from the particularly in and around the home, are essential pre­
nutritional standpoint. Infants born with adequate birth requisites for the control of the most common infections and
weight have relatively low mortality even under poor parasitic diseases.
environmental conditions. The next critical period of
childhood is the period of weaning. Severe malnutrition 3. UNCONTROLLED REPRODUCTION
coincides with the age at which babies are usually weaned. The health hazards for the mother and the child resulting
Susceptibility to infection and severity of illness are from unregulated fertility have been well recognized -
significantly less in well nourished, than in malnourished increased prevalence of low birth weight babies, severe
children. Nutrition protection and promotion is, therefore, anaemia, abortion, antepartum haemorrhage and a high
an essential activity of MCH care. maternal and perinatal mortality, which have shown a sharp
Measures to improve the nutritional status of mothers and rise after the 4th pregnancy. Statistics have shown that in
children may be broadly divided into direct and indirect almost every country in the world, a high birth rate is
nutrition interventions (4). Direct interventions cover a wide associated with a high infant mortality rate and under-five
range of activities, viz. supplementary feeding programmes, death rate (Table 1).
distribution of iron and folic acid tablets, fortification and
enrichment of foods, nutrition education, etc. Indirect TABLE 1
nutrition interventions have still wider ramifications because Selected rates by country for crude birth rates, infant
they are not specifically related to nutrition. These include mortality rates and under-five mortality rates (mid 2020)
measures such as control of communicable diseases through Crude birth IMR per Under-five
immunization, improvement of environmental sanitation, Country rate per 1000 live mortality rate
provision of clean drinking water, family planning, food 1000 population births per 1000 live
hygiene, education and primary health care. Nutritional (mid 2020) (mid 2020) births (2020)
surveillance is becoming increasingly important for India 17 28 33
identifying subclinical malnutrition, as it tends to be Pakistan 27 54 65
overlooked in both the mother and the child. The primary Bangladesh 18 24 29
health worker (community worker) can play a vital role in Thailand 10 7 9
improving the nutritional status of mothers and children. Sri Lanka 15 6 7
China 9 5 7
2. INFECTION Switzerland 10 4 4
UK 10 4 4
Maternal infections may cause a variety of adverse effects USA 11 5 6
such as foetal growth retardation, low birth weight, Singapore 9 2 2
embryopathy, abortion and puerperal sepsis. In industrial Japan 7 2 2
societies, the risk of the mother acquiring infections during
pregnancy is relatively low, but in underdeveloped areas, the Source : (5, 6)

by R△J
 ANTENATAL CARE 599
Because family planning has a striking impact on the (2) To detect “high-risk” cases and give them special
health of the mother and the child, a number of countries attention;
have integrated family planning in the MCH care activities. (3) To foresee complications and prevent them;
The introduction of new types of IUD; easier and safer (4) To remove anxiety and dread associated with
techniques of pregnancy termination and female delivery;
sterilization; oral pills and long-acting injectable medroxy­ (5) To reduce maternal and infant mortality and
progesterone acetate (MPA) have contributed a good deal in morbidity;
the utilization of family planning services. In some countries,
MCH programmes are extending their scope to include (6) To teach the mother elements of child care, nutrition,
family-life education in schools. There is also an increasing personal hygiene, and environmental sanitation;
acceptance of the role of traditional midwives and (7) To sensitize the mother to the need for family
community health workers, with suitable training for the planning, including advice to cases seeking medical
extension of family planning services to remote rural areas. termination of pregnancy; and
(8) To attend to the under-fives accompanying the
Maternal and child health mother.
The term “maternal and child health” refers to the The above objectives are achieved by the following
promotive, preventive, curative and rehabilitative health programme of health care services :
care for mothers and children. It includes the sub-areas of
maternal health, child health, family planning, school health, (1) Antenatal visits
handicapped children, adolescence, and health aspects of Ideally the mother should attend the antenatal clinic once
care of children in special settings such as day care (4). a month during the first 7 months; twice a month, during the
The specific objectives of MCH are (a) reduction of next month; and thereafter, once a week, if everything is
maternal, perinatal, infant and childhood mortality and normal. A high proportion of mothers in India are from
morbidity; (b) promotion of reproductive health; and lower socio-economic group, and many of them are working
(c) promotion of the physical and psychological development women. Attendance at the antenatal clinic may mean loss of
of the child and adolescent within the family. The ultimate daily wages. Consequently, it is difficult for them to attend
objective of MCH services is lifelong health (4). the antenatal clinic so often. In these cases, a minimum of
4 visits covering the entire period of pregnancy should be
Pregnancy detection the target, as shown below :

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The simple way to confirm pregnancy in the first trimester The suggested schedule is as follows (7) :
is to conduct a urine examination using a pregnancy test kit.
The kit detects pregnancy on the basis of presence of human 1st visit - within 12 weeks, preferably as soon as the
pregnancy is suspected, for registration of
chorionic gonadotrophin hormone in the urine. The test is
performed soon after a missed period and is simple to pregnancy and first antenatal check-up.
perform. The pregnancy test should be offered to any 2nd visit - between 14 and 26 weeks.
women who is in reproductive age group and comes with a 3rd visit - between 28 and 34 weeks.
history of amenorrhoea or symptoms of pregnancy. The 4th visit - between 36 weeks and term.
Government of India has made “Nischay” pregnancy test kit
available across the country. Other test kits are also available It is advisable for the woman to visit medical officer at the
in the market. The kit is provided to ASHA or other link PHC for an antenatal check-up during the period of
workers and the women should be advised appropriately on 28-34 weeks (3rd visit). Besides this, she may be advised to
the result of the test (7). avail investigation facilities at the nearest PHC/CHC/FRU.
Registration of pregnancy within 12 weeks is the primary
ANTENATAL CARE responsibility of the ANM. Opportunities such as Village
Health Nutrition Day should be availed to ensure early
Antenatal care (ANC) can be defined as the care provided registration of pregnancy and antenatal check-up.
by skilled health-care professionals to pregnant women and
pregnant adolescent girls in order to ensure the best health Early pregnancy detection is important for the following
conditions for both mother and baby during pregnancy. The reasons (7) :
components of ANC include: risk identification; prevention 1. It facilitates proper planning and allows for adequate
and management of pregnancy-related or concurrent care to be provided during pregnancy for both the
diseases; health education and health promotion (8). ANC mother and the foetus.
reduces maternal and perinatal morbidity and mortality both 2. Record the date of last menstrual period and calculate
directly, through detections, and indirectly, through the the expected date of delivery.
identification of women and girls at increased risk of 3. The health status of the mother can be assessed and any
developing complications during labour and delivery, thus medical illness that she might be suffering from can be
ensuring referral to an appropriate level of care (8). detected. Also to obtain and record the baseline
Ideally this care should begin soon after conception and information on blood pressure, weight, haemoglobin etc.
continue throughout pregnancy. In some countries, 4. It helps in timely detection of complications at an early
notification of pregnancy is required to bring the mother in stage and helps to manage them appropriately by
the prevention care cycle as early as possible. referral as and where required.
Objectives 5. It also helps to confirm if the pregnancy is wanted and if
not, then refer the women at the earliest to a 24 hours
The objectives of antenatal care are ; PHC or FRU that provides safe abortion services. The
(1) To promote, protect and maintain the health of the health personnel should be alert to the possibility of sex
mother during pregnancy; selective abortion as such abortions are illegal.

by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

6. Early detection of pregnancy and provision of care from the regular ANC check-up. An antenatal check-up after a missed
initial stage facilitates a good interpersonal relationship appointment should include all the components of the
between the care giver and the pregnant woman. missed visit(s) as well as those that correspond to the present
visit. For example, the woman should be given her TT
Estimation of number of pregnancies in a specified injection and supply of IFA tablets, her weight and blood
area and pregnancy tracking (7) pressure should be checked besides being screened for
To ensure complete registration, it is essential that the complications.
ANM should know the estimated number of pregnancies to A policy decision has been taken for a name-based
be registered annually in her area. Calculating the expected tracking system whereby pregnant women and children can
number of annual pregnancies in the area will help her judge be tracked for their ANCs and immunization along with a
how good her pregnancy registration is. In case the number feedback system for the ANM, ASHA etc. This has been
of pregnancies registered is less than that of the estimated done to ensure that all pregnant women receive their ANCs
pregnancies, she needs to track down the pregnancies she and PNCs, and children receive full immunization. This will
has missed, with the help of ASHAs and AWWs. Estimating also help in tracking and ensuring ANC/PNC for missed/left
the number of pregnancies will also help her judge whether out cases.
she has an adequate stock of the supplies required to
provide routine ANC (such as TT injections, IFA tablets and PREVENTIVE SERVICES FOR MOTHERS
ANC record forms) and tackle any complications that arise (ANTENATAL CHECK-UP)
during this period.
The first visit, irrespective of when it occurs, should
The number of expected pregnancies per year : include the following components :
The ANM must know the population size and birth rate of I. History-taking
the area under her jurisdiction. The expected number of live During the first visit, a detailed history of the woman
births may be calculated as shown below : needs to be taken to : (1) Confirm the pregnancy (first visit
Birth rate (per population only); (2) Identify whether there were complications during
Expected no. of 1000 population) of the area any previous pregnancy/confinement that may have a
live births bearing on the present one; (3) Identify any current medical/
(Y)/year 1000 surgical or obstetric condition(s) that may complicate the

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As some pregnancies may not result in a live birth (i.e. present pregnancy; (4) Record the date of 1st day of last
abortions and stillbirths may occur), the expected number of menstrual period and calculate the expected date of delivery
live births would be an under-estimation of the total number by adding 9 months and 7 days to the 1st day of last
of pregnancies. Hence, a correction factor of 10% is menstrual period; (5) Record symptoms indicating
required, i.e. add 10% to the figure obtained above. complications, e.g. fever, persisting vomiting, abnormal
So, the total number of expected pregnancies vaginal discharge or bleeding, palpitation, easy fatigability,
breathlessness at rest or on mild exertion, generalized
(Z) = Y + 10%ofY swelling in the body, severe headache and blurring of vision,
As a thumb rule, in any given month, approximately half burning in passing urine, decreased or absent foetal
the number of pregnancies estimated above should be in movements etc; (6) History of any current systemic illness,
records. e.g., hypertension, diabetes, heart disease, tuberculosis,
Example of estimation of the number of pregnancies annually renal disease, epilepsy, asthma, jaundice, malaria,
reproductive tract infection, STD, HIV/AIDS etc. Record
Birth rate = 25/1000 family history of hypertension, diabetes, tuberculosis, and
population
thalassaemia. Family history of twins or congenital
Population under the sub-centre = 5000 malformation; and (7) History of drug allergies and habit
Therefore, expected number of live births = (25x5000)/1000 forming drugs.
= 125 births II. Physical examination
Correction factor (pregnancy wastage) = 10% of 125 1. Pallor : Presence of pallor indicates anaemia. The
= say 13 woman should be examined for pallor at each visit.
Therefore, total no. of expected = 125 + 13 = 138 Examine woman's conjunctiva, nails, tongue, oral
pregnancies in a year mucosa and palms. Pallor should be co-related with
haemoglobin estimation.
In any month, the ANM should have about 69
pregnancies registered with her. 2. Pulse : The normal pulse rate is 60 to 90 beats per
If the number of women registered is less than expected, minute. If the pulse rate is persistently low or high, with
or without other symptoms, the woman needs medical
the ANM should approach community leaders and key
people to ensure that the pregnant women are registered attention.
and come for ANC. ASHA and link worker should visit every 3. Respiratory rate : It is important to check the respiratory
house in the area and ensure that all pregnant women are rate, especially if the woman complaints of
registered. Some women may be receiving ANC from the breathlessness. Normal respiratory rate is 18-20 breaths
private sector. Ensure that their names together with the per minute.
names of the facilities where they are registered are 4. Oedema : Oedema (swelling), which appears in the
mentioned in the antenatal register. evening and disappears in the morning after a full night's
The ANM must keep track of all pregnant women in her sleep, could be a normal manifestation of pregnancy.
area. In case a registered women does not turn-up for her Any oedema of the face, hands, abdominal wall and
ANC check-up, ANM must follow her and counsel her for the vulva is abnormal. Oedema can be suspected if a woman

by R△J
 ANTENATAL CARE 601
complains of abnormal tightening of any rings on her The duration of pregnancy should always be expressed
fingers. She must be referred immediately for further in terms of completed weeks. In the first half of
investigations. If there is oedema in association with high pregnancy the size of the uterus is of the greatest value in
blood pressure, heart disease, anaemia or proteinuria, confirming the calculated duration of pregnancy.
the woman should be referred to the medical officer. 2. Foetal heart sounds : The foetal heart sounds can be
5. Blood pressure : Measure the woman’s blood pressure at heard after 6th month. The rate varies between 120 to
every visit. This is important to rule out hypertensive 140 per minute. They are usually best heard in the
disorders of pregnancy. Hypertension is diagnosed when midline; after the 28th week, their location may change
two consecutive readings taken four hours or more apart because of the position and lie of the foetus.
show the systolic blood pressure to be 140 mmHg or 3. Foetal movements : Foetal movements can be felt by the
more and/or the diastolic blood pressure to be 90 mmHg examiner after 18-22nd week by gently palpating the
or more. High blood pressure during pregnancy may abdomen.
signify Pregnancy-Induced Hypertension (PIH) and/or 4. Foetal parts : These can be felt about the 22nd week.
chronic hypertension. If the woman has high blood After the 28th week, it is possible to distinguish the head,
pressure, check her urine for the presence of albumin. back and limbs.
The presence of albumin (4-2) together with high blood 5. Multiple pregnancy : This must be suspected if the uterus
pressure is sufficient to categorize her as having is larger than the estimated gestational age or palpation
pre-eclampsia. Refer her to the MO immediately. If of multiple foetal parts.
the diastolic blood pressure of the woman is above
110 mmHg, it is a- danger sign that points towards 6. Foetal lie and presentation : Relevant only after 32 weeks
imminent eclampsia. The urine albumin should be of pregnancy.
estimated at the earliest. If it is strongly positive, the 7. Inspection of abdominal scar or any other relevant
woman should be referred to the FRU IMMEDIATELY. If abdominal findings.
the woman has high blood pressure but no urine
albumin, she should be referred to the MO at 24x7 PHC.
A woman with PIH, pre-eclampsia or imminent
eclampsia requires hospitalization and supervised
treatment at a 24-hour PHC/FRU.

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6. Weight : A pregnant woman’s weight should be taken at
each visit. The weight taken during the first visit/
registration should be treated as the baseline weight.
Normally, a woman should gain 9-11 kg during her
pregnancy. Ideally after the first trimester, a pregnant
woman gains around 2 kg every month. If the diet is not
adequate, i.e. if the woman is taking less than the
required amount of calories, she might gain only 5-6 kg
during her pregnancy. An inadequate dietary intake can
be suspected if the woman gains less than 2 kg per
month. She needs to be put on food supplementation. FIG. 1
The help of the AWW should be taken in this matter, Uterine fundal height at various stages of pregnancy
especially for those categories of women who need it the (numbers indicate weeks of pregnancy)
most. Low weight gain usually leads to Intrauterine
Growth Retardation and results in the birth of a baby IV. Assessment of gestational age (9)
with a low birth weight. Excessive weight gain (more
Measurement of gestational age has changed over the
than 3 kg in a month) should raise suspicion of pre-
time. As the dominant effect of gestational age on survival
eclampsia, twins (multiple pregnancy) or diabetes. Take
and long-term impairment has become apparent over the
the woman’s blood pressure and test her urine for
last 30 years, perinatal epidemiology has shifted from
proteinuria and sugar. If the blood pressure is high and
the urine is positive for protein or sugar, refer her to measuring birth weight alone to focusing on gestational age.
medical officer. The most accurate "gold standard” for assessment is routine
early ultrasound assessment together with foetal
7. Breast examination : Observe the size and shape of the measurements ideally in the first trimester. Gestational age
nipples for the presence of inverted or flat nipples. assessment based on the date of last menstrual period (LMP)
III. Abdominal examination was previously the most widespread method used and
remains the only available method in many settings. Many
Examine the abdomen to monitor the progress of the countries now use “best obstetric estimate”, combining
pregnancy and foetal growth. The abdominal examination ultrasound and LMP as an approach to estimate gestational
includes the following : age. It can have a large impact on the number of preterm
1. Measurement of fundal height : Enlargement of the births reported.
uterus and the height of the uterine fundus is as shown Any method using ultrasound requires skilled technicians,
in Fig. 1. equipment and for maximum accuracy, first trimester
a. 12 u/eeks - Uterine fundus just palpable per antenatal clinic attendance. These are not common in low-
abdomen. income settings, where majority of preterm births occur.
b. 20 weeks - Fundus flat at the lower border of Alternative approaches to LMP in these settings include
umbelicus. fundal height, clinical assessment of the newborn after birth
c. 36 weeks - Fundus felt at the level of xiphisternum. or birth weight as a surrogate.
by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

V. Laboratory investigations The “risk approach” is a managerial tool for improved

The following laboratory investigations are carried out at MCH care. Its purpose is to provide better services for all, but
the facilities indicated below : with special attention to those who need them most. Inherent
in this approach is maximum utilization of all resources,
а. At the sub-centre : including some human resources that are not conventionally
- Pregnancy detection test. involved in such care - traditional birth attendants,
- Haemoglobin examination. community health workers, women’s groups, for example.
- Urine test for presence of albumin and sugar. The risk strategy is expected to have far-reaching effects on
- Rapid malaria test. the whole organization of MCH/FP services and lead to
b At the PHC/CHC/FRU : improvements in both the coverage and quality of health
- Blood group, including Rh factor. care, at all levels, particularly at primary health care level.
- VDRL/RPR. MAINTENANCE OF RECORDS
- HIV testing.
A Mother and Child Protection Card should be duly
- Rapid malaria test (if unavailable at SC).
completed for every woman registered. It contains a
- Blood sugar testing.
registration number, identifying data, previous health history
- HBsAg for hepatitis B infection. and main health events etc. The case record should be
Essential components of every antenatal check-up handed over to the woman. She should be instructed to bring
1. Take the patient's history. the record with her during all subsequent check-ups/visits and
also to carry it along with her at time of delivery. This card has
2. Conduct a physical examination-measure the weight,
been developed jointly by the Ministry of Health and Family
blood pressure and respiratory rate and check for pallor
Welfare (MOHFW) and Ministry of Women and Child
and oedema.
Development (MOWCD) to ensure uniformity in record
3. Conduct abdominal palpation for foetal growth, foetal lie keeping. This will also help the service provider to know the
and auscultation of foetal heart sound according to the details of previous ANCs/PNCs both for routine and
stage of pregnancy. emergency care. The information contained in the card
4. Carry out laboratory investigations, such as haemoglobin should also be recorded in the antenatal register as per the
estimation and urine tests for sugar and proteins. Health Management Information System (HMIS) format.

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Interventions and counselling
HOME VISITS
1. Iron and folic acid supplementation and medication as
needed. Home visiting is the backbone of all MCH services. Even if
2. Immunization against tetanus. the expectant mother is attending the antenatal clinic regularly,
it is suggested that she must be paid at least one home visit by
3. Group or individual instruction on nutrition, family
the Health Worker Female or Public Health Nurse. More visits
planning, self care, delivery and parenthood.
are required if the delivery is planned at home. The mother is
4. Home visiting by a female health worker/trained dai. generally relaxed at home. The home visit will win her
5. Referral services, where necessary. confidence. The home visit will provide an opportunity to
б. Inform the woman about Janani Suraksha Yojana and observe the environmental and social conditions at home and
other incentives offered by the government. also an opportunity to give prenatal advice.
RISK APPROACH (10) (2) Prenatal advice
The central purpose of antenatal care is to identify “high A major component of antenatal care is antenatal or
risk” cases (as early as possible) from a large group of prenatal advice. The mother is more receptive to advice
antenatal mothers and arrange for them skilled care, while concerning herself and her baby at this time than at other
continuing to provide appropriate care for all mothers. times. The “talking points” should cover not only the
These cases comprise the following : specific problems of pregnancy and child-birth but overflow
1. Elderly primi (30 years and over). into family and child health care.
2. Short statured primi (140 cm and below). (i) DIET : Reproduction costs energy. A pregnancy in total
3. Malpresentations, viz breech, transverse lie, etc. duration consumes about 60,000 kcal, over and above
4. Antepartum haemorrhage, threatened abortion. normal metabolic requirements. Lactation demands about
5. Pre-eclampsia and eclampsia. 550 kcal a day. Further, child survival is correlated with birth
6. Anaemia. weight. And birth weight is correlated to the weight gain of
7. Twins, hydramnios. the mother during pregnancy. On an average, a normal
healthy woman gains about 9-11 kg of weight during
8. Previous still-birth, intrauterine death, manual
pregnancy. Several studies have indicated that weight
removal of placenta.
gain of poor Indian women averaged 6.5 kg during
9. Elderly grandmultiparas. pregnancy (11). Thus pregnancy imposes the need for
10. Prolonged pregnancy (14 days-after expected date considerable extra calorie and nutrient requirements. If
of delivery). maternal stores of iron are poor (as may happen after
11. History of previous caesarean or instrumental delivery. repeated pregnancies) and if enough iron is not available to
12. Pregnancy associated with general diseases, viz. the mother during pregnancy, it is possible that foetus may
cardiovascular disease, kidney disease, diabetes, lay down insufficient iron stores. Such a baby may show a
tuberculosis, liver disease, malaria, convulsions, normal haemoglobin at birth, but will lack the stores of iron
asthma, HIV, RTI, STI, etc. necessary for rapid growth and increase in blood volume
13. Treatment for infertility. and muscle mass in the first year of life. Stresses in the form
14. Three or more spontaneous consecutive abortions. of malaria and other childhood infections will make the

by R△J
 ANTENATAL CARE 603
deficiency more acute, and many infants become severely addition to congenital malformations such as microcephaly.
anaemic during early months of life. A balanced and The X-ray examination in pregnancy should be carried out
adequate diet is therefore, of utmost importance during only for definite indications, X-ray dosage kept to minimum.
pregnancy and lactation to meet the increased needs of the Furthermore, in all women of child-bearing age among
mother, and to prevent “nutritional stress”. whom there is a possibility of pregnancy, elective X-ray
(ii) PERSONAL HYGIENE : Of equal importance is should be avoided in the two weeks preceeding the
advice regarding personal hygiene, (a) Personal cleanliness : menstrual period.
The need to bathe every day and to wear clean clothes (v) WARNING SIGNS : The mother should be given
should be explained. The hair should also be kept clean and clear-cut instructions that she should report immediately in
tidy, (b) Rest and sleep : 8 hours sleep, and at least 2 hours case of the following warning signals : (a) swelling of the feet
rest after mid-day meals should be advised, (c) Bowels: (b) fits (c) headache (d) blurring of the vision (e) bleeding or
Constipation should be avoided by regular intake of green discharge per vagina, and (f) any other unusual symptoms.
leafy vegetables, fruits and extra fluids. Purgatives like castor (vi) CHILD CARE : The art of child care has to be learnt.
oil should be avoided to relieve constipation, (d) Exercise: Special classes are held for mothers attending antenatal
Light household work is advised, but manual physical labour clinics. Mother-craft education consists of nutrition education,
during late pregnancy may adversely affect the foetus, advice on hygiene and childrearing, cooking demonstrations,
(e) Smoking: Smoking should be cut down to a minimum. family planning education, family budgeting, etc.
Expectant mothers who smoke heavily produce babies much
smaller than the average - it is because nicotine has a (3) Specific health protection
vasoconstrictor influence in the uterus and induces a degree
of placental insufficiency. The adverse effects of smoking (i) ANAEMIA : According to NFHS IV, about 50 per cent of
range from low birth-weight to an increased risk of perinatal pregnant women in India are anaemic. The major aetiological
death of the infant (12). Women who smoke during factors being iron and folic acid deficiencies. It is well known
pregnancy give birth to babies which on an average weigh that anaemia per se is associated with high incidence of
170g less at term than the babies of non-smokers. The premature births, postpartum haemorrhage, puerperal sepsis
perinatal mortality amongst babies whose mothers smoked and thromboembolic phenomena in the mother. The
during pregnancy is between 10-40 per cent higher than in Government of India has initiated a programme in which 100
non-smokers, (f) Alcohol: Evidence is mounting that alcohol mg of elemental iron and 500 mcg of folic acid are being

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can cause a range of fertility problems in women. Moderate distributed daily for 100 days to pregnant women through
to heavy drinkers who became pregnant have greater risk of antenatal clinics, primary health centres and their subcentres.
pregnancy loss (13), and if they do not abort, their children (ii) OTHER NUTRITIONAL DEFICIENCIES : The mother
may have various physical and mental problems (14). should be protected against other nutritional deficiencies
Heavy drinking has been associated with a fetal syndrome that may occur, particularly protein, vitamin and mineral
(FAS) which includes intrauterine growth retardation and especially vit A and iodine deficiency. In some MCH Centres
developmental delay. More recently, it has been shown that fresh milk is supplied free of cost to all expectant mothers;
the consumption of even moderate amount of alcohol where this is not possible, skimmed milk should be given.
during pregnancy is associated with an increased risk of Capsules of vitamin A and D are also supplied free of cost.
spontaneous abortion (15). (g) Dental care: Advice should (iii) ASYMPTOMATIC BACTERIURIA (ASB): Urinary
also be given about oral hygiene, (h) Sexual intercourse: tract infection during pregnancy are associated with risks to
This should be restricted especially during the last trimester. both mother and foetus. It includes pyelonephritis preterm
(iii) DRUGS : The use of drugs that are not absolutely birth, low birth weight and increased perinatal mortality.
essential should be discouraged. Certain drugs taken by the Because of physiological changes during pregnancy, the
mother during pregnancy may affect the foetus adversely pregnant woman is more prone to urinary tract infection.
and cause foetal malformations. The classical example is Midstream urine culture is the recommended method for
thalidomide, a hypnotic drug, which caused deformed diagnosis of ASB. If culture facility is not available on-site,
hands and feet of the babies born. The drug proved most midstream urine gram-staining is recommended for the
serious when taken between 4 to 8 weeks of pregnancy. diagnosis (8). The patient should be appropriately treated
Other examples are LSD which is known to cause for ASB.
chromosomal damage, streptomycin which may cause 8th (iv) GESTATIONAL DIABETES: Hyperglycaemia first
nerve damage and deafness in the foetus, iodide-containing detected at any time during pregnancy should be classified as
preparations which may cause congenital goitre in the either gestational diabetes mellitus or diabetes mellitus in
foetus (16). Corticosteroids may impair foetal growth, sex pregnancy according to WHO criteria. Gestational diabetes
hormones may produce virilism, tetracyclines may affect the is high blood sugar that develops during pregnancy and
growth of bones and enamel formation of teeth. Anaesthetic usually disappears after giving birth. It can occur at any stage
agents including pethidine administered during labour can of pregnancy but is more common in the second half. Having
have depressant effect on the baby and delay the onset of gestational diabetes also means that the woman is at
effective respiration. Later still in the puerperium, if the increased risk of developing type 2 diabetes in the future. At
mother is breast-feeding, there are certain drugs which are the first antenatal visit, family history of diabetes should be
excreted in breast milk. A great deal of caution is required in recorded to determine if the woman is more at risk of
the drug-intake by pregnant women (17). gestational diabetes (8). The general symptoms are excessive
(iv) RADIATION : Exposure to radiation is a positive thirst and hunger, frequent urination, drowsiness or fatigue,
danger to the developing foetus. The most common source dry itchy skin, blurring of vision, slow healing of wounds.
of radiation is abdominal X-ray during pregnancy. Case The second pregnancy may be associated with type 2
cohort studies have shown that mortality rates from diabetes. Hyperglycaemia during pregnancy can harm
leukaemia and other neoplasms were significantly greater mother and the foetus, increasing risk of high blood pressure,
among children exposed to intrauterine X-ray. This is in preeclampsia, miscarriage or stillbirth, birth defects and big

by R△J
604^ PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

baby (birth weight more than 4.5 kg). (ix) Rh STATUS : The foetal red cells may enter the
(v) TOXEMIAS OF PREGNANCY : The presence of maternal circulation in a number of different circumstances,
albumine in urine and an increase in blood pressure during labour, caesarean section, therapeutic abortion,
indicates toxemias of pregnancy. Their early detection and external cephalic version, and apparently spontaneously in
management are indicated. Efficient antenatal care the late pregnancy. The intrusion of these cells, if the mother
minimizes the risk of toxemias of pregnancy. is Rh-negative and the child is Rh-positive, provokes an
immune response in her so that she forms antibodies to Rh
(vi) TETANUS : If the mother was not immunized earlier, which can cross the placenta and produce foetal haemolysis.
2 doses of adsorbed tetanus toxoid should be given - the first The same response may be produced to a greater degree by
dose at 16-20 weeks and the second dose at 20-24 weeks of a transfusion of Rh-positive blood. In a pregnant woman,
pregnancy. The minimum interval between the 2 doses isoimmunization mainly occurs during labour, so that the
should be one month. No pregnant woman should be denied first child although Rh-positive, is unaffected except where
even one dose of tetanus toxoid, if she is seen late in the mother has been already sensitized. In the second or
pregnancy. For a woman who has been immunized earlier, subsequent pregnancies, if the child is Rh-positive, the
one booster dose will be sufficient. When such a booster has mother will react to the smallest intrusion of foetal cells by
been given, it will provide necessary cover for subsequent producing antibodies to destroy foetal blood cells causing
pregnancies, during the next 5 years. It is advised not to haemolytic disease in the foetus. Clinically haemolytic
inject tetanus toxoid at every successive pregnancy because disease takes the form of hydrops foetalis, icterus gravis
of the risk of hyperimmunization and side-effects. neonatorum (of which kernicterus is often a sequel) and
(vii) SYPHILIS : Syphilis is an important preventable congenital haemolytic anaemia.
cause of pregnancy wastage in some countries. Pregnancies It is a routine procedure in antenatal clinics to test blood
in women with primary and secondary syphilis often end in for Rhesus type in early pregnancy. If the woman is
spontaneous abortion, stillbirth, perinatal death, or the birth Rh-negative and the husband is Rh-positive, she is kept
of a child with congenital syphilis. Syphilitic infection in the under surveillance for determination of Rh-antibody levels
pregnant woman is transmissible to the foetus. Neurological during antenatal care. The blood should be further
damage with mental retardation is one of the most serious examined at 28 weeks and 34-36 weeks of gestation for
consequences of congenital syphilis. When the mother is antibodies. Rh anti-D immunoglobulin should be given at 28
suffering from syphilis, infection of the foetus does not occur weeks of gestation so that sensitization during the first

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before the 4th month of pregnancy; it is most likely to occur pregnancy can be prevented. If the baby is Rh-positive, the
after the 6th month by which time the Langhan’s cell layer Rh anti D immunoglobulin is given again within 72 hours of
has completely atrophied (18). Infection of the foetus is most delivery. It should also be given after abortion. Post maturity
likely to occur when the mother is suffering from primary or should be avoided. Whenever there is evidence of
secondary stages of syphilis than late syphilis. haemolytic process in foetus-in-utero, the mother should be
It is routine procedure in antenatal clinics to test blood for shifted to an equipped centre specialized to deal with Rh
syphilis at the first visit. Since the mother can subsequently get problems. The incidence of haemolytic disease due to Rh
infected with syphilis, the ideal procedure would be to test factor in India is estimated to be approximately one for
blood for syphilis both early and late in pregnancy. Congenital every 400 to 500 live births.
syphilis is easily preventable. Ten daily injections of procaine (x) HIV INFECTION : HIV may pass from an infected
penicillin (600,000 units) are almost always adequate (18). mother to her foetus, through the placenta or to her infant
(viii) GERMAN MEASLES : Maternal viraemia associated during delivery or by breast-feeding. About one-third of the
with the rubella infection during pregnancy may result in children of HIV-positive mothers get infected through this
infection of placenta and foetus. Only a limited number of route. The risk of transmission is higher if the mother is
foetal cells become infected. The growth rate of infected cell is newly infected or if she has already developed AIDS.
reduced, resulting in fewer number of cells in affected organ at Voluntary prenatal testing for HIV infection should be done
birth. The infection may lead to deranged and hypoplastic as early in pregnancy as possible for pregnant women who
organ development, resulting in structural anomalies in the are at great risk (if they or their partner has a number of
newborn. The timing of infection determines the extent of sexual partners; has a sexually transmitted disease; uses
teratogenic effect. In general, the earlier in pregnancy infection illicit injectable drugs etc.). Universal confidential voluntary
occurs, the greater the damage to the foetus. Infection during screening of pregnant women in high-prevalence areas may
first trimester of pregnancy results in abnormalities in infant in allow infected women to choose therapeutic abortion, make
about 85 per cent of cases, but detectable defects are found in an informed decision on breast-feeding, or receive
about 16 per cent of infants who acquired infection during appropriate care. Screening should not be used as a
second trimester. Birth defects are uncommon if maternal substitute for primary prevention through community-wide
infection occurs after 20 weeks of gestation (19). education on safe sexual practice, making condoms readily
Ideally we should prevent infection during pregnancy by available and preventing parenteral transmission (20).
preventing and controlling the disease in the general (xi) HEPATITIS B INFECTION : Spread of infection from
population. Currently this is being attempted by vaccination HBV carrier mothers to their babies appears to be a factor
of all school-aged children with rubella vaccine, and for the high prevalence of HBV infection in some regions.
including the rubella vaccine in the routine immunization The mechanism of perinatal infection is uncertain. Most
schedule. Supplementing the community control of infection infections appear to occur at birth. Transmission of the virus
is the vaccination of all women of childbearing age who are to the baby after delivery is likely if both surface antigen and
sero-negative. Before vaccinating, it is advisable that e antigen are positive. Vertical transmission can be blocked
pregnancy be ruled out and effective contraception be by immediate post-delivery administration of B
maintained for 8 weeks after vaccination because of the immunoglobulin and hepatitis B vaccine. Please refer to
possible risk to the foetus from the virus. page 254 for details.

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 INTRANATAL CARE 605
(xii) PRENATAL GENETIC SCREENING : Prenatal convulsions, malpresentations, prolapse of the
genetic screening includes screening for chromosomal cord, etc.; and
abnormalities associated with serious birth defects, screening (iv) Care of the baby at delivery - resuscitation, care
for direct evidence of congenital structural anomalies, and of the cord, care of the eyes, etc.
screening for haemoglobinopathies and other inherited
conditions detectable by biochemical assay. Universal Domiciliary care
genetic screening is generally not recommended. Screening Mothers with normal obstetric history may be advised to
for chromosomal abnormalities and for direct evidence of have their confinement in their own homes, provided the
structural anomalies is performed in pregnancy in order to home conditions are satisfactory. In such cases, the delivery
make the option of therapeutic abortion available when may be conducted by the Health Worker Female or trained
severe defects are detected. Typical examples are screening dai. This is known as “domiciliary midwifery service.”
for trisomy 21 (Down’s syndrome) and severe neural tube The advantages of the domiciliary midwifery service are :
defects. Women aged 35 years and above, and those who
(1) the mother delivers in the familiar surroundings of her
already have an afflicted child are at higher risk.
home and this may tend to remove the fear associated with
(4) Mental preparation delivery in a hospital; (2) the chances for cross infection are
generally fewer at home than in the nursery/hospital; and
Antenatal care does not mean only palpation, blood and (3) the mother is able to keep an eye upon her children and
urine examination and pelvic measurements. These are no domestic affairs; this may tend to ease her mental tension.
doubt important aspects of antenatal care. Mental preparation
is as important as physical or material preparation. Sufficient Domiciliary midwifery is also not without disadvantages :
time and opportunity must be given to the expectant mothers (1) the mother may have less medical and nursing supervision
to have a free and frank talk on all aspects of pregnancy and than in the hospital; (2) the mother may have less rest; (3) she
delivery. This will go a long way in removing her fears about may resume her domestic duties too soon; and (4) her diet
confinement. The “mothercraft” classes at the MCH Centres may be neglected. Strictly speaking, many homes in India are
help a great deal in achieving this objective. unsuitable for even a normal delivery. The argument that
childbirth is a natural event and should take place at home
(5) Family planning does not guarantee that everything will be normal.
Family planning is related to every phase of the maternity Since 72.2 per cent of India’s population live in rural
areas, most deliveries will have to take place in the home

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cycle. The mother is psychologically more receptive to
advice on family planning than at other times. Educational with the aid of Female Health Workers or trained dais.
and motivational efforts must be initiated during the Domiciliary out-reach is a major component of intranatal
antenatal period. If the mother has had 2 or more children, health care : The Female Health Worker, who is a pivot of
she should be motivated for puerperal sterilization. In this domiciliary care, should be adequately trained to recognize
connection, the All India Postpartum Programme services the ‘danger signals’ during labour and seek immediate help
are available to all expectant mothers in India. in transferring the mother to the nearest Primary Health
Centre or Hospital. The danger signals are :
(6) Paediatric component (1) sluggish pains or no pains after rupture of
It is suggested that a paediatrician should be in membranes;
attendance at all antenatal clinics to pay attention to the (2) good pains for an hour after rupture of
under-fives accompanying the mothers. membranes, but no progress;
(3) prolapse of the cord or hand;
INTRANATAL CARE (4) meconium-stained liquor or a slow irregular or
excessively fast foetal heart;
Childbirth is a normal physiological process, but
complications may arise. Septicaemia may result from (5) excessive ‘show’ or bleeding during labour;
unskilled and septic manipulations, and tetanus neonatorum (6) collapse during labour;
from the use of unsterilized instruments. The need for (7) a placenta not separated within half an hour after
effective intranatal care is therefore indispensable, even if delivery;
the delivery is going to be a normal one. The emphasis is on (8) post-partum haemorrhage or collapse; and
the cleanliness. It entails - clean hands and fingernails, a (9) a temperature of 38 deg C or over during labour.
clean surface for delivery, clean cord care i.e., clean blade There should be a close liaison between
for cutting the cord and clean tie for the cord, no application domiciliary and institutional delivery services.
on cord stump, and keeping birth canal clean by avoiding
harmful practices. Hospitals and health centres should be Institutional care
equipped for delivery with midwifery kits, a regular supply About one per cent of deliveries tend to be abnormal,
of sterile gloves and drapes, towels, cleaning materials, soap and four per cent “difficult”, requiring the services of a
and antiseptic solution, as well as equipment for sterilizing doctor. Institutional care is recommended for all ‘high-risk”
instruments and supplies. There are delivery kits available cases, and where home conditions are unsuitable.
with the items needed for basic hygiene for delivery at The mother is allowed to rest in bed on the first day after
home, where a midwife with a midwifery kit is not likely to delivery. From the next day, she is allowed to be up and
be present. The aims of good intranatal care are : about. The current practice is to discharge the woman after
(i) thorough asepsis; 48 hours lying-in period after a normal delivery.
(ii) delivery with minimum injury to the infant and
mother; Rooming-in
(iii) readiness to deal with complications such as Keeping the baby’s crib by the side of the mother’s bed is
prolonged labour, antepartum haemorrhage, called “rooming-in”. This arrangement gives an opportunity

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 PREVENTIVEMEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS
6Q6_
for the mother to know her baby. Mothers interested in end of one year. In rural areas only limited postnatal care is
breast feeding usually find there is a better chance for possible. Efforts should be made by the FHWs to give at least
success with rooming-in. Rooming-in also allays the fear in 3 to 6 postnatal visits. The common conditions found on
the mother’s mind that the baby is not misplaced in the examination during the late postnatal period are
central nursery. It also builds up her self-confidence. subinvolution of uterus, retroverted uterus, prolapse of uterus
and cervicitis. Postnatal examination offers an opportunity to
POSTNATAL CARE detect and correct these defects.
(2) Anaemia : Routine haemoglobin examination should
Care of the mother (and the newborn) after delivery is
be done during postnatal visits, and when anaemia is
known as postnatal or postpartal care. Broadly this care falls
into two areas: care of the mother which is primarily the discovered, it should be treated. In some cases, it may be
responsibility of the obstetrician; and care of the newborn, necessary to continue treatment for a year or more.
which is the combined responsibility of the obstetrician and (3) Nutrition : Though a malnourished mother is able to
paediatrician. This combined area of responsibility is also secrete as much breast milk as a well nourished one, she
known as perinatology. does it at the cost of her own health. The nutritional needs
of the mother must be adequately met. Often the family
Care of the mother budget is limited; the mother should be shown the means
The objectives of postpartal care are : how she can eat better with less money.
(1) To prevent complications of the postpartal period; (4) Postnatal exercises : Postnatal exercises are necessary
(2) To provide care for the rapid restoration of the to bring the stretched abdominal and pelvic muscles back to
mother to optimum health; normal as quickly as possible. Gradual resumption of normal
(3) To check adequacy of breast-feeding; house-hold duties may be enough to restore one’s figure.
(4) To provide family planning services; and PSYCHOLOGICAL : The next big area of postnatal care
(5) To provide basic health education to mother/ involves a consideration of the psychological factors peculiar
family. to the recently delivered woman. One of the psychological
problems is fear which is generally borne of ignorance.
Complications of the postpartal period Other problems are timidity and insecurity regarding the
Certain complications may arise during the postpartal baby. If a woman is to endure cheerfully the emotional

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period which should be recognized early and dealt with stresses of childbirth, she requires the support and
promptly. These are (1) Puerperal sepsis : This is infection of companionship of her husband. Fear and insecurity may be
the genital tract within 3 weeks after delivery. This is eliminated by proper prenatal instruction. The postpartum
accompanied by rise in temperature and pulse rate, foul­ psychosis is perhaps precipitated by birth; and it is rather
smelling lochia, pain and tenderness in lower abdomen, etc. uncommon.
Puerperal sepsis can be prevented by attention to asepsis,
before and after delivery. This is particularly important in SOCIAL : It has been said that the most important thing a
domiciliary midwifery service. (2) Thrombophlebitis : This is woman can do is to have a baby. This is only part of the
an infection of the veins of the legs, frequently associated truth. The really important thing is to nurture and raise the
with varicose veins. The leg may become tender, pale and child in a wholesome family atmosphere. She, with her
swollen. (3) Secondary haemorrhage : Bleeding from vagina husband, must develop her own methods.
anytime from 6 hours after delivery to the end of the
puerperium (6 weeks) is called secondary haemorrhage, and Breast-feeding
may be due to retained placenta or membranes. (4) Others : Postnatal care offers an excellent opportunity to find out
Urinary tract infection and mastitis, etc. It is extremely how the mother is getting along with her baby, particularly
important to look for these complications in the postpartal with regard to feeding. For many children, breast milk
period and prevent or treat them promptly. provides the main source of nourishment in the first year of
life. In some societies, lactation continues to make an
Restoration of mother to optimum health important contribution to the child’s nutrition for 18 months
The second objective of postpartal care is to provide care or longer. In the world’s more affluent societies, breast­
whereby, the woman can recuperate physically and feeding appears to have become a lost art and the feeding
emotionally from her experience of delivery. The broad bottle has usurped the breast. When the standard of
areas of this care fall into three divisions : environmental sanitation is poor and education low, the
PHYSICAL content of the feeding bottle is likely to be as nutritionally
poor as it is bacteriologically dangerous. It is therefore very
(1) Postnatal examinations : Soon after delivery, the health
important to advise the mothers to avoid the feeding bottle.
check-ups must be frequent, i.e., twice a day during the first 3
days, and subsequently once a day till the umbilical cord A great asset in India is that an average Indian mother,
drops off. At each of these examinations, the FHW checks although poor in nutritional status, has a remarkable ability
temperature, pulse and respiration, examines the breasts, to breast-feed her infant for prolonged periods, sometimes
checks progress of normal involution of uterus, examines extending to nearly 2 years and beyond. Longitudinal and
lochia for any abnormality, checks urine and bowels and cross-sectional studies indicate that poor Indian women
advises on perineal toilet including care of the stitches, if any. secrete as much as 400 to 600 ml of milk per day during the
The immediate postnatal complications, viz. puerperal sepsis, first year (Table 2). No other food is required to be given until
thrombophlebitis, secondary haemorrhage should be kept in 6 months after birth. At the age of 6 months, breast milk
mind. At the end of 6 weeks, an examination is necessary to should be supplemented by additional foods rich in protein
check-up involution of uterus which should be complete by and other nutrients (e.g., animal milk, soft-cooked mashed
then. Further visits should be done once a month during the vegetables, etc.). These are called supplementary foods
first 6 months, and thereafter once in 2 or 3 months till the which should be introduced very gradually in small amounts.

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 CARE OF CHILDREN .6.07
TABLE 2 even political attitudes and leadership. The childhood
Output of breast milk at different stages of lactation period is also a vital period because of the so called
socialization process, that is, transmission of attitudes,
Months of Number Per day mean-output customs and behaviour. In addition, of course, they are
lactation examined of breast milk (ml) vulnerable to disease, death and disability owing to their
age, sex, place of living, socio-economic class and a host of
0-2 20 530 other variables. Certain specific biological and psychological
3-4 18 640 needs must be met to ensure the survival and healthy
5-6 14 730 development of the child and future adult.
7-8 14 660 It is customary to divide the childhood into the following
9-10 17 600 age-periods :
11-12 30 525 1. Infancy (upto 1 year of age) :
13-15 11 515 a. Neonatal period (first 28 days of life).
16-18 29 440 b. Post neonatal period (28th day to 1 year).
19-24 14 400 2. Pre-school age (1-4 years).
25-36 12 425
3. School age (5-14 years).
37-38 4 345 Antenatal paediatrics
Fifty years ago, the main purpose of antenatal care was the
Family planning prevention of maternal mortality. With the fall in the maternal
It has already been stressed that family planning is related mortality to about 0.2 per 1000 live births, attention has
to every phase of maternity cycle. Every attempt should be shifted to the child - first to decrease perinatal mortality,
made to motivate mothers when they attend postnatal clinics secondly to prevent perinatal morbidity; and more recently to
or during postnatal contacts to adopt a suitable method for the “foetus at risk”. This has given rise to the concept of
spacing the next birth or for limiting the family size as the antenatal paediatrics. Recent technical developments such as
case may be. Postpartum sterilization is generally amniocentesis, ultrasonography, fetoscopy and chorion
recommended on the 2nd day after delivery. Although biopsy have contributed significantly to the diagnosis of

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lactation confers some protection against conception, it congenital abnormalities and inborn errors of metabolism
cannot be depended upon; contraceptives have to be (22, 23). This knowledge has led to the recognition that
supplied immediately postpartum. To ask the mother to come causation and possible prevention may lie in intra-uterine
at the time of her first menstruation may be too late. A life. The emphasis has greatly changed in the care of the child
contraceptive must therefore be used, that will not affect with the prevention of disorders (e.g., low birth weight, foetal
lactation in the early postpartum period. In this connection, disorders and neonatal asphyxia) assuming greater
IUD and conventional (non-hormonal) contraceptives are importance.
the choices during the first 6 months following delivery. In Antenatal care should, appropriately, begin even before
general, combined or sequential oral “pills” should be the mother conceives and enters the maternity cycle; this
avoided in a lactating mother as they do suppress lactation. care comprising such measures as genetic counselling for
Fortunately, evidence is accumulating that progestogens prospective parents; limitation and proper spacing of births
alone have little or no effect on lactation. The injection of with intervals of 2-3 years; delaying a young woman’s first
medroxy-progesterone acetate (MPA) after delivery has been pregnancy until she is physically and socially mature enough
found to be successful in ensuring spacing of pregnancy to cope with it; ensuring adequate maternal nutrition;
without suppressing lactation; however, because of its side­ protection of the unborn against intrauterine infections and
effects (e.g., irregular uterine bleeding, prolonged infertility) other adverse influences. In a developing country such as
some countries have limited its use to multiparae at ages 35 India, all this may not be possible, but certainly some
and over, or who have already completed their families. MPA elements, such as improvement of maternal nutrition, family
is not recommended for general use. planning and counselling could go a long way in ensuring
maternal and foetal health.
Basic health education
Health education during the postnatal period should INFANCY
cover the following broad areas : (a) hygiene - personal and
environmental; (b) feeding for mother and infant; Infants (0-1 year) constitute about 2.92 per cent of the
(c) pregnancy spacing; (d) importance of health check-up; total population in India. Of the 136 million children born
and (e) birth registration. each year in the world, 90 per cent are in the third world.
Although the chances of survival of these newborns has
CARE OF CHILDREN improved by 50 per cent in the last 20 years, the first few
hours, days and months of their lives are still an obstacle
This section focuses on children in the age group race. From the time of birth, 20-30 per cent of babies are
0-14 years. This is the most important age group in all under-weight. That makes them vulnerable to infection and
societies, not because they constitute about 40 per cent of disease. About 40 per cent of total infant mortality occurs in
the total population, but because there is a renewed the first month of life. Then comes the weaning period, when
awareness that the determinants of chronic disease in later one out of four surviving children receives neither the quality
life and health behaviour are laid down at this stage (21). nor the quantity of food needed to replace the substances
Family influences and education are of the highest provided by mother’s milk. The result is that more and more
importance, and these experiences ultimately influence children in developing countries reach adulthood with their
patterns of their future life-styles, occupational skills, and health already largely impaired. An infant mortality rate of

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608 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

58 per thousand, as compared to 5 per thousand in the (v) early detection and treatment of congenital and
developed countries, places India in the unenviable position acquired disorders, especially infections.
of being among the less developed in the world. Many low- Congenital infections caused by toxoplasmosis, rubella,
cost measures are available for saving life human (alpha) herpes-virus 1 or 2, human (beta) herpes
of millions of children, like immunization, breast feeding, virus, and syphilis (TORCHES synonyms) is associated with
birth spacing, growth monitoring, improved weaning, oral high mortality rate in the neonates (24).
rehydration. Attention is focused on these elements of child
health care in developing countries. Immediate care
NEONATAL CARE 1. CLEARING THE AIRWAY
A flow chart of the optimum care of the newborn is as Establishment and maintenance of cardio-respiratory
shown in Fig. 2. This aspect of family health services has functions (e.g., breathing) is the most important thing the
been termed neonatology. This branch of medicine is, moment the baby is born, and everything else is secondary.
perhaps, more than any other, dependant on teamwork in To help establish breathing, the airways should be cleared of
which disciplines of obstetrics and gynaecology, paediatrics, mucus and other secretions. Positioning the baby with his
preventive and social medicine, community health services head low may help in the drainage of secretions. This
and nursing have an important part to play, if any impact is process can be assisted by gentle suction to remove mucus
to be made on the vast problems of perinatal and neonatal and amniotic fluid. Resuscitation becomes necessary if
mortality and morbidity. The paediatrician has a key role as natural breathing fails to establish within a minute, as in the
a coordinator and guide for the whole team. case of babies who have already been subject to hypoxia
during labour. In these cases, resuscitation may require more
Early neonatal care active measures such as suction, application of oxygen
The first week of life is the most crucial period in the life mask, intubation and assisted respiration. All labour wards
of an infant. In India, 61.3 per cent of all infant deaths occur should be equipped with resuscitation equipment including
within the first month of life. Of these, more than half may oxygen. If the heart has stopped beating for 5 minutes, the
die during the first week of birth. This is because the new baby is probably dead.
born has to adapt itself rapidly and successfully to an alien
external environment. The risk of death is the greatest 2. APGAR SCORE

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during the first 24-48 hours after birth. The problem is more The Apgar score is taken at 1 minute and again at
acute in rural areas where expert obstetric care is scarce, and 5 minutes after birth. Today it is considered as negligence to
the home environmental conditions in which the baby is omit Apgar scoring of a newborn infant, especially low birth
born, are usually unsatisfactory. weight babies (25). It requires immediate and careful
The objective of early neonatal care is to assist the observation of the heart rate, respiration, muscle tone, reflex
newborn in the process of adoption to an alien environment, response and colour of the infant. Each sign is given a score
which involves : of 0, 1 or 2 (Table 3). It provides an immediate estimate of
the physical condition of the baby. A perfect score should be
(i) establishment and maintenance of cardio­
respiratory functions; 9 or 10; 0-3 indicates that the baby is severely depressed
and 4-6 moderately depressed. A score below 5 needs
(ii) maintenance of body temperature; prompt action. Infants with low Apgar scores at 5 minutes of
(iii) avoidance of infection; age are subject to a high-risk of complications and death
(iv) establishment of satisfactory feeding regimen; and during the neonatal period (25).

Delivery

High-risk infant

Without complications With complications

Temporary observation unit

(recovery room for high-risk infants)

5E 3

Special care nursery with

neonatal intensive care unit

Special procedures *

FIG. 2
Flow chart of optimum newborn care

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 NEONATAL CARE
609
TABLE 3 6. MAINTENANCE OF BODY TEMPERATURE
Apgar score The normal body temperature of a newborn is between
36.5 to 37.5°C. A newborn baby is projected out of warm
Score womb of the mother into an environment which may be
Sign
0 1 2 10 to 20°C cooler especially in winter months in India.
Heart rate Absent Slow Over 100 A newborn has little thermal control and can lose body
(below 100) heat quickly. Immediately after birth; most of the heat loss
Respiratory effort Absent Slow Good occurs through evaporation of the amniotic fluid from the
Irregular crying body of the wet child. As much as 75 per cent of the heat
Muscle tone Flaccid Some flexion Active
loss can occur from the head. It is important that
of extremities movements immediately after birth the child is quickly dried with a
clean cloth and wrapped in warm cloth and given to the
Reflex response No response Grimace Cry
mother for skin-to-skin contact and breast-feeding. Practices
Colour Blue, pale Body pink Completely such as separating the baby from the mother for the first
Extremities pink 12-24 hours of life are harmful. Pre-term and low birth
blue
weight babies lose heat more easily through their thin skin
Severe Mild No as they have less sub-cutaneous fat for insulation. Putting
Total score = 10 depression depression depression the newborn on a cold surface such as metallic tray, rubber
0-3 4-6 7-10 sheeting or weighing scale should be avoided, and the child
should be kept away from cold walls, open windows and
from draught (27).
3. CARE OF THE CORD
In the case of the normal infant, the umbilical cord should 7. BREAST-FEEDING
be cut and tied when it has stopped pulsating. The Breast-feeding should be initiated within an hour of birth
advantage is that the baby derives about 10 ml of extra instead of waiting several hours as is often customary.
blood, if the cord is cut after pulsation ceases. This is Although there is little milk at that time, it helps to establish
particularly important in India, where anaemia is frequent. feeding and a close mother-child relationship, known as
Care must be taken to prevent tetanus of the newborn by “bonding”.

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using properly sterilized instruments and cord ties. It is The first milk which is called “colostrum” is the most
essential to apply an antiseptic preparation on the cord suitable food for the baby during this early period because it
stump and the skin around the base. The cord should be contains a high concentration of protein and other nutrient
kept as dry as possible. It dries and shrivels up and separates the body needs; it is also rich in anti-infective factors which
by aseptic necrosis in 5-8 days. protect the baby against respiratory infections and diarrhoeal
4. CARE OF THE EYES diseases. Supplementary feeds are not necessary. The
regular milk comes on the third to sixth day after birth. The
Before the eyes are open, the lid margins of the newborn baby should be allowed to breast-feed whenever it wants.
should be cleaned with sterile wet swabs, one for each eye Feeding the baby on demand helps the baby to gain weight.
from inner to outer side. Instil a drop of freshly prepared It is very important to advise mother to avoid feeding bottles.
silver nitrate solution (1 per cent) to prevent gonococcal
conjunctivitis, alternatively, a single application of Neonatal examinations
tetracycline 1 per cent ointment can be given. Any discharge
from the eye of an infant is pathological and calls for a. FIRST EXAMINATION
immediate treatment. The first examination is made soon after birth, and
Ophthalmia Neonatorum : A variety of organisms are preferably in the delivery room. This examination is (a) to
implicated - N. gonorrhoea, C. trachomatis (commonest), ascertain that the baby has not suffered injuries during the
staphylococcus, streptococcus, Candida spp, etc. The most birth process; (b) to detect malformations especially those
serious cause of conjunctivitis of the newborn is infection requiring urgent treatment; and (c) to assess maturity.
with N. gonococcus as it can rapidly cause blindness. The following abnormalities found on examination
C. trachomatis is also an important cause of neonatal should be immediately attended to : (a) cyanosis of the lips
conjunctivitis. Since gonococcal ophthalmia neonatorum and skin; (b) any difficulty in breathing; (c) imperforated
has become much less frequent than conjunctivitis due to anus; (d) persistent vomiting; (e) signs of cerebral irritation
other acquired organisms, application of topical neomycin such as twitchings, convulsions, neck rigidity, bulging of
might be more useful (26). anterior fontanel, and (g) temperature instability.
As a preventive measure, specific maternal genital tract b. SECOND EXAMINATION
infection should be treated effectively prior to, or during
pregnancy, and specific care should be taken while The second examination should be made preferably by a
conducting face or breech delivery. paediatrician within 24 hours after birth. This examination
should form the first stage of a continual process of health
5. CARE OF THE SKIN care surveillance. It is a detailed systematic examination
from head to foot, conducted in good light. The following
A newborn baby is wet from amniotic fluid and can easily
protocol will be found useful for such an examination (28).
become cold. Drying the baby with clean cloth to remove
vernix, meconium and blood clots is done by the nursing 1. Body size:
staff. The baby is then wrapped in dry, clean cloth from head Body weight; crown-heel length; head and thoracic
to foot to prevent heat loss. First bath is given after perimeters.
temperature stabilization, preferably after a week. 2. Body temperature.

by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

3. Skin : during the immediate perinatal period and throughout

Observe for cyanosis of lips and skin; jaundice; infancy. It is not a contraindication of breast-feeding.
pallor; generalized erythema; vesicular and bullous If the newborn is infected, there is a risk that he/she will
lesions. become a chronic carrier, and tend to develop active chronic
4. Cardio-respiratory activities : hepatitis, cirrhosis or primary cancer of liver during adulthood.
Cardiac murmurs; absence of femoral pulse; central 50 per cent of severe cases of infantile hepatitis before age one
cyanosis, a respiratory rate of over 60 per minute; year are the outcome of untreated perinatal transmission. ,
thoracic cage retraction on inspiration. It is possible to prevent perinatal transmission by
5. Neuro-behavioural activity : seroprophylaxis combined with vaccination - an intra­
(i) Posture : neck retraction; frog-like posture; muscular injection of 0.5 ml of hepatitis B immunoglobulin
hyper-extension of all limbs; hyperflexion of all along with hepatitis B vaccine within 24 hours of birth. The
limbs; asymmetrical posture (ii) Muscle tone : vaccine must be repeated at 6, 10 and 14 weeks of age.
tendon reflexes; cry; movements. This prophylaxis has proved effective. The real problem
6. Head and face : is to detect mothers who are chronic carriers of the HBs
Hydrocephalus; large fontanelles; prominent scalp antigen, and the high cost of prevention.
vein (i) Eyes : cataract; coloboma; conjunctivitis NEWBORN WITH A HIV-POSITIVE MOTHER : The
(ii) Ears : dysmorphism; accessary auricles; pre- rapidity of the propagation of HIV infection is a source of
auricular pits (iii) Mouth and lips : Hare lip; cleft great concern. About 30 per cent babies born to HIV­
palate. positive mothers get infected. Transmission of infection
7. Abdomen : mostly occurs at the end of the pregnancy, and it is not
Signs of distension; abnormal masses; imperforate influenced by the type of delivery. The virus has been
anus. isolated in breast-milk. Although there is probably a risk of
8. Limbs and joints : transmission of infection through breast-milk, prohibiting
Deformities of joints; congenital dislocation of the breast-feeding is debatable, as it is so essential for the
hips; extra digits. survival of newborn in developing countries. The risk of
9. Spine : transmission depends on the severity of the mother’s case. It
Neural tube defects is higher from mothers with AIDS, but may also occur from

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seropositive cases. The infection can be prevented by giving
10 External genitalia : ART. Please refer to page 402 for details. The question of
Male : Hypospadius; undescended testis; hydrocele; whether to perform BCG vaccination arises - it is
Female : fused labia; enlarged clitoris. contraindicated in infected children, and therefore, should
not be performed in the offspring of HIV positive mothers
The infected newborn (27) until it is determined whether the baby is infected or not.
Neonatal infection is particularly frequent in Africa. It is This is only feasible at the end of several months when the
the main cause of neonatal mortality in many developing maternal antibodies are completely eliminated (27).
countries. Contributing factors are related to the environment
(traditional practices, poor hygiene), the course of pregnancy MEASURING THE BABY
(premature rupture of membranes) and constitutional
fragility (prematurity, small-for-date, dysmaturity). Measurements of birth-weight, length (height) and head
Transplacental contamination is one of the important cause circumference are the simplest and one of the reliable means
of infection in new-borns. Early detection of newborns at risk by which the health and maturity of a baby is evaluated.
of transplacental infection is important, so that close 1. Birth-weight
monitoring and preventive action may be implemented.
The birth-weight should be taken preferably within the
NEONATAL TETANUS : It can be prevented by first hour of life, before significant post-natal weight loss has
vaccination of pregnant women and sero-vaccination of occurred (29). The naked baby should be placed on a clean
newborns in case of at-risk delivery. These measures have towel on the scale pan. In home delivery, weight is taken by
proved effective in those countries where they are placing the baby in a sling bag using a salter weighing scale.
systematically applied. The child is weighed to the nearest 100 g according to the
CONGENITAL SYPHILIS : The frequency of congenital standard method for weight measurement.
syphilis is on rise in some large African cities. Diagnosis is The average birth-weight of infants is lower in many
essentially based on the evidence of syphilis in the mother, developing countries than it is in developed countries. There
since clinical signs of congenital syphilis often do not occur are reasons to believe that this difference is not of genetic
at once. In case of doubt and if there is risk of inadequate origin but is due largely to maternal malnutrition.
subsequent medical surveillance of the baby, treatment
with 2.4 to 4.8 million I.U. of Benzathine Penicillin may be 2. Length (height)
recommended. This need not be taken immediately if the baby’s
NEWBORN WITH A HBV-POSITIVE MOTHER : Chronic condition gives rise to any anxiety, but should be recorded
carriers of hepatitis virus are extremely frequent in some within the first 3 days. Length can be taken most accurately
countries. Babies may be infected at birth when the mother with a measuring board (infantometer) with a fixed head
is a carrier of this virus. The risk of transmission is piece on which the infant lies supine with its legs fully
somewhere around 20 per cent when the mother has the extended and the feet flexed at right angles to the lower legs.
HBs antigen only, and around 90 per cent when she also has Two people are needed to hold the baby correctly. The
the HBe antigen. Transmission occurs through the blood and sliding board is moved firmly against the feet before the
the genital secretions and therefore affects the newborn reading is taken. Length is taken to the nearest 0.1 cm.

by R△J
 MEASURING THE BABY

3. Head circumference blood of newborns, potential victims of IDD could be

This measurement may change slightly during the first identified and proper prevention can be taken at such an
3 days owing to moulding during labour. It is taken with a early stage of life, (c) Coombs’ test : This is done routinely
on infants of all Rh-negative mothers, (d) Sickle cell or other
tape measure at the maximum circumference of the head in
haemoglobinopathies : Agar-gel electrophoresis is done on
the occipito-frontal diameter.
infants whose mothers have sickle cell or other
The purpose of taking these measurements are : haemoglobinopathies, e.g., thalassaemia, G6PD.
(i) to assess the baby’s size against known standards (e) Congenital dislocation of hip : The test consists of
for the population; manipulating the hip of the child from the adducted to
(ii) to compare the size with estimated period of abducted position while the thigh is flexed. A positive or
gestation; and abnormal result is indicated by a click or snap being
(iii) to provide a baseline against which subsequent produced during the test. The test is carried out on all babies
progress can be measured. at 6-14 days after birth, and at monthly intervals until the
child is 4 months old. Diagnosis within a week or two of
Anthropometric measurements may be classified as (30) : birth means that treatment can be completed before the
(a) Weight kg infant could normally have reached the stage of standing.
(b) Length total height, sitting height, Failure to diagnose the condition will expose the child to a
heel knee-length whole series of difficult operations in later life (20).
(c) Perimeters head, chest, abdomen, arm, The requirements for effective screening for inborn errors
calf are discussed in detail in chapter 4.
(d) Diameters : biacromial, bicristal,
biepicondylar, Identification of “at-risk” infants
bistyloid, bicondylar The number of infants (and children 1-5 years of age) in
(e) Skinfold thickness : triceps, biceps, superiliac a community, or attending a child health clinic, may be so
subscapular. large that it may not be possible to give sufficient time and
attention to all of them. It is therefore necessary to identify
NEONATAL SCREENING particularly those “at-risk” and give them special intensive
The object of screening newborns is primarily to detect care, because it is these “at-risk” babies that contribute so

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infants with treatable genetic, developmental and other largely to perinatal, neonatal and infant mortality. The basic
abnormalities, and secondarily, to provide their parents with criteria for identifying these babies include :
genetic counselling. The Apgar score and routine clinical 1. birth weight less than 2.5 kg;
examinations are simple screening tests which should be 2. twins;
carried out on all newborn infants. 10 to 15 ml of cord blood 3. birth order 5 and more;
should be collected at birth and saved in the refrigerator for 4. artificial feeding;
7 days for typing, coombs’ testing and other tests if needed. 5. weight below 70 per cent of the expected weight
Recent years have witnessed development of numerous tests (i.e., II and III degrees of malnutrition);
for screening congenital metabolic disorders, inherited 6. failure to gain weight during three successive months;
haemoglobinopathies and red blood cell disorders. Since 7. children with PEM, diarrhoea; and
these diseases are rare, general screening of the population 8. working mother/one parent.
for them is neither justified nor technically possible. However,
only a few tests qualify for a screening programme. The most Late neonatal care
common disorders which are screened are discussed below. The remaining three weeks of the neonatal period carry
(a) Phenylketonuria (PKU) : PKU is a rare (incidence 1 in the common and serious hazards of infection and failure of
10,000-20,000 births) disorder of amino acid metabolism. satisfactory nutrition. Diarrhoea and pneumonia take a
This is an autosomal recessive trait in babies who are heavy toll of life in infants exposed to an unsatisfactory
homozygous with a deficiency in the enzyme phenylalanine environment. The case fatality rate of what would normally
hydrozylase (PAH) which normally converts phenylalanine be trivial episodes can increase dramatically when
to tyrosin. The deficiency results in raised serum elementary care is not given.
phenylalanine concentrations causing mental retardation
and tendency to seizures if the child does not receive low LOW BIRTH WEIGHT
phenylalanine diet. Mass screening of blood phenylalanine The birth weight of an infant is the single most important
in neonates is performed in many countries by the Guthrie determinant of its chances of survival, healthy growth and
test. It is possible to test for all three types of metabolic error, development.
namely PKU, galactosaemia and maple syrup urine disease
by taking blood from the 6-10 days old baby by heel prick There are two main groups of low birth weight babies -
and collecting 3 or 4 separate drops of it on thick absorbent (a) those born prematurely (short gestation); and (b) those
filter paper. The treatment of PKU consists of a diet free of with foetal growth retardation. In countries where the
phenylalanine. Careful dietary management in affected population of low birth weight infants is less, short gestation
children results in normal physical and mental development, period is the major cause. In countries where the proportion
(b) Neonatal hypothyroidism : This is the most common is high (e.g. India), the majority of cases can be attributed to
disorder that is screened. Congenital hypothyroidism leads foetal growth retardation.
to serious sequelae, including severe mental retardation, By international agreement low birth weight has been
which can be prevented if medical treatment is given within defined as a birth weight of less than 2.5 kg (upto and
the first 1-2 months of life. The test involves measuring the including 2499 g), the measurement being taken preferably
radioimmunoassays of the thyroid hormone T4 or the within the first hour of life, before significant postnatal
thyroid-stimulating hormone (TSH). By examining the cord weight loss has occurred (30). Apart from birth weight,

by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

babies can also be classified into 3 groups according to preterm birth (spontaneous onset of labor or following
gestational age, using the word “preterm”, “term” and prelabor premature rupture of membranes (pPROM) and
“postterm”, as follows (29) : (2) provider-initiated preterm birth (defined as induction of
a. Preterm : Babies born before the end of 37 weeks labor or elective caesarean birth before 37 completed weeks
gestation (less than 259 days). of gestation for maternal or fetal indications (both “urgent”
b. Term : Babies born from 37 completed weeks to or “discretionary”), or other non-medical reasons.
less than 42 completed weeks (259 to 293 days) Spontaneous preterm birth is a multi-factorial process,
of gestation. resulting from the interplay of factors causing the uterus to
c. Postterm : Babies born at 42 completed weeks or change from quiescence to active contractions and to birth
any time thereafter (294 days and over) of before 37 completed weeks of gestation. The precursors to
gestation. spontaneous preterm birth vary by gestational age, social
and environmental factors, but the cause of spontaneous
A LBW infant then, is any infant with a birth weight of preterm labor remains unidentified in upto half of all cases.
less than 2.5 kg regardless of gestational age. It includes two Maternal history of preterm birth is a strong risk factor and
kinds of infants : most likely driven by the interaction of genetic, epigenetic
and environmental risk factors.
PRETERM BABIES (9)
Elevated risk of preterm birth also demands increased
Preterm is defined as babies born alive before 37 weeks attention to maternal health, including the antenatal
of pregnancy are completed. There are sub-categories of diagnosis and management of NCDs and other conditions
preterm birth, based on gestational age : known to increase the risk of preterm birth. Premature
- extremely preterm (<28 weeks) babies, in turn, are at greater risk of developing NCDs, like
- very preterm (28 to <32 weeks) hypertension and diabetes, and other significant health
- moderate to late preterm (32 to 37 weeks). condition later in life, creating an intergenerational cycle of
risk. The link between prematurity and an increased risk of
These are babies born too early. Their intrauterine NCDs takes on an added public health importance when
growth may be normal. That is, their weight, length and considering the reported increase in the rates of both
development may be within normal limits for the duration of worldwide. Table 4 summarizes the types of preterm births
gestation. Given good neonatal care, these babies may catch and the risk factors involved.

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up growth and by 2 to 3 years of age will be of normal size
and performance. TABLE 4
Types of preterm birth and risk factors involved
INCIDENCE
More than 1 in 10 of the world’s babies born in 2015 were Type: Risk Factors- Examples:
born prematurely, making an estimated 15 million preterm
Spontaneous Age at pregnancy Adolescent pregnancy,
births (defined as before 37 weeks of gestation) of which preterm birth: and pregnancy advanced maternal age,
more than 1 million died as a result of their prematurity. spacing or short inter-pregnancy
Prematurity is now the second-leading cause of death in interval
children under 5 years, and the single most important cause Multiple Increased rates of twin and
of death in the critical first month of life. For the babies who pregnancy higher order pregnancies
survive, many face a lifetime of significant disability. with assisted reproduction
Preterm births is a global problem. More than 60 per cent Infection Urinary tract infections,
of preterm births occur in Africa and South Asia. In the lower malaria, HIV, syphilis,
income countries, on average, 12 per cent babies are born bacterial vaginosis.
too early compared to 9 per cent in higher-income countries. Underlying Diabetes, hypertension,
Within countries, poorer families are at higher risk. The maternal chronic anaemia, asthma, thyroid
i0 countries with the greatest number of preterm births in medical conditions disease
2015 are : (1) India 3519100; (2) China 1172300; (3) Nigeria Nutritional Undernutrition, obesity,
773600; (4) Pakistan 748100; (5) Indonesia 675700; (6) USA micronutrient deficiencies
517400; (7) Bangladesh 424100; (8) Philippines 348900; Lifestyle/ Smoking, excess alcohol
(9) DPR of the Congo 341400; and (10) Brazil 279300 (31). work related consumption, recreational
drug use, excess physical
The 10 countries with the highest rates of preterm birth work/activity
per 100 live births is; (1) Malawi 18.1; (2) Comoros 16.7;
Maternal Depression, violence
(3) Congo 16.7; (4) Zimbabwe 16.6; (5) Equatorial Guinea psychological against women
16.5; (6) Mozambique 16.4; (7) Gabon 16.3; (8) Pakistan health
15.8; (9) Indonesia 15.5; and (10) Mauritania 15.4 (31). Genetic and other Genetic risk, e.g., family
There is a dramatic difference in survival of premature history, Cervical
babies depending on where they are born. More than 90 per incompetence
cent of extremely preterm babies (less than 28 weeks) born Provider- Medical induction There is an overlap for
in low-income countries die within the first few days of life; initiated or caesarean birth indicated provider-initiated
yet less than 10 per cent of extremely preterm babies die in preterm birth: for: obstetric preterm birth with the risk
high income countries. indication, Foetal factors for spontaneous
indication preterm birth.
Causes of preterm births (9) Other-Not medically
indicated
Preterm birth is a syndrome with a variety of causes which
can be classified into two broad subtypes: (1) spontaneous Source : (9)

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 LOW BIRTH WEIGHT

SMALL-FOR-DATE (SFD) BABIES : Some of the problems premature babies may experience
Also known as small for gestational age babies. These include (34) :
may be born at term or preterm. They weigh less than the • Temperature instability - inability to stay warm due to
10th percentile for the gestational age. These babies are low body fat
clearly the result of retarded intrauterine foetal growth. • Respiratory problems;
Computation : The percentage of LBW babies is - hyaline membrane disease/respiratory distress
computed as : syndrome - a condition in which the airsacs cannot
Live-born babies with birth weight less than 2.5 Kg stay open due to lack of surfactant in the lung
--------------------------------------------- -------------------------- X100 - chronic lung disease/bronchopulmonary dysplasia-
Total number of live births long-term respiratory problems caused by injury to the
The factors associated with intrauterine growth lung tissue
retardation are multiple and interrelated to mother, the - air leaking out of the normal lung spaces into other
placenta or to the foetus. The maternal factors include tissues
malnutrition, severe anaemia, heavy physical work during - incomplete lung development
pregnancy, hypertension, malaria, toxaemia, smoking, low - apnea (stopping breathing) - occurs in about half of
economic status, short maternal stature, very young age, babies born at or before 30 weeks
high parity and close birth spacing, low education status etc.
(32). The placental causes include placental insufficiency • Cardiovascular
and placental abnormalities. The foetal causes include foetal - patent ductus arteriosus (PDA) - a heart condition
abnormalities, intrauterine infections, chromosomal that causes blood to divert away from the lungs
abnormality and multiple gestation. - too low or too high blood pressure
SFD babies have a high risk of dying not only during the - low heart rate - often occurs with apnea
neonatal period but during their infancy, thus significantly • Blood and metabolic;
raising the rate of infant and perinatal mortality and - anaemia - may require blood transfusion
contribute greatly to immediate and long term health - jaundice - due to immaturity of liver and
problems. Most of them become victims of protein-energy gastrointestinal function

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malnutrition and infections. - too low or too high levels of minerals and other
In the developing countries, adverse prenatal and post­ substances in the blood such as calcium and glucose
natal development of the child is associated with (sugar)
3 interrelated conditions : malnutrition, infection and • Gastrointestinal;
unregulated fertility which are often due to poor socio­
economic and environmental conditions. - difficulty feeding - many are unable to coordinate
suck and swallow before 35 weeks gestation
IMPORTANCE - poor digestion
LBW is one of the most serious challenges in maternal and - necrotizing enterocolitis (NEC) - a serious disease of
child health in both developed and developing countries. Its the intestine common in premature babies
public health significance may be ascribed to numerous • Neurologic;
factors - its high incidence; its association with mental - intraventricular haemorrhage - bleeding in the brain
retardation and a high risk of perinatal and infant mortality - periventricular leukomalacia - softening of tissues of
and morbidity (half of all perinatal and one-third of all infant the brain around the ventricles (the spaces in the brain
deaths are due to LBW); human wastage and suffering; the containing cerebrospinal fluid).
very high cost of special care and intensive care units and its - poor muscle tone
association with socio-economic underdevelopment (33). - seizures - may be due to bleeding in the brain
LBW is the single most important factor determining the - retinopathy of prematurity - abnormal growth of the
survival chances of the child. Many of them die during their blood vessels in a baby's eye
first year. The infant mortality rate is about 20 times greater
for all LBW babies than for other babies. The lower the birth • Infections - premature infants are more susceptible to
weight, the lower is the survival chance. Many of them infection and may require antibiotics
become victims of protein-energy malnutrition and
PREVENTION
infection. LBW is thus an important guide to the level of care
needed by individual babies. LBW also reflects inadequate Experts opine that the rates of LBW babies could be
nutrition and ill-health of the mother. There is a strong and reduced to not more than 10 per cent in all parts of the
significant positive correlation between maternal nutritional world (35). It is clear from the multiplicity of causes that
status and the length of pregnancy and birth weight. A high there is no universal solution. Interventions have to be
percentage of LBW therefore points to deficient health status cause-specific. Main attention has been given in recent
of pregnant women, inadequate prenatal care and the need years to ways and means of preventing LBW through good
for improved care of the newborn. prenatal care and intervention programmes, rather than
“treatment” of LBW babies born later.
As premature babies are born before their bodies and
organ systems have completely matured, they may need DIRECT INTERVENTION MEASURES
help breathing, eating, fighting infection and staying warm.
Very premature babies who are born before 28 weeks, are The incidence of LBW can be reduced if pregnant women
especially vulnerable. Many of their organs may not be “at risk” are identified and steps are taken to reduce the risk.
ready for life outside the mother's uterus and may be too For this approach the women need to be identified early in
immature to function well. pregnancy. To achieve this goal, the mothers health card -

by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS
61 4
which is simple and can be used by primary health care infections can affect foetal growth in several ways; and
worker - has been found very useful. The risk factors are : (iii) Early detection and treatment of medical disorders :
mother’s malnutrition, heavy work load, diseases and These include hypertension, toxemias, and diabetes.
infections and high blood pressure. Added to malnutrition,
too many and too frequent pregnancies contribute to the INDIRECT INTERVENTION
continued depletion of her body. Both malnutrition and Family planning, avoidance of excessive smoking,
morbidity due to infections during pregnancy are amenable improved sanitation measures, and measures aimed at
to correction or can be prevented. Some of the direct improving the health and nutrition of young girls, each have a
interventions are as follows : role to play. These measures can be expected to be more
(i) Increasing food intake : Studies have shown that even effective and to have lasting effects only if, at the same time
a relatively small dietary improvement in the malnourished there are improvements in the socio-economic and
pregnant mother, even during the last trimester, can result in environmental conditions and in the distribution of health and
a significant improvement in the birth weight of an infant. In social services especially in the under-served areas.
Southern India, treatment of anaemic mothers led to an Government support could be provided through such
increase in birth weight of offspring. Direct intervention measures as maternity leave with full wages and child benefits.
covers a wide range of activities, viz. supplementary feeding, Fig. 3 summarizes the integrated services delivery
distribution of iron and folic acid tablets, fortification and package for maternal and newborn care.
enrichment of foods, etc.; (ii) Controlling infections : Many
maternal infections go unrecognized. They should be TREATMENT
diagnosed and treated (e.g., malaria, urinary tract infection, From the point of view of treatment, LBW babies can be
infections due to cytomegalovirus, toxoplasmosis, rubella divided in to 2 groups : (a) those under 2 kg and (b) those
and syphilitic infection) or otherwise prevented. These between 2-2.5 kg. The first group requires first class modern

REPRODUCTIVE CHILDBIRTH CARE: EMERGENCY EMERGENCY

CARE: - Skilled care and immediate NEWBORN CARE: CHILD CARE:
- Family planning. newborn care (hygiene, warmth, - Extra care of preterm - Hospital care of

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- STIs, HIV and breast-feeding) and resuscitation. babies, including childhood illness,
Kangaoroo Mother Care including HIV
immunizations. - Antenatal steroids, antibiotics for
pPROM. - Emergency care of sick care.
- Care after
pregnancy loss. - PMTCTofHIV. newborns
(context-specific e.g.
- Emergency obstetric care if needed. CPAP, surfactant).

REPRODUCTIVE ANTENATAL CARE: POSTNATAL CARE: CHILD HEALTH CARE:

HEALTH CARE: - 4-visit focused ANC package. - Promotion of healthy Immunizations, nutrition, e.g. Vit A.
- Family planning, - IPTp and bednets for malaria behaviours, e.g. hygiene, supplementation and growth
including birth breastfeeding, warmth. monitoring.
spacing. Prevention and management of IPTi and bednets for malaria.
STIs and HIV - Early detection of and
- Prevention and referral for illness. - Care of children with HIV, including
management of - Calcium supplementation. cotrim oxazole.
- Extra care of at-risk - First level assessment and care of
STIs and HIV. Diagnosis and treatment of mothers and babies. childhood illness (IMCI).
- Nutritional maternal chronic conditions
Prevention of mother-to Diagnosis and treatment of
counselling. child transmission of HIV. prematurity associated disability.

- Adolescent and Counselling and Where skilled care Healthy home care including:
pre-pregnancy preparation for is not available, - Promoting preventive care, including newborn care (hygiene,
nutrition. newborn care, consider clean warmth), nutrition (exclusive breast-feeding, complementary
- Gender violence. breast-feeding, birth and feeding) and family planning for women.
birth and immediate
- Education. emergency newborn care - Seeking curative services for women, babies and children,
- Prevention of STIs preparedness. (hygiene, warmth including oral rehydration salts for prevention of diarrhoea, and
and HIV. and immediate where referral is not available, consider case management for
breast-feeding). pneumonia, malaria and neonatal sepsis
- Optimize prepreg­
nancy maternal
conditions.

INTERSECTORAL Improved living and working conditions including housing, water and sanitation, and nutrition; education and
empowerment, especially of girls; folic acid fortification; safe and healthy work environment for women and
pregnant women

Pre-pregnancy Pregnancy Birth Newborn/Postnatal Childhood

FIG. 3
Integrated service delivery packages for maternal, newborn and child health
Source : (9)
by R△J
 FEEDING OF INFANTS
■15
neonatal care (which is hardly available globally) in an infections. The data suggests that infant mortality rates in
intensive care unit until the weight reaches that of the developing countries are 5-10 times higher among children
second group. The second group may need an intensive who have not been breast-fed or who have been breast-fed
care unit for a day or two. for less than 6 months. Despite the marked advantages of
breast-feeding, its popularity has declined significantly in
KANGAROO MOTHER CARE & many parts of the world.
Kangaroo mother care for low birth-weight babies was
introduced in Colombia in 1979 by Drs. Hector Martinez Advantages of breast-feeding
and Edzar Rey as a response to, inter alia, high infection and Among the advantages of breast milk are the following :
mortality rates due to overcrowding in hospitals. It has since (1) it is safe, clean, hygienic, cheap and available to the infant
been adopted across the developing world and has become at correct temperature; (2) it fully meets the nutritional
essential element in the continuum of neonatal care. The requirements of the infant in the first few months of life; (3) it
four components of kangaroo mother care are all essential contains antimicrobial factors such as macrophages,
for ensuring the best care option, especially for low birth­ lymphocytes, secretory IgA, anti-streptococcal factor,
weight babies. They include skin-to-skin positioning of a lysozyme and lactoferrin which provide considerable
baby on the mother's chest: adequate nutrition through protection not only against diarrhoeal diseases and necrotizing
breast-feeding; ambulatory care a- a_result of earlier enterocolitis, but also against respiratory infections in the first
discharge from hospital; and support for the mother and her months of life; (4) it is easily digested and utilized by both the
family in caring for the baby (36). normal and premature babies; (5) it promotes “bonding”
The intensive care comprises of:- (a) Incubatory care: that between the mother and infant; (6) sucking is good for the baby
is, adjustment of temperature, humidity and oxygen supply. - it helps in the development of jaws and teeth; (7) it protects
There is increasing evidence that low levels of oxygen in a babies from the tendency to obesity; (8) it prevents
baby’s blood stream (hypoxia) can produce cerebral palsy. malnutrition and reduces infant mortality; (9) it provides
Therefore, continuous monitoring of the level of oxygen in several biochemical advantages such as prevention of
baby’s blood stream is now carried out in the best incubatory neonatal hypocalcaemia and hypomagnesemia (37); (10) it
care units. If the oxygen is excessive, it may lead to retrolental helps parents to space their children by prolonging the period
fibroplasia; (b) Feeding : Breast-feeding is rarely possible - of infertility; and (11) special fatty acids in breast milk lead to
the baby cannot suck. However, breast milk should be used if increased intelligence quotients and better visual acuity. A

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available. Feeding is often by nasal catheter; and breast-fed baby is likely to have an IQ of around 8 points higher
(c) Prevention of infection : Infection presents the greatest than a non-breast fed baby (38).
hazard. Death may occur within a few hours following Early initiation of breast-feeding lowers the mother's risk
respiratory infection. Prevention of infection is therefore, one of postpartum haemorrhage and anaemia, boosts mother's
of the most important functions of an intensive care unit. immune system, delays next pregnancy and reduces the
The leading causes of death in low birth weight babies insulin of diabetic mothers. It protects mothers from ovarion
are : and breast cancers and osteoporosis (38).
a. atelectasis; It is neither necessary nor desirable to train a baby to
b. malformation: “feed by the clock”. It should be explained to the mother,
c. pulmonary haemorrhage: however, that intervals between feeds are necessary for
d. intracranial bleeding, secondary to anoxia or birth herself and for the baby, though they may vary between 1 to
trauma; and 4 hours, according to the baby’s needs, size, strength of
sucking and the mother’s milk supply.
e. pneumonia and other infections.
(^Facility based newborn care services like newborn care (2) Artificial feeding
corner, newborn stablization unit and special newborn care The main indications for artificial feeding are failure of
unit have improved the management oFlow birth weight
breast milk, prolonged illness or death of the mother. It is
babies. Some of these units are linked to obstetric units
crucial for the baby to be fed “breast-milk substitutes” - e.g.,
capable of monitoring the foetus. The development of
dried whole milk powder, fresh milk from a cow or other
perinatal intensive care units has been associated with a
animal, or commercial formulae.
decline in neonatal mortality.
PRINCIPLES OF ARTIFICIAL FEEDING
FEEDING OF INFANTS
In planning an artificial feed, the nutritional needs of
A detailed discussion of the feeding of infants is outside infants should be kept in view. These include :
the scope of this book. However, a brief mention may be 1. Infants require an average of 100 kcal of energy
made of some of the important aspects of the problem. per kg of body weight per day, i.e., about 150 ml
of milk per kg of body weight each day;
(1) Breast-feeding 2. The estimated protein requirement is about 2 g/kg
Under any circumstances, breast milk is the ideal food for of body weight during the first 6 months; it
the infant. No other food is required by the baby until declines to about 1.5 g/kg by the end of one year.
6 months after birth. Under normal conditions, Indian This works out to 13-14 g protein daily during the
mothers secrete 450 to 600 ml of milk daily with 1.1 gm first year of life. In terms of calories, 8 to 10 per
protein per 100 ml. The energy value of human milk is cent of calories are given as protein;
70 kcals per 100 ml. 3. The carbohydrate requirement is about 10 g/kg of
A child who is breast-fed has greater chances of survival body weight daily;
than a child artificially fed. Prolonged breast feeding does 4. After 4 months of age, undiluted boiled and
protect the infant from early malnutrition and some cooled milk should be given;
by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

5. Infants need feeding at frequent intervals about TABLE 6

6-8 times a day; older babies 5 times a day; and Comparison between breast milk during the 1st month of
6. During illness (e.g., fevers) the calorie need is lactation and unprocessed cow milk
increased, and it should be met. Breast milk Cow milk
Constituent
grammes per litre grammes per litre
(a) DRIED MILK : The safest milk is undoubtedly dried
whole milk, which is scientifically prepared for infant PROTEINS 11 33
feeding. It is free from bacteria; there is little danger from - Casein 4 28
flies; it does not become sour and is simple to reconstitute. It - Soluble proteins 7 5
is usually fortified with vitamins. But it is expensive and, Lactalbumin 3.5 15 to 1.8
therefore, beyond the reach of many Indian families. Beta-lactaglobulin 0 3.7
(b) COW’S MILK : A cheaper alternative which is well Lactotransferrin 1 to 2 0.2 to 0.5
within the reach of many Indian families is cow’s milk, which Immunoglobulin 1 to 2 0.5
in fact is widely used for infant feeding. Most health workers Lysozyme 0.5 Traces
give very conflicting advice on the use of cow’s milk for NON-PROTEIN • 0.32 0.32
infant feeding. A small minority of over-enthusiastic NITROGENOUS
paediatricians recommend undiluted cow’s milk right from SUBSTANCES
the birth, forgetting the fact that human milk is made for the LIPIDS : 35 35
human baby and cow’s milk for the calf. Both cannot be - Linoleic acid 3.5 1
equated. Most authorities in India and abroad including the CARBOHYDRATES : 70 50
World Health Organization have persistently recommended - Lactose 62 50
dilution of cow’s milk during the first 2 months in order to - Nitrogenous 8 0
reduce the solute load on neonatal kidneys. The oligosaccharides
Government of India in the Ministry of Health and Family 8
MINERALS • 2
Welfare in the “Manual for Health Worker (Female) Vol. I
- Ca (Calcium) 0.33 1
(1978) have also recommended dilution of cow’s milk
- P (Phosphorus) 0.15 1
during the first two months. A suggested schedule for infant
- Fe (Iron) 0.4 to 1.5 mg 0.3 to 0.5 mg
feeding with cow’s milk is given in Table 5.

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VITAMINS :
TABLE 5 -C 60 mg 20 mg
Quantities per feeding - assuming five feedings per day -D 50 IU 25 IU
ENERGY: 640-720 kcal 650 kcal
Infant’s weight (kg)
2670-3000 kJ 2717 kJ
3 4 5 6
Source : (40)
Cow’s milk (ml) 70 100 150 180 “living” fluid, (b) FATS : Mother’s milk is especially rich in
Water (ml) 20 20 0 0 fats, which represents between 35-50 per cent of total energy
Sugar (g) 5 10 10 10 value. There are two main ways in which the fats of human
kcal 64 103 135 153 milk differ from those of other milks - first, levels of essential
Protein (g) 2.1 3.0 4.5 5.4 polyunsaturated fatty acids, especially linoleic acid and
- Place milk, water, and sugar in pan alpha-linolenic acid are higher in human milk than in cow’s
- bring to boil, then cool milk; secondly, the fats of human milk are easier for the baby
pour into feeding utensil to digest and absorb than are those of cow’s milk. With cow’s
milk, unabsorbed fatty acids tend to bind with calcium and
Source : (39) prevent it from being absorbed. Although there is less calcium
Artificial feeding is a hazardous procedure in poor homes in human milk than in cow’s milk, it is much better absorbed,
because of the dangers of contamination and over-dilution (c) CARBOHYDRATES : Human milk contains more lactose
of the feed. than most other milks. It may be specially useful for the
growing brain. In the intestine, lactose helps the “right” kind
The composition of cow’s milk and human milk is given of bacteria (i.e., Lactobacillus bifidus) to grow. Lactobacillus
in Table 6. and lactose help to keep the intestinal contents acidic, which
Table 6 shows that cow’s milk and human milk are inhibits the growth of harmful bacteria. Lactose plays an
dissimilar in many respects. The differences may be seen as important role in maintaining low electrolyte concentration.
great as the difference between “brain” and “brawn”, (d) VITAMINS AND MINERALS : If the mother takes
(a) PROTEIN: One of the striking difference is the low protein adequate amount of vitamins, there is no reason why the
content of human milk; this is about 3 times less than in cow’s child should have a vitamin supplement. The earlier teaching
milk and lower than in most mammals. The proteins in that human milk was deficient in vitamin D is no longer
human breast milk and in cow’s milk are completely different. accepted. Vitamin D is present in human milk in water­
Human milk contains more cystine, essential for the soluble form. Human milk contains more vitamin A and
prematures, and less methionine than cow’s milk. It is rich in vitamin C than cow’s milk. Another factor which was
taurine, indispensable for infants, but which they, unlike supposed to be deficient in human milk was iron, but again
adults, are unable to synthesize. Breast milk is almost recent work has shown that iron contained in human milk has
completely digested and utilized for growth, whereas much of a high level of bio-availability, thanks to complex phenomena
cow’s milk protein is excreted by the infant undigested (the action of lactoferrin, acidity of the digestive track,
producing whitish curdy stool. Breast milk contains other presence of appropriate proportions of zinc and copper). The
proteins whose functions are not nutritive, but anti-infective, coefficient of uptake of the iron in breast milk may be as high
e.g., IgG, lysozyme, living cells, etc. Human milk is virtually a as 70 per cent, whereas it is only 30 per cent for cow’s milk
by R△J
 GROWTH AND DEVELOPMENT
617
and infant formulas (40), and no iron supplement is pacifiers; and (10) Coordinate discharge so that parents and
necessary for the baby reared on human milk. Human milk is their infants have timely access to ongoing support and
richer in copper, selenium and cobalt than cow’s milk. It care (42). The “Baby friendly” hospitals in India are also
contains less sodium than cow’s milk and does not put any expected to adopt and practice guidelines on other
unnecessary strain on the infant’s kidneys. The calcium/ interventions critical for child survival including antenatal
phosphorus ratio is high, so that the uptake of calcium is care, clean- delivery practices, essential newborn care,
better than cow’s milk. The high phosphorus content of cow’s immunization and ORT (431
milk causes this mineral to be assimilated to the detriment of
calcium. It has the added disadvantage of combining with National guidelines on infant and young child
certain fatty acids to form non-soluble calcium soaps. feeding
WEANING : Weaning is not sudden withdrawal of child from In view of the vulnerability of young infant to the risk of
the breast. It is a gradual process starting around the age of 6 breast milk substiutes, the Government of India enacted the
months, because the mother’s milk alone is not sufficient to Infant Milk Substitutes, Feeding Bottles and Infant Food
sustain growth beyond 6 months. It should be supplemented (Regulation of Production, Supply and Distribution) Act 1992.
by suitable foods rich in protein and other nutrients. These It came into force on 1st Aug. 1993. It prohibits the promotion
are called “supplementary foods”. These are usually cow’s of infant food, infant milk substitutes and feeding bottles as
milk, fruit juice, soft cooked rice, suji, dhal and vegetables. Government of India is committed to promote breast-feeding.
The weaning period is the most crucial period in child The new norms of infant and young child feeding i.e.,
development, for during the weaning process children are exclusive breast-feeding for the first 6 months (replacing the
particularly exposed to the deleterious synergistic interaction 4-6 months age range of earlier guidelines), introduction of
of malnutrition and infection. Weaning, if not done properly, complementary foods at 6 months while continuing breast­
is often followed by diarrhoea and months of growth failure feeding upto the age of 2 years or beyond; replaces the
leading to kwashiorkor, marasmus and immunodeficiency previous policy. The infant milk substitutes, feeding bottles
marked by recurrent and persistent infections which may be and infant foods (Regulation of Production, Supply and
fatal. A knowledge of weaning foods and practices is an Distribution) Amendment Act 2003, was passed and came
important aspect of preventive and social paediatrics. At the into action since 1st January 2004 (38). Goals set to be
age of one year, the child should receive solid foods achieved by the year 2007 were :
consisting of cereals, pulses, vegetables and fruits. There is
1. Intensify nutrition and health education to improve

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now enough evidence to show that children can be properly
infant and child feeding and caring practices so as to
weaned by local foods of a kind usually consumed by the
(a) bring down the prevalence of under-weight
older children and adults in their families. Efforts should
children under three years from the current level of
therefore be made to design and promote the use of
47 per cent to 40 per cent; (b) reduce prevalence of
adequate home-made weaning foods.
severe undernutrition in children in the 0-6 years age
Baby friendly hospitals initiatives (2018)^ group by 50 per cent;
2. Enhance early institution of breast feeding (colostrum
(Since lg93 WHO’s efforts to improve infant and young feeding) from the current level of 15.8 per cent to
child nutrition have focused on promoting breast feeding. It 50 per cent;
has been calculated that breast feeding could prevent deaths
3. Enhance the exclusive breast-feeding rate for the
of at least one million children a year. A “baby-friendly
first six months from the current rate of 55.2 per cent
hospital -initiative” (BFHI), created and promoted by WHO
(for 0-3 months) to 80 per cent; and
and UNICEE has proved highly successful in encouraging
proper infant feeding practices, starting at birth (41). BFHI is 4. Enhance the complementary feeding rate at six months
supported by the major professional medical and nursing from the current level of 33.5 per cent to 75 per cent.
bodies in India. The implementation guidelines have been
revised recently in the year 2018. The ten steps summarize a GROWTH AND DEVELOPMENT
package of policies and procedures that facilities providing
maternity and newborn services should implement to 1. Definition
support breastfeeding. The steps are : (la) Comply fully_wiih A phenomenon peculiar to the paediatric age group is
the international code of marketing of breast-milk substitutes growth and development. The term growth refers to increase
and relevant World Health~Assembly resolutions; (lb) Havg_a^ in the physical size of the body, and development to increase
written infant feeding policy that is routinely communicated in skills and functions. Growth and development are
to staff and parents; (lc) Establish ongoing monitoring and considered together because the child grows and develops as
data^management system; ~ (2) Ensure that staff have a whole. Growth and development include not only physical
sufficient knowledge, competence and skills to support aspect, but also intellectual, emotional and social aspects.
breastfeeding; (3) Discuss the importance and management Normal growth and development take place only if there is
of breastfeeding with pregnant women and their families; optimal nutrition, if there is freedom from recurrent episodes
(4) Facilitate immediate and uninterrupted skin _to_skin of infections, and if there is freedom from adverse genetic
contact and supporLmothers to initiate breastfeeding as soon and environmental influences. MCH care is concerned with
as possible after birth; (5) Support mothers to initiate and the process of growth and development, which is the
maintairfTreastfeeding and mhnage common difficulties; foundation of human life. It is the nature of this process of
(6) Do not provide breastfed newborn^any food or fluids physical and psychological growth and development of the
other than breast milk, unless medically indicated; (7) Enable child which is crucial for health or ill-health, for life or death.
mothers ancFfHeir infants to remain together and to practice
rooming-in24jiours a day; (8) Support mothers to recognize Determinants of growth and development
and respond to their infant’s cue's for feeding; (9) Counsell It is beyond the scope of this book to delve into the
mothers on the use and risk of feeding bottles, teats ancT subject of growth and development which indeed is a vast

by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS
618______
one, except to make a passing reference to some of the more life. The study of normal development and its determinants
important factors influencing it. Briefly these are : is the basis for paediatric education.
(1) GENETIC INHERITANCE : Genetic factors influence The process of growth from birth to age 20 may be
growth and development, especially height and weight, represented diagrammatically in 3 curves (Fig. 4) which
mental and social development and personality. shows the level accomplished (as a percentage of
(2) NUTRITION : Nutrition influences growth and development between birth and maturity). These curves are
development before as well as after birth. In fact, retardation so drawn that height at age 20 corresponds to 100 on the
of growth rate is an indication of malnutrition. When the vertical scale. It will be seen from Fig. 4 that the growth of
diet is improved the child begins to grow in height and the brain is spectacular during the pre-school age.
weight. (3) AGE : Growth rate is maximum during foetal life,
during the first year of life and then again at puberty. At 2. Normal growth
other periods, growth is slower. (4) SEX : At about the age of
10 to 11 years, female children show a sudden increase in CONCEPT OF NORMALITY
height and weight. This growth spurt corresponds to When speaking of human growth and development,
puberty. In male children, the growth spurt occurs a little mention must be made of the difficulty of defining normality.
later, i.e., between 12 and 13 years. (5) PHYSICAL A normal child may be defined as one whose characteristics
SURROUNDINGS : Sunshine, good housing, lighting and fall within the range of measurements accepted as normal
ventilation have their effects on growth and development for the majority of children in the same (or reference) age
(6) PSYCHOLOGICAL FACTORS: Love, tender care and group. Conventionally, these limits - the limits of normal
proper child-parent relationship do affect the social, variation - are assumed to include two standard deviations
emotional and intellectual development of children. above and below the mean (i.e., between the 3rd and the
(7) INFECTIONS AND PARASITOSIS : Certain infections of 97th centiles). This presupposes the availability of accurate
the mother during pregnancy (e.g., rubella, syphilis) affect measurement techniques of growth, and a satisfactory set of
the intrauterine growth of the foetus. Infections after birth reference values or standards for comparison.
(e.g., diarrhoea, measles) slow down growth and
development, especially in the malnourished child. The As far as physical development is concerned, we have
intestinal parasites (e.g., roundworms) by consuming measurement techniques. For example, we measure growth in
considerable quantities of nutrients hamper growth and terms of kilograms and centimetres. But very great difficulties
are encountered in connection with psychomotor, emotional

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development. (8) ECONOMIC FACTORS : The standard of
living of the family is an important factor. Children from and social development; most measurement techniques are
well-to-do families have better height and weight. The based on observations such as “milestones of development.”
economic factor is connected with the nutrition and living of
the people. (9) OTHER FACTORS: These comprise the birth Methods of assessment (44, 45)
order of the child, birth spacing, birth weight in single and In children, the parameters of growth generally used are :
multiple pregnancies, education of the parents, etc. In short, weight, height (or length in infants), and head and chest
a normal childhood implies proper physical, mental and circumferences. These characteristics are measured and
emotional development, and is a prerequisite for a full adult compared with the reference standards. Three methods are

FIG. 4
Growth after birth

by R△J
 GROWTH AND DEVELOPMENT 619
generally used for making comparisons : (i) The first method develop their own reference standards; in the interim,
is based on mean (or median) values. The median, rather the WHO reference value should provide an effective
than mean is used where possible because of the skewed substitute (47).
distribution of most anthropometric measurements.
A variation of 2 standard deviations from either side of the Reference versus standard values
mean (or median) is considered as within normal limits; A distinction must be made between reference values and
(ii) The second method is by means of percentile or standard values. If the values are derived from a population,
(centiles). Percentiles are easier to understand than standard racially different from the population under study, such
deviations. Percentiles refer to the percentage of individuals values should be considered as reference values only and
falling below a particular level. By definition 3 per cent of not as standard values (52). That is, reference values cannot
children are below the 3rd percentile, and a further 3 per be used as standard values applicable to a population
cent are above the 97th percentile. The remaining 94 per racially different. For example, it would be absurd to apply
cent of individuals who fall between these two lines the Harvard standards of growth to Pigmies and Eskimos
(i.e. between 3rd and 97th percentiles) should therefore be who are racially different (51).
regarded as being within the range of “normal.” However,
the 6 per cent of the children outside this range may not Surveillance of growth and development
necessarily be “abnormal”, particularly if their growth is Surveillance of growth and development is a specific
parallel with their centile lines. A measurement outside function of the mother and child health services. It is an
3 standard deviation (above 99th and below 1st centile) is important component of the routine anticipatory care of
more likely to indicate a significant degree of abnormality; children. The main purpose of growth surveillance is to
and (iii) Thirdly, it is also possible to assess the growth of a identify those children who are not growing normally.
child by such indices as weight for length, and weight for Surveillance also reflects the effectiveness of other
height. These are age-independent indices. components of child care such as nutrition, sanitation and
The assessment of growth may be longitudinal or cross- control of infection. Surveillance of growth and
sectional. Longitudinal assessment of growth entails development covers the following aspects :
measuring the same child at regular intervals. This provides
valuable data about a child’s progress. Cross-sectional PHYSICAL GROWTH
studies are also essential to compare a child’s growth with 1. Weight-for-age

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that of his peers. Cross-sectional comparisons involve large Measurement of weight and rate of gain in weight are the
number of children of the same age. These children are best single parameters for assessing physical growth. A
measured and the range of their measurements (e.g., single weight record only indicates the child’s size at the
weight, height) is plotted, usually on percentile charts. moment; it does not give any information about whether a
Reference values child’s weight is increasing, stationary or declining. This is
because, normal variation in weight at a given age is wide.
For national and international comparisons and for What is important is careful repeated measurement at
monitoring, reference or “standard” values of growth are intervals, ideally monthly, from birth to 1 year, every two
essential. The well known reference standards are : months during the second year and every 3 months
(i) Harvard (or Boston) standards (46) : These are based on thereafter upto 5 years of age, since this age group is at
observations made on children in Boston from 1930 to greatest risk from growth faltering. By comparing the
1956. They have been carefully compiled longitudinally on a measurements with reference standards of weight of children
large series of children, mostly from North European origin. of the same age (Table 7), the trend of growth becomes
They became widely used throughout the world; (ii) WHO obvious. This is best done on growth chart. Serial weighing
reference values (47, 48) : The Harvard values were is also useful to interpret the progress of growth when the
replaced by WHO reference values for weight and height. age of the child is not known. Thus, without the aid of a
These values were based on extensive cross-sectional data growth chart, it is virtually impossible to detect changes in
assembled by the United States National Centre for Health the rate of growth, such as sudden loss of weight or halt in
Statistics (NCHS) which were considered the best available gain. Each baby should have its own growth chart.
for international use. The WHO reference values are used
for children upto 5 years of age since the influence of ethnic A baby should gain at least 500 gram wt. per month in
or genetic factors on young children at this age period is the first three months of life. That is the minimum. The
considered insignificant, given the similar socio-economic children who gain less weight are malnourished. It is usual
environment; and (iii) Indian standards (49) : The Indian for babies to gain about 1 kg a month, especially in the first
Council of Medical Research (ICMR) undertook a 3 months. Healthy babies, on an average double their birth
nationwide cross-sectional study during the year 1956 and weight by 5 months, and treble it by the end of first year and
1965 to establish the much needed reference standards of quadruple by the age of two. During the first year, weight
growth and development of Indian children, for the country increases by about 7 kg. After that the increase in weight is
as a whole, as well as for each of the states in the country. As not so fast - only about 2.5 kg during the second year and
the Indian data are based on measurements of children from then until puberty by about 2 kg per year. The weight
belonging to the lower socio-economic groups which form and height gain patterns in India are as shown in Table 8.
the majority of Indian communities, the values cannot be In different parts of India, the average birth weight is
considered as representing standard values (50). between 2.7 and 2.9 kg (54). The Indian infant manages to
The use of local standards of reference is not grow well upto the age of 3-4 months, even at the expense
recommended unless these are based on well-nourished and of its malnourished mother. Thereafter, the growth falters
healthy samples of local population. Further, local standards due to lack of supplementary feeding (55). However, Indian
do not permit international comparisons (51). It was the children from well-to-do families display growth patterns as
opinion of WHO that countries or regions might eventually good as their counterparts in the Western world (49).
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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

TABLE 7
2006 - WHO standards of weight for age of boys and girls upto the age of 5 years (kg)
Boys Girls
Anc> fmrinthcl
-2SD Median + 2SD -2SD Median +2SD

0 2.5 3.3 4.4 2.4 3.2 4.2

4 5.6 7.0 87 5.0 6.4 8.2
8 6.9 8.6 10.7 6.3 7.9 10.2
12 7.7 9.6 12.0 7.0 8.9 11.5
16 8.4 10.5 13.1 7.7 9.8 12.6
20 9.1 11.3 14.2 8.2 10.4 13.5
24 9.7 12.2 15.3 9.0 11.5 14.8
28 10.2 12.9 16.3 9.7 12.3 16.0
32 10.8 13.7 17.4 10.3 13.1 17 1
36 11.3 14.3 18.3 10.8 13.9 18.1
40 11.8 15.0 19.3 11.3 14.6 19.2
44 12.2 15.7 20.2 11.8 15.3 20.4
48 12.7 16.3 21.2 12.3 16.1 21.5
52 13 2 17.0 22.2 12.8 16.8 22.6
56 13.6 17.7 23.2 13.3 17.5 23.8
60 14.1 18.3 24.2 13.7 18.2 24.9

Source : (53)

TABLE 8 something like 20 cm in their height, and girls gain about

16 cm. The spurt is followed by a rapid slowing of growth.
Average weight and height increase during the first 5 years
Indian girls reach 98 per cent of their final height on an

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Age Increments average by the age of 16.5 years, and boys reach the same
stage by the age of 17.75 years. With the exception of a few
Weight increments per week ethnic groups, there is evidence showing that all children
0-3 months 200 g have a similar growth potential.
4-6 months 150 g
Height is a stable measurement of growth as opposed to
7-9 months 100 g
body weight. Whereas weight reflects only the present health
10-12 months 50 - 75 g
status of the child, height indicates the events in the past
Weight increments per year also. The use of growth (height) centile chart is particularly
1-2 years 2.5 kg valuable in studying the trend of height curve.
3-5 years 2.0 kg
Low height for age : This is also known as nutritional
Length increments per year stunting or dwarfing. It reflects past or chronic malnutrition.
1st year 25 cm The cut-off point commonly taken for the diagnosis of
2nd year 12 cm stunting is 90 per cent of the United States NCHS height-for­
3rd year 9 cm age values (56). Waterlow recorded the use of 2SD below
4th year 7 cm the median reference as the cut-off point.
Sth year 6 cm
3. Weight-for-height
Source : (52) Height and weight are interrelated. Weight in relation to
Weight-for-age is often used to classify malnutrition and height is now considered more important than weight alone. It
determine its prevalence. Jelliffe suggested that 80 per cent of helps to determine whether a child is within range of “normal”
the median weight-for-age of the reference be the cut-off point weight for his height. For example, a child on the 75th centile
below which children could be considered malnourished. of both his height and weight is neither overweight nor under­
weight, but a child on the 75th centile of his weight chart and
2. Height (length)-for-age the 25th centile of his height chart is clearly overweight.
Height should be taken in a standing position without Low weight for height : This is also known as nutritional
foot wear. If the height machine is not available, the wasting or emaciation (acute malnutrition). It is associated
measuring scale fixed to the wall can be employed. This with an increased risk of mortality and morbidity (56).
arrangement is suitable for children 2 years and above. The A child who is less than 70 per cent of the expected weight-
measuring scale should be capable of measuring to an for-height is classed as severely wasted.
accuracy of 0.1 cm (48). A very great effort should be made The WHO has compiled reference value for children giving
to measure children accurately. Errors in the measurement weight according to height. For details see reference 53.
of a young child may lead to significant errors in the
classification of the nutritional status. The WHO standards Weight records
(2006) for height-for-age are as shown in Table 9. Weight records are generally kept by all infant clinics; the
The length of a baby at birth is about 50 cm. It increases aim is the prevention of underfeeding, and in the developing
by about 25 cm during first year, and by another 12 cm world, the weight chart is an important tool in the
during the second year. During growth spurt, boys add prevention of malnutrition.
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 GROWTH AND DEVELOPMENT
6.21
TABLE 9
2006 - WHO standards for length/height-for-age of boys and girls upto the age of 5 years (cm)
Boys Girls
Age (months)
-2SD Median + 2SD -2SD Median +2SD
0 46.1 49.9 53.7 45.4 49.1 52.9
4 59.7 63.9 68.0 57.8 62.1 66.4
8 66.2 70.6 75.0 64.0 68.7 73.5
12 71.0 75.7 80.5 68.9 74.0 79.2
16 75.0 80.2 85.4 73.0 78.6 84.2
20 77.7 83.2 88.8 76.7 82.7 88.7
24 81.7 87.8 93.9 80.0 86.4 92.9
28 83.8 90.4 97.0 82.2 89.1 96.0
32 86.4 93.4 100.4 84.9 92.2 99.4
36 88.7 96.1 103 5 87.4 95.1 102,7
40 90.9 98.6 106.4 89.8 97.7 105.7
44 93.0 101.0 109.1 92.0 100.3 108.6
48 94.9 103.3 111.7 94.1 102.7 111.3
52 96.9 105.6 114.2 96.1 105.0 114.0
56 98.8 107.8 116.7 98.1 107.3 116.5
60 100.7 110 0 119.2 99.9 1094 118 9

Source : (53)

4. Head and chest circumference 2. Personal-social development;

At birth the head circumference is about 34 cm. It is 3. Adaptive development; and
about 2 cm more than the chest circumference. By 6 to 4. Language development.
9 months, the two measurements become equal, after which The developmental landmarks or milestones of
the chest circumference overtakes the head circumference. development provide an estimate of the time when the child

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In severely malnourished children, this overtaking may be can be expected to attain certain skills or points in
delayed by 3 to 4 years due to poor development of the development. Since the milestones are averages, each child
thoracic cage. In a ICMR study (49), the crossing over of is bound to differ from the other. For instance, some children
chest and head circumference did not take place until the sit up and speak earlier than others. Table 10 shows some of
age of two years and six months. This has been attributed to the normal developmental milestones and ages at which
growth retardation in poor Indian children. these are reached in the Indian context. When a child takes
Besides increase in height and weight, the term “growth” longer time to cross these milestones, the possibility of his
also includes various physiological events which occur at being mentally handicapped should not be overlooked.
predictable periods such as, dentition, ossification of bones The behavioural development of the child is a complex
and secondary sexual characteristics. affair. The work of ethnologists and sociologists show how
BEHAVIOURAL DEVELOPMENT quickly the child’s behaviour conform to the models adult
society offers them. For proper behaviour development, the
A closely related development is behavioural child must be assured emotional and moral stability, that is,
development. It is assessed in four fields : a home where he will find bonds of affection, regular
1. Motor development; discipline and parents who accept him and provide him with

TABLE 10
Milestones of development
The ‘milestones’ given here are approximations and to assess any individual child, all types of growth development
and behaviour must be taken into account.
Motor Language Adaptive Socio-personal
Age development development development development

6-8 weeks - - Looks at mother and smiles

3 months Holds head erect - - -
4-5 months - listening begins to reach recognizes mother
out for objects
6-8 months sits without support experimenting transfers objects enjoys hide
with noises hand to hand and seek
9-10 months crawling increasing releases objects suspicious of strangers
range of sounds
10-11 months stands with support first words
12-14 months walks wide base builds
18-21 months walks narrow base joining words beginning to explore
beginning to run
24 months runs short sentences dry by day

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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS
622
models of balanced conduct. Many children will not breast-fed infants and young children (0 to 60 months boys
find themselves in ideal conditions. They consequently and girls) from widely diverse ethnic background and
have trouble with behaviour, speech, sleep and appetite cultural settings. In addition their mothers followed health
and these problems will have to be anticipated, diagnosed practices such as breast feeding their children, and not
and treated. smoking during and after pregnancy.
The new standards were generated for boys and girls
THE GROWTH CHART aged 0-60 months - percentile and Z-score curves for
length/height-for-age, weight-for-age, weight-for-lerigth,
Clhe growth or “road-to-health” chart (first designed by
weight-for-height and BMI-for-age. The last standard is an
David Morley and later modified by WHO) is a visible display
addition of the set of indicators previously available as part
of the child’s physical growth and development. It is designed of the NCHS/WHO reference.
primarily for the longitudinal follow-up (growth monitoring)
of a child, so that changes over time can be interpreted^ As expected, there are notable differences with the
NCHO/WHO reference that vary by age, sex,
It is important to note that in the weight-for-age chart, the anthropometric measure and specific percentile or Z-score
height of the child is not taken into consideration. This is curve. Differences are particularly important in infancy.
becauseweight is the most sensitive measure of growth, and Stunting will be greater throughout childhood when assessed
any deviation from “normal” can be detected easily by using the new WHO standards compared to the NCHS/
comparison with reference curves. A child can lose WHO reference. The growth pattern of breast-fed infant will
weight, but not height. In short, the growth chart offers a result in a substantial increase in rates of underweight during
simple and inexpensive way of monitoring weight gain, and the first half of infancy and a decrease thereafter. For
in factchUdTfealth over time. wasting, the main difference is during infancy when wasting
1. WHO child growth standards, 2006 (53) rate will be substantially higher using the new WHO
standards. With respect to overweight, use of the new
In 1993 the WHO undertook a comprehensive review of standards will result in a greater prevalence that will vary by
the uses and interpretation of anthropometric references. age, sex and nutritional status of the index population.
The review concluded that the NCHS growth references,
The new WHO standards depict normal early childhood
which had been recommended for international use since
the late 1970s, did not adequately represent early childhood growth under optimal environmental conditions and can be
used to assess children everywhere, regardless of ethnicity,

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growth and that new growth curves were necessary. A
Multicentre Growth Referenece Study (MG RS) was socio-economic status and type of feeding.
undertaken between 1997 and 2003 in Brazil, Ghana, India, Fig. 5 and 6 show the comparison of WHO with NCHS
Norway, Oman and USA and primary growth data and weight-for-age reference curve from birth to 5 years of age
related information were gathered from 9,440 healthy for boys and girls respectively (53).

Comparison of WHO with NCHS weight-for-age Z-scores for boys

Source : (53)

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 THE GROWTH CHART 623

02468 12 16 20 24 28 32 36 40 44 48 52 56 60
Age (months)

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FIG. 6
Comparison of WHO with NCHS weight-for-age Z-scores for girls
Source : (53)

2. Growth chart used in India signals growth failure, which is the earliest sign of the
India has adopted the new WHO Child Growth Standards protein-energy malnutrition and may precede clinical signs
(2006) in February 2009, for monitoring the young child by weeks and months. Such a child needs special care. The
growth and development within the National Rural Health objective in child care is to keep the child in normal zone.
Mission and the ICDS. The same standards will be used for Uses of growth chart
research too in future.
A growth chart has many potential uses :
These standards are available for both boys and girls
below 5 years of age. With these new standards the child 1. for growth monitoring which is of great value in
care workers will know when the nutrition and care needs of child health care;
the child is being compromised and it will enable them to 2. diagnostic tool: for identifying “high-risk” children.
take timely corrective action at different levels. For example, malnutrition can be detected long
A joint “Mother and Cjiild Protection Card” has been before signs and symptoms of it become apparent;
developed, as shown in Fig. 7 and 8, which provides space 3. planning and policy making: by grading
for recording the family identification and registration, birth^ malnutrition, it provides an objective basis for
record, pregnancy record, institutional identification, care planning and policy making in relation to child
during pregnancy, preparation for. delivery, registration health care at the local and central levels;
under JananTSuraksha Yojana, details about immunization 4. educational-tool: because of its visual character,
procedures, breast-feeding and introduction _ of the mother can be educated in the care of her own
supplementary food, milestones of the baby, birth spacing child and encourage her to participate more
and reasons forspecial care. The chart is easily understood actively in growth monitoring;
by the health workers and the mother, with a vi§ua[record of 5. tool for action: it helps the health worker on the
the health and nutritional status of the child. It is kept By the type of intervention that is needed; it will help to
motherland brought to the health centre at each visit. make referrals easier;
The growth chart shows normal zone of weight for age, 6. evaluation: it provides a good method to evaluate
undernutrition (below -2SD) and severely underweight zone the effectiveness of corrective measures and the
(below -3SD). In some states like Maharashtra, the impact of a programme or of special interventions
growth chart contains normal weight for age zone and for improving child growth and development; and
undernutrition zone of grade one, second, third and fourth. 7. tool for teaching: it can also be used for
Ht is the direction of growth that is more important than the teaching, for example, the importance of adequate
position of dots on the line. The importance of the direction feeding; the deleterious effects of diarrhoea.
of growth is illustrated at”the Jeft hand, upper corner of The growth chart has been described as a passport to
the chart. Flattening or falling *of the child's weight curve child health care (57). It has won international recognition

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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

and is now a standard method of monitoring children’s 1. Large numbers

health and nutritional status. Pre-school age children (1-4 years) represent about
Alternative methods of growth monitoring 9.7 per cent of the general population in India. A large
majority of these children live in rural and tribal areas and in
Growth charting is only one method of growth monitoring. urban slums. By virtue of their numbers, they are entitled to
There are other indicators such as height-for-age, weight-for- a large share of health and social services. Further, children
height, and arm circumference. The last two are independent are the human resources of the future. Their development is
of age and are particularly useful when age is not known. in the interest of the total national development; therefore,
they need special attention. Unfortunately, pre-school age
CARE OF THE PRE-SCHOOL CHILD children are comparatively less attended to.
Children between 1-4 years of age are generally called pre­
school age children or toddlers. In the history of health services 2. Mortality
of many developing countries, their social and health needs The pre-school age (1-4 years) mortality in India is
were realized rather late. Today, more than ever before, the pre­ 2.3 per cent of all deaths. This high mortality which is largely
school age child has become a focus for organized medical­ due to infection and malnutrition is characteristic of this age
social welfare activities, and their death rate is considered a group in underprivileged areas. Malnutrition was shown
significant indicator of the social situation in a country. to be an underlying cause in 3.4 per cent of all deaths
The pre-school age is distinguished by the following in young children and associated cause in no less than
characteristics : 46 per cent (40).

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Have your child weighed at the AWC every month

FIG. 7
ICDS growth chart for boys

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 CARE OF THE PRE-SCHOOL CHILD

zW GIRLS: Weight-for-age - Birth to 3 years

(As per WHO Child Growth Standards)

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Ensure equal care for the girl child

FIG. 8
ICDS growth chart for girls

3. Morbidity accidents. Some childhood diseases and conditions do not

The data on the extent of morbidity of pre-school kill their victims, but cause serious disability (e.g., blindness,
children are scarce. Some hospital records and a few surveys paralysis); and some diseases become manifest later in life
(e.g., heart disease and mental retardation). In many
suggest that children in this age group are usually victims of
PEM accompanied by retarded growth and development. developing countries, periods of illness take up 25-30 per
Surveys indicate that the main morbidity problems are cent of the child’s life and each represents either loss of
malnutrition and infections. The prevalence of severe weight or failure to gain weight. These episodes are well
protein-energy malnutrition ranged between 5-6 per cent, documented by several authors (55).
and mild protein energy malnutrition about 40 per cent.
4. Growth and development
PEM is often associated with other nutritional deficiency
such as anaemia, xerophthalmia, etc. Diarrhoea, diphtheria, The importance of the first 5 or 6 years of life of a child
tetanus, whooping cough, measles and other eruptive for its growth and development is well known. Any adverse
fevers, skin and eye infections, and intestinal parasitic influences operating on children during this period (e.g.,
infestations are usually common under the existing malnutrition and infection) may result in severe limitations
environmental conditions. Atleast 5 per cent of the pre­ in their development, some of which at least are irreversible.
school age children belonging to poor socio-economic The concept of vulnerability calls for preventive care and
groups show signs of vitamin A deficiency. Accidents are special actions to meet the biological and psychological
also becoming frequent, especially burns and trauma from needs inherent in the process of human growth and
home accidents, and to an increasing degree, traffic development (33).

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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

5. Accessibility boys on all three measures. The prevalence of stunting

While the infant may be easily reached, the toddler is hard increases with a child’s age from 6-8 months through 6-23
to reach, and it is therefore difficult to look after his health. months, and it decreases slightly thereafter. Over 44 per cent
Special inputs are needed (e.g., day care centres, play group of children who were reported to be very small at birth are
centres, children’s clubs) to reach the toddler and to bring him stunted, compared with 35 per cent of children who were of
into the orbit of health care. Operations research all over the average size or larger. Children born to thin mothers (BMI less
world has demonstrated that parents are unlikely to travel than 18.5 kg/m2) are more likely to be stunted, wasted, and
more than 5-8 kms to obtain medical care. For the toddler who underweight than children born to mothers with a normal
needs to be carried, the distance may be reduced even further. BMI, stunting is higher in rural areas (37 per cent) than in
urban areas (30 per cent). 46 per cent of children born to
6. Prevention in childhood of health problems in mothers with no schooling are stunted, compared to 26 per
adult life cent of children born to mothers with 12 or more years of
schooling. The corresponding proportion of underweight
Results of research indicate how events in early life (e.g. children are 42 and 23 per cent respectively. The prevalence
child’s diet, infections) affect its health when it becomes an of stunting decreases steadily with an increase in wealth
adult, and how many conditions can be prevented through quintiles, from 46 per cent of children in households in the
early action, for example, dental diseases in adulthood. Early lowest wealth quintile to 23 per cent of children in households
treatment of streptococcal infection can prevent rheumatic in the highest wealth quintile. Prevalence of stunting in
heart disease. Longitudinal studies suggest that the children under five years age is highest in Meghalaya (47 per
foundations of obesity, hypertension, cardiovascular diseases, cent), followed by Bihar (43 per cent), Uttar Pradesh and
and certain mental disorders may be laid in early life. Some of Jharkhand (40 per cent each), and it is lowest in Puducherry
the chronic orthopaedic ailments of the adult are probably (20 per cent) and Sikkim (22 per cent). Bihar has the highest
connected with anomalies in the development or minor level of underweight children (41 per cent). Maharashtra has
uncorrected infirmities of the infant (e.g. talipes, congenital the highest level of wasting (26 per cent) (58).
dislocation of the hip). Many of the measures subsequently
undertaken to treat these disorders often do not fully succeed. Malnutrition makes the child more susceptible to
infection, recovery is slower and mortality is higher.
Since young children are “vulnerable” to social and Undernourished children do not grow to their full potential
health hazards which can retard or arrest their physical and of physical and mental abilities. Malnutrition in infancy and
mental development during these critical years, they deserve childhood leads to stunted growth. It also manifests by

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special attention by the administration, general population clinical signs of micronutrient and vitamin deficiencies.
and the family. Prevention and appropriate treatment of diarrhoea, measles
and other infections in infancy and early childhood are
CHILD HEALTH PROBLEMS important to reduce malnutrition rates as infection and
The problems facing the health worker in the developing malnutrition often make vicious cycle. Exclusive breast­
world are vast and are nowhere more evident than in the feeding in first 6 months of life is very important.
field of childcare. The main health problems encountered in Specific nutritional deficiencies
the child population comprise the following :
1. low birth weight; (a) Protein-energy malnutrition
2. malnutrition; Protein-energy malnutrition (PEM) has been identified as
3. infections and parasitosis; a major health and nutrition problem in India. It occurs
4. accidents and poisoning; and particularly in weaklings and children in the first years of
5. behavioural problems. life. It is characterized by low birth weight if the mother is
malnourished, poor growth in children and high level of
1. Low birth weight mortality in children between 12 and 24 months, and is
This has been discussed in detail earlier. estimated to be an underlying cause in 30 per cent of deaths
among children under age 5.
2. Malnutrition As many as 27 per cent of the children in the low income
Malnutrition is the most widespread condition affecting countries have low height for their age i.e. stunting, and
the health of children. Scarcity of suitable foods, lack of 17 per cent children have low weight for height. The rate of
purchasing power of the family as well as traditional beliefs low height for age reflects the cumulative effects of
and taboos about what the baby should eat, often lead to an undernutrition and infections since birth or even before
insufficient balanced diet, resulting in malnutrition. It is birth; high rates are often suggestive of bad environmental
estimated that no less than 45 per cent of the children who conditions and/or early malnutrition. On the other hand, a
died before the age of 5 years were found to have greater frequency of low weight' for height, often reflects
malnutrition *as underlying factor and 80 per cent of newborn current severe undernutrition or disease. The scenario in
mortality occurs in babies who are of low birth weight (55). India is discussed in detail under the heading malnutrition.
During 2020, more than 22 per cent of the world’s children
under the age of 5 years were stunted and 6.7 per cent were (b) Micronutrient malnutrition
having wasting for their age. The proportion ranged from 0.7 Micronutrient malnutrition refers to a group of conditions
per cent of children in the Regions of Americas to 14.1 per caused by deficiency of essential vitamins and minerals such
cent in the countries of South East Asia Region (59). In India, as vitamin A, calcium, iodine, iron and zinc. It is estimated
the National Family Health Survey (NFHS-5) 2019-21 that about 2 billion people are affected by this type of
included survey of the nutritional status of young children. malnutrition. Vitamin A deficiency is still the most common
Both chronic and acute undernutrition were found to be high. cause of preventable childhood blindness worldwide; iodine
The prevalence of undernutrition is almost same among girls deficiency causes goitre, cretinism and brain damage; and
and boys, although, girls are slightly less well nourished than anaemia results from insufficient iron intake.

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 CHILD HEALTH PROBLEMS

Nutritional anaemia : It affects all age groups, including children are frequent in the developing countries also,
pre-school children, school children and elders. Even mild especially burns and trauma as a result of home accidents
anaemia reduces resistance to fatigue. It has a profound and, to an increasing degree, traffic accidents. Children and
effect on psychological and physical behaviour. Overall, young adolescents are particularly vulnerable to domestic
67 per cent of children are having same degree of anaemia, accidents - including falls, burns, poisoning and drowning.
29 per cent of children have mild anaemia, 36 per cent have
moderate anaemia, and 2 percent have severe anaemia (58). 5. Behavioural problems
Vitamin A deficiency and nutritional blindness : Young Behavioural disturbances are notable child health
children are at greater risk of developing xerophthalmia, partly problem, the importance of which is increasingly recognized
because their vitamin A requirements are proportionately in most countries. Children abandoned by their families
greater than those of any other group and partly because they present severe social and health problems. Over 60,000
suffer most from infections. The result is that severe, blinding children are abandoned each year in India (61).
corneal destruction is most frequently seen in children between
the age of six months and six years. Vitamin A deficiency is in 6. Other factors affecting the health of children
fact, the single most frequent cause of blindness among pre­
school children in developing countries. Some 20 per cent a. Maternal health
children with this deficiency are at increased risk of death from A major determinant of child health is the health of his/
common infections, and around 2 per cent are blinded or suffer her mother. Child health is adversely affected (the risk begin
serious sight impairment. to appear even before birth) if the mother is malnourished, if
Iodine deficiency : Iodine deficiency disorders pose a she is under 18 years (too young) or over 35 (too old), if her
public health problem as about 1.5 billion people are living last child was born less than 2 years ago (too close), if she
in environments lacking this mineral. As a result at least has already more than 4 births (too many) and if she is
30,000 babies are stillborn each year and over 120,000 are deprived of basic pregnancy care. A healthy mother brings
born mentally retarded, physically stunted, deaf-mute or forth a healthy baby, with better chances of survival.
paralysed. Even when children are born otherwise healthy,
lack of iodine may still cause mental dullness and apathy. b. Family
Nutritional deficiencies not only lead to severe illnesses, In pre-school years, the child is very much an organic part
entailing long and costly treatment, but also influence of the immediate family. Whatever happens to him or her

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physical development, psychic behaviour and susceptibility affects the other members of the family, and vice versa.
to infection. Therefore, “child health” has to be “family health”. It
depends upon the family’s physical and social environment,
3. Infectious and parasitic diseases which includes its lifestyle, customs, culture, traditional
Young children fall an easy prey to infectious diseases. habits, and the childbearing and childrearing practices are
The leading childhood diseases are : diarrhoea, respiratory greatly influenced by this. The family and social environment
infections, measles, pertussis, polio, neonatal tetanus, has a considerable influence on the development of speech,
tuberculosis, and diphtheria. It is known that a child may get personality and the intellectual potentials of the small child.
affected several times in a year; the incidence increases with Other factors are the family size, the family relationships, and
the aggravation of a state of malnutrition. Of about 4 million family stability. Infancy and early childhood is the time when
deaths a year from acute respiratory infections in the the child contracts common contagious illness from contact
developing world, a quarter are linked to malnutrition, and a with others (elder brothers and sisters, playmates,
further quarter associated with complications of measles, schoolmates). Data shows that the number of episodes of
pertussis, malaria and HIV/AIDS. During 2018, about 8 per infectious diarrhoea increases with the size of the family.
cent of under-five mortality worldwide was due to diarrhoeal Studies also show an increase in the prevalence of
diseases, about 12 per cent due to ARI, about 2 per cent malnutrition in families with more than 4 children. In short,
deaths were due to measles and about 5 per cent due to fewer children would mean better nutrition, better health
malaria. In India, during the year 2020, 1,991 cases of care, less morbidity and lower infant mortality.
diphtheria, 12,081 cases of measles, 11,985 cases of
pertussis, and 162 cases of neonatal tetanus were c. Socio-economic circumstances
reported (60). The actual figures may be several times
higher since there is considerable under-reporting. This is so, The socio-economic situation in which the family is
for example, in the case of eruptive fevers, malaria, placed is a very important factor in child health. In every
intestinal parasites such as ascariasis, hookworm, giardiasis region of the world, the physical and intellectual
and amoebiasis etc. which are common because of poor development of children varies with the family’s socio­
environmental sanitation and paucity of potable drinking economic level. Under-privileged children of the same age
water. The prevention and treatment of children’s illnesses are smaller, lighter and less advanced in psychomotor and
may interrupt the transmission of infection in the intellectual performance, compared to children of privileged
community. group. A detailed analysis of socio-economic factors shows
the part played by the parents’ education, profession and
These few facts, which are merely examples and could be income, their housing, the urban or rural, industrialized or
multiplied, show that the prevention and treatment of
non-industrialized nature of the population.
infections and parasitosis of children are bound to have
important long-term consequences. Poverty, illiteracy (especially mothers’ illiteracy) and
sickness create a vicious circle spanning from one generation
4. Accidents and poisoning to the next, and from which it is difficult for the individual to
In the developed world, accidents and poisoning have escape. The differences in health between rich and poor,
become a relatively more important child health problem. which can be observed in all age-groups are particularly
There is every reason to believe that accidents among striking among children.

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62- PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

d. Environment RIGHTS OF THE WOMEN AND CHILDREN

After the first week of a child’s life, the environmental Women and children are the most vulnerable section of
factors play a very great role as determinants of infant and the society. It is, therefore, vital to improve their health and
childhood morbidity and mortality. Tetanus infection of the well-being in order to achieve complete development of
newborn may take a heavy toll of the newborn in the first few overall human resources.
weeks of life. Diarrhoea, pneumonia and other infections -
bacterial, viral and parasitic - are extremely common in One of the core function assigned to the WHO in its
children exposed to insanitary and hostile environment. The Constitution of 1948 was to “promote maternal and child
stages at which these infections occur vary according to the health and welfare”. By the 1950s, national health plans and
ecological conditions, home and family hygiene, local policy documents from development agencies invariably
epidemiological conditions and the extent to which they come stressed that mothers and children were vulnerable groups
into contact with earth, water and above all with adults and and, therefore, priority “targets” for public health action.
other children. An insufficient supply of safe water, The notion of mother and children as vulnerable group was
inadequate disposal of human excreta and other waste, an also central to the primary health care movement launched
abundance of insects and other disease carriers are among the at Alma-Ata in 1978. The plight of mothers and children
environmental factors continuously menacing family health. soon came to be seen as much more than a problem of
biological vulnerability. The 1987 Call to Action for Safe
Another important factor which influences child Motherhood explicitly framed it as “deeply rooted in the
development is environmental stimulations. Children also adverse social, cultural and economic environment of the
develop skills if they are given the opportunity. Stimulation, society, and specially the environment that societies create
particularly the interaction with people who take interest for women”. Women's relative lack of decision-making
and talk to them helps children to develop. Other sources of power and their unequal access to employment, finances,
environmental stimulation are the radio, TV and illustrated education, basic health care and other resources are
magazines. considered to be the root causes of their ill-health, and that
of their children. The unfairness of this situation has made it
e. Social support and health care obvious that the health of mothers and children is an issue
Other factors affecting the health status of children include of rights, entitlements and day to day struggle to secure
community and social support measures, ranging from creches these entitlements. The milestones in this establishment of
and day care facilities to organized health care systems. the rights of women and children are as shown in Fig. 9 (62).

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The Universal Declaration of Human Rights states that 1948 -
"motherhood and childhood are entitled to special care and The General Conference of the International Labour
- 1952
assistance". Organization adopts the Maternity Protection Convention.
The Declaration of the Rights of the Child. 1959 -

- 1966 The International Covenant on Economic, Social and Cultural

Rights recognizes the right to the highest attainable standard of
physical and mental health.

The Convention on the Elimination of All Forms of 1981 -

Discrimination Against Women enjoins States parties to ensure
appropriate maternal health services.
- 1989 The Convention on the Rights of the Child guarantees children's
At the United Nations World Summit on Children governments 1990 -
declare their "joint commitment... to give every child a better right to health. States commit themselves to ensuring
appropriate maternal health services.
future", and recognize the link between women's rights and
children's well-being.
The United Nations Human Rights Committee expresses 1993 -
concern over high rates of maternal mortality. - 1994 The United Nations International Conference on Population and
- 1995 Development and the United Nations Fourth World Conference
The United Nations Human Rights Committee rules that, when 1996 - on Women affirm women's right of access to appropriate health
abortion gives rise to a criminal penalty even if a woman is care services in pregnancy and childbirth.
pregnant as a result of rape, a woman' right to be free from
inhuman and degrading treatment might be violated.
-2000 The United Nations Committee on Economic, Social and Cultural
Rights states that measures are required to “Improve child and
maternal health, sexual and reproductive health services”.
The United Nations Committee on the Rights of the Child states 2003 2003 The United Nations Commission on Human Rights, states that
that adolescent girls should have access to information on the sexual and reproductive health are integral elements of the right
impact of early marriage and early pregnancy and have access to health.
to health services sensitive to their needs and rights.
The United Nations Committee on the Rights of the Child adopts its
General Comment on HIV/AIDS and that on the Rights of the Child.
The United Nations Committee Against Torture calls for an end to the 2004 2004 The United Nations Sub-Commission on the Promotion and
extraction of confession for prosecution purposes from women Protection of Human Rights adopts a resolution on “harmful
seeking emergency medical care as a result of illegal abortion. The traditional practices affecting the health of women and the girl
United Nations Special Rapporteur on the Right to Health reports that
all forms of sexual violence are inconsistent with the right to health. ▼ child”.

FIG. 9
Milestones in the establishment of the rights of women and children

by R△J
 RIGHTS OF THE CHILD

RIGHTS OF THE CHILD therefore, demands the kind of commitment that will not be
superseded by other priorities. The following are the goals
One of the most encouraging signs of our times is the that have been accepted by almost all nations.
awakening of the public to the needs and rights of children.
The needs of children and our duties towards them are Social goals for the year 2000 (63)
enshrined in our Constitution; the relevant articles are :
The end-of-century goals agreed to by the nations
a. Article 24 prohibits employment of children below following the 1990 World Summit for children were :
the age of 14 in factories;
1. A one-third reduction in 1990 under-five death rates
b. Article 39 prevents abuse of children of tender (or to 70 per 1000 live births, whichever is less);
age; and
2. A halving of 1990 maternal mortality rates;
c. Article 45 provides for free and compulsory
3. A halving of 1990 rates of malnutrition among the
education for all children until they complete the
world’s under-five (to include the elimination of
age of 14 years.
micronutrient deficiencies, support for breast-feeding
In the country’s Five Year Plans, special attention has by all maternity units, and a reduction in the incidence
been given to the welfare of children particularly the weaker of low birth weight to less than 10 per cent;
sections. Various schemes have been introduced and 4. Achievement of 90 per cent immunization among
implemented to achieve this goal. However, despite under-ones, eradication of polio, elimination of
constitutional provisions, organized efforts for stepping up neonatal tetanus, a 90 per cent reduction in measles
child welfare services did not take place until 1959. cases and a 95 per cent reduction in measles deaths
(compared to pre-immunization level);
UN DECLARATION OF THE RIGHTS OF THE CHILD 5. A halving of child deaths caused by diarrhoeal
The year 1959 ushered in a new era in child welfare. To disease;
meet the special needs of the child, the General Assembly of 6. A one-third reduction of child deaths from acute
the United Nations adopted on 20th November 1959, the respiratory infections;
Declaration of the Rights of the Child. India was a signatory 7. Basic education for all children and completion of
to this Declaration. The Rights of the Child are : primary education by at least 80 per cent girls as
1. Right to develop in an atmosphere of affection well as boys;

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and security and, wherever possible, in the care 8. Clean water and safe sanitation for all communities;
and under the responsibility of his/her parents; 9. Acceptance in all countries of the Convention on
2. Right to enjoy the benefits of social security, the Rights of Child, including improved protection
including nutrition, housing and medical care; for children in especially difficult circumstances; and
3. Right to free education; 10. Universal access to high quality family planning
4. Right to full opportunity for play and recreation; information and services in order to prevent
5. Right to a name and nationality; pregnancies that are too early, too closely spaced,
too late or too many.
6. Right to special care, if handicapped;
7. Right to be among the first to receive protection NATIONAL POLICY FOR CHILDREN
and relief in times of disaster;
8. Right to learn to be a useful member of society Keeping in view the constitutional provisions and the
and to develop in a healthy and normal manner United Nations Declaration of the Rights of the Child, the
and in conditions of freedom and dignity; Government of India adopted a National Policy for Children
9. Right to be brought up in a spirit of in August 1974. The Policy declares :
understanding, tolerance, friendship among “It shall be the policy of the State to provide adequate
people, peace and universal brotherhood; and services to children, both before and after birth and
10. Right to enjoy these rights, regardless of race, through the period of growth, to ensure their full physical,
mental and social development. The State shall
colour, sex, religion, national or social origin. progressively increase the scope of such services so that,
within a reasonable time, all children in the country enjoy
UNIVERSAL CHILDREN’S DAY optimum conditions for their balanced growth”.
November 14 is observed as Universal Children’s Day. It was According to the Declaration, the development of
started by the International Union for Child Welfare and the children has been considered an integral part of national
UNICEF. In 1954, the UN General Assembly passed a formal development. The Policy recognizes children as the “nation’s
resolution establishing Universal Children’s Day and assigned supremely important asset” and declares that the nation is
to UNICEF the responsibility for promoting this annual day. responsible for their “nurture and solicitude”. It further spells
A non-governmental organization (Defence for Children out various measures to be adopted and priorities to be
International, Geneva) was set up in 1979 (during the assigned to children’s programmes with a focus on areas like
International Year of the Child) to ensure ongoing, child health, child nutrition and welfare of the handicapped
systematic international action specially directed towards and destitute children.
promoting and protecting the Rights of the Child. A high level National Children’s Board with the Prime
The 1990 World Summit for children agreed on a series Minister as Chairman was established. It provides a forum
of specific social goals for improving the lives of the children where problems relating to child welfare and their purposeful
including measurable progress against malnutrition, development into useful members of society are evolved,
preventable diseases and illiteracy. The vital vulnerable reviewed and coordinated into an effective programme (64).
years of childhood should be given a first call on society’s Following the enunciation of the National Policy for
concerns and capacities. A child has only one chance to Children, a number of programmes were introduced by the
develop normally, and the protection of that one chance, Government of India, viz. The LCDS Scheme, programmes
by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS
630
of supplementary feeding, nutrition education and framework within which to promote the development
production of nutritious food, constitution of the “National and protection of children. The guiding principles of
Children’s Fund” under the Charitable Endowments Act, the NPAC are :
1980, institution of National Awards for Child Welfare, a. To regard the child as an asset and a person with
Welfare of the Handicapped (65). human rights;
b. To address issues of discriminiation emanating
Review of existing policies and legislations (66) from biases of gender, class, caste, race, religion
The Constitution of India follows the principle of and legal status in order to ensure equality;
protective discrimination and thereby commits itself to c. To accord utmost priority to the most
safeguard the rights of children through policies, laws and disadvantaged, poorest of the poor and the least
action. These commitments are reflected through the served child in all policy and programme
national polices which are as follows : interventions; and
1. National Policy for Children, 1974 provides the d. To recognize the diverse stages and settings of
conceptual basis for an integrated approach to address childhood, and address the needs of each,
the whole child and commits the State to provide providing all children the entitlements that fulfill
adequate services to children, both before and after their rights and meet their needs in each situation.
birth and through the period of growth, to ensure their Time targets in the NPAC 2005 extend to 2012, the end-
full physical, mental and social development. year of the Eleventh Plan. The NPAC 2005 has identified
2. National Policy on Education, 1986 and its National 12 key priority areas for the highest and most sustained
Plan of Action, which has a full section on early attention in terms of outreach, programme interventions and
childhood care and education. It clearly recognizes the resource allocations. These are :
holistic nature of child development, and that ECCE is - Reducing infant mortality rate.
the crucial foundation for human resource - Reducing maternal mortality rate.
development and cumulative lifelong learning. It is - Reducing malnutrition among children.
viewed as a feeder and support programme for - Achieving 100% civil registration of births.
universal elementary education - especially for first - Universalization of early childhood care and
generation learners, and an important support service development and quality education for all children

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for working mothers and girls. achieving 100% access and retention in schools,
3. The National Children's Fund was created during the including pre-schools.
international year of the child in 1979 under the - Complete abolition of female foeticide, female
Charitable Endowment Fund Act, 1890. The fund infanticide and child marriage and ensuring the
provides financial assistance to voluntary agencies for survival, development and protection of the girl child.
implementing programmes for the welfare of children - Improving water and sanitation coverage in both rural
including rehabilitation of destitute children. and urban areas.
4. National Health Policy, 2002 accords primacy to - Addressing and upholding the rights of children in
preventive and first line curative care at primary health difficult circumstances.
level, and emphasizes convergence, and strategies to - Securing for all children all legal and social protection,
change care behaviours in families and communities. from all kinds of abuse, exploitation and neglect.
5. National Charter for Children, 2003 intends to secure - Complete abolition of child labour with the aim of
for every child its inherent right to be a child and progressively eliminating all forms of economic
enjoy a healthy and happy childhood, to address the exploitation of children.
root causes that negate the healthy growth and - Monitoring, review, and reform of policies,
development of children, and to awaken the programmes and laws to ensure protection of
conscience of the community in the wider societal children’s interest and rights.
context to protect children from all forms of abuse, - Ensuring child participation and choice in matters and
while strengthening the family, society and the nation. decisions affecting their lives.
The national charter for children affirms India's A new alienation of children from their rights has arisen
commitment to the child. However, it does not declare with the plight of children affected by HIV/AIDS. Since the
India's acceptance of children's entitlements as their finalization of the NPAC the issues of these children have
rights. The national policy for children, 1974 still also been accepted as key priorities by MWCD and therefore
stands as the official policy commitment to children of found a place in the Eleventh Plan among critical concerns
India. With India's accession to the UNCRC and its two that need to be addressed.
optional protocols rights based framework has been
8. Integrated Child Protection Scheme (ICPS) (67, 68)
accepted as the guiding frame for policy measures and
programming for children. This is clearly reflected in During the year 2009-10, the Ministry of Women and
the national plan of action for children, 2005. Child Development launched a new centrally
sponsored scheme called “Integrated Child Protection
6. Commission for the Protection of Child Rights Act, 2005 Scheme” (ICPS) with a view to create a safe and secure
provides for the constitution of a national commission environment in the country for the comprehensive
and state commissions for protection of child rights and development of children who are in need of care and
children’s courts for providing speedy trial of offences protection, children in conflict and in contact with law
against children or of violation of child rights and for (either as a victim or as a witness or due to any other
matters connected therewith or incidental thereto. circumstances), children of migrant families, children of
7. National Plan of Action for Children, 2005 articulates prisoners, prostitutes, working children, street children,
clearly the rights, perspective, and agenda for the trafficked or sexually exploited children, child drug
development of children. It provides a robust abusers, child beggars etc.
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 NATIONAL POLICY FOR CHILDREN 631
The objectives of the scheme are : (1) Improve access to 10. Protection of Children from Sexual Offences (POCSO)
and quality of child protection services; (2) Raise public Act, 2012
awareness about child rights; (3) Clearly articulated In order to effectively address the heinous crime of
responsibilities and accountability for child protection; sexual abuse and sexual exploitation of children
(4) Establish structures at all government levels for through less ambiguous and more stringent legal
delivery of statutory and support services to children in provisions, the Ministry of Women and Child
difficult circumstances; and (5) Setting-up of an Development introduced the Protection of Children
evidence based monitoring and evaluation system. from Sexual Offences (POCSO) Act, 2012.
The services provided under ICPS are as follows : The Act defines a child as any person below 18 years of
(1) Emergency outreach service through ‘Child line’, age and regards the best interest and well-being of a
dedicated number is 1098. It is a 24-hour toll free child as being of paramount importance at every stage,
telephone service available to all children in distress. to ensure a healthy physical, emotional, intellectual
(2) Open shelters for children in need, in urban and and social development of the child. It defines different
semi-urban areas. forms of sexual abuse, including penetrative and non-
(3) Family based non-institutional care through penetrative assault, as well as sexual harassment and
sponsorship, foster-care, adoption, cradle baby pornography, and deems a sexual assault to be
centres and after-care. “aggravated” under certain circumstances, such as
(4) Institutional services through shelter homes, children when abused child is mentally ill or when the abuse is
homes, observation homes, special homes, and committed by a person in a position of trust or
specialized services for children with special needs. authority vis-a-vis the child, like a family member,
(5) Web-enabled child protection management system police officer, teacher or doctor. People who traffic
including website for missing children. children for sexual purpose are also punishable under
(6) General grant-in-aid for need based interventions. the provisions relating to abetment in the said Act (70).
9. National Policy for Children 2013 (NPC) (69) An ordinance providing the death penalty for rapist of
girls below 12 years of age “The Criminal Law
The National Policy for Children 2013 is a long term Amendment Ordinance, 2018” was promulgated. The
sustainable, multi-sectoral, and integrated approach salient features of the Ordinance are:
for the development and protection of children i.e.

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0-18 years age group. Survival, health, nutrition, a. Minimum punishment for rape made 10 years;
development, education, protection and participation b. Minimum punishment of 20 years to a person
are the key priorities of the policy. It reiterates the committing rape on a girl aged below 16 years;
State’s commitment to ensure equitable access to c. Minimum punishment of 20 years rigorous
essential, preventive, promotive, curative and imprisonment and maximum death penalty / life
rehabilitative health care for all children. Towards this imprisonment for committing rape on a girl aged
goal, NPC envisages that state shall take measures to : below 12 years,
d. Police officer committing rape anywhere shall be
- Improve maternal health care (pre-natal, natal, awarded rigorous imprisonment of minimum
post-natal); 10 years;
- Provide universal access to services for informed . e. Investigation of rape cases to be completed within
choices related to births and spacing; 2 months;
- Address key causes of child mortality through f. Appeals in rape cases to be disposed within 6
appropriate interventions including access to safe months; and
drinking water and sanitation; g. No anticipatory bail can be granted to a person
- To improve new born and child care practices; accused of rape of girl of age less than 16 years.
- To protect children from water borne, blood borne,
The POCSO Act 2012 was further amended in the year
vector borne, communicable and other childhood 2019 with insertion of the following clause :
diseases by providing universal and affordable
access to appropriate services; Under the Act, a person is guilty of using a child for
- Prevent disabilities, physical and mental through pornographic purposes if he uses a child in any form of media
timely measures to take pre-natal, natal, peri-natal for the purpose of sexual gratification. The Act also penalises
and post-natal care of mother and child; persons who use children for pornographic purposes resulting
- Ensure availability of services, support and in sexual assault. The Bill defines child pornography as any
provisions for nutritive attainment in a life cycle visual depiction of sexually explicit conduct involving a child
approach with focus on infant and young child including photograph, video, digital or computer generated
feeding (IYCF) practices and on the health and image indistinguishable from an actual child. The punishment
nutrition needs of adolescent girls and other is minimum 5 years in Jail. The Act penalises storage of
vulnerable groups; pornographic material for commercial purposes with a
- Prevent HIV infections at birth and ensure proper punishment of upto three years, or a fine or both (71).
treatment to infected children; and The POCSO amendment Bill 2020 proposes that child
- Provide the adolescents access to information offenders between 15 and 18 years of age should be covered
regarding ill effects of alcohol and substance use, under the ambit of the POCSO Act 2012 and be given the
and support for the choice of healthy life style. same punishment as is given to adults (72).
The state commits to allocate the required financial, The growing vulnerability of children in urban settlements,
material and human resources for the implementation including those caught in the shifting frame of migratory and
of NPC 2013. The Ministry of Women & Child transient labour are also now in the MWCD portfolio. Their
Development is the nodal ministry for implementation distress and the difficult circumstances of their childhoods
of NPC. merit special measures of development and protection.

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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

11. National Plan of Action for Children, 2016 - Achieve and maintain a cure rate of
The Government of India adopted a new National Plan > 85% in new sputum positive
of Action for Children (NPAC) 2016 which is based on patients of TB and reach elimination
the principles embedded in earlier Action Plan. The level by 2025.
Action Plan has four key priority areas: survival, health - Achieve and maintain elimination
and nutrition; education and development; protection status of leprosy by 2018, Kala-azar
and participation. The NPAC seeks to ensure by 2017 and lymphatic filariasis in
convergence of ongoing programmes and initiation of endemic pockets by 2017.
new programmes so as to focus on objectives through - Antenatal coverage and skilled birth
well-defined strategies and activities to achieve desired attendance at birth above 90 per
level of outcome for children. cent by 2025.
Goals and targets set by Government of India for child - More than 90 per cent full
health under various national and international immunization by one year of age
commitments are as follows (66) : by 2025.
- Reduction of 40 per cent in
CHILD HEALTH GOALS/TARGETS prevalence of stunting of under-five
Common Minimum To raise public spending on health to at children by 2025.
Programme least 2-3% of GDP over the next five - Access to safe water and sanitation
years and focus on primary health care to all by 2020.
...special attention will be paid to the NITI Aayog Three - Reduce infant mortality rate to
poorer sections in the matter of health Year Action 30/1000 live births by 2020.
care. Agenda 2017-18 - Reduce under 5 mortality rate to
Twelfth Five - Reduction of infant mortality rates to 2019-20 38/1000 live births by 2020.
Year Plan to 25 per thousand live births - Reduce incidence of TB to
2012-17 by 2017. 130/100,000 by 2020.
- To raise the sex ratio for age group - Eliminate Kala-azar and lymphatic
0-6 from 914 to 950 by 2017. filariasis.

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- Prevention and reduction of under­ Global Strategy By 2030, end all forms of
nutrition in children under 3 years to for Women’s, malnutrition (stunting and wasting
half of NFHS-3 (2005-06) levels. Children’s and in children under 5 years of age).
National Plan of - To reduce infant mortality rate to Adolescent Health By 2030, end preventable deaths of
Action for below 30 per 1000 live births by (2016-2030) with newborns and children under 5
Children, 2005 2010. 2030 Sustainable years of age, with all countries
- To reduce child mortality rate to Development aiming to reduce neonatal mortality
below 31 per 1000 live births by Agenda to atleast as low as 12 per 1000 live
2010. births and under five mortality to at
- To reduce neonatal mortality rate least as low as 25 per 1000 live
to below 18 per 1000 live births by births.
2010.
- To explore possibilities of covering DELIVERING THE MCH SERVICES
all children with plan for health MCH (mother and child health) is not a new speciality. It is
insurance. a method of delivering health care to special group in the
Millennium - Reduce by two-thirds, between 1990 population which is especially vulnerable to disease, disability
Development and 2015, the under-five mortality or death. These groups (i.e., children under the age 5 years
Goals (MDG) rate (Goal 4). and women in the reproductive age group (15-44 years)
- Reduce by three-quarters, between comprise about 32.4 per cent of the total population in India.
1990 and 2015, the maternal The MCH services encompass the curative, preventive
mortality rate. and social aspects of obstetrics, paediatrics, family welfare,
- Combat HIV/AIDS, malaria and nutrition, child development and health education. The
other diseases. specific objectives of MCH are :
National Health - Reduce under five mortality to 1. reduction of morbidity and mortality rates for
Policy, 2017 23 per 1000 live births by 2025. mothers and children;
- Reduce infant mortality rate to 28 2. promotion of reproductive health; and
by 2019. 3. promotion of the physical and psychological
- Reduce neo-natal mortality to 16 development of the child within the family.
and stillbirth rate to “single digit” Through concern with child development and the health
by 2025.
education of parents and children, the ultimate objective of
- Increase life expectancy at birth MCH services is life-long health.
from 67.5 to 70 years by 2025.
- Reduce prevalence of blindness to Sub-areas
0.25/1000 by 2025, and reduce The components of MCH include the following sub-areas:
disease burden by one third
from current level. a. maternal health
- Achieve global target of HIV/AIDS of b. family planning
90-90-90 by 2020. c. child health

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 DELIVERING THE MCH SERVICES 633
d. school health including hospitalization, while at the same time essential
e. handicapped children care is provided for the rest of the mothers and children so
f. care of the children in special settings such as day care that every one gets care appropriate to their need.
centres. It is also possible to assess the “degrees” of risk of each
The content of MCH care will vary according to the factor, by scoring according to their (a) magnitude - i.e.,
demographic, social and economic patterns. Factors such as extent and severity; (b) treatability - responsiveness to
urbanization, rural migration, changing patterns of women’s treatment and control; (c) cost-effect - in terms of alleviating
work and status have far-reaching effects on childbearing human suffering; and (d) community attitude - social
and child-rearing. It is now generally accepted that the MCH concern. Such an approach when applied on a community­
services should always be flexible and based on, and wide basis enables the determination of priority activities,
adapted to the local needs and resources of the community within the MCH programme based on the “degrees” of risk.
it serves; they should be moulded to the local traditions, Application of the risk approach to the problems of
cultures and other environmental characteristics and cannot mothers and children is a departure from past or traditional
be modelled on patterns copied from other countries. Health practices to promote the health of mothers and children.
care, social legislation and social support measures also will
have to be adapted to these changing needs and problems 3. Manpower changes
of the community. The special category of “maternal and child health
MCH care is now conceived of as all activities which worker” (e.g., auxiliary-nurse-midwives, health visitors) at
promote health and prevent or solve health problems of the peripheral level is gradually being phased out. A wide
mother and children, irrespective of whether they are curative, range of workers are now considered necessary for maternal
diagnostic, preventive or rehabilitative, and whether they are and child health work. They include :
carried out in health centres or in the home by primary health (i) Professionals : Specialists
care workers, traditional dais, or highly trained specialists. (ii) Field workers : Multi-purpose workers, Health Guides,
dais (traditional birth attendants), Bal Sevikas,
Recent trends in MCH care Anganwadi workers, extension workers, ASHA etc
Maternal and child care was traditionally designed and (iii) Voluntary workers Members of women’s
provided in the form of vertical programmes with “standard” organizations

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technical content based on models from a few developed Taking for example, the local dais in the past were not
countries. Applied in different socio-economic situations, generally recognized by the national health authorities, who
such vertical programmes have been unable to provide more thought that their services were inimical to the safety of the
than minimum coverage because of their cost, and they mother and child. The current trend is to assist them perform
have scarcely been of a kind to solve the priority problems of safe deliveries through training and supervision. In India,
the majority of mothers and children. The emergence of where 70 per cent of population lives in rural areas, there are
some new concepts is now changing the organization not enough obstetricians to attend to all deliveries. Therefore,
and management of MCH care in increasing number of a trained dai or midwife is absolutely essential in every village.
countries. These are discussed below : The same thing can be said about paediatrics. It is now
recognized that obstetric and paediatric services can only be
1. Integration of care
improved by cooperation and liaison with these practitioners.
Conventional MCH services tended to be fragmented into
antenatal care, postnatal care, infant care, family planning 4. Primary health care
etc. The various components were dealt with separately by Primary health care is now recognized as a way of making
different staff or departments. This approach has changed essential health care available to all. It has all the elements
over the years. The trend now is an “integrated” approach. necessary to make a positive impact on the health of
This integration is based on the fact that it is inconvenient mothers and children - i.e., MCH care, family planning,
for the mother to go to one place to receive care for herself, control of infections, education about health problems and
to another for care for her children, and yet another for how to prevent them, and measures to ensure nutritious
family planning services. food - all closely related. Primary health care emphasizes
An integrated approach implies that all those involved in family oriented care and support, and community self-
maternity care from the obstetrician down to the local dai, reliance in health matters. MCH care is an indispensable
must work as a team. Obstetric and paediatric units should priority element of primary health care in every country.
be closely linked so that there can be regular contact between
obstetricians, paediatricians, community physicians, health Targets for MCH Services
and social workers so that services for the care of the mother From time to time Government of India has suggested
and the child in the hospital and community be planned and MCH goals with quantifiable time bound targets for
reviewed including teaching and research. This approach achievement. Table 11 shows the MCH indicators with their
helps to promote continuity of care as well as improves goal period and the current level of achievement.
efficiency and effectiveness of MCH care.
Organization of MCH/FP services
2. Risk approach The mother and child health, and family planning
A promising means of improving the coverage and services were integrated in the Fourth Five Year Plan for
efficiency of MCH care and family planning is the “risk better effectiveness. They both are now an integral part of
approach”. This is a managerial tool for better use of scarce primary health care, which places emphasis on community
resources. It is based on the early detection of mothers and participation and intersectoral coordination. The National
children with high-risk factors. All mothers and children with Health Policy 2002 and National Population Policy 2000 has
high risk factors are given additional and more skilled care provided the necessary directives for reorienting and

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634 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

TABLE 11
MCH goals and current level of achievement (India)
Goals and target period
Indicator Current
level Three Year Action Agenda National Health Sustainable Development
of Niti Ayog (2018-19--20) Policy 2017 Goals (2030)
A. Family Planning Indicators
Crude birth rate 19.5 (2020) - 21 -
Total fertility rate 2.0 (2020) 2.1 2.1 by 2025 -
Couple protection rate (%) 67.0 (2015-19) - Meet all needs -
B. Mortality indicators per 1000
Infant mortality 28 (2020) 30 < 28 by 2019 -
Neonatal mortality 20 (2020) - 16 by 2025 < 12
Maternal mortality per 100,000 97 (2018-2020) 120 100 by 2020 70
Under-5 mortality 32 (2020) 38 23 by 2025 <25
c. Services (% coverage)
Infants immunized (2020) - > 90 by 2025
- Measles2 81 - -
-dpt3 85 - -
- Polio. 85 -
-BCG 85 - -
- HepB3 85 - -
-Hib3 85 - -
- Rotavirus 82 - -
-PCV3 90 - —
Pregnant women TT 90 - -
Antenatal care coverage % (2015-2020) - 100
at least once 79.0

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at least four times 51.0 90
Institutional deliveries 88.6 (2019-2021) - 80
Deliveries by trained personnel 81.0(2013-2018) - 100
D. Prevalence of low-birth-weight babies 28 (2011-2016) - -

Source : (73, 74)

restructuring the health services, based on primary health Municipal Corporations and voluntary organizations. The
care approach with short and long-term goals. services of obstetricians are available at district hospitals,
The infrastructure in rural areas is based on the complex of which are the apical hospitals for MCH care at the district
community health centres, primary health centres and their level. For specialized care of children, paediatric units have
subcentres. They provide preventive and promotive health been established in several district hospitals.
care services. Since deliveries by trained health personnels Table 12 shows the evolution of maternal and child
are crucial in reducing maternal and infant mortality in rural health programmes in India.
areas, the government of India undertook a scheme to train
local dais to conduct safe deliveries. These dais are now TABLE 12
available in most villages. Mention must be made of ICDS Evolution of maternal and child health programmes in India
(Integrated Child Development Services) projects which are
functioning all over the country providing a package of basic Year Milestones
health services (eg. supplementary nutrition, immunization, 1952 Family Planning programme adopted by Government of
health check-up, referral, nutrition and health education, and India (GOI)
non-formal education services) to mother and children. 1961 Department of Family Planning created in Ministry of
Maternal health care was a part of family welfare Health
programme from its inception. Interventions were introduced 1971 Medical Termination of Pregnancy Act (MTP Act), 1971
on vertical schemes, but family planning remained a 1977 Renaming of Family Planning to Family Welfare
separate intervention. In 1992, the Child Survival and Safe 1978 Expanded Programme on Immunization (EPI)
Motherhood Programme integrated all the schemes for better 1985 Universal Immunization Programme (UIP) +
compliance. More recently, Reproductive and Child Health National Oral Rehydration Therapy (ORT) Programme
Programme was launched in 1997, which integrated family 1992 Child Survival and Safe Motherhood Programme (CSSM)
planning, Child Survival and Safe Motherhood Programme, 1996 Target-free approach
Preventive management of STD/RTI, AIDS, and a client 1997 Reproductive and Child Health Programme-1 (RCH-1)
approach to health care. This programme has entered into 2005 Reproductive and Child Health Programme-2 (RCH-2)
phase II, with reorientation to make it consistant with the 2005 National Rural Health Mission
requirement of the National Rural Health Mission. 2013 RMNCH+A Strategy
2013 National Health Mission
In urban areas, the general trend is towards institutional 2014 India Newborn Action Plan (INAP)
delivery. In larger cities, almost 90 per cent of deliveries 2021 NMNCAH+N Strategy
take place in maternity hospitals and maternity homes.
Some of the institutions are under the auspices of the Source : (75)

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 INDICATORS OF MCH CARE 635
INDICATORS OF MCH CARE six-week (42 day) postpartum period, and the increased
availability of modern life-sustaining procedures "and
/paternal and child health status is assessed through technologies enables more women to survive adverse
measurements of mortality, morbidity, growth and outcomesof pregnancy and delivery, and also delays some
development. In many countries, mortality rates are still the deaths beyond that postpartum period. Specific co es or
oTrtp'source of information. Morbidity data are scarce and “late maternal deaths”, are included in the ICD-10 (096 and
poorly standardized. In recent years, attention has been paid 097) to capture these delayed maternal deaths, which may
to systematizing the collection, interpretation and not be categorized as maternal deaths in~civil re istration
dissemination of data on growth and development. The and vital statistics systems despite being caused by
commonly used mortality indicators of MCH care are : pregnancy-related events. } *
1. Maternal mortality ratio Maternal deaths and late maternal deaths are combined
2. Mortality in infancy and childhood in the 11th revision of the ICD under the new grouping of
a. Perinatal mortality rate “comprehensive maternal deaths”.
b. Neonatal mortality rate Pregnancy-related death (also known as death occurring
c. Post-neonatal mortality rate during pregnancy, childbirth and puerperium) : is defined as
d. Infant mortality rate “The death of a woman while pregnant or within 42 days of
e. 1-4 year mortality rate termination of pregnancy, irrespective of the cause_oLdeath
f. Under-5 mortality rate (obstetric and non-obstetric)”; this definition includes
unintentional, accidental and incidental causes. This
g. Child survival rate.
definition allows measurement of deaths that occur during
pregnancy, childbirth and puerperium while acknowledging
MATERNAL MORTALITY RATIO
that such measurements do not strictly conform to the
According to WHO, a maternal death is defined as “the standard “maternal death” concept in settings where
death of a woman while pregnant or within 42 days of accurate information about cause of death base on
termination of pregnancy, irrespective of the duration and site medical certification is unavailable (1).
~f pregnancy, from any cause relate ! to or aggravated by the The number of maternal deaths in a population (during a
pregnancy or its management but not from unintentional or specified time period, usually one calendar year) reflects two

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incidental causes” (1). factors: (i) the risk of mortality associated with a single
("This definition allows identification of a maternal death, pregnancy or a single birth (whether live birth or stillbirth);
based on the cause of the death being identified as either a and (ii) the fertility level (i.e. the number of pregnancies or
direct or indirect maternal cause. It is calculated as : births that are experienced by women of reproductive age,
i.e. age 15-49 years).
Total no. of female deaths due to
(^Maternal mortality ratio (MMR) : is defined as the
complications of pregnancy, childbirth or
within 42 days of delivery from “puerperal number of maternal deaths during a given time period per
causes” in an area during a given year 100,000 live births during the same time period; thus, it
---------------------------------------------------------- X 1000 (or 100,000) quantifies the risk of maternal death relative to the number
Total no. of live births in the same
of live birthsT" and essentia y captures the first factor
area and year
mentioned above (1).
C Direct obstetric deaths (or direct maternal deaths) : those C Maternal mortality rate (MMRate) : is defined and
resulting from obstetric complications of the pregnant state calculated as the number of maternal deaths divided by
(pregnancy, labour and puerperium), from interventions, person-years lived by women of reproductive age in a
omissions, incorrect _ treatment, or from a_ chain of population. The MMRate captures both the risk of maternal
events resulting from any of the above. Deaths due to death per pregnancy or per birth (whether live birth or
obstetric haemorrhage or hypertensive disorders in stillbirthjfand the level of fertility in the population (i.e.
pregnancy, lor example, or those due to complications of both factors mentioned above) (1).
anaesthesia or caesarean section are classified as direct
maternal deaths (1). Adult lifetime risk of maternal death : for women in the
population, is defined as the probability that a 15 year-old
C Indirect obstetric deaths (or indirect maternal deaths) : girl (in the year of the estimate) will_eventually die from a
those resulting from previous existing disease or disease that maternal cause. This indicator takes into account competing
developed during pregnancy and which was not due to direct causes of death/l).
obstetric causes, but which was aggravated by physiological
{The proportion of maternal deaths_________ of women of
effects of pregnancy. For example, deaths~3ue to aggravation
reproductive age (PM) : The number of maternal deaths in a
(by pregnancy) of an existing cardiac or renal disease are
given time period divided by the total deaths, among
considered indirect maternal deaths.
women aged 15-49 years.
<^The maternal mortality rate, the direct obstetric rate and The 43rd World Assembly in 1990 adopted the
the indirect obstetric rate are fine measures of the quality of recommendation that countries consider the inclusion on
maternity services. death certificates of questions regarding current pregnancy
C^Lote maternal jleath : It is “the death of a woman from and pregnancy within one year preceding death in order to
direct or indirect obstetric causes, after mor- than 42 days improve the quality of maternal mortality data and provide
bur ess than one ear after termination of pregnancy” (1). alternative methods of collecting data on deaths during
LikeYnafernal deaths, late maternal deaths also include both pregnancy or related to it, as well as to encourage the
direct and indirect maternal/obstetric deaths. Complications recording of deaths from obstetric causes occurring more
of pregnancy or childbirth can lead to death beyond the than 42 days following termination of pregnancy.

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636 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

Approaches for measuring maternal mortality (1) Between 2000 and 2017, the sub-region of South Asia
In the absence of complete and accurate civil registration achieved the greatest percentage reduction in MMR, i.e. from
systems, MMR estimates are based upon a variety of methods : 384 to 157 (59 per cent). Central Asia (52 per cent), Eastern
Asia (50 per cent), Europe (53 per cent), and Northern Africa
(1) (jbivil registration systems : This approach involves (54 per cent) halved their MMR during that period.
routine registration of births and deaths. Ideally, maternal
mortality statistics should be obtained through civil A woman is most vulnerable at the post-partum period.
registration data, About 50-70 per cent maternal deaths occur in the
postpartum period of which 45 per cent deaths occur in the
(2) Q~lousehold survey : Where civil registration data are
first 24 hours after delivery and more than two-thirds during
not available, household survey provides an alternative.
the first week. Between 11-17 per cent of maternal deaths
(3) (Sisterhood methods : Sisterhood methods obtain occur during child birth itself (76).
information by interviewing a representative sample of
respondents about the survival of all their adult sisters (to Maternal mortality ratios strongly reflect the overall
determine the number of ever married sisters, how many are effectiveness of health systems, which in many low-income
alive, how many are dead, and how many died during developing countries suffer from weak administrative, technical
pregnancy, delivery, or within six weeks of pregnancy. and logistical capacity, inadequate financial investment and a
(4) (Reproductive-age mortality studies (RAMOS) : This lack of skilled health personnel. Scaling up key interventions -
approach involves identifying and investigating the causes for example, increasing the number of births attended by skilled
of all deaths of women of reproductive age in a defined health personnel, providing access to emergency obstetric care
area/population by using multiple sources of data. when necessary and providing post-natal care for mothers and
(5) Verbal autopsy : This approach is used to assign cause babies - could sharply reduce both maternal and neonatal
of death through interview with family or community deaths. Enhancing women’s access to family planning,
members, where medical certification of cause of death is adequate nutrition, improved water and sanitation facilities and
not available. Records of births and deaths are collected affordable basic health care protection from abuse, violence,
periodically among small populations, under demographic discrimination, empowerment of women, greater involvement
surveillance systems maintained by the research institutions of men in maternal and child care, would lower mortality rates
in developing countries. further still. These are not impossible, impractical actions, but
(6) (Qensus : A national census, with the addition ofa limited proven, cost-effective provisions that women of reproductive

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number of questions, could produce estimates of maternal age have a right to expect.
mortality: this approach eliminates sampling errors and hence The low status of women in the society coupled with their
allows a'more detailed breakdown of the results, including time low literacy levels prevent the women from taking antenatal
trends, geographic subdivisions and social strata. \ care even if services are available. Most deliveries take place
at home without the services of the trained midwifery
Incidence personnel. There is an inverse relationship between lifetime
WORLD SCENARIO risk of maternal death and the availability of the trained
health worker during pregnancy and at the time of delivery.
The methodology employed by the Maternal Mortality
Estimation Inter-Agency Group to estimate 1990-2015 It is a tragic situation as these deaths are not caused by
maternal mortality ratio followed an improved approach disease but occurred during or after a natural process. It is
referred to as Bayesian maternal mortality estimation model one of the leading cause of death for women of reproductive
or BMat model. These results supersede all previously age in many parts of the world. Most maternal deaths and
published estimates for the years within that time period and pregnancy complications can be prevented if pregnant
differences with previously published estimates should not women have access to good-quality antenatal, natal and
be interpreted as representing time trends (1). postnatal care, and if certain harmful birth practices are
avoided. Estimates of antenatal care coverage, deliveries
An estimated 295,000 maternal deaths occurred globally conducted by skilled personnel, lifetime risk of maternal
in 2017, yielding an overall MMR of 211 (199-243) death and maternal mortality ratio in some developing and
maternal deaths per 100,000 live births. The global adult developed countries are shown in Table 13.
life-time risk of maternal mortality (i.e. the probability that a
15 years old woman will die eventually from a maternal Maternal health, however, goes beyond the survival of
cause) is approximately 1 in 190 for the year 2017. For the pregnant women and mothers. For every woman who dies
purpose of categorization, MMR is considered to be high if it from causes related to pregnancy or childbirth, it is estimated
is 300-499, very high if it is 500-999, and extremely high if that there are 20 others who suffer pregnancy-related illness
it is > 1000 maternal deaths per 100,000 live births (1). or experience other severe consequences. The number is
MMR in the world’s least developed countries is high, striking: An estimated 10 million women annually who
estimated at 415 maternal deaths per 100,000 live births survive their pregnancies experience such adverse outcomes.
which is more than 40 times higher than MMR in Europe Causes
(10), and almost 60 times higher than in Australia and New
Zealand (7)..The lifetime risk of maternal death in least Maternal deaths mostly occur from the third trimester to
developed countries is 1 in 56, Sub Saharan Africa is the the first week after birth (with the exception of deaths due to
only Region with very high MMR for 2017, estimated at 542 complications of abortion). Studies show that mortality risks
with life time risk of maternal death at 1 in 37. Three for mothers are particularly elevated within the first two days
countries namely, South Sudan (1150), Chad (1140) and after birth. Most maternal deaths are related to obstetric
Sierra Leone (1120) fall under extremely high MMR in 2017. complications - including postpartum haemorrhage,
Nigeria (67000) and India (35000) had the highest estimated infections, eclampsia and prolonged or obstructed labour -
number of maternal deaths accounting for approximately and complications of abortion. Most of these direct causes of
35 per cent of estimated global maternal deaths (1). maternal mortality can be readily addressed if skilled health

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 INDICATORS OF MCH CARE 637
TABLE 13
Maternal mortality ratio, deliveries conducted by skilled personnel, antenatal care coverage
and lifetime risk of maternal deaths in some developing and developed countries.
Country Antenatal care Deliveries conducted by Lifetime risk Maternal mortality
coverage (%) (2013-2018) skilled personnel (%) maternal death ratio (per 100,000
At least once At least four times (2012-2021) (one in) (2017) live births) (2020)

India 79 51 81 290 97 (2018-2020)

Bangladesh 64 31 59 250 173
Bhutan 98 85 96 250 183
Indonesia 98 77 95 240 177
Myanmar 81 59 60 190 195
Nepal 84 69 77 186 220
Thailand 99 90 99 1,900 37
Sri Lanka 99 93 100 1,300 36
Pakistan 86 51 71 140 188
China 100 81 100 2,100 29
Japan 100 100 100 16.700 5
Singapore 100 100 100 9,900 8
UK - 99 8,400 7
USA - 97 99 3,000 19
World 87 59 84 190 211

Source : (59)

personnel are on hand and key drugs, equipment and treatment with relatively simple anticonvulsant drugs in

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referral facilities are available. cases of eclampsia.
About 80 per cent of maternal deaths are due to direct Of the estimated 210 million pregnancies that occur
causes i.e. obstetric complications of pregnancy, labour and every year, about 42 million end in induced abortion, of
puerperium to interventions or incorrect treatment. As shown which only approximately 60 per cent are carried out under
in Fig. 10 the single most common cause-accounting for a safe conditions. More than 20 million induced abortions
quarter of all maternal deaths - is obstetric haemorrhage, each year are performed by people lacking the necessary
generally occurring postpartum which can lead to death very skills or in an environment lacking the minimal medical
rapidly in the absence of prompt life-saving care. standards, or both.
Puerperal infections, often the consequence of poor Around 8% of maternal deaths occur as a result of
hygiene during delivery, or untreated reproductive tract prolonged or obstructed labour. Other direct causes include
infections account for about 15% of maternal mortality. ectopic pregnancies, embolism and deaths related to
Such infections can be easily prevented. Hypertensive interventions. Around 20 per cent of maternal deaths are due
disorders of pregnancy, particularly eclampsia (convulsions), to indirect causes, that is, the result of pre-existing diseases or
result in about 13% of all maternal deaths. They can be disease that developed during pregnancy, which are not due
prevented through careful monitoring during pregnancy and to direct obstetric cause but are aggravated by the
physiological effect of pregnancy. One of the most significant
Severe bleeding
is anaemia, which can cause death. Maternal anaemia affects
about half of all pregnant women. Pregnant adolescents are
3
more prone to anaemia than older women, and they often
Indirect receive less care. Infectious diseases such as malaria, and
intestinal parasites can exacerbate anaemia, as can poor
quality diet - all of which heighten vulnerability to maternal
15% Infection
death. Severe anaemia contributes to the risk of death in
cases of haemorrhage. Other important causes of indirect
death are hepatitis, cardiovascular diseases, diseases of the
endocrine and metabolic system and infections such as
b Other tuberculosis, malaria and increasingly HIV/A1DS (77). Each
causes Eclampsia year, approximately 50 million women living in malaria­
endemic countries throughout the world become pregnant.
Around 10,000 of these women die as a result of malaria (78).
Unsafe abortion Obstructed labour
Social correlates
Indirect causes including for example: anaemia,
malaria, heart diseases A number of social factors influence maternal mortality.
Other direct causes including, for example : ectopic The important ones are : (a) Women’s age : The optimal
pregnancy, embolism, anaesthesia-related child-bearing years are between the ages of 20 and 30 years.
FIG. 10 The further away from this age range, the greater the risks
Causes of maternal deaths worldwide of a woman dying from pregnancy and childbirth.

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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS
638
(b) Birth interval : Short birth intervals are associated with - Eliminate all harmful practices and all discrimination
an increased risk of maternal mortality, (c) Parity: High and violence against women and girls
parity contributes to high maternal mortality. - Achieve universal and equitable access to safe and
Not only are these three variables interrelated, but there affordable drinking water, and to adequate
are also other factors which are involved, e.g., economic sanitation and hygiene
circumstances, cultural practices and beliefs, nutritional - Enhance scientific research, upgrade technological
status, environmental conditions and violence against capabilities and encourage innovation
women. The social factors often precede the medical causes - Provide legal identity for all, including birth
and make pregnancy and child-birth a risky venture. registration
- Enhance the global partnership for sustainable
Global Strategy for Women’s, Children’s and development.
Adolescent’s Health 2016-2030
INDIA
The Global Strategy for Women’s, Children’s and
Adolescent’s Health, 2016-2030 was launched in the year Despite significant improvements in maternal health over
2015 with a vision to have by the year 2030, a “world in the last decade or so, which is evident in the reductions in
which every woman, child and adolescent in every setting maternal mortality in the country, an estimated 44,000
realize their rights to physical and mental health and well­ mothers continue to die every year due to causes related to
being, has social and economic opportunities, and is able to pregnancy, childbirth and the post-partum period. The major
participate fully in shaping prosperous and sustainable medical causes of these deaths are haemorrhage, sepsis,
society” (79). The strategy is a road map for the post-2015 abortion, hypertensive disorders, obstructed labor and other
agenda as described by the Sustainable Development Goals causes including anaemia. A host of socio-economic-cultural
and seeks to end all preventable deaths of women, children determinants like illiteracy, low socio-economic status, early
and adolescents and create an environment in which these age of marriage, low level of women’s empowerment,
groups not only survive, but thrive, and see their traditional preference for home deliveries and other factors
environments, health and wellbeing transformed. The global contribute to the delays leading to these deaths.
strategy goals of SURVIVE, THRIVE and TRANSFORM and From year 2000 onwards, SRS (Sample Registration
the targets to be achieved by 2030 are as follows (79) System) included a new method called the “RHIME” or
Representative, Re-sampled, Routine Household Interview

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O SURVIVE of Mortality with Medical Evaluation. This is an enhanced
End preventable deaths form of “verbal autopsy” which is the key feature of a
- Reduce global maternal mortality to less than 70 per prospective study of 1 million deaths within the SRS. RHIME
100,000 live births include random re-sampling of field-work by an
independent team for maintaining quality of data. For
- Reduce newborn mortality to at least as low as 12
comparability with WHO estimates for India and for other
per 1000 live births in every country
countries, the WHO’s “Global Burden of Disease”
- Reduce under-5 mortality to at least as low as 25 per
categorization of maternal deaths have been used, which
1000 live births in every country includes various categories with their ICD-10 codes such as :
- End epidemics of HIV, tuberculosis, malaria, neglected haemorrhage, sepsis, hypertensive disorder, obstructed
tropical diseases and other communicable diseases labour, abortion, and other conditions.
- Reduce by one third premature mortality from non-
communicable diseases and promote mental health The SRS report has been grouped into three categories;
and well-being (a) EAG states of Bihar and Jharkhand, Madhya Pradesh
and Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh and
O THRIVE Uttaranchal and Assam. These states have high mortality
Ensure health and well-being indicators; (b) This category includes southern states of
Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. These
- End all forms of malnutrition, and address the states have comparatively better health indicators; (c) The
nutritional needs of adolescent girls, pregnant and remaining states have been classified as others (80).
lactating women and children
Table 14 shows live births, maternal deaths, maternal
- Ensure universal access to sexual and reproductive
mortality ratio in India by states during 2018-2020, special
health-care services (including for family planning)
survey of deaths using RHIME. During this period the
and rights
life time risk of maternal death of women in the age group
- Ensure that all girls and boys have access to good 15-49 has been reported to be 0.3 per cent. This is
quality early childhood development substantially higher for women in the category EAG states and
- Substantially reduce pollution-related deaths and Assam (0.5 per cent) as compared to women in the category
illnesses southern (0.1 per cent) or in the “other” states (0.2 per cent).
- Achieve universal health coverage including
financial risk protection and access to quality India is among those countries which have a high maternal
essential services, medicines and vaccines mortality ratio. According to the estimates the MMR has
.reduced from 167 per lakh live births in 2011-13 to
• TRANSFORM /97 per lakh live-births in 2018-2020. States of Kerala,
Maharashtra, Andhra Pradesh, Gujarat, Tamil Nadu,
Expand enabling environment
Karnataka, Telangana, Haryana and Jharkhand have already
- Eradicate extreme poverty achieved the goal of a MMR of 100 per lakh live births. In EAG
- Ensure that all girls and boys complete free, and Assam category of states, MMR is about 137 per lakh live
equitable and good quality primary and secondary births, with Assam on top (195) and Madhya Pradesh (173),
education Uttar Pradesh (167), Chhattisgarh (137), Odisha (119),

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 INDICATORS OF MCH CARE
639
TABLE 14 Causes
Maternal Mortality Ratio (MMR), 95% Confidence The major causes of maternal mortality according to the
Interval (CI), Maternal Mortality Rate and lifetime risk; 2001-2003 SRS survey are haemorrhage (38 per cent),
India, EAG and Assam, South and other states, sepsis (11 per cent), hypertension (5 per cent), obstructed
2018-2020 labour (5 per cent), abortion (8 per cent) and other
conditions (34 per cent). Anaemia (19 per cent) is not only
India and MMR 95% CI Maternal Lifetime the leading cause of death but also an aggravating factor in
major states mortality risk haemorrhage, sepsis and toxaemia. Illegal abortions are also
rate
one of the leading causes of maternal death. That this should
India Total 97 (88-106) 6XL 0.21% continue despite MTP facilities points to the need for wider
Assam £95) (117-272) 12.1 042% dissemination of information about these facilities. Induced
Bihar 118 (78-157) 11.2 0.39% abortions also point to a large unmet need for contraceptives,
Jharkhand 56 (10-101) 4.2 0.15% as with each pregnancy the woman faces increased risk of
Madhya Pradesh 173 (126-220) 15.3 0.53% death. The percentage distribution of causes of maternal
Chhattisgarh 137 (54-219) 9.9 0.35% deaths during the year 2001-2003 are as shown in Fig. 11.
Odisha 119 (71-167) 7.3 0.25% Other conditions
Rajasthan 113 (71-155) 9.6 0.33% 34%
Uttar Pradesh 167 (126-207) 14.3 0.50%
Uttarakhand 103 (52-154) 6.3 0.22%
EAG and Assam Subtotal 137 (121-154) 11 0.38%
Andhra Pradesh 45 (13-78) 2.4 0.08% Abortion
Telangana 43 (4-83) 2.3 0.08% 8% -
Karnataka 69 (35-103) 3.5 0.12%
Kerala
Tamil Nadu
CH
54
(0-42)
(24-85)
09
2.7
0.03%
0.09%
Obstructed
labour
5%
South Subtotal 49 (35-64) 2 0.09% Haemorrhage
Hypertensive 38%

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Gujarat 57 (28-86) 3.9 0 14% disorders
Haryana 110 (58-162) 8.0 0.28% 5% Sepsis
11%
Maharashtra 33 (10-56) 1.8 0.06%
Punjab 105 (40-170) 5.4 0.19% FIG. 11
West Bengal 103 (64-143) 5.0 0.18%
Major causes of maternal deaths in India (2003)
Other states 77 (55-98) 3.9 0 14%
(Figures may not add to 100 due to round-off)
Other Subtotal 76 (63-89) 4 0 15%
Source : (81)
Source : (80)
The determinants of maternal mortality in India are as
Rajasthan (113) closely following. Assam, Madhya Pradesh listed in Table 16.
and Rajasthan have shown an acceleration in reduction in last TABLE 16
three years (80). Determinants of maternal mortality in India
The age distribution of maternal and non-maternal
deaths from the 2018-2020 Special Survey of Deaths are Medical causes Social factors
given in Table 15. It shows that more than two-thirds of the Obstetric causes:
maternal deaths are of women in age group 20-34 years. In Toxaemias of pregnancy Age at child birth
contrast, non-maternal deaths are more evenly distributed Haemorrhage Parity
over the reproductive age span of 15-49 years. Infection Too close pregnancies
TABLE 15 Obstructed labour Family-sfce
Age distribution of maternal and non-maternal deaths, Unsafe abortion Malnutrition
India, 2018-2020 Poverty
Illiteracy
Maternal deaths Non-maternal deaths Ignorance and prejudices
Age groups
Proportion 95% CI Proportion 95% CI Lack of maternity services
Non-obstetric causes' Shortage of health manpower
15-19 6% (4-8) 9% (8-9)
Anaemia Delivery by untrained dais
20-24 32% (27-36) 11% (11-12)
AssociatecLdiseases, e. g., Poor environmental sanitation
25-29 30% (25-34) 12% (12-13)
cardiac, renal, hepatic Poor communications and
30-34 20% (16-24) 13% (12-14) transport facilities
metabolic and infectious
35-39 8% (6-11) 14% (13-15) Malignancy Social customs, etc.
40-44 3% (1-4) 18% (17-19) Accidents
45-49 2% d-3) 22% (21-23)
15-49 100% 100% Newer approaches such as “risk approach” and primary
health care are steps in the right direction to reduce maternal
(Figures may not add to 100 due to round-off) mortality and morbidity. Despite best antenatal care, some
Source : (80) women may develop complications without warning signs

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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS
64Q
and require emergency care. Essential obstetric care and world as a whole, the problem of maternal mortality is
establishment of first referral units (FRUs) for emergency principally one of applying existing obstetric knowledge
obstetric care is, therefore, a high priority under the safe through antenatal, intranatal and postnatal services rather
motherhood component of Reproductive and Child Health than developing new skills. Any attempt to lower MMR must
Programme. Janani Suraksha Yojna, Janani Shishu take into consideration the following measures :
Suraksha Karyakram, establishment of MCH wings and 1. Early registration of pregnancy;
mother and child traking system; and RMNCH+A and more
2. At least four antenatal check-ups;
recently RMNCAH+N are key strategies to accelerate the
pace of decline of MMR. Equally important is an attack on 3. Dietary supplementation, including correction of
social and cultural factors (e.g., ignorance, low levels of anaemia;
female literacy, prejudices inherent in the socio-cultural 4. Prevention of infection and haemorrhage during
milieu, low levels of nutrition and poor environmental puerperium;
sanitation). It calls for socio-economic development of the 5. Prevention of complications, e.g., eclampsia,
community through active community involvement. malpresentations, ruptured uterus;
National maternal health care indicators 6. Treatment of medical conditions, e.g.,
hypertension, diabetes, tuberculosis, etc;
The estimates of maternal mortality can only be used as a 7. Anti-malaria and tetanus prophylaxis;
rough indicator of maternal health situation in any given
country. Hence indicators such as antenatal check-up, 8. Clean delivery practice;
institutional delivery and delivery by trained personnel etc. 9. In India, a large number of maternal deaths could
are used to assess the maternal health status. These be prevented with the help of trained village level
indicators also reflect the status of the ongoing programme health workers;
interventions and the situation of maternal health (60). 10. Institutional deliveries for women with bad
Table 17 shows the national average of key indicators as per obstetric history and risk factors;
NFHS-5 conducted in India (57). 11. Promotion of family planning - to control the
number of children to not more than two, and
Preventive and social measures spacing of births;
High maternal mortality reflects not only in inadequacy 12. Identification of every maternal death, and

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of health care services for mothers, but also a low standard searching for its cause; and
of living and socio-economic status of the community. In the 13. Safe abortion services.

TABLE 17
National average of key indicators (per cent) in India 2019-2021

Indicators NFHS-5 (2019-2021)

Maternal and Child Health Urban Rural Total
Maternity Care (for last birth in the 5 years before the survey)

Mothers who had antenatal check-up in the first trimester (%) 75.5 67.9 70.0
Mothers who had at least 4 antenatal care visits (%) 68.1 54.2 58.1
Mothers whose last birth was protected against neonatal tetanus (%) 92.7 91.7 92.0
Mothers who consumed iron folic acid for 100 days or more when they were pregnant (%) 54.0 40.2 44.1
Mothers who consumed iron folic acid for 180 days or more when they were pregnant (%) 34.4 22.7 26.0
Registered pregnancies for which the mother received Mother and Child Protection (MCP) card {%) 94.9 96.3 95.9
Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health 84.6 75.4 78.0
personnel within 2 days of delivery (%)
Average out of pocket expenditure per delivery in public health facility (Rs.) 3,385 2,770 2,916
Children born at home who were taken to a health facility for check-up within 24 hours of birth (%) 3.8 4.3 4.2
Children who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other 85 7 76.5 79.1
health personnel within 2 days of birth (%)

Delivery Care (for births in the 5 years before the survey)

Institutional births (%) 93.8 86.7 88.6

Institutional births in public facility (%) 52.6 65.3 61.9
Home births that were conducted by skilled health personnel (%) 2.1 3.7 3.2
Births attended by skilled health personnel (%) 94.0 87.8 89.4
Births delivered by caesarean section (%) 32.3 17.6 21.5
Births in private health facility that were delivered by caesarean section (%) 49.3 46.0 47.4
Births in a public health facility that were delivered by caesarean section (%) 22.7 11.9 14.3

Source : (58)

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 MORTALITY IN INFANCY AND CHILDHOOD

MORTALITY IN INFANCY AND CHILDHOOD weight most frequently associated with a gestation period of
22 weeks. But for international comparison, however, they
Mortality rates are good indicators to measure the level of suggested a boundary of 1000 g or more, which is more
health and health care in different countries. They also help frequently associated with a gestation period of 28 weeks.
in assessing the overall socio-economic development of a
country and correlate well with certain economic variables STILLBIRTH RATE
such as GNP Medical and social progress have substantially The most widespread use of the term is, “death of a foetus
reduced mortality in childhood. weighing 1000 g (this is equivalent to 28 weeks of gestation)
It has become customary to consider mortality in and or more” occurring during one year in every 1000 total births
around infancy in a number of time periods convenient from (live births plus stillbirths). Stillbirth rate is given by the
both the analytical and programmatic point of view as under : formula :
a. perinatal period Foetal deaths weighing over 1000 g at birth
b. early neonatal period during the year
Stillbirth
rate =----------------------------------------------------------------- x 1000
c. late neonatal period Total live + stillbirths weighing over 1000 g at birth
d. neonatal period during the year
e. post neonatal period It is a frequent occurrence in the developing countries. Its
These are as illustrated in Fig. 12. prevention involves the detection and treatment of
FOETAL DEATH : Foetal death is death prior to the infectious pathology in the course of pregnancy as well as of
complete expulsion or extraction from its mother of a high blood pressure and its complications, Rh
product of conception, irrespective of the duration of incompatibility, diabetes and premature rupture of the
pregnancy; the death is indicated by the fact that after such membrane. Some causes are difficult or impossible to
separation the foetus does not breathe or show any other eliminate, such as multiple pregnancies, cord anomalies,
evidence of life, such as beating of the heart, pulsation of foetal malformations, placenta anomalies.
the umbilical cord, or definite movement of voluntary Approximately 1.9 million babies were stillborn in the
muscles (82). Defined variously as death after the 20th or year 2019 worldwide, the rate was 14 per 1000 total births.
28th week of gestation (the definition of length of gestation The rate varies between 22 per 1000 total births in least
varies between countries). developed countries to 3 in Western European countries

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Some observers have expressed the view that vital (74). In India, the SRS estimates for the year 2020 for the
statistical reports are less reliable on foetal deaths occurring whole country was about 3 per 1000 total births
at 20-27 weeks than on those occurring after 28 completed (4 for the rural and 3 for the urban areas). Among the bigger
weeks, and have preferred to analyze the data separately for states, the highest level of stillbirths has been estimated for
the two intervals. Stillbirths are seldom reported in Odisha (10). Table 18 shows the statewise break-up of
developing countries. stillbirth rate.
Because of the above difficulties WHO has recommended TABLE 18
that within any country the term “stillbirth” be applied to a Perinatal mortality rates and stillbirth rates by residence,
foetus born dead, and weighing over 500 g - the birth India and bigger states, 2020
India and Perinatal mortality rate Stillbirth rate
bigger states/UTs Total Rural Urban Total Rural Urban
India 18 21 12 3 4 3
Andhra Pradesh 14 16 9 1 1 3
Assam 17 18 8 3 3 2
Bihar 17 18 12 1 1 1
Chhattisgarh 26 26 24 6 6 6
Delhi 6 8 6 0 0 0
Gujarat 15 18 11 4 4 3
Haryana 21 23 17 7 6 7
Himachal Pradesh* 13 14 10 4 4 4
Jammu & Kashmir 11 11 10 3 2 4
Jharkhand 15 16 10 2 2 2
Karnataka 14 17 9 3 4 2
Kerala 8 6 10 4 4 4
Madhya Pradesh 28 30 20 5 6 4
Maharashtra 11 14 6 3 4 1
Odisha 30 32 20 10 10 6
Punjab 12 11 13 3 3 4
Rajasthan 20 21 16 4 4 5
Tamil Nadu 8 11 5 2 3 1
Telangana 13 14 11 2 1 4
Uttar Pradesh 24 27 15 4 4 2
Uttarakhand 18 17 20 6 6 6
28 weeks Birth 7 Days 28 Days 1 Year
of gestation West Bengal 15 15 11 4 5 4

FIG. 12 * (Based on three year period 2018-20)

Mortality in and around infancy Source : (73)

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642 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

The estimates provided by Lancet Stillbirth Series for Why perinatal mortality rate ?
India is 22 per 1000 live births for the year 2009. This With the decline of infant mortality rate to low levels in
estimate is being used as a target-setting excercise by India many developed countries, perinatal mortality rate has
Newborn Action Plan (launched in June 2014). With the assumed greater significance as a yardstick of obstetric and
current level of average annual rate of reduction, which is
paediatric care before and around the time of birth.
less than 1 per cent, India is expected to reach SBR of 19 per
1000 live births by 2030 (83). First, two types of death rate i.e., stillbirths and deaths
under the first week of life are combined in perinatal
PERINATAL MORTALITY RATE mortality rate because The factors responsible for these two
As currently defined, the term “perinatal mortality” types of deaths are often similar, being :i.ose operating
includes both late foetal deaths (stillbirths) and early before and around the time of birth. Secondly, a proportion
neonatal deaths. The Eighth Revision of the International of deaths which occur after birth are incorrectly registered as
Classification of Diseases (ICD) defined the “perinatal stillbirths, thereby inflating the stillbirth rate and lowering
period” as lasting from the 28th week of gestation to the the neonatal death rate. The perinatal mortality rate, being a
seventh day after birth. The Tenth Revision (1993) of ICD combination of stillbirths and early neonatal deaths, is not
added that: influenced by this error, by removing from consideration the
dividing line between a stillbirth and a live birth with death
i) Babies chosen for inclusion in perinatal statistics shortly after birth.
(this means late foetal deaths, live births and early
neonatal deaths) should be those above a Although perinatal period occupies less than 0.5 per cent
minimum birth weight, i.e., 1000 g at birth (less than 168 hours) of the average life span, there are more
(A birth weight of 1000 g is considered equivalent deaths within this period than during the next 30-40 years
to gestational age of 28 weeks); of life in many developing countries (85). The value of
perinatal mortality rate is that it gives a good indication of
ii) if the birth weight is not available, a gestation
the extent of pregnancy wastage as well as the quality and
period of at least 28 weeks should be used; and
quantity of health care available to the mother and the
iii) where (i) and (ii) are not available, body length newborn. It reflects the results of maternity care more clearly
(crown to heel) of at least 35 cm should be used. than the neonatal death rate.
But the preferred criterion is birth weight.

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Incidence
The Conference for the Tenth Revision (ICD-10) made no
changes to these definitions. Perinatal mortality is a problem of serious dimensions in
all countries. It now accounts for about 90 per cent of all
DEFINITIONS (84) foetal and infant mortality in the developed countries. In
The WHO’s definition, more appropriate in nations with India, stillbirths are seldom registered. Consequently, most
well established vital records of stillbirths is as follows : studies on perinatal mortality in this country are hospital­
based. The SRS estimates for perinatal mortality rate in
Late foetal deaths (28 weeks gestation and more) India for the year 2020 was about 18 per 1000 live births
4- early neonatal deaths (first week) in one year and stillbirths, with about 21 for rural areas and 12 for the
PMR=--------------------------------------------------------------------- X 1000 urban .areas. The statewise perinatal mortality rate is shown
Live births + late foetal deaths
(28 weeks gestation and more) in Table 18.
in the same year In developed countries, perinatal mortality rates have
gradually declined during the past decades due to improved
The WHO’s definition, more appropriate in nations with
obstetric and perinatal technologies.
less well established vital records, is :
Late foetal deaths (28 weeks + of gestation) Social and biological variables
Perinatal + postnatal deaths (first week) in a year
A number of social and biological factors are known to be
mortality =--------------------------------------------------------------- X 1000
rate Live births in a year
associated with perinatal mortality. The degree to which
these factors influence perinatal mortality varies from
There is a difference in denominator of the perinatal country to country. Many of these factors also endanger the
mortality rate defined by the WHO and industrially developed life of the mother, causing high maternal mortality. An
nations. This makes international comparisons difficult. appreciation of these factors (at-risk factors) will certainly
make the greatest impact on reducing perinatal mortality.
International comparisons The overall risk is increased in the following categories :
For international comparisons, the WHO Expert (1) Low socio-economic status; (2) High maternal age
Committee on the Prevention of Perinatal Mortality and (35 years or more); (3) Low maternal age (under 16 years);
Morbidity (1970) recommended a more precise formulation : (4) High parity (fifth and subsequent pregnancies, especially
“Late foetal and early neonatal deaths weighing over 1000 g with short intervals between pregnancies); (5) Heavy
at birth, expressed as a ratio per 1000 live births weighing smoking (10 or more cigarettes daily); (6) Maternal height -
over 1000 g at birth”. It is calculated as : short stature (as compared with average for locality);
(7) Poor past obstetric history (one or more previous
Late foetal and early neonatal stillbirths and neonatal deaths, one or more premature live­
deaths weighing over 1000 g born infants); (8) Malnutrition and severe anaemia; and
Perinatal at birth
(9) Multiple pregnancy.
mortality =---------------------------------------------------- X1000
rate Total live births weighing over For further details see page 648 under “factors affecting
1000 g at birth infant mortality”.

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 NEONATAL MORTALITY RATE 643
Causes of perinatal mortality The neonatal mortality rate is tabulated as :
About two-thirds of all perinatal deaths occur among Number of deaths of children under
infants with less than 2500 g birth weight. The causes involve 28 days of age in a year
=------------------------------------------------------x 1000
one or more complications in the mother during pregnancy
Total live births in the same year
or labour, in the placenta or in the foetus or neonate.
Main causes : The main causes of death are intrauterine Causes of neonatal mortality
and birth asphyxia, low birth weight, birth trauma, and The main causes of neonatal death globally are as shown
intrauterine or neonatal infections. The various causes of in Fig 13.
perinatal mortality may be grouped as below :
Preterm birth
(a) Antenatal causes Intrapartum-related complications
complications 35%
(1) Maternal diseases : hypertension, cardiovascular 24%
diseases, diabetes, tuberculosis, anaemia
(2) Pelvic diseases : uterine myomas, endometriosis,
ovarian tumours Diarrhoea
(3) Anatomical defects : uterine anomalies, 1%
incompetent cervix
(4) Endocrine imbalance and inadequate uterine Tetanus
1%
preparation
(5) Blood incompatibilities
Other
(6) Malnutrition 7%
(7) Toxaemias of pregnancy Sepsis
(8) Antepartum_haemorrhages 15%
Congenital
(9) Congenital defects Pneumonia abnormalities
(10) Advanced maternal age 6% 11%

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(b) Intranatal causes
FIG. 13
(1) Birth injuries
Global distribution of neonatal deaths by cause, 2018
(2) Asphyxia
(3) Prolonged_effort time Source : (86)

No woman should die giving life. Nor should any mother

(c) Postnatal causes endure pregnancy and childbirth, only to go through the
(1) Prematurity agony of having her child born dead or watching the baby
die minutes after birth. Yet for countless women around the
(2) Respiratory distress syndrome
world this scenario remains a tragic reality. The first 28 days
(3) Respiratory and alimentary infections of life - the neonatal period, is the most vulnerable time for
(4) Congenital anomalies a child's survival. In order to continue to accelerate progress
in under-five mortality, focussing on newborns is critical.
(d) Unknown causes
Neonatal mortality is a measure of intensity with which
In some cases; the causes are not clinically ascertainable.
“endogenous factors” (e.g., low birth weight, birth injuries)
Interventions for the reduction of perinatal mortality affect infant life. The neonatal mortality is directly related to
the birth weight and gestational age. Intrapartum related
Measures to reduce perinatal mortality rates are essential complications, low birth weight and preterm birth is a causal
to accelerate the declining trend in neonatal and infant factor in 60 per cent of neonate deaths.
mortality rates. For further details, refer to Table 21.
Prematurity and congenital anomalies account for about
International certificate of perinatal death 60 per cent of newborn deaths, and these often occur in the
first week of life. A further quarter of neonatal deaths are
For international comparability, the 9th (1975) Revision attributable to asphyxia - also mainly in the first week of life.
of International Classification of Diseases (ICD-9) In the late neonatal period, that is, after the first week,
recommended a special certificate of cause of perinatal deaths attributable to infection (including diarrhoea and
death. The ICD has also a list of 100 causes (the “P” list) for tetanus) predominate. The importance of tetanus as a cause
tabulation of perinatal morbidity and mortality (28). of neonatal death, however, has diminished sharply due to
Prevention of perinatal mortality intensified immunization efforts.
Neonatal mortality rates of babies born to mothers with
See page 650 under Preventive & Social Measures.
no education are nearly twice as high as those of babies
born to mothers with secondary education or higher. The
NEONATAL MORTALITY RATE
family's wealth and rural/urban residence also remain
Neonatal deaths are deaths occurring during the neonatal powerful determinant of inequities in neonatal mortality.
period, commencing at birth and ending 28 completed days Ending child marriage, reducing adolescent pregnancy and
after birth. Neonatal mortality rate is the number of neonatal extending birth intervals are crucial to reducing the risk of
deaths in a given year per 1000 live births in that year. newborn mortality.

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644 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

Direct causes of newborn death vary from region to

region. In general, the proportions of deaths attributed to
prematurity and congenital disorders increase as the
neonatal mortality rate decreases, while the proportions
caused by infections, asphyxia, diarrhoea and tetanus
decline as care improves. Patterns of low birth weight vary
considerably between countries. Babies with a low birth
weight are especially vulnerable to the hazards of the first
hours and days of life, particularly if they are premature.
Majority of low-birth-weight babies are not actually
premature but have suffered from in utero growth restriction,
usually because of the mother’s poor health. These babies
too are at increased risk of death.
The main causes of neonatal mortality are intrinsically
linked to the health of the mother and the care she receives
before, during and immediately after giving birth. Asphyxia months years years years years
and birth injuries usually result from poorly managed labour Mortality rates
and delivery, and lack of access to obstetric services. Many FIG. 14
neonatal infections, such as tetanus and congenital syphilis, Global mortality rates by age, 2020
can be prevented by care during pregnancy and childbirth. Source : (6)
Inadequate calorie or micronutrient intake also results in
poorer pregnancy outcomes. It has been argued that nearly Sub-Saharan Africa is 11 times more likely to die in the first
three quarters of all neonatal deaths could be prevented if month than a child born in high-income country (6).
women were adequately nourished and received appropriate
care during pregnancy, childbirth and in the postnatal period. India
However, neonatal mortality is the most difficult part of In India the SRS estimates for the year 2020 was about
infant mortality to alter, because of the endogenous factors 15 per 1000 live births, in early-neonatal period (0-7 days),
which are not sensitive to improvements in environmental with about 17 for rural areas and 9 for urban areas. Table 19

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conditions. Neonatal mortality is greater in boys throughout shows the early neonatal mortality rate and percentage
the world, because newborn boys are biologically more share of early neonatal mortality to infant deaths in the
fragile than girls. country and the major states. Among the bigger states,
TABLE 19
Incidence
Early neonatal mortality rates and percentage share of
About 2.5 million newborns died before they are 4 weeks early neonatal deaths to infant deaths by residence,
old and half of them died in their first 24 hours in the year India and bigger states/UTs, 2020
2020. 98 per cent of these deaths occur in developing
countries. India and Early neonatal Percentage of early
bigger states/UTs mortality rate neonatal deaths to
The global number of neonatal deaths declined from infant deaths
5.0 million in 1990 to 2.4 million in 2019 - 6,700 deaths Total Rural Urban Total Rural Urban
every day in 2020, compared to 14,000 in 1990. Neonatal
deaths accounted for about 47 per cent of all under-five India 15 17 9 53.3 54.7 46.8
deaths in 2020, increasing from 40 per cent in 1990 due Andhra Pradesh 13 15 6 52.6 57.9 35.1
to faster global decline in mortality among children aged Assam 14 15 6 39.6 39.6 38.1
1-59 months, than in their first month of life. Based on a Bihar 16 17 12 59.5 60.9 47.4
recent systematic review, about a third of all neonatal deaths Chhattisgarh 20 20 18 51.9 50.5 59.5
occur on the day of birth and close to three quarters die in Delhi 6 8 6 49.0 40.0 49.4
the first week of life. These findings suggest that focusing on Gujarat 11 14 8 50.5 51.5 48.1
the critical period before and immediately following birth is Haryana 14 17 10 51.4 54.4 43.7
essential to saving more newborn lives (6). Himachal Pradesh* 10 10 6 54.9 55.6 41.3
Jammu & Kashmir 8 8 6 47.3 48.3 42.9
The mortality rate comparison for children under 19 Jharkhand 13 15 8 53.6 56.4 39.3
years of age is as shown in Fig. 14. Karnataka 11 13 6 55.5 61.8 40.8
In 2020, the neonatal mortality rate was estimated to be Kerala 4 2 6 60.7 48.9 66.7
at 17 deaths per 1000 live births globally. The probability of Madhya Pradesh 23 25 16 52.8 52.5 54.6
dying after the first month, in post-neonatal period was Maharashtra 8 11 5 50.8 54.1 43.1
11 per 1000, and probability of dying after reaching 1 year Odisha 21 22 14 58.1 58.8 52.3
of age and before reaching 5 years of age was at 10 per Punjab 9 9 9 46.8 44.6 50.3
1000 live births. Rajasthan 16 18 11 50.4 50.6 49.0
Tamil Nadu 6 9 4 50.0 56.6 41 1
The burden of neonatal mortality is uneven across
Telangana 10 13 7 48.4 51.3 41.8
regions. Some countries have relatively high neonatal
Uttar Pradesh 21 23 13 54.8 56.5 45.9
mortality given their level of under-five mortality. Most of
Uttarakhand 13 12 15 51.7 48.1 62.1
these countries are in Southern Asia. Sub-Saharan Africa
West Bengal 10 11 8 54.2 56.9 44.7
had the highest neonatal mortality rate in 2020, at 27 deaths
per 1000 live births, followed by Central and Southern Asia *(Based on three year period 2018-2020)
with 23 deaths per 1000 live births. A child born in Source : (73)

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 POST-NEONATAL MORTALITY RATE 645
Kerala (4), Madhya Pradesh (23), and Odisha (21) are the Prematurity & All other remaining
two extremes. The percentage of early neonatal deaths to low birth weight 1.4%
the total infant deaths during the year 2020, at the national 48.1% Injuries
0.9%
level, has been 53.3, and it varied from 54.7 in rural areas to
Diarrhoea
46.8 in urban areas. In most of the states rural proportion is 3.1%
relatively higher than the urban proportion. Among the
bigger states, the percentage for total varied from 39.6 in
anomalies
Assam to 60.7 in Kerala. \ 4%
Table 20 shows the neonatal mortality rate in the country
and the percentage of neonatal deaths to infant deaths for \ Ill-defined
the year 2020, both at the national and state levels. At the \ or cause
national level, the neonatal mortality rate was 20 and \unknown
ranged from 12 in urban areas to 23 in rural areas. Among \ 5%
Birth asphyxia
the bigger states neonatal mortality ranges from 31 in & birth trauma
Madhya Pradesh to 4 in Kerala. The percentage of neonatal 12.9% Sepsis
deaths to total infant deaths was 71.9 per cent at the Neonatal Other non­ 5.4%
national level and varied from 62.4 per cent in urban areas Pneumonia communicable diseases
to 74.1 per cent in rural areas. Among the bigger states 12% 7.1%
Bihar (77.7) registered the highest percentage of neonatal FIG. 15
deaths to infant deaths, and the lowest was in Assam (53.0).
Causes of neonatal deaths in India, 2017
TABLE 20 Source : (87)
Neonatal mortality rates and percentage share of neonatal
deaths to infant deaths by residence, cent of the country's total annual live births) being born with
India and bigger states, 2020 a birth weight less than 2500 grams. Of these 7.5 million
babies, about 60 per cent are born at term after foetal
India and Neonatal Percentage of
bigger states/UTs mortality rate neonatal deaths.to growth retardation, while the remaining 40 per cent are born
infant deaths preterm, constituting one fourth of global burden of preterm

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Total Rural Urban Total Rural Urban births. Preterm babies in addition to being at a higher risk of
neonatal mortality, are at an increased risk of post-neonatal
India 20 23 12 71.9 74.1 62.4 mortality, stunting, and long-term neuro-developmental
Andhra Pradesh 17 21 8 70.3 77.7 45.4 impairment during childhood (83).
Assam 19 20 10 53 0 52.6 61.7
Bihar 21 22 17 77.7 79.0 66.6 Interventions for the reduction of neonatal mortality
Chhattisgarh 26 28 20 68.8 69.3 65.9
Measures to reduce neonatal mortality rates and to
Delhi 9 12 9 71.3 60.0 71.8
Gujarat 20
improve newborn health are enumerated in Table 21.
16 9 68.7 73.6 56.8
Haryana 19 22 15 68.6 70.3 64.2 POST-NEONATAL MORTALITY RATE
Himachal Pradesh* 13 13 10 72.7 73.0 66.5
Jammu & Kashmir 12 12 10 71.1 70.5 73 9 Deaths occurring from 28 days of life to under one year
Jharkhand 17 19 11 68.8 71.8 53.2 are called “post-neonatal deaths”. The post-neonatal death
Karnataka 14 18 8 74.7 85.0 50.5 rate is defined as : “the ratio of post-neonatal deaths in a
Kerala 4 3 6 66.4 66.0 66.7 given year to the total number of live births in the same
Madhya Pradesh 31 34 19 70.8 71.8 64.8 year; usually expressed as a rate per 1000” (88).
Maharashtra 11 15 6 70.2 75.3 58.3
Odisha 28
The post-neonatal mortality rate is tabulated as :
29 20 77.6 78.2 72.1
Punjab 12 12 12 65.7 63.7 69.0 Number of deaths of children between
Rajasthan 23 26 14 71.5 73.6 60.7 28 days and one year of age in a given year
Tamil Nadu 9 12 6 70.5 78.6 59.6 = ------------------------------------------------------------ X1000
Telangana 15 17 13 71.8 68.7 79.0 Total live births in the same year
Uttar Pradesh 28 31 18 74.1 76.1 63.8 Whereas neonatal mortality is dominated by endogenous
Uttarakhand 17 17 18 71 0 70.1 73.8 factors, post-neonatal mortality is dominated by exogenous
West Bengal 14 15 11 72.9 76 1 61.5 (e.g., environmental and social) factors. Diarrhoea and
*(Based on three year period 2018-2020) respiratory infections are the main causes of death during
Source : (73) the post-neonatal period. Malnutrition is an additional
factor, reinforcing the adverse effects of the infections. In the
CAUSES OF NEONATAL DEATHS IN INDIA developed countries, the main cause of post-neonatal
The major causes of neonatal deaths are shown in mortality is congenital anomalies. Studies show that post-
Fig. 15. neonatal mortality increases steadily with birth order, and
that infants born into already large families run a higher risk
It is estimated that 40 per cent of all stillbirths and of death from infectious diseases.
neonatal deaths take place during labour and the day of
birth, and about 75 per cent of total neonatal deaths occur In some areas of South East Asia (including India), during
within the first week of life. Notably half of all the maternal the post-neonatal period girls die more frequently than boys.
deaths also take place in this period (83). This is attributed to neglect of the female children in terms of
India accounts for 40 per cent of the global burden of low nutrition and health care.
birth weight babies with 7.5 million babies (or about 30 per The SRS estimates for post-neonatal mortality rate in
by R△J
 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

TABLE 21
Priority areas to improve newborn health
Before and during pregnancy • Delayed child-bearing
• Well-timed, well-spaced and wanted pregnancies
• Well-nourished and healthy mother
• Pregnancy free of drug abuse, tobacco and alcohol
• Tetanus and rubella immunization
• Prevention of mother-to-child transmission of HIV
• Female education
During preganancy • Early contact with health systems including .
- Birth and emergency preparedness
- Early detection and treatment of maternal complications
- Monitoring of foetal well-being and timely interventions for foetal complications
- Tetanus immunization
- Prevention and treatment of anaemia
- Prevention and treatment of infections (malaria, hookworm, syphilis and other STIs)
Voluntary HIV counselling and testing, and prevention of mother-to-child transmission of HIV
• Good diet
• Prevention of violence against women
During and soon after delivery • Safe and clean delivery by skilled attendant
• Early detection and prompt management of delivery and foetal complications
• Emergency obstetric care for maternal and foetal conditions
• Newborn resuscitation
• Newborn care ensuring warmth and cleanliness
• Newborn cord, eye and skin care
• Early initiation of exclusive breast-feeding
• Early detection and treatment of complications of the newborn
• Special care for infants born too early or too small and/or complications
• Prevention and control of infections

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• Prevention of mother-to-child transmission of HIV
• Information and counselling on home care, danger signs and care seeking
During the first month of life • Early post-natal contact
• Protection, promotion and support of exclusive breast feeding
• Prompt detection and management of diseases in newborn infant
• Immunization
• Protection of girl child
Source : (89)

India for the year 2020 was about 8 per 1000 live births for INFANT MORTALITY RATE
the whole country, and 8 for rural areas and 7 for the urban
areas. The state-wise break-up is shown in Table 22. Infant mortality rate (IMR) is defined as “the ratio of
TABLE 22 infant deaths registered in a given year to the total number
SRS estimates of post neonatal mortality in India, 2020 of live births registered in the same year; usually expressed
as a rate per 1000 live births” (90). It is given by the
State Post-neonatal mortality rate formula :
Total Urban Rural
Number of deaths of children
Andhra Pradesh 7 10 6 less than 1 year of age in a year
Assam 17 6 18 IMR =---------------------------------------------------- X 1000
Bihar 6 8 6 Number of live births in the same year
Chhattisgarh 12 11 12
Gujarat 7 7 7
IMR is universally regarded not only as a most important
Haryana 9 8 9
5
indicator of the health status of a community but also of
Himachal Pradesh 5 5
Jharkhand 8 10 7 the level of living of people in general, and effectiveness
Karnataka 5 8 3 of MCH services in particular. Infant mortality is given a
Kerala 2 3 1 separate treatment by demographers because : (a) infant
Madhya Pradesh 13 10 13 mortality is the largest single age-category of mortality;
Maharashtra 5 4 5 (b) deaths at this age are due to a peculiar set of diseases
Odisha 8 8 8 and conditions to which the adult population is less exposed
Punjab 6 5 7 or less vulnerable; (c) infant mortality is affected rather
Rajasthan 9 9 9 quickly and directly by specific health programmes
Tamil Nadu 4 4 3 and hence may change more rapidly than the general death
Telangana 6 4 8
rate.
Uttar Pradesh 10 10 10
Uttarakahand 7 6 7
West Bengal 5 7 5 International comparisons
India 8 7 8 During the past decades, there has been a steady decline
Source : (73) in infant mortality (Table 23)
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 INFANT MORTALITY RATE

TABLE 23 quality of life), with medical services playing secondary role.

Infant mortality rate in selected countries (1990-2020) On the other hand, in most of the developing countries, this
—------------------------------------
pattern has been almost turned upside down. That is,
Country 1990 2020
medical services (e.g., mass control of disease,
India 88 28 immunization, antibiotics and insecticides) have made the
Sri Lanka 18 6 major impact, with social and economic progress taking the
Bangladesh 100 24 supporting role. Therefore, infant mortality rates are
Pakistan 106 54 reluctant to fall below 100 per 1000 live births in many
Thailand 30 7 developing countries. It is now conceded that only socio­
Myanmar 78 35 economic development can re-accelerate the progress and
China 42 5 lead to further significant fall in infant deaths.
Nepal 99 24
New Zealand 9 4 Infant mortality in India
USA 9 5
UK 8 4 India is still among high infant mortality rate countries
Japan 5 2 [28 in the year 2020). IMR has declined slowly from 204
World 63 27 during 1911-15, to 129 per 1000 live births in 1970 and
remained static at around 127 for many years, and then
1990 is the baseline for MDGs
declined a bit once again to 114 in 1980 and coming down to
Source : (6) 28 in the year 2020. Despite this significant decline, the rates
There are wide variations between countries or regions in are high as compared to developed countries (Table 23)
the levels of infant mortality. The world average of IMR for which are now mostly in the range of 3-7 per 1000 live births.
2020 has been estimated at about 27 per 1000 live births. India is a vast country with widely differing populations.
However, IMR varies from 4 per 1000 live births in the The all-India rate masks variations that exist among sub­
developed countries to 46 per 1000 live births in the least groups of the population. An examination of state-wise IMR
developed countries. The average in the South Asian for the year 2020 shows a vast regional variation, with
countries was 35 per 1000 live births. Although infant Madhya Pradesh having IMR of 43 and Kerala as low as 6 per
mortality declined significantly, the drop was greatest for the thousand live births during the year 2020. Among the larger

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developed countries and lowest for least developed States Kerala, Maharashtra, Punjab, Tamil Nadu, West
countries. The developed world had a much greater Bengal, Andhra Pradesh, Haryana, Karnataka, Gujarat,
reduction in infant mortality compared to child mortality, Himachal pradesh, Bihar, and Jharkhand have achieved IMR
while in the developing world the situation was reverse (6). below the national average of 28. Within each state there is
The IMRs in industrialized countries were around 200 or rural urban variation. A critical infant mortality belt runs
even more, some 150 years ago. Even at the beginning of the through Odisha, Madhya Pradesh, Assam, Chhattisgarh, Uttar
20th century. USA, UK, Japan, France, etc, had rates above Pradesh, and Rajasthan; all these states have infant mortality
140 per 1000 live births. Within 50 years (1950) a spectacular rates above the national average.
fall in the rate was observed in all developed countries. By Table 24 shows infant mortality rates in major states of
1980s, most developed countries achieved IMR rates below India.
10 per 1000 live births. Demographers opine that in most
developed countries, further decline in IMRs would be TABLE 24
difficult to achieve without some revolutionary advances in Infant mortality rates in major states of India (2020)
perinatology. Any further reduction in infant mortality in India and major states/UTs Total Rural Urban
developed countries will depend upon preventing one of its
principal causes, namely, congenital abnormalities. Andhra Pradesh 24 26 18
Assam 36 39 17
In general, the infant mortality rates reflect the socio­ Bihar 27 27 25
economic development of a country. Deaths during the first Chhattisgarh 38 40 31
four weeks are largely preventable by good health care. Delhi 12 20 12
Much of the variations between developed and developing Gujarat 23 27 17
world in death among newborn can be explained by Haryana 28 31 23
differences in antenatal care - about half of all pregnant Himachal Pradesh* 17 18 15
women in the least developed countries have no antenatal Jammu & Kashmir 17 18 13
care, and 7 out of 10 babies are born without the help of a Jharkhand 25 26 21
trained birth attendant. The other major factors being Karnataka 19 21 16
malnutrition and high parity of the mother, low birth weight Kerala 6 4 9
of the baby, and congenital anomalies. Madhya Pradesh 43 47 30
The decline in infant mortality has been attributed to : Maharashtra 16 20 11
(a) improved obstetric and perinatal care, e.g., availability of Odisha 36 37 28
oxygen, foetal monitoring during labour, improved Punjab 18 19 17
techniques for the induction of labour (b) improvement in the Rajasthan 32 35 23
quality of life, that is, economic and social progress (c) better Tamil Nadu 13 15 10
control of communicable diseases, e.g., immunization and Telangana 21 24 17
oral rehydration (d) advances in chemotherapy, antibiotics Uttar Pradesh 38 40 28
and insecticides (e) better nutrition, e.g., emphasis on breast Uttarakhand 24 25 24
feeding, and (f) family planning, e.g., birth spacing. West Bengal 19 19 17

In the industrial world, the dominant factor in the decline India 28 31 19

of infant mortality was economic and social progress (i.e., Source : (73)
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 PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

There is plenty of evidence to show that better control of TABLE 26

infant mortality is related to a wider spread of literacy Causes of infant mortality
(particularly female literacy) and primary health care. Also, Neonatal mortality Post-neonatal mortality
the states with the highest infant mortality are also the states (0-4 weeks) (1-12 months)
with the highest fertility. Table 25 illustrates the impact of the
above variables on infant mortality. 1. Low birth weight 1. Diarrhoeal diseases
and prematurity 2. Acute respiratory
TABLE 25 2. Birth injury and difficult labour infections
IMR, female literacy rate and birth rate 3. Sepsis 3. Other communicable
in major Indian States 4. Congenital anomalies diseases
5. Haemolytic diseases of newborn 4. Malnutrition
IMR Female Birth rate 6. Conditions of placenta and cord 5. Congenital anomalies
per 1000 literacy per 1000 7. Diarrhoeal diseases 6. Accidents
State
live births rate population 8. Acute respiratory infections
(2020) (2011) (2020) 9. Tetanus

Andhra Pradesh 24 59.74 15.7 The principal causes of infant mortality in India are low
Assam 36 67.27 20.8 birth weight (57%), respiratory infections (17%), diarrhoeal
diseases (4%), congenital malformations (5%) and cord
Bihar 27 53.33 25.5
infection (2%), birth injury (3%) and unclassified about
Chhattisgarh 38 60 59 22.0 (18%) (62). Neonatal deaths make a major contribution to
Gujarat 23 70.73 19.3 infant mortality. Whereas in developing countries, the
Haryana 28 66.77 19 9 high infant mortality is mainly due to low birth weight, and
Himachal Pradesh 17 76 60 15.3 the combined effects of infection (e.g., diarrhoea, respiratory
Jharkhand 25 56.21 22.0 infections) and malnutrition, in developed countries, it is
Karnataka 19 63.13 16.5 mainly due to congenital anomalies, anoxia and hypoxia.
Kerala 6 91.98 13.2 Factors affecting infant mortality
Madhya Pradesh 43 60.20 24.1
Infant mortality is due to the interaction of several factors

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Maharashtra 16 70.48 15.0
in combination. They may be classified as biological,
Odisha 36 64.36 17.7 economic and social factors.
Punjab 18 71.34 14.3
Rajasthan 32 52.66 23.5 1. BIOLOGICAL FACTORS
Tamil Nadu 13 73.86 13.8 (a) Birth weight
Telangana 21 - 16.4
Birth weight is a major determinant of infant and
Uttar Pradesh 38 59.26 25.1 perinatal mortality and morbidity. Babies of low birth weight
Uttarakhand 24 - 16.6 (under 2.5 kg) and high birth weight (over 4 kg) are at
West Bengal 19 71.16 14.6 special risk. Virtually, all infants weighing less than 1000 g at
birth succumb. One major cause of low birth weight is poor
Source : (73, 91, 92) maternal nutrition - not only during pregnancy, but even
before that. It has been observed that the mother who was
Table 25 shows that Kerala has managed to surpass all adequately nourished during her own growing-up years has
the Indian states in certain important measures of social an excellent chance of delivering a normal size baby even if
development. It has the lowest infant mortality rate, the she has taken an inadequate diet during her pregnancy. An
lowest birth rate and the highest literacy rate. increase in birth weight would lower the perinatal and
neonatal mortality.
Mortality pattern (b) Age of the mother
(a) Age : Deaths in the age-group 0-1 year account for There is a definite relationship between the age of the
10.5 per cent of the total deaths in the country. About 71.7 mother and the fate of the child. Infant mortality rates are
per cent of infant deaths occur within the first month greater when the mother is either very young (below the age
(neonatal period) of life. Of these, 54.6 per cent may die of 19 years) or relatively older (over 30 years). Very young
during the first week of birth (73). The risk of death is the mothers also tend to be poorer and less educated (94).
greatest during the first 24-48 hours after birth. The (c) Birth order
problem is more acute in rural areas where expert obstetric The live births are classified according to their order of
care is scarce, (b) Sex : Whereas in all developed countries, rank. The highest mortality is found among first born, and
male death rates are higher than female deaths, in India, the lowest among those born second. The risk of infant
after the age of one month (post-neonatal period) female mortality escalates after the third birth. The fate of the 5th
deaths are invariably higher than male deaths. Social and later children is always worse than the fate of the 3rd
scientists have attributed this phenomenon to social factors child. Infant mortality from nutritional deficiencies are 3-4
unfavourable to females in India (93). times higher for infants born with fifth or higher birth order
compared to the first three. These deaths occur mostly in
Medical causes of infant mortality post-neonatal period.
The causes of infant mortality are multifactorial. The (d) Birth spacing
medical causes are shown in Table 26 under two Repeated pregnancies exert a great influence on infant
subdivisions - neonatal and post-neonatal mortality. mortality. They cause malnutrition and anaemia in the
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 INFANT MORTALITY RATE 649
mother, again predispose to low birth weight, which results (c) Early marriages
in higher infant death. The mother who becomes pregnant The baby of teen-age mother has the highest risk for
again too early and whose youngest baby is displaced from neonatal and post-neonatal mortality.
the breast, and prematurely weaned - that baby is more
prone to develop (a) protein energy malnutrition (d) Sex of the child
(b) diarrhoea and dehydration, both of which cause an In most parts of India, female infants receive far less
increased mortality in infants and young children. The attention than males. This is especially the case, where there are
Khanna Study in India showed that IMR was highest for already several female children. In many families, the birth of a
infants born after an interval of one year, lower for those female child is unwelcome. Statistics show that female infant
born after an interval of 2-3 years, and lowest for those mortality is higher than the male infant mortality. But when the
born after an interval of 4 years (95). A WHO study in rural total infant mortality is split into neonatal and postneonatal
India also showed similar findings (96). Evidence from the deaths, the picture gets reversed, i.e., neonatal death rate is
World Fertility Survey - the largest survey into human higher for males than for female infants; post-neonatal death
behaviour ever undertaken - suggests that the risks to life rate is higher for female infants than male infants (93).
for babies born within a year of each other is 2-4 times
(e) Quality of mothering
higher than for babies born more than 2 years apart. Wider
spacing of births curtails infant mortality, and is considered The art of child care has to be learnt. Even in conditions
as important part of health care as immunization (97). of extreme poverty, children could reasonably survive if they
had an efficient mother. It is the “quality of mothering” that
(e) Multiple births
helps to reduce infant mortality.
Infants born in multiple births face a greater risk of death
than do those in single births due in large part to the greater (f) Maternal education
frequency of low birth weight among the former. Illiteracy is the greatest barrier to any improvement in the
(f) Family size health conditions. Mother’s education level, even within the
same socio-economic class is a key determinant of their
Studies show the infant mortality increases with family children’s health. There is extensive evidence (e.g. Kerala
size. The number of episodes of infectious diarrhoea, experience) that maternal education plays a major role in
prevalence of malnutrition, and severe respiratory infections the decline of infant and child mortality, presumably

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have been found to increase with family size. Besides the reflecting personal health behaviour, care and access to and
frequency of disease, the duration of illness is also affected use of health services. Women with schooling tend to marry
by the family size. It was found that the duration of illness is later, delay child-bearing and are more likely to practice
much longer in families with 3 or more children. Deprivation family planning. They generally have fewer children with
of maternal care is also found in large families. Fewer wider spacing between births.
children would mean better maternal care, a better share of
family resources, less morbidity and greatly decreased infant (g) Quality of health care
mortality. Another likely factor affecting infant mortality in
(g) High fertility contemporary India is inadequate prenatal care and
infrequent attendance at delivery.
Fertility is one of the most important factors that
influence infant mortality. High fertility and high infant The percentage of deliveries attended by untrained
mortality go together. persons or relatives is very high in rural India. Shortage of
trained personnel like dais, midwives and health visitors is
(2) ECONOMIC FACTORS another determinant of high infant mortality in India.
According to estimates only 47 per cent of the deliveries are
One of the most important variables affecting infant
attended by trained birth attendants.
mortality rates, both directly and indirectly, is socio-economic
status. The availability and quality of health care and the (h) Broken families
nature of the child’s environment are closely related to socio­ Infant mortality tends to be high where the mother or
economic status. Statistics reveal that infant mortality rates are father has died or separated.
highest in the slums and lowest in the richer residential
localities. Major improvements in health status and a decrease (i) Illegitimacy
in infant mortality require continuing socio-economic Illegitimacy is also an important factor contributing to
development, including provision of health services. high infant mortality rate. A child born out of wedlock is
generally unwanted both by the mother as well as society.
(3) CULTURAL AND SOCIAL FACTORS Consequently such a child does not receive the care in terms
(a) Breast-feeding of nutrition and medical care that it needs.
Infant health is related to breast feeding because of the (j) Brutal habits and customs
nutritional content and natural immunizing agents contained Certain age-old customs and beliefs greatly influence
in breast milk, at least for fully breast-fed infants. Early infant mortality rate. These include depriving the baby of
weaning and bottle-fed infants living under poor hygienic the first milk or colostrum, frequent purgation, branding the
conditions are more prone to die than the breast-fed infants skin, application of cowdung to the cut end of umbilical
living under similar conditions. cord, faulty feeding practices and early weaning.
(b) Religion and caste (k) The indigenous dai
The differences are attributed to socio-cultural patterns of The untrained midwife is greatly responsible for the high
living, involving age-old habits, customs, traditions affecting infant mortality in India. She is usually an illiterate person
cleanliness, eating, clothing, child care and almost every devoid of all knowledge of rules of hygiene. Her unhygienic
detail of daily living. delivery practice is an important cause of high infant mortality.
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65£L PREVENTIVE MEDICINE IN OBSTETRICS, PAEDIATRICS AND GERIATRICS

(1)Bad environmental sanitation 6. Sanitation

Infants are highly susceptible to bad environmental For infants and young children, the risk of dying is very
sanitation. Lack of safe water supply, poor housing closely related to the environment in which they live.
conditions, bad drainage, overcrowding,, and insect Exposure to infections through contaminated food and
breeding, all increase the risk