Biomedical Waste (BMW)

● Covered by Environment protection Act 1986

→ section 6,8 and 25
→ Ministry of Environment and Forest

Schedules
I - categories, treatment and disposal
II - colour coding and containers
III - label for bags, containers
IV - label for transportation
V - standards for treatment and disposal

1998 guidelines: 10 categories, 4 colour coded bags, Disposal

2017 guidelines: 4 categories, disposal

YELLOW CATEGORY

1​ -> Human Anatomical waste [Placenta, appendix, gallbladder, amputations]

2​ -> Animal waste [animal houses - Micro, pharm and physio deptartments]
6​ -> Solid waste [cotton/ cloth - gauge piece, bandages, dressings, swabs]

10​ -> Chemical waste - disinfectant

- production of biologicals
5​ -> Discarded medicine - expired medicine
- cytotoxic drug

8​ -> liquid chemical waste - cleaning

- housekeeping
- disinfecting activity

3​ -> Microbiological, biotechnological, laboratory waste - Culture

- live vaccines
- toxins
- biologicals

Seperate unit -> Bed lines, mattresses, beddings

Disposal
1,2 and 6 Incineration/ plasma pyrolysis /deep burial

10 and 5 Incineration/ plasma pyrolysis /deep burial

8 Chemical treatment → drains

3 +Seperate Non chlorinated chemical treatment →

unit incineration

RED CATEGORY

7​ -> Solid/Contaminated (Recyclable) - plastic rubber [tubing, catheters, cannula]

​Disposal​ - Autoclaving/ Microwaving/ Hydroclaving

​↓
Destruction/ Shredding
↓
Energy recovery/ Fuel/ Road making

WHITE CATEGORY

4​ -> Wasted sharps - needle part of syringe

- surgical blades, scalpels

Disposal​ - Autoclaving /dry heat

↓
Shredding/ Mutilation/ Encapsulation
↓
Foundries/ landfills/ Sharps pit

BLUE CATEGORY

● Glassware
● Metallic body implants - orthopedics, ENT, dental surgery
- cardiovascular thoracic surgery

​ hemical treatment/ autoclaving/ hydroclaving/ microwaving

​Disposal - C
↓
Recycling
OLDER METHODS

Incineration

● Temperature - Above 1200​°​C

● Principal: high temperature dry oxidation
● Suitable for incineration - combustible > 60%
- non combustible
- solids < 5%
- fines < 20%
- moisture content < 30%
● C/I for Incineration
- PVC plastic waste (fumes causes angiosarcoma of liver)
- pressurized waste ---> explosion
- heavy metal waste ---> Pb, Cd, Hg
- Reactive chemical waste ---> silver (from X-ray films)
- Radioactive waste (Recommended - sea burial)

Autoclave

● Temperature - 121​°​C (for 60 min. & 15 psi), 135​°​C, 149​°​C.

● Principal: steam under high pressure
● Check sufficiency - Geobacillus Stearothermophilus(GBS) spores

Hydroclave

● Temperature - 121​°​C or 132​°C

​
● Principal: steam under pressure
● Check sufficiency - bacillus subtilis spores

Microwave

● Wavelength = 12 nm wave
● Frequency = 2450 mHz
● Principal: generation of convection currents in heated h20 molecules
● checks sufficiency - bacillus atrophaeus spore
NEWER METHODS

Encapsulation
● Filling container with Biomedical Waste and Immobilization material (foam,
sand, cement clay) and Seal the container.

Plasma pyrolysis
​
● Temperature: > 1200​°C

Inertization
● Large volume of toxic Biomedical Waste is converted to non toxic/inert waste .
● Converted via 15% cement + 15% lime

Screw feed Technology

● Biomedical Waste mixed with inertizing material → Rotating Auger (heating +
shredding)
● Principal: dry thermal process (no burning)
● Advantage - reduce weight by 20 to 25%
- reduce volume by 80%
● Used for: Sharps waste and infectious waste
● C/I - radiological, cytotoxic, pathological waste

Dry heat
● Temperature: > 185​°​C

Composting methods
● Land + cow dung
● Vermicomposting
1. Earthworms (Eisenia fetida) + Land + Mature cow dung (khad) + Coconut husk
Special waste

Waste Disposal

HIV infected material 1% hypochlorite → categorise

Mercury Recollect → recycle → reuse (R​³​)

E-waste recycle

Blood spill 1% hypochlorite → drain

Family planning and Contraception

Couple protection rate (CPR)

1. It is an indicator of prevalence of contraceptive practice in a community.
2. CPR = ​total ECs protected by any 4 approved methods​ X 100
total ECs in community
CPR (India) = 54%
3. Eligible couple (EC) - Currently married couple with wife in a reproductive age group.
4. The 4 approved method of family planning:
a. Condoms b. OCPs c. IUDs d. Sterilization
5. Effective Couple protection rate (ECPR)
● CPR X Effectivity of Contraceptive method.
● Effectivity of Contraceptive method
- Condom: 50%
- IUDs: 95%
- OCPs & Sterilization: 100%

Contraceptive Failure/Efficacy
1. Contraceptive Failure - Assessed by measuring the Number of unplanned pregnancies
that occur during a specified period of exposure and use of a contraceptive method.
2. Pearl index (PI)
● Total number of failures per 100 women years (HWY) of exposure.
● HWY - 100 women using particular contraception for 1 year
● PI = ​total accidental pregnancy​ X 1200
total months of exposure
● Disadvantage: assumes constant failure rate over time.
● PI of few Contraceptive methods
Contraceptive Method PI (per HWY)

Male condom 2-14

Female condom 5-21

Vaginal sponge 9-21

Oral pill 0.1-0.5

IUD 0.5-2.0

Sterilization 0.1
(Vasectomy -
superior)
3. Life Table Analysis (LTA)
● calculates failure rate per month of use by single women
 ● Better measure than Pearl Index.

Conventional contraception
1. Aka ​Coitus-dependent contraception
2. Contraceptives which are used at or just prior to the time of intercourse.
3. Methods of contraception
a. Male condoms
b. Spermicides (Non-oxynol-9)
● MAO: rupture the plasma membrane of acrosomal cap.
Interception / Emergency contraception
1. Aka ​Post-coital contraception​ or ​Coitus-independent contraception
2. Contraceptives which are used after unprotected intercourse.
3. Methods of contraception
a. Combined OCPs​ → taken < 72 hours of unprotected sex
● Yuzpe & Lancee Method - 4 pills followed by 4 pills with a gap of 12 hrs,
completed within 72 hrs.
b. Progesterone only pills​ → taken < 72 hours of unprotected sex
● 1 pill followed by 1 pill with a gap of 12 hrs, completed within 72 hrs.
● Dose: I pill = 0.75 mg
c. Mifepristone (RU 486)​ → taken < 72 hours of unprotected sex
d. High dose estrogen​ → given continuously for 5 days
e. IUDs​ → Within 5 days of unprotected sex
4. Recommended Contraception
● Most effective - IUDs.
● MC recommended by RCH - Combined OCPs.
i) IUDs are contraindicated in Nulliparous women. In India, most of the women
who report for pregnancy are Unmarried/Nulliparous.

Natural Method of Family Planning

1. Safe period [Rhythm method /Calendar method] ​- PI = 60 HWY

2. Basal body temperature (BBT) method
3. Cervical mucus method
4. Symptothermic method
5. Sexual Abstinence
6. Coitus interruptus /Withdrawal method ​- PI = 0 HWY
7. Lactational amenorrhea method (LAM)
Barrier method of family planning

1. Condoms
Male condom Female condom

Pearl index 2-15 5-21

Insertion Easy to use Difficult technique

HIV protection ✓ ✓✓ (covers skin

(STIs) around ext. genitals)

Reuse X ✓

Material Latex (translucent) Polyurethane/ Nitrile

(transparent)

Length short long

No. of rings 1 2

2. Diaphragm
● Used along with Spermicides.
● Reusable [Wash → Dry → Use].
● Inserted 4 hours before sex and remains in the vagina 6 hours after sex.
High level of motivation is required, hence used by educated women.
● Complication
a. yeast infection, bacterial vaginosis
b. toxic shock syndrome

1. Vaginal Sponge
● Brande name: TODAY.
● Used along with Spermicides.
● Inserted 4 hours before sex and remains in the vagina 4 hours after sex.
● Complication
c. yeast infection, bacterial vaginosis
d. toxic shock syndrome

Chemical method of family planning

1. Spermicide
2. Foam
 3. Jelly

Intrauterine devices (IUDs)

● Types of IUDs
1st generation IUDs 2nd generation IUDs 3rd generation IUDs

Non medicated Medicated (Bio-active) Medicated (Bio-active)

(inert) IUD IUD IUD

No medication is Metallic ions (Cu) are Hormones are added

added to IUD added to IUD to IUD

1. Lippes Loop 1. CuT 7 1. Progestasert

2. Grafenberg Ring 2. CuT 220 B 2. LNG​—​IUD
3. CuT 380 A (Ag)/(Au)
1. CuT 380 A
a. 380 - surface area of Cu in ​mm²​.
b. A - determines size of IUD → small size.
c. Ag/Au - Silver /Gold → ​↑​ effectivity + ​↑ ​shelf life (10yrs).
1. Progestasert
a. rate of progesterone release - 65 mcg/day
b. total progesterone content - 38 mg
c. shelf life - 1 to 1.5 year
● Side effects & Management of IUDs
Bleeding - Reassure the female: do not remove IUD.
- FeS04 200mg, 3 X daily for 8 weeks.
- If bleeding is heavy or persistent: Remove IUD.

Pain - Slight pain: give pain relievers & Observe

→ mild analgesics → Aspirin (NSAID).
→ strong analgesics → Codeine (Opioid)
[usually not given coz it suppress the pain of
Uterine perforation & peritonitis].
- Intolerable pain: Remove IUD.

Pregnancy - If women requests → Legally induced abortion.

with IUD - If women wants to continue pregnancy
in-situ → gently remove IUD (may cause spontaneous
abortion)
Hormonal Methods of Contraception

1. Combined OCP
● Combined OCP under RCH programme
MALA-N MALA-D

Estrogen Ethinyl estradiol (0.03 mg) Ethinyl estradiol (0.03 mg)

Progesterone Norgestrel (0.15mg) Desogestrel (0.15mg)

Status Free of cost Subsidized cost

₹ 3/per packet
● MALA-N
1. Once a day pill - 1/day
2. Each strip Contains 28 tablet: 4 row X 7 column
3. 21 Combined OCP + 7 ferrous fumarate tablet (Dose: 1 tab = 60 mg)
4. Purpose of using iron tablet
- so that women does not forget to take next strip
- prevents anemia
● Absolute contraindication for using Combined OCPs
a. Cancer - Breast cancer, Cervical cancer.
b. Hepatocellular adenoma
c. Undiagnosed abnormal uterine bleeding
d. Thromboembolism
e. Cardiovascular abnormality
f. Hyperlipidemia
g. Pregnancy

1. Centchroman
● BRAND name: Old - Saheli; New - Chhaya.
● Developed by Central drug Research Institute (CDRI), Lucknow, India.
● Synthetic NON-STEROIDAL oral contraceptive
● Contains: Ormeloxifene [SERM]
● Dosage - 1 tablet X twice a week X 3 months → 1 tablet X once a week.
● Pearl Index (PI) = 1.83-2.84 per HWY.
● Contraindication - ​Polycystic Ovarian Syndrome (PCOS).

1. Progestogen-only pill (POP)

● aka mini/micro Contraceptive pills
● does not affect milk production → can be given to lactating mother.
 1. Quinestrol
● estrogen medication - ‘Once a month pill’
● Not used nowadays.

1. Gossypol
● Male oral pill
● Derived from chineses cotton oil
● Limitation - permanent azoospermia

1. DEPOT formulation
● IM injectable hormone
● Depot formulation:
DMPA = Depot Medroxy progesterone Dose: 150 mg i/m every
acetate. 3 months

NET-EN = Norethisterone Enanthate Dose: 200 mg i/m every

2 months
● DMPA is available as ‘Antara’ under RCH programme.

1. Norplant
● Subdermal implant
● Contains:​ ​6 silastic capsules containing 35 mg LNG each.
● Capsules are inserted surgically beneath the skin of forearm.
● Effectiveness - 5 years

Terminal Methods of Contraception

1. Vasectomy
a. Remove a minimum 1 cm of Vas deferens. Ends are ligated and folded back.
No scalpel vasectomy/ Keyhole vasectomy:
- Tiny puncture by surgical hook on scrotum → Vas pulled out → Cut, tie
ends & push back → bandage is applied over it [NO stitches].
b. Post-operative advice: use Barrier methods for 3 months till aspermia. Person is
not sterile UNTIL after 30 ejaculations post vasectomy.
c. MCC of failure of Vasectomy in India: misidentification of Vas deferens.
To prevent this: surgeons cut suspected Vas deferens → squeeze contents out &
examine under microscope → if sperm present → continue w/ procedure.
 2. Tubectomy
a. Block both the fallopian tube.
b. Methods commonly used:
- Mini-laparotomy procedure
- Laparoscopic procedure

Ideal contraceptives
1. 35 yr old educated (temporary spacing) - Diaphragm.
2. Newly married - Combined OCPs.
3. Couple meet occasionally & Teenage girl - Condoms.

MC used Contraception used in India

1. Sterilization - 39% [Tubectomy > Vasectomy].
Concepts of health disease and prevention

1. HDI vs PQLI
Human Development Index (HDI) Physical quality of life index (PQLI)

Components
Life expectancy at birth (LB​b​/LE​0​) Life expectancy at 1 year (LE​1​)

Income Infant mortality rate [IMR]

- Real GNI per capita
- ​Purchasing power parity (PPP)
Education / Literacy rate
Education / Literacy rate
- Mean years of schooling
- Expected years of schooling
- Enrollment ratio
- Education index

Range 0 to +1 0 to 100

Value in India 0.624 (130 rank) 65 (49 rank)

2. ​Goalposts to construct HDI

Maximum value Minimum Value

Life Expectancy at birth 83.4 (Japan) 20.0

Mean years of schooling 13.1 0

Expected years of schooling 18.0 0

Combined Education index 0.978 (Australia) 0

Per capita income ($) 107,721 (Qatar) 100

3. ​Human poverty Index (HPI)

● HPI is complementary to Human Development Index

● Types of HPI
a. HPI - 1 → Developing countries
b. HPI - II → Developed countries
● HPI is replaced by ​Multidimensional poverty index (MPI)
Multidimensional poverty index (MPI)

Components
Dimension Indicators

Health - Child mortality

- Nutrition

Education - Years of schooling

- School attendance

Living standards - Cooking fuel

- Toilet
- Water
- Electricity
- Floor
- Assets

Range 0 to +1

Value in India 0.413 (191 rank)

Value Interpretation

0.200 - 0.333 Vulnerable

> 0.333 Poverty
> 0.500 Severe poverty
4. ​Below Poverty line [BPL]

a. Calorie Intake
- Rural: < 2400 kcal/day
- Urban: < 2100 kcal/day

b. Income per Capita [In India]

Tendulkar committee Rangarajan Committee

Rural: < 27 ​₹/day Rural: < 32 ​₹/day

Urban: < 33 ​₹/day Urban: < 47 ​₹/day

22% of India lives BPL 29% of India lives BPL

c. ​Income per Capita [World bank]

- Earning: < 1.90 $/day → Extremely poor
< 3.10 $/day → Moderately poor
Time distribution of disease

1. Short term fluctuations [Epidemic]

● short term: disease develops within days-weeks-months
● Definitions
​—​ ​ Occurrence of number of cases of a disease ‘clearly in excess of normal
expectancy [NE]’
​—​ NE is derived by looking at average number of cases of the disease in the
previous 3 to 5 years in that geographical area
—​ If NE = 0, ‘Even 1 case is considered epidemic (Occurrence of a new
disease/Re-occurrence of an eradicated disease in a population)
​— Epidemic is when: No. of cases > Mean + 2SD
● Types
a. Single exposure, point source epidemic
● Single exposure - person is exposed to pathogen 1 time
Point source - spread of pathogen from 1 source
● All cases develop within 1 incubation Period of the disease
● Graph: Sharp rise and Fall in no.of cases.
● ‘Clustering of cases’ in a narrow interval of time.
● Example → Food poisoning, measles, chickenpox, cholera,
Bhopal gas tragedy, Chernobyl tragedy.
b. Multiple exposure, point source epidemic
● Multiple exposure - person is exposed to pathogen > 1
Point source - spread of pathogen from 1 source
● There is > 1 incubation period of the disease in Cases.
● Graph: Sharp rise in case. Fall in case is interrupted by
secondary peaks.
● Example → Contaminated well, typhoid, Gonorrhea outbreak
legionnaires disease.
c. Propagated epidemic
● Graph: Gradual rise and gradual fall over a long time.
● Results from person-person transmission .
● Speed of propagation depends upon herd immunity and
secondary attack rate.
● Example → HIV, tuberculosis, Polio
2. ​Periodic fluctuations
● periodic - disease occurs repeatedly
● Types:
a. Seasonal trend
→ Malaria, dengue - ​monsoon
→ Measles - early spring
→ URI - winters
→ Heat stroke, GI infections - summers
 b. Cyclical trend
→ Measles - every 3-4 yrs
→ Rubella - every 6-8 yrs
→ Influenza - every 10-15 yrs
3. Long term fluctuations [Secular trends]
● Long term: disease takes several years → decades to develop.
● Example​: i) NCD - Diabetes, hypertension, obesity [​↑ing​ in India]
ii) CD - poliomyelitis, diphtheria, pertussis [​↓ing in India​]

Endemic
1. Constant presence of a disease /pathogen in a defined geographical area.
2. ‘Usual or Expected frequency of a disease’.
3. Types
a. Hyperendemic​ - affects all age group equally.
b. Holoendemic​ - affects most of the children population
4. Example: In India → respiratory diseases, TB, HIV, diabetes, CHD.

Pandemic
1. An Epidemic affecting a large population over a large geographical area
[States → Nation → Continent → Globe]
2. Country to Country spread. Crosses international border.
3. Example:
a. Swine flu (H1N1)
b. Avian influenza (H5N1)
c. HIV
d. Ebola
e. Zika virus

Sporadic
1. There is No Epidemiological linkage
- Cases are scattered about in time,space & person.
- Cases shows little or no connection with each other.
2. Example: Schizophrenia, Snake bite, Arsenic poisoning
Disease control
Is reducing the transmission
of Disease agent to such a
low level that it ceases to be
a public health problem.
It aims at:
a. ↓ Incidence of disease
b. ↓ duration of disease
c. ↓ complication of disease
d. ↓ financial burden
India has Targeted
→ Tuberculosis
Disease elimination
Is complete interruption of
transmission of disease in a
defined geographical region or
Country, but causative
organism may persist in
environment.
India has eliminated
→ Guinea worm
→ Leprosy
→ Yaws
→ Maternal & neonatal tetanus
→ Poliomyelitis
→ Trachoma
India has Targeted
→ Kala-azar
→ Lymphatic filariasis
Disease eradication
Is complete
extermination of
organism from Globe.
Exhibits ‘All or None
phenomenon’ (either
eradicated or not).
World has Eradicated
→ Smallpox
→ Rinderpest
Next Global Target
→ Poliomyelitis
→ Measles
→ Guinea worm
 Monitoring Surveillance

Definition Performance and analysis of routine Continuous scrutiny of the factors

measurements aimed at detecting that determine the occurrence and
changes in environment or health distribution of disease and other
status of a population. Consistently conditions of ill health with attention,
overlooking progress of Health activity. authority & suspicion.

Term Smaller concept Broader concept

1. Passive
2. Active
3. Sentinel

Feedback Absent Present

Inbuilt action Present Present

Type of activity One time linear process Continuous cyclical process

1. data collection
2. data compilation
3. data analysis
4. Interpretation
5. Application

Passive surveillance Active surveillance Sentinel surveillance

Patient reports to health system - Health system goes to Helps in identifying missing
90% of cases reported community to search for cases cases and supplementing
- 8 to 10% cases reported notified cases.

Example:​ Patient with fever Example: Example:

coming to PHC, CHC, dispensary, 1. Multipurpose health worker National AIDS control program
private practitioner, hospital. (​♂​)​ → Malaria is linked to
2. ​Surveillance Medical Officer a. Blood bank
(SMO) → Polio b. Antenatal care clinic
3. ASHA / TB Supervisor c. STD clinic
→ Tuberculosis
Levels of prevention

1. Primordial prevention
a. It is prevention of the emergence or development of risk factors in population
groups where it has not appeared.
b. Modes of Intervention
● Individual health education
● Mass health education
2. Primary prevention
a. It is the action taken prior to onset of disease which removes the possibility that
the disease will ever occur. Risk factor present but no disease yet.
b. Modes of Intervention
● Health Promotion
● Specific protection
3. Secondary prevention
a. It halts the progress of disease at its incipient stage and prevents complication.
Disease has started in body.
b. Modes of Intervention
● Early diagnosis
● Treatment
4. Tertiary prevention
a. Is applied when disease has advance beyond early stages, it aims to reduce or
limit impairments and disabilities, minimise suffering caused by existing
departures from good health.
b. Modes of Intervention
● Disability limitation
● Rehabilitation

International Classification of Diseases (ICD)

1. It is the international "standard ​diagnostic​ tool for ​epidemiology​, ​health management​ and
clinical purposes." The ICD is maintained by the ​World Health Organization​ (WHO),
which is the directing and coordinating authority for health within the ​United Nations
System​. The ICD is originally designed as a ​health care​ classification system​, providing
a system of diagnostic codes for classifying ​diseases​, including nuanced classifications
of a wide variety of signs, symptoms, abnormal findings, complaints, social
circumstances, and external causes of injury or disease.
2. 3 Volumes of ICD are - Classification, Instruction manual, Alphabetical index.
3. ICD editions:
a. 10th edition:​ ICD-10 has 3 volumes and 24 chapters.
ICD-10 Clinically modified (CM) has 3 volumes and 21 chapters.
b. 11th edition:​ ICD-11 has 3 volumes and 26 chapters.
Disease​—>​Impairment​—>​Disability​—>​Handicap spectrum

1. Disease:​ Any abnormal condition of an organism that impairs function.

2. Impairment:​ Any loss or abnormality of ​psychological, physiological or anatomica​l
structure or function.
3. Disability:​ any restriction/inability to perform a routine activity.
4. Handicap:​ limits/prevents a fulfilment of a social role.

Event Classification Interpretation

Road traffic accident Disease impairs function of a person

Loss of foot Impairment loss of Anatomical structure and form of foot.

Cannot walk Disability cannot perform routine daily activities

Unemployed Handicapped cannot earn for family members

Cases of disease
Case​ - Person having particular disease and disorder or condition under investigation
1. Primary case:​ first case of communicable disease introduced into population.
2. Secondary case:​ all cases that develop from contact with primary case.
3. Index case:​ first case that comes to the notice of the investigator → registered.

Carrier of disease
Carrier​ - Infected person that Harbour is a specific agent in the absence of discernible clinical
disease, and serves as a potential source of infection for others.
1. Contact:​ Carrier who develops infection from Case.
2. Paradoxical:​ Carrier develops infection from Carrier.
3. Pseudo:​ Carrier harbouring avirulent organism.
4. Chronic:​ Carrier sheds infectious agent > 6 months.
5. Incubatory:​ Carrier sheds infectious agent during IP of disease.
6. Convalescent:​ Carrier sheds infectious agent during recovery phase.

Incubation period [IP]

Incubation period​ - Time interval between invasion by an infectious agent and appearance of
first sign or symptom of the disease.
1. Generation time: Entry of organism → Max infectivity.
2. Latent period: Onset of disease → first detection of disease.
3. Median IP: time taken for 50% of secondary cases to occur.
4. Serial Interval: gap in onset b/w primary & secondary case.
Iceberg Phenomenon of Disease
1. Iceberg Phenomenon is a dynamic process
2. Parts of Iceberg
a. Floating Tip
- Apparent cases → Clinical cases.
- detected via diagnosis by Clinician.
b. Submerged
- Inapparent cases → Carrier, Preclinical, Subclinical, latent cases
- detected via Screening by Epidemiologists.
c. Water surface
- is b/w Inapparent cases and Apparent cases.
1. Iceberg phenomenon is not seen in
a. Rabies
b. Tetanus
c. Measles
d. Rubella
e. Pertussis

Standard of living ​(HISON HERO)

● H​ - Housing
● I​ - Income
● S​ - Sanitation
● O​ - Occupation
● N​ - Nutrition
● H​ - Health
● E​ - Education
● R​ - Recreation
● O​ - Other services

Socio economic indicator ​(He FLAGGED)

● H​ - Housing
● F​ -Family size
● L​ - Literacy rate
● A​ - Availability per capita calorie
● G​ - GNP per capita
● G​ - Growth rate
● E​ - unEmployment level
● D​ - Dependency ratio

Case Fatality Rate (CFR)

 1. CFR = total death / total cases X 100
2. It represents
a. killing power of a disease.
b. virulence of organism
3. Limitation of CFR
● only applicable for acute disease.
● time interval is not specified.

Disability adjusted life years (DALYs)

1. DALY is the best indicator of Burden of disease in population.
2. DALY - Years lost to premature death and years lived with disability.
3. DALY can measure mortality and disability together
a. DALY = YLL + YLD.
b. YLL = years of Lost Life; YLD = Years lost to disability.
c. 1 DALY = 1 Year of healthy life lost.
4. Sullivan’s Index
● aka Disability free life expectancy (DFLE).
● Life expectancy MINUS Duration of disability.
● disability = bed disability days + restricted activity days
Demography

1. Demography is the Scientific study of human population.

2. It focuses attention on:
a. Changes in population size
b. Composition of population
c. Distribution of population in space
3. Crude birth rate = total live birth / total mid year population X 1000
CBR = 20.4 (India)
4. Crude death rate = total death / total mid year population X 1000
CDR = 6.4 (India)
5. Growth rate / Demographic gap = CBR - CDR

Demographic cycle

Demographic cycle CBR CDR

I - High stationary High High

II - Early expanding High Starts to ​↓

III - Late expanding Starts to ​↓ Already ​↓

IV - Low stationary low low

V - Declining CBR < CDR CDR > CBR

● India is in Stage III of Demographic cycle.

● Demographic gap (DG) status
- maximum - late stage II
- starts contracting - early stage III
- Minimum - Stage I & IV
- Negative - Stage V
● Demographic transition
a. High CBR/CDR → Low CBR/CDR
b. Signifies Economic development of a country
Fertility Indicator

Total fertility rate (TFR) - total number of children born to a women

in her reproductive age.
- gives us ‘Complete family size’ (no. of
alive children in family).

Gross reproduction rate (GRR) - total number of girls born to a woman in

her life span.
- Assuming no mortality .

Net reproduction rate (NRR) - total number of girls born to a woman in

her life span
- Considering Mortality.

● General fertility rate (GFR) = ​ total live birth ​X 1000 per yr

women in her reproductive age (15-49)

● Age specific fertility rate (ASFR) = ​ total live birth ​X 1000 per yr
women in any age specific group

Important relations:
→ GRR/NRR = ½ X TFR
→ CBR = (8 X TFR) + 1
→ Child Women ratio = total children (0-4yr) / total women (15-49yr)

Goals
→ TFR = 2.1 by 2017
→ NRR = 1 by 2017
→ Couple protection rate (CPR) > 60%; Ideal - Vasectomy

Dependence Ratio [DR]

1. DR = ​pop < 15yr + pop > 65yr

pop 15-65 yr
numerator​ - Economically dependent age group
denominator​ - Economically productive age group
1. DR (india): 0.62 - this means ‘100 earning people in India are supporting 162 people
(100 themselves and 62 not earning dependents on them)’
Sex ratio

1. Sex ratio = ​No. of females​ X 1000

No. of Males
2. Sex ratio Data
a. India: 943 [Highly unfavourable]
b. Kerala: 1084 [highest]
c. Daman & Diu: 618 [lowest]
3. Child Sex ratio = ​No. of female (0-6yr)
No. of males (0-6yr)
4. Child Sex ratio Data
a. India: 914 [Highly unfavorable]
b. Mizoram: ​976​ [highest]
c. Haryana: ​120 ​[lowest]

Literacy rate

1. Literacy rate = ​ total literates ​ X 100

total population ​≥ 7yr
2. Literate (India) - Any person who can read and write with understanding, in any 1
language of India and who is > 7 years of age.
3. Literacy rate is used in PQLI, HDI, ​HPI – 1.
4. Literacy rate Data
a. India: 74%
b. Kerala: 94% (highest)
c. Bihar: 64% (lowest)

Growth Rate [GR]

1. Growth rate - change in the number of individuals in a population per unit time.
2. Growth Rate data [India]
a. Annual growth rate (AGR)
● AGR = Crude Birth Rate - Crude Death Rate
● AGR = 1.64%, since India is in very Rapid growth phase (1.5-2.0%),
population of India will double in 35 to 47 years.
3. Population distribution
a. Geriatric (>60yr): 8%
b. Children (0-5yr old): 10%
c. Urban India - 3%
Population (Age-Sex) pyramid

1. Population Pyramid - It is a graphical illustration that shows distribution of various age

groups in a population.
2. X-axis → % of population
Y-axis → age (5-year interval)
3. Double Histogram
a. 2 back to back bar graphs.
b. Males on left side & Females on right side
4. Types of population pyramid
● Stationary pyramid
● Expansive pyramid
● Constrictive pyramid
1. Utility of Population Pyramid
● Shape → Indicate fertility pattern
a. Upright ​△ w/ b
​ road base-narrow top: developing countries
b. Spindle shaped (bulge in middle): developed countries
● Span → indicates life expectancy
a. Shorter pyramid: developing countries
b. Taller pyramid: developed countries
● Symmetry → indicates sex ratio
a. Asymmetric pyramid: developing countries
b. Symmetric pyramid: developed countries
Data Collection

1. Census of India
● Conducted once every 10 years
a. first census: 1871
b. first disability census: 1881
● Census Stop - 00.00 hrs on March 01
● Big grade Indian divide: 1921
● Regulatory body - Ministry of Home Affairs.
● Identification by (newly included)
a. 10 fingerprint
b. Iris scan
c. Photograph
d. Aadhar number
e. National Population register

1. Sample registration system

● Conducted once every 6 months
● It has a dual record system → advantage: Elimination of errors of duplication.
a. Field investigation - Continuous Enumeration by enumerator .
b. Independent retrospective survey - Every 6m by investigator-supervisor.
● It estimates fertility & mortality
→ IMR, MMR, NNMR, U5MR, CBR, CDR, Growth Rate
● Regulatory body - Ministry of Home Affairs.

1. National family health survey (NFHS)

● Conducted once every 5-6 year
● 4 rounds of the survey have been completed till date
a. First - NFHS 1: 1992-93
b. Last - NFHS 4: 2014-15
● Conducted by - International Institute for population Sciences (IIPS)
● Few key findings of NFHS 4, India
a. total fertility rate (TFR): 2.2
b. ≥​ 4 Antenatal visit: 51%
c. Institutional deliveries: 79%
d. exclusive breastfeeding: 55%
e. Underweight: 36%
f. Wasted: 21%
g. Stunted: 38%
1. District level household survey (DLHS)
● Conducted once every 5 year
● 4 rounds of the survey have been completed till date
a. First - DLHS 1: 1998-99
b. Last - DLHS 4: 2012-13

1. Vital / Civil registration system

● Registration of births, deaths and marriages
a. Births/Death must be registered < 21 days
b. Marriages must be registered within 30/60/90 days
● Birth registration responsibility - hospital or Institute.
● child born to NRI parents outside India → birth registration within
60 days after arriving in India.
 Preventive Obstetrics Pediatrics Genetics

1. National family planning + Maternal child health (MCH) ----> Child survival and safe
motherhood (CSSM)

2. Child survival and safe motherhood (CSSM) + Reproductive tract infection (RTI)/
Sexually transmitted infection (STI) ---> Reproductive child health (RCH)

3. Reproductive child health (RCH) ---> ​National Health Mission (NHM)

Obstetric and newborn care

Essential care Emergency care

Level 1 Basic Emergency Obstetric and Comprehensive Emergency

Primary Health Care (PHC) Newborn Care Obstetric and Newborn Care
(​BEmONC​) (​CEmONC​)
5 components
● Registration Level 2 Level 3
● Antenatal care 1) 24X7 PHC 1) District hospital
● Safe delivery 2) Community Health Center (CHC) 2) first referral unit (FRU)
● Postnatal care
● Newborn care 7 Components 9 Components
● Manual removal of placenta ● BEmONC (7 components)
● Oxytocics ● Blood transfusion
● Antibiotics ● Surgery
● Anticonvulsant
● Assisted delivery
● Vacuum aspiration
● Newborn resuscitation
Antenatal Visits

1. Recommended antenatal visit = ​13 to 14

- 0-7 month = 1 per month ​[TOTAL VISIT - 7]
- 8th month = 2 per month ​[TOTAL VISIT - 2]
- 9 month onwards = 4-5 per month (1 per week) ​[TOTAL VISIT - 4-5]

1. Minimum Antenatal visit ​≥ 4

- 1st​ AN visit = Registration of pregnancy
- 2nd​ AN visit = 14-26 weeks of POG
- 3rd​ AN visit = 28-34 weeks of POG
- 4th​ AN visit = 36 weeks POG - Term

Postnatal Visits

1. Minimum Postnatal visits ​≥ 3

- 1st​ PN visit = < 3 days after delivery
- 2nd​ PN visit = 1 week after delivery
- 3rd​ PN visit = 8 week after delivery

1. Postnatal visit is given by

● Multipurpose worker
● ANA
● Additional PN visit by ASHA Worker = ​6-7
- 6 visit (Institutional delivery) = ​Day 3, 7, 14, 21, 28, 42
- 7 visit (Home delivery) = ​Day 1, 3, 7, 14, 21, 28, 42
 MCH indicator

MCH indicator Calculation Cause Statistics

IMR (Infant mortality Infant death (birth - 1yr) / Live Low birth weight 34
rate) birth X 1000 Premature birth

MMR (Maternal Maternal death / Live birth X Direct - postpartum 130

mortality rate) 100,000 hemorrhage
a. death while pregnant Indirect - anaemia
b. death during delivery
c. death within 42 days of
termination of pregnancy

U5MR (Under five Children (birth - 5yr age) death / Low birth weight 43
mortality rate) Live birth X 1000 Premature birth

NNMR (Neonatal Neonatal death / Live birth X 1000 Low birth weight 25
mortality rate) 1] Early NNMR = birth - 7days Premature birth
2] Late NNMR = 7 - 28 days
3] Post NNMR = 28 days - 1yr

PNMR (Perinatal Late fetal + Early Neonatal death / Low birth weight 24
mortality rate) Live birth X 1000 Premature birth
1] Late fetal = 28th wk POG - birth
2] Early Neonatal = birth - 7days

SBR (Stillbirth rate) Still birth (28th wk POG - birth) / Maternal Infection 22
Live birth X 1000 Placental abruption

Iron Folic acid Tablets

Adult ​(pregnant / lactating women) Pediatric ​(0 - 5 yr)

Dose Iron - 100mg Iron - 20mg

Folic acid - 500mcg Folic acid - 100mcg

Duration 1) 1 tablet/day X 100 days 1) 1 tablet/day X 100 days

during 2nd trimester (4th,5th & 6th month) Upto 5 years
2) 1 tablet/day X 100 days (IN SYRUP FORM)
give 100 days postpartum
Tetanus Toxoid

1. Primigravida​ - ​a woman who is pregnant for the first time.

2 doses are given 1 month apart → duration of protection = all pregnancies upto 3 yrs
a. 1st dose (TT-1) --> as early as possible in pregnancy [PARTIALLY IMMUNIZED]
b. 2nd dose (TT-2) --> 1 month after 1st dose [COMPLETELY IMMUNIZED]
2. Multigravida​ - ​a pregnant woman who has been pregnant two or more times.
a. 1 dose (TT-booster) as soon as possible --> if next pregnancy < 3yrs
b. Full course of 2 dose --> if next pregnancy > 3yrs

Birth weight (BW)

1. Average birth weight = 2.8 kg

2. WHO classification of low birth weight
● Low birth weight (LBW) < 2.5 kg
● Very low birth weight (VLBW) < 1.5 kg
● Extreme low birth weight (ELBW) < 1 kg
1. Minimum sample required to estimate the prevalence of LBW should be > 500 baby
2. LBW in Gestational age (WHO criteria does not change)
● Preterm (< 37 wks) - due to premature delivery
● Term (37-42 wks) - due to Intrauterine growth retardation
● Post term (> 42 wks) - due to intrauterine growth retardation
1. Birth weight is measured by ​Salter’s scale
2. Birth weight Vs Age
a. doubles (2X) by 5 month
b. triples(3X) by 1 year
c. quadruples(4X) by 2 yr

Birth length (BL)

1. Average birth length = 50 cm

2. Birth length is measured by ​Infantometer
3. Birth length Vs Age
a. Height at 1 yr = 75 cm
b. Height at 4 yr [doubles 2X] = 100 cm
Breast feeding

1. WHO guidelines:
a. Exclusive breastfeeding till 6 months of age
b. Continue breastfeeding till a minimum of 2 years
1. ‘Exclusive’ means no Prelacteal feeding except:
a. Vaccines: OPV, Rotavirus vaccine
b. Medication: ORS
c. Supplementation: Vit. B
1. Nutritional importance of breast milk
● Energy content = 65 Kcal/100ml
● Protein content = 0.9-1.1 g/100ml
● Most abundant Ig type = IgA
● Essential FA - DHA (​Docosahexaenoic acid)
● Abundant AA: Taurine
● Vitamin: vit. A & C

​Breastfeeding initiative guidelines

● After vaginal delivery

a. Start BF immediately / <1 hr (RCH India)
b. BF at delivery table → oxytocin released in mother → expulsion of placenta
→ low risk of Postpartum haemorrhage
● After C-section
a. Start BF immediately / < 4 hr

Human milk Vs Cow milk

Human milk Cow milk

Lactose, Iron, Water, Calcium, phosphate, Vitamin A Protein, Fats, Calcium, Phosphate,
& C, Copper, Cobalt, Selenium, Cysteine, Taurine, Vitamin B & D, Sodium, Potassium,
Linolenic acid, Linoleic acid, PUFA. Methionine.

casein​:​whey ratio = 40:60 casein​:​whey ratio = 80:20

Growth Development
1. Best indicator for:
a. Growth - weight (Wt. for age)
b. Development - weight (Wt. for age)
c. Nutritional status - weight (Wt. for age)
1. Mid-arm circumference (MAC)
● 2nd best indicator for Growth Development
● Measured by Shakir’s Tape
● MAC is measured from 6mth - 5yr (as MAC remains constant)
● Table
MAC (cm) Colour zone Interpretation Management

>13.5 green Satisfactory at home through diet

nutritional status

12.5 - 13.5 yellow mild-moderate Refer to PHC

malnutrition

< 12.5 red severe malnutrition Refer to Pediatricians

Protein Energy malnutrition

1. Estimation of PEM
a. ↓ weight for age = Underweight → (Acute ON Chronic PEM)
b. ↓ weight for height = Wasting / Emaciation → (Acute PEM)
c. ↓ Height for age = Stunting / Dwarfing → (Chronic PEM)
Growth Chart

1. passport to child growth

2. developed by David Morley
3. Graph plot of Weight (Y-axis) vs Age (X-axis)
4. Types of Growth Chart

● WHO growth chart

1. Originally based on ​National Center for Health Statistics​ (NCHS).
2. Interpretation:
a. Above URC = overnourished
b. b/w URC and LRC = Road to health
c. Under LRC = undernourished
3. Graphical values
→ URC (Upper reference curve) = 50th percentile for Boys
→ LRC (Lower reference curve) = 3rd percentile for Girls
→ space b/w URC & LRC = road to health [95% of healthy normal child fall here]
→ If the plotted point is exactly on or above the 1st curve, between the 1st & 2nd
curve (Green zone) and exactly on the 2nd curve: Child's growth is normal
→ gap between URC and LRC = 2SD
→ LRC = 80% of URC

● ICDS Growth Chart

1. Originally based on ​Multicentre Growth Reference Study (​MGRS​).
2. It has 3 reference curve:
a. Reference standard line ---> [50th percentile for boys]
b. 2SD below Reference standard line---> [3rd percentile for girls]
c. 3SD below Reference standard line
1. Interpretation:
→ above standard line - over nourished
→ b/w standard line & 2SD - normal nutritional status
→ b/w 2SD & 3SD - mild to moderate PEM
→ below 3SD - severe PEM
School Health
1. School Health program was 1st recommended by - ​Bhore Committee (1943)​.
2. Comprehensive School Health program was laid down by - ​Rennuka Roy School Health
Committee (1961).
3. Healthful School Environment
● 1 classroom for 40 students maximum
● Per capita space > 10 sq feet
● Doors and Windows area > 25% of floor area
● Desk of minus type (to keep spine straight)
● Natural light from left side (most children are R-handed)
● 1 urinal per 60 students; 1 sanitary latrine 100 students
1. NRHM guidelines: Recommended frequency of School Health Examination should be
once every 6 months.
1. School vision screening programme
● Teachers do the screening; 1 teacher per 150 students
● Visual acuity cutoff for referral to PHC: < 6/9

Preventive Geriatrics
1. Age group > 60 years.
2. 8% of India is geriatric.
3. MC health disorder - Cataract.
4. MC cause of death above 70yrs age - CV disorder
Primary Health Care

1. Hallmarks of Primary Health Care

a. Acceptability
b. Accessibility
c. Availability
d. Affordability
2. Components of Primary Health Care
a. E - essential drugs [most ED - PCM]
b. L- locally endemic disease prevention and control
c. E- education concerning health problems
d. M- maternal and child health including family planning
e. E- expanded programme on immunization (EPI) → UIP
f. N- nutrition and promoting proper food supply
g. T- treatment of common disease and injuries
h. S- safe water supply and sanitation
3. Principles of Primary Health Care
a. equitable distribution
● social, demographic, economical
b. community participation
● ASHA, barefoot doctors
c. intersectoral coordination
● Agriculture, education, panchayats
d. appropriate Technology
● ORS, standpipes, exclusive BF, Kangaroo Mother Care
Village Healthcare

Levels of Primary Health Care

a. Primary:​ first contact level between population and health system
b. Secondary​: first referral unit (FRU)
c. Tertiary:​ second referral unit (SRU)

Health Centres
Care delivered by Plains Hilly/Tribal Beds Number Staff
area (infrastructure)

Tertiary
1. Medical College and - - - 500 -
associated hospital

Secondary
1. CHC (community health 1/120000 pop. 1/80000 pop. 30 5500 46-52
centre)

Primary
1. PHC (primary health 1/30000 pop. 1/20000 pop. 4-6 25000 13-21
centre)
2. Sub-centre 1/5000 pop. 1/3000 pop. 0 155000 3-4
[Only sub-centre is run by Central Government. Rest is run by State Government]
Sub-centres
Type A Type B

Delivery (labor) No Yes

takes place

Health worker (​♂​) 1 1

Health worker (​♀) 1 2

Safai Karamchari 1 1
[ANM can substitute female health worker if required]
a. Total staff in Type A = 3
b. Total staff in Type B = 4

Primary Health Centre

Type A Type B

No. of Deliveries < 20 ≥ 20

per month

MBBS 1 2

AYUSH 1 2
[Health Assistant is present at PHC]
a. Total staff in Type A = 13-18
b. Total staff in Type B = 14-21

Community Health Centre

1. Total MD/MS Medical officers - 9
4 major clinical dept 3 new added 2 extra added

Medicine Ophthalmology Dental

Surgery Anaesthesia AYUSH

GYN-OBS Public Health specialist

Pediatrics
[Health supervisor is present at CHC]
a. Total staff = 46-52
Grass root level worker
1. ASHA = ​Accredited Social Health Activist
2. MPW = ​Multi Purposes Health ​Worker
3. VHG/CHW = ​Village Health Guide (new) / Community Health Worker (older)
4. TBA = ​Traditional birth attendant
5. AWW = ​Anganwadi worker

Health workers
Location Population norm Education Training

ASHA Village 2/1000 10th pass 23 days

MPW Sub centre 1/5000 12th pass 12 month

VHG Village 1/1000 6th pass 3 month

TBA Village 1/1000 - 1 month

AWW Anganwadi centre 1/400 - 1/800 10th pass 4 month

Urban Healthcare

Health centres
Tertiary Medical College and Hospital

Secondary Urban CHC

1. Non metro → 1/250,000 pop.
2. Metro → 1/500,000 pop.

Primary Urban PHC → 1/50,000 pop.

a. USHA (Urban social help activist) → 1/1000 - 1/ 2500 pop.
b. U-ANM (Urban Auxiliary Nurse Midwifery) → 1/10000 pop.
POPULATION NORMS

1. HEALTH CENTRES
Plains Hilly area

1 sub-centre 1/5000 1/3000

1 PHC 1/30000 1/20000

1 CHC 1/120000 1/80000

1 AWC 1/400-1/800 1/300 - 1/800

1 U-PHC 1/50000

1 U-CHC 1/250000
1/500000

1. WORKERS
1 ASHA 1/500

1 MPW 1/5000

1 VHG 1/1000

1 TBA 1/1000

1 AWW 1/400 - 1/800

1 USHA 1/1000 - 1/2500

1 U-ANM 1/10000

1 pharmacist 1/10000

1 lab technician 1/10000

1 health assistant 1/30000

1 health supervisor 1/120000

1 doctor 1/1000

1 ophthalmologist 1/50000
1. TB control
1 TB microscope 1/ 100000

1 TB unit 1/500000

1 Senior TB Lab supervisor 1/500000

1. Malaria Control
1 Malaria microscopy 1/25000

1. Leprosy control
1 Set centre 1/25000

1 Urban Leprosy centre 1/50000

1 Leprosy control centre 1/450000

AYUSH

1. ISM​ and ​H​ (Indigenous Medicine and Homeopathy) have now been re-designated as
‘AYUSH system’ of medicine.
2. Father of Homeopathy - ​Samuel Hahnemann
3. Full form of ​AYUSH
● A​ - Ayurveda → [indian origin]
● Y​ - Yoga and Naturopathy → [indian origin]
● U​ - Unani → [greek origin]
● S​ - Siddha → [indian origin]
● H​ - Homeopathy → [german origin]
1. Additional component of AYUSH = Sowa-Rigpa → [chinese origin].
2. Types of Medicine
a. State medicine
- provision of free medical services to the people at Govt expense.
- present in India
b. ​ Socialized medicine
- provision of medical services and professional education by Govt,
but program is regulated and operated by professional groups.
- started by Russia (absent in India)
- Advantages
---> prevents competition between practitioners and clients
---> provision of medical services supported by State govt
---> social Equity
Occupational disease

1) Physical agent

Heat hyperpyrexia, exertion, stroke

Cold Chilblains (chill burns), frostbite

light Cataract, miners nystagmus

pressure Caisson’s disease

noise deafness

radiation leukaemia, aplastic anaemia

others burn injury and accidents

2) Chemical agent

Gas Poisoning

​Dust Pneumoconiosis

metals ​heavy metal poisoning

chemicals ​poisoning (solvent)

3) Biological agent
​ Infections: Brucellosis, Anthrax, Leptospirosis.

4) Occupational Dermatitis
5) Occupational cancers
6) Others: neurosis, hypertension
Pneumoconiosis

1) Cause - Due to exposure of dust

Disease Exposure source

Silicosis Silica dust

Byssinosis cotton fibre

farmer's lung moldy hay

siderosis iron dust

anthracosis Coal dust

bagassosis molasses (sugarcane)

stannosis tin dust

asbestosis asbestos dust

bird fancier’s lung Avian/Bird droppings

Compost lung compost

​ 2) Particle Size:

Particle Feature
size

<0.5 μ Always Brownian motions

0.5-3 ​μ most dangerous particle size

3-5 ​μ mid respiratory tract - trapped

5-10 ​μ upper respiratory tract - trapped

>10 μ Fall near the machine where it is produced

​ 3) Epidemiology

a. Most common pneumoconiosis - silicosis.

b. most common cause of death in pneumoconiosis - Silicosis
c. most common cause of disability in pneumoconiosis - Silicosis
 d. Notifiable disease under Factory Act ---> Silicosis
---> Anthracosis
---> Asbestosis
---> Byssinosis
e.​ ​Byssinosis is most commonly seen in Spinners (occupation).
f. Bagassosis control - 2% propionic acid.

Disease Association

Silicosis Bauxite miners, SnowStorm, TB, cement & glass industry.

anthracosis progressive massive, Fibrosis coal miners

asbestosis mesothelioma, lung cancer

byssinosis cotton, textile industry

bagassosis thermoactinomyces sacchari

farmer's lung micropolyspora Faeni

compost lung Aspergillus

Lead poisoning

1 . Diseases: -> painter's colic

-> plumbism
2. Most common source in India - petrol/gasoline.
3. most common mode of transfer: inhalation

4. Clinical feaures:
a. Due to inorganic lead
→ Bartonian line - blue line on gum (PbS)
→ Pallor - 1st and most consistent sign
→ Wrist and foot drop - nerve palsy [Radial + Peroneal nerve]
→ Colic
b. Due to organic lead
→ Encephalopathy

5. Lead screening - Coproporphyrin in urine ​> 150 mcg/L

6. Diagnosis
- aminolevulinic acid in urine > 5mg/L
- Pb Level in blood > 70 mcg/100mL
- Pb Level in urine > 0.8 mg/L

7. RBC findings:
- Basophilic stippling
- microcytic hypochromic anaemia

8. treatment of choice: EDTA, penicillamine

9. prognostic test - peripheral blood smear

​Occupational cancer

1) Common occupational cancer - squamous cell carcinoma of skin.

Occupational cancer Exposure

Angiosarcoma of lung PVC

mesothelioma Asbestos

leukaemia Benzene

bladder cancer (transitional carcinoma) benzidine, aniline

nasal sinus carcinoma Nickel, chromium, wood dust

lung carcinoma Radon, silica

Caissons disease / decompression sickness

1. Seen in deep sea divers

2. Due to low pressure

a. Nitrogen gas Effervescences
→ Bends
→ Chokes
→ Prickles (Painful nerve stimuli)
→ paralysis
→ aseptic bone necrosis
b. Air expansions
→ Barotitis
→ Barosinusitis
→ Barodontalgia
→ Emphysema (most dangerous)
→ Abdominal distension

3. Treatment of choice
a. recompression chamber
b. hyperbaric oxygen therapy
Nutrition

Definition​ - Science that studies interaction of nutrients in relation to (a)maintenance (b)growth

(c)repair (d)health (e)disease in human body.

Nutrients​ - Based on requirement

Macro-nutrients (gm) Micro-nutrients (mg) Trace (mcg)

Carbohydrates Iron Copper

Fats Iodine Chromium
Proteins Zinc Selenium
Calcium
Vitamin A
● Proximate (most req.) principle of diet = Macronutrients
● Energy level = Fats (9 kcal/g), Protein (4.5 kcal/g), Carbohydrate (4.1 kcal/g)
● Importance level = protein > fats > carbohydrates
● Balanced diet (req. for healthy living) - first balance
→ protein - 10-15%
→ fat - 15-30%
→ carbohydrate - 50-70%

​PROTEIN

● Table
Quantity Quality

Indicator 1. Protein energy ratio 1. DIAAS [Digestible indispensable

amino acid score] ​- best indicator
2. PDCASS [Protein digestibility
corrected amino acid score]
3. NPU [net protein utilisation]
4. Biological value
5. Protein efficiency ratio
1. Importance value: Quality > Quantity.
2. Highest quality = Egg - reference protein in diet {NPU = 100}.
Highest quantity = Soyabean (43.2% protein).
 ● Net protein Utilization (NPU)
1. NPU = ​BV X DC​ BV - Biological value
100 DC - Digestibility coefficient
2. NPU = ​Nitrogen retained by body​ X 100
Nitrogen intake by body

​Highest NPU value:

→ Egg (96)
→ Cow Milk (81)
→ Meat (79).
​Egg has highest NPU:​ → contain all essential AA in balanced proportion.

1 avg. Hen Egg contains

- 6 g fats
- 1.5 mg Fe​²+
- 30 mg Ca²+
- 250 mg Cholesterol
- 70 kcal energy

Soyabean - among pulses, it is highest in

- Protein --> NPU
- Fat
- Energy --> 432 kcal /100g
- Iron
- Vitamin B1, B2

● Essential Amino acids (10)

1. amino acids which are not synthesized in adequate amounts in the human body
so they have to be supplemented in diet from outside to prevent deficiency.
2. PVT TIM HALL​ - ​Ph ​ enylalanine, ​V​aline, ​T​ryptophan, ​T​hreonine, ​I​soleucine
​M​ethionine, H
​ ​istidine, ​A​rginine, ​L​eucine, ​L​ysine.
​Semi-Essential Amino acids (2)
1. generally not required by human body, but very essential at some point of life
when their body requirement is increased as in:
→ infancy →adolescence →pregnancy →lactation
1. HA​ - ​H​istidine and ​Ar​ ginine
 ● Limiting amino acids
1. Definition - Amino acids most deficient in proteins of a food item​.
2. Table
Major food item Limiting amino acid

maize Tryptophan​ + lysine

wheat Threonine​ + lysine

pulses Methionine​ + cysteine

​ upplementary action of protein in diet​ - deficiency develops due to only
3. S
consumption of a particular type of food item with limiting AA hence two or more
food items are eaten together so that they protein supplement one another.

​Essential fatty acids (EFA)

Definition​ - These fatty acids cannot be synthesized completely in human body they can only be
supplemented from the food.

List of Essential FA
1. Linoleic acid
2. Linolenic acid
3. Eicosapentaenoic acid (EPA)
4. Docosahexaenoic acid (DHA)

Linoleic acid - most important EFA

→ serves as the basis for production of other EFA
→ produced in least amount by human body

Richest source of EFA

Safflower > Sunflower > Corn oil > Soyabean oil >> Olive oil > groundnut oil >> coconut oil.

PUFA - safflower
SFA - Coconut oil
MUFA - olive oil
Linolenic acid - Flaxseed oil ​(not used in India)​ > Soyabean oil
EPA - Fish oil
Iron
Richest source
1. dried Pumpkin seeds
2. pistachio nuts
3. cashew nuts

Vitamin A
Richest source​ - Halibut liver oil
Richest ‘Fruit’ source​ - Ripe mango
Richest ‘Vegetable’ source​ - Carrot

Vitamin D
Richest source - Halibut liver oil
[no plant/vegetable source - it depends on sunlight(hv)]

Vitamin C
Richest source
1. amla (Indian gooseberry)
2. guava - noncitrus fruit
3. cabbage - vegetable

Golden rice
● Genetically modified crops (GMC)
● it is made rich → Iron
→ vitamin A (​β​ carotene)

Poor sources:
1. Egg - Carbs and Vit C
2. Milk - Iron and Vit C
3. Meat - Calcium
4. Fish - Carbs and Iodine
Recommended dietary allowance [RDA]
- Nutritional requirement that can satisfy the need of > 97.5% (Mean + 2SD) of population.
- RDA is often higher than the recommended minimum requirement
→ RDA = daily requirement + additional requirements (for period of growth/ illness)
→ includes all nutrients except ENERGY
- RDA ‘safe level approach’ is NOT USED FOR ENERGY since excess energy intake
is stored as fat leading to ​↑ risk of CVD. Here only actual requirement is taken.

Reference Indian man and woman

Reference Indian man Reference Indian woman

Age 18-29 y 18-29 y

Weight 60 kg 55 kg

Height 1.73 m 1.61 m

BMI 20.3 21.2

Activity → 8 hrs sleep
→ 8 hrs moderate activity
→ 4-6 hrs sitting & moving about
→ 2 hrs walking & active recreation

Energy Requirement according to Level of activity

Man Woman

Sedentary 2300 kcal/day 1900 kcal/day

Moderate 2700 kcal/day 2200 kcal/day

Heavy 3500 kcal/day 2900 kcal/day

Energy Requirement of Infants

0-6 month 6-12 month

Used by doctor 92 kcal/kg/day 80 kcal/kg/day

Used by mother 500 kcal/day 670 kcal/day

Additional energy requirement

1. during pregnancy = +350 kcal/d
2. during lactation:
- 0-6 month = +600 kcal/d
- 6-12 month = +520 kcal/d
Protein requirement per day
a. Man = 0.83 g/kg/d
b. Women = 0.83 g/kg/d
c. Infant:
- 0-6 month = 1.16 g/kg/d
- 6-12 month = 1.69 g/kg/d

Nutrient Requirements per day

Iron Folic acid Calcium Vit A - Retinol Iodine
(mg/d) (mcg/d) (mg/d) (mcg/d) (mcg/d)

Require Intake

Man 0.8 17 200 600 600 150

Women 1.6 21 200 600 600 150

Pregnancy 2.8 35 500 1200 800 250

Lactation 1.6 21 300 1200 950 250

- Folic acid for Adolescents = 400 mcg/d

- Calcium for infants = 500 mg/d
- Vitamin A for infants = 350 mcg/d

Daily requirement of other nutrients

1. Sodium: 2000 mg/d
2. Potassium: 3500 mg/d
3. Zinc: 10-12 mg/d
4. Vitamin K: 0.03 mg/kg/d
Fluorine
● Major source is drinking water
● In India, Recommended level of fluorides in drinking water = 0.5-0.8 ppm
● In temperate countries where water intake is low, optimum level of fluorides
in drinking water is 1-2 ppm
● ‘Fluorine is a double edged sword’
a. Inadequate intake → dental caries
b. Excess intake
- Level >1.5 ppm → dental fluorosis (mottling)
- Level 2-6 ppm → skeletal fluorosis
- Level >10 ppm → crippling fluorosis
● 1st sign of Fluorosis in body - Mottling of upper central incisors and
also the molar teeth.
● Nalgonda Technique​ - This technique has been developed by National environmental
engineering research institute (NEERI), Nagpur for defluoridation of water.
It involves addition of
- lime
- alum
- bleaching powder
● Household level​ of defluoridation can be done by adding
- alumina
- Phosphates
Food standards in India

a. CODEX Alimentarius - The food standards in India are based on this.

b. PFA standards - Prevention of Food Adulteration Act 1954.
c. AGMARK standards - ​'Ag' is agriculture and 'mark' is certification mark.
d. BIS - Bureau of Indian Standards.
e. FSSAI - ​Food Safety and Standards Authority of India.
(Minimum prescribed food standard = FSSAI)

Food Adulteration

● It is the deliberate reduction in quality and nature of food item by:

1. addition of a foreign or inferior substance
2. removal/substitution of a vital element

● Any mismatch between the actual content and those mentioned on a food packets

● Food Adulteration disease

Disease Toxin Adulteration Food

Lathyrism BOAA Khesari Dal Arhar dal

(β-N-oxalyl-amino-L- (Lathyrus sativus)
alanine)

Epidemic dropsy Sanguinarine Argemone mexicana oil Mustard oil

Endemic Ascites Pyrrolizidine alkaloids Crotalaria seeds Food dishes

Ergotism Clavine alkaloids Claviceps fusiformis Cereals (stored

for long time)

Aflatoxicosis Aflatoxin Aspergillus flavus Groundnut

● Specific adulterant
Food Adulterant

Black pepper dried papaya seed

Red Pepper brick powder

Turmeric lead chromate

Coriander powder cow dung

Vitamin A (Retinol)

1. Ocular manifestation of Vitamin A deficiency: Xerophthalmia (dry eye).

2. WHO classification of Xerophthalmia
Primary signs Secondary signs

X1A - Conjunctival xerosis XN - Night blindness

X1B - Bitot spots XF - Xerophthalmic fundus
X2 - Corneal xerosis XS - Xerophthalmic scarring
X3A - Corneal ulceration
X3B - Keratomalacia

1. 1st clinical sign of Vitamin A deficiency: Conjunctival Xerosis.

Characteristic appearance of ‘Emerging like sand banks at receding tide’
2. 1st clinical symptom of Vitamin A deficiency: Night blindness.
3. Most specific manifestation of Vitamin A deficiency: Bitot’s spots

1. Prevalence criteria for determining the Xerophthalmia problem in a community:

● Night blindness > 1.0%
● Bitot’s spots > 0.5%

1. Therapeutic TXT of Xerophthalmia

Child <1yr Child >1yr

Oral Intra-muscular Oral Intra-muscular

Day 0, Dose 1 1 lac IU 50k IU 2 lac IU 1 lac IU

Day 1, Dose 2 1 lac IU 50k IU 2 lac IU 1 lac IU

Day >14, Dose 3 1 lac IU 50k IU 2 lac IU 1 lac IU

IM = oral dose X 0.5
1 lac IU = 15 mg
Vitamin B1 (thiamine)
Deficiency leads to:
1. Beri Beri​ - seen in polished rice eaters
2. Wernicke Korsakoff Psychosis​ - seen in alcoholics

Vitamin B2 (Riboflavin)
Deficiency leads to:
1. Ariboflavinosis​ - it is a clinical triad of
→ ​Cheilosis​ - chapped and fissured lips
→ ​Angular stomatitis​ - inflammation at mouth corner
→ ​Atrophic glossitis​ - smooth glossy tongue

Vitamin B3 (Niacin)
Deficiency leads to:
1. Pellagra
● Characterized by ‘4D’s + ‘2D’s
a. Diarrhoea e. Delirium
b. Dementia f. Depression
c. Dermatitis
d. Death
● Common in maize/jowar eating populations:
- Limiting AA is tryptophan while Excess AA is Leucine.
- 50mg of Tryptophan is converted to 1mg of Niacin in body.
- Excess of leucine interferes in conversion of Tryptophan to Niacin.

Vitamin B5 (Pantothenic Acid)

Deficiency leads to:
1. Burning feet /sole syndrome

Vitamin B6 (Pyridoxine)
Deficiency leads to:
1. Microcytic anemia​ & ​Peripheral neuritis
● Seen in Isoniazid therapy under RNTCP.

Vitamin B9 (Folic acid)

Deficiency leads to:
1. Megaloblastic anemia
2. Neural tube defects

Vitamin B12 (Cyanocobalamin)

Deficiency leads to:
1. Megaloblastic anemia, Pernicious anaemia, Peripheral neuritis, Subacute combined
degeneration of spinal cord
● Commonly seen in strict Vegetarians.
Vitamin C (Ascorbic acid)
Deficiency leads to:
1. Scurvy​ - its symptoms are
→ delayed wound healing
→ gum bleeding
→ fracture

Vitamin D2 (Ergocalciferol) + Vitamin D3 (Cholecalciferol)

Deficiency leads to:
1. Rickets​ - in children
2. Osteoporosis​ & ​Osteomalacia​ - in adults
Genetics and health

Gene - sequence of DNA which codes for a molecule that has function.
Genome - sum total of genetic information of an organism.
Genomics - study of Human Genome.
Gene therapy - introduction of a gene sequence into a cell to modify its behaviour.

DNA technology - development of new Diagnostic techniques

Eg- restriction enzyme

​Euthenics​ - environmental manipulation for gene expression.

Positive Euthenics Negative Euthenics

pollution, over pollution, lack vaccination for diseases,

of education genetic engineering

​Eugenics​ - genetic manipulation for gene expression.

Positive eugenics ​Negative eugenics

In vitro fertilization abortion

Gene cloning sterilization

Egg transplantation family planning

Genetic counselling
Prospective type Retrospective type

Identify heterozygous individual through Seeking advice when hereditary disorders

screening and then advise them - Prevention has already occurred - Looking for solution
of child to develop the disease before born. after child with disease has born

● Thalassemia ● Congenital anomalies

● Sickle Cell disease

Human Genome Project

1. Started by Dr James D Watson in 1990
2. total number of human gene is 19,000-20,000
Hardy weinberg law
Allele Frequency remain constant from one generation to another, so equilibrium is reached.
p + q = 1 (old generation)
p2 + q2 +2pq = 1 (new generation)

Female

A (p) a (q)

Male A (p) AA (p2) Aa (pq)

a (q) Aa (pq) Aa (q2)

Single locus with two allele ‘A’ and ‘a’

‘A’ allele with frequency ‘p’
‘a’ allele with frequency ‘q’

Homozygous genotype - AA and aa Homozygous genotype frequency - p2 and q2

Heterozygous genotype - Aa Heterozygous genotype frequency - pq

Hardy weinberg law is applicable in case of:

1. Large population
2. Static population
3. Random mating population
Hardy weinberg law is not applicable in case of:
1. Small population
2. Dynamic population
3. Non random mating population
4. Assortative population
5. Mutation
6. Gene flow and drift
7. Natural selection
8. Migration
Blood group in India

ABO blood group Rh blood group

O - 40% Rh+ve - 94%

B - 33% Rh-ve - 6%

A - 22%

AB - 5%

Bombay blood group

1. Cannot Express ABO antigen due to absence of H antigen.
2. Cannot receive blood from anyone except Bombay blood group.

Amniocentesis
a process in which amniotic fluid is sampled using a hollow needle inserted into the uterus, to
screen for abnormalities in the developing fetus.

Indications for amniocentesis

1. Women’s age > 35 yr old
2. Association - Down syndrome in previous pregnancy
- Metabolic defect
- Chromosomal abnormality
3. Sex determination warranted
Mental health

Sterns IQ test [Standard test]

1. IQ points = ​mental age​ X 100
chronological age
2. Chronological age is determined by
- Actual age
- Date of birth
- Bone ossification
3. This test is useful upto 15 years of age

International classification of IQ
Classification IQ score

Idiot 0-24

Imbecile 25-49

Moron 50-69

Borderline 70-79

Low normal 80-89

Normal 90-109

Superior 110-119

Very superior 120-139

Near genius ≥ 140

Mental retardation (MR) classification based on IQ

Classification IQ score Remarks

Normal IQ ≥ 70

Mild MR 50-69 Most common MR

Moderate MR 35-49

Severe MR 21-34 Not found much due to low survival rate

Profound MR ≤ 20 Not found much due to low survival rate

Most common cause of MR in india is Down’s syndrome.

National mental health Programme

● Launched - 1982
● Aim
1. prevention and treatment of Mental Health disorders.
2. use of Mental Health technology to improve health.
3. Application of Mental Health principle in development
and to improve the quality of life.
● Objective
1. Availability and accessibility for all
2. Application of Mental Health knowledge in General Health Care
3. Promote community participation

The mental health act (1987)​ is currently known as ​The Mental Health care (2011)

Mental health disorders in India

● Most common mental health problem
Unipolar depression > alcohol disorder > ​Schizophrenia > Bipolar disorder
● Most common cause of death in mental health
Alzheimer's disease and other dementia
● Number of Disability-Adjusted Life Year (DALY) lost in unipolar depression
64,963 DALY [prevalence = 1400 / 100,000 population]
● Most common substance abuse
Tobacco
● Most common narcotic substance abused
Cannabis
● Current mental morbidity
18-20 / 1000 population
● Suicides due to mental health disorders
Rate - 10.6 / 100,000 / year
Most common mode - Hanging
International health agencies

1. World Health Organisation (WHO)

● Established - 1945
● Constitution - 7th April 1948 → World Health Day
● Headquarters - Geneva, Switzerland
● 2018 theme was ‘Universal health coverage’.
● WHO composition
- World Health assembly
- The Executive board
- The Secretariat
1. United Nations Children fund (UNICEF)
● Headquarters - New York, USA
● It is associated with
- GOBI = growth monitoring, ORS, Breastfeed, Immunization
- FFF = family planning, family education, food supplementation
1. International Labour Organisation (ILO)
● Established - 1919
● Headquarters - Geneva, Switzerland
● Focus areas
- right of workers
- child labour
- forced labour
- discrimination
1. Food and Agriculture Organisation (FAO)
● Currently running as ​FFHC - Freedom from Hunger campaign
● Established - 1945
● Headquarters - Rome, Italy
● Focus areas
- hunger
- food security
- Malnutrition
- Agriculture
- Forestry
- Fisheries
- Rural poverty
- food systems
- disaster livelihoods
1. International Red Cross (IRS)
● Headquarters - Geneva, Switzerland
● Purpose - to assist prisoners and civilians in armed conflicts emergency
and disaster situations.
​International measures for Disease Control

1. ​Diseases under International health regulations (WHO)

● Cholera
● Plague
● Yellow fever
● Wild poliomyelitis
● Human influenza
● Severe acute respiratory syndrome [SARS]
● Smallpox
1. Diseases under International surveillance (WHO)
● Poliomyelitis
● Relapsing fever
● Rabies
● Louse borne typhus
● Human Influenza
● Malaria
● Salmonellosis
1. Diseases under research and training (WHO)
● Trypanosomiasis
● Filariasis
● Schistosomiasis
● Leishmaniasis
● Malaria
● Leprosy
1. List of Quarantinable diseases (CDC)
● Diphtheria
● Plague
● Yellow fever
● Smallpox
● Infectious TB
● Viral hemorrhagic fever [VHF]
● Severe acute respiratory syndrome [SARS]
 Bioterrorism Agents

Category A Category B Category C

Easily disseminated Moderate dissemination New emerging pathogens

High mortality rates Moderate morbidity + low mortality High morbidity and mortality

1. Botulism 1. Brucellosis 1. Nipah virus

2. Tularemia 2. Clostridium perfringens 2. Hantavirus
3. Anthrax 3. Staphylococcal enterotoxin B
4. Smallpox 4. Epidemic typhus
5. Plague 5. Glanders
6. VHF 6. ​Melioidosis
7. Psittacosis
8. Q fever
9. Ricin toxin
10. Viral encephalitis
11. Water safety threats
12. Food safety threats

Most commonly used

- Anthrax
Most dangerous
- Smallpox
Most Lethal toxin
- botulinum

1. International health regulations (IHR)

● Regulate air travel during pregnancy
● Criteria for boarding the plane
- Upto 36 weeks of gestation with Single fetus
- Upto 32 weeks of gestation with Twins
- The airline recommends that​ ​women past their 28th week of gestation
carry a letter from a doctor or midwife that says you are fit for travel,
confirming your pregnancy dates and that there are no complications.
Health Communication

1. Communication process​: The process of exchanging (a) ideas (b) feelings

(c) information, in the field of health.

1. Components of communication process:

Sender (source) National Health Programme - under ​Ministry
of Health and Family Welfare (MOHFW)

Channel (medium) TV, radio, newspaper

Message (content) OPV vaccine, sterilization

Receiver (audience) Target population

Feedback (effects) Opinion polls, service

1. Approaches for health communication

Individual based Group based Mass approach based

- Home visit - Lecture / Speeches - TV

- Personal contact / - Demonstration - Radio
Interpersonal - Focus Group discussion - Newspaper
communication (IPC) - Panel discussion - Poster
- Spikes Techniques - Symposium - Internet
/ protocol(p) spikes - Workshop - Exhibition
- Gather approach - Role play / Sociodrama
- Conference / Seminars
- ​Flannelgraph

Methods of Healthcare

A]​ Group based

1. Lecture
● aka chalk and talk method
● one person addressing audience
● Features
- group size < 30
- time < 15-20 min
- Advantage → large population covered in small time
- Disadvantage → no question and answers
1. Focus Group discussion (FGD)
● Group size of 6 to 12 persons
- 1 Group leader: initiates discussion, helps discussion in a proper manner,
prevents side conversation, encouraging to participate,
and sums up the discussion.
- 1 Recorder: records/draws sociogram (interaction b/w participants),
reports on issues discussed, and agreements reached.

1. Panel discussion
● Discussion among 4-8 experts in front of audiences
● Features
- no specific order of speeches
- no preparation of speech
- Ask doubt at the end

1. Workshops
● Series of 4 or more meetings
● Features
- imparts training and skills to participants
- group work, group discussion, plan of action
- help from consultant & resource person

1. Symposium
● Series (1st lecture on disease epidemiology → 2nd lecture on disease
management) of lecture by expert in front of audience
● Features
- No discussion among the experts
- Specific order of speeches
- set speeches/lectures

1. Role play / Social drama

● aka street play
● situation is dramatized by a group of people in front of audience
● it is followed by discussions
● ideal audience size < 25

1. Conference / Seminars
● Combination of the ‘group methods’ organised on a big (macro) level
- university level
- state level
- national level
 1. Demonstration
● it is a carefully planned presentation to show how to perform a skill or procedure
● demonstrator carries out step by step in front of audience and involves them
● Ex - health worker → ORS preparation.
● Features
- seeing is believing
- learning by doing

1. Flannelgraph
● Series of photographs → posted on a piece of cloth in chronological sequence.
● Ex- teaching the life cycle of plasmodium.

B]​ Individual based

1. Interpersonal communication (IPC)

● One to one (face to face) communication.
● Ex: OPD -doctor-patient interaction.
● Most effective method.
- Effectiveness: IPC > FGD

1. Spikes Techniques / protocol(p) spikes

● Communication of disease (Cancer or HIV) diagnosis & prognosis.
● Best for Breast cancer
● SPIKES
- S → set up interview {call patient and family members}
- P → perception {patient’s perception}
- I → invitation to explain {when they are ready to listen}
- K → knowledge {stage, money required, side effects}
- E → emotion {patient’s emotion}
- S → summary strategy

1. Gather approach / Contraceptive counselling

● Comes under Reproductive and Child Health (RCH)
● Previously known as cafeteria method
● GATHER
- G → greet
- A → ask - about which method they prefer {temporary/permanent}
- T → tell - about the available contraceptive methods
- H → help - to choose the best contraceptive method
- E → explain - how to use & side effects
- R → return visit
Classification of health Communication

Didactic communication Socratic communication

Type One way communication Two way communication

Uni-directional Bi-directional

Includes Lecture Focus Group discussion

Flannel graph Panel discussion
TV Symposium
Radio Role play
Newspaper Workshop
Poster Interpersonal communication
Charts Seminar/ Conference
Demonstration
Spikes
Gather approach

Doctor patient communication

Based on 3 Levels
1) Intellectual - based on literacy and comprehension of doctor and patient
→ non-technical level
2) Emotion - bonding between doctor and patient
3) Cultural - Doctor and patient with same culture
→ religion, region, socioeconomic status

Types
● Default - neither doctor no patient has focus
● Paternalistic - doctor is dominant
● Consumeristic - patient is in focus
● Mutualistic - both doctor and patient jointly involved in decision making
Health education

Definition by John M. Last

- Process by which individual and group learn to behave in a particular manner
conducive to promotion, maintenance and Restoration of health.

Approaches to health education

1. Regulatory approach / Managed Prevention

● Coercive or legislative approach
● Ex - Ban smoking
1. Services approach
● Providing health services at doorstep
● short term
● not based on felt needs
● Ex - Pulse polio
1. Health education approach
● Slow process but enduring results
1. Primary Healthcare approach
● Community involvement
● Intersectoral coordination

Principles of health education

1. credibility
2. interest
3. participation
4. motivation
5. comprehension
6. reinforcement
7. learning by doing
8. known to unknown
9. setting an example
10. good human relations
11. feedback leaders

Health education Health propaganda

Appeals to reason emotion

Thought process present absent

Knowledge and skills actively acquired instilled in minds

Behaviour reflective reflexive

Process behaviour centred information centre

Mass media

1. Definition:
Diversified collection of media technologies intended to reach a mass audience.

1. Advantage
● reaches Large Population in small time
● highly effective for low literacy population
● reach to remote areas
● gets attention
1. Disadvantage
● One way communication
● may not effect in change of behaviour

1. Types of Mass media

● TV → most popular /most effective
● Radio
● Internet → fastest growing
● Newspaper
● Museum
● Exhibit
● Folk media
Water

Safe and Wholesome water Criteria​ ​- Water free from → colour/ order
→ chemical agent
→ biological agents
→ usable for domestic purposes
Disinfection of water
1. Boiling (BEST method) - destroys everything
2. Chlorine (2nd best method) - can’t destroy → Cyclops (copepods)
→ Poliovirus
→ Hepatitis a virus
→ cyst and ova of parasites
→ bacterial spore
3. UV rays
4. Ozone gas

CHLORINATION

● Chlorine is better than other disinfectants due to:

1. Residual action - Cl2 + h20 = 24 hrs action
2. no need to Retreat water
● Chlorine act best when pH of water is 7
● % age of available chlorine in bleaching powder (100g) = 33% (33g)
● 2.5 g of Bleaching powder is required for disinfection of 1000L water
● Cl2 + impurities → impurities Destroyed ​→​ additional Cl2 (free/residual Cl2)
→ remain in h20 to protect for next 24 hr
● Disinfecting action of Chlorine in water is due to formation of:
1. Hypochlorous acid (HOCL) → main - 90% action
2. Hypochlorite ion (​ClO​−​) → rest - 10% action

​Recommended Free / Residual chlorine levels

1. Drinking water ≥ 0.5 mg/L(ppm) Contact period 1 hour

2. Drinking water to kill cyclops ≥ 2 mg/L (ppm) Contact period 1 hour

3. Swimming pools ≥ 1 mg/L (ppm) Contact period 1 hour

● Residual free chlorine level in water can be estimated by:

1. Instrument - Chloroscope.
2. Test - ​Orthotolidine (OT) test
- Orthotolidine-Arsenite (OTA) test
Ortho-toulidine (OT) test: Measure the level of
→ free / residual chlorine
→ total chlorine - free + combined chlorine
Ortho-toulidine Arsenite (OTA) test: Measure the level of
→ free / residual chlorine
→ Combined chlorine

OTA test is better than OT test as:

1. Detects both free and combined chlorine separately
2. Not affected by interfering substances (N02-, Fe, Mn)

​Chlorine demand estimation by Horrock’s Apparatus

● Use - To find out the dose of bleaching powder required for disinfection of water.
● Contents:
1. 6 white cups (200 ml capacity each)
2. 1 black cup (with a Circular mark inside)
3. 2 metals spoons
4. 7 glass stirring rods
● Indicator:
1. Starch iodide - producing blue colour
(development of blue colour indicates presence of free residual chlorine)
● Procedure
1. Take 1 level spoonful of bleaching powder (2g) in the black cup along with
normal water up to the circular mark (Stock soln). Fill the six white cups with
water to be tested. With the pipette, add 1 drop of stock solution to 1st cup ---> 6
drop to 6th cup. Stir and wait. Add 3 drops of Starch iodide Indicator to each of
the white cups. Wait until colour develops.
● Dose of bleaching powder required [Chlorine demand]
= n X 2 gms to disinfect 455 L of water
[n - number of first Cup which shows distinct blue colour]
Hardness of water

1. Estimated by its soap destroying or neutralizing power.

2. types of hard water
a. Temporary hardness - Ca2+/Mg2+ salts of hc03-
b. Permanent hardness - Ca2+/Mg2+ salts of S04-, Cl-, No3-.
1. Softening of water is recommended when:
Hardness is > 150 mg/L or > 3 mEq/L
1. Removal of hardness of drinking water
a. Temporary hardness → boiling
→ lime
→ sodium carbonate
→ permutit process
b. Permanent hardness → sodium carbonate
→ base exchange

Normal ph of Water = 6.5-8

Public Health classification of Water borne diseases

1. Water borne disease:​ occurs due to drinking contaminated water transmitted

by faeco oral route.
Example -​ Typhoid, Cholera, Dysentery (Salmonella & Ecoli), Viral hepatitis A.
1. Water washed diseases:​ include infections of outer body surface which occurs
due to inadequate use of water or improper hygiene.
Example -​ Scabies, Trachoma, Typhus, Bacillary dysentery, Amoebic dysentery.
1. Water based diseases:​ refers to infections transmitted through an aquatic
invertebrates animal (play a role in transmission cycle).
Example -​ ​Schistosomiasis,​ Dracunculiasis (Guinea worm disease).
1. Water related diseases /Water breeding diseases:​ are infections spread by insects
that depend on water.
Example -​ Malaria, dengue, Yellow fever, ​Onchocerciasis​ .

Bacterial indicator of water quality

1. Coliform bacteria​ [E.coli] → BEST overall indicator

a. Presumptive coliform test (MPN Multiple tube method):​ screening test for the
presence and quantification of coliforms in drinking water.
i) Calculate revised Most probable number (MPN) from McCrady’s table.
ii) Diagnostic/Confirmatory test - ​EIKJMAN’S test
2. Fecal streptococci - ‘recent’ contamination
3. Clostridium perfringens - ‘remote’ contamination

Guideline aspects of drinking water quality

Colour < 15 TCU (True colour unit) or < 5 HAZEL

Turbidity < 1 NTU (​Nephelometric Turbidity Unit)

Hardness < 100-300 mg/L

Total dissolved solute (TDS) < 500 mg/L

Compounds
1. fluorides < 1 ppm
2. nitrates < 45 ppm
3. nitrites < 3 ppm

Radioactivity
1. Alpha (​α)​ particle < 0.5 Bcq/L
2. Beta (​β) particle < 1.0 Bcq/L
Medical entomology

Arthropod borne diseases

Vector Disease

Sandfly (Phlebotomus 1. Kala Azar (Visceral leishmaniasis)

argentips) 2. Oriental sore (Cutaneous leishmaniasis)
3. Oroya fever
4. Sandfly fever

Tse-Tse fly (Glossina palpalis) 1. Sleeping sickness of Africa

(African trypanosomiasis)

Reduviid bug (Triatominae) / 1. Sleeping sickness of America

Kissing bug / Assassin bug (American trypanosomiasis /Chagas disease)

Rat fly (Xenopsylla) 1. Plague

2. Endemic typhus
3. Chiggerossis

Soft tick 1. Q fever (not in humans)

2. ​Kyasanur Forest disease (outside India)
3. Relapsing fever

Hard tick 1. ​Kyasanur Forest disease (in India)

2. Tick paralysis
3. Tick encephalitis
4. Babesiosis
5. Congo fever
6. tularemia

Louse 1. Epidemic typhus

2. trench fever
3. relapsing fever
4. Pediculosis

Blackfly (Simulum) 1. ​Onchocerciasis / River blindness

→ highest flight range (Not present in India)
= 100 miles
 Mosquito Vectors

Anopheles Culex Aedes Mansonia

Diseases Malaria - Bancroftian filariasis - Dengue / DHF Malayan (brugian)

transmitted - Japanese encephalitis - Chikungunya filariasis
- West nile fever - Yellow fever
- Rift valley fever
- Zika fever

Breeding Clean water Dirty polluted water Artificial collection of Water bodies w/
Habitat water (rain) aquatic plants

Eggs - Laid singly Laid in small - Laid singly Laid in star shaped
- Boat shaped clusters/rafts - Cigar shaped clusters
- Lateral floats

Larvae - No siphon tube - Siphon tube - Siphon tube - Siphon tube

- Rest ​∥​ to - Rest ​⊥​ to - Rests in dark bottom - Rest attached to
undersurface undersurface corners rootlets of plants
of water of water

Adults - Straight body inclined ‘Hunch back’ rest White Stripes on body
at an angle to Surface and legs
- Spotted wings

Flight 3-5 kms 11 kms 100 m

range

Remark Sophisticated Mosquito Nuisance mosquito Tiger mosquito

Lifespan of mosquito = 8-34 days

● Mosquito control measures in India
1. Physical
- Source reduction (overall best) → ​primordial level of prevention
- Mosquito nets
a. Size of mesh = 0.0475 inch
b. minimum number of holes per sq inch = 150
2. ​Chemical → Primary level of Prevention
- ​Dichloro Diphenyl Trichloroethane (DDT)
- Pyrethrins {Natural agent obtained from pyrethrum}
- Malathion {least toxic OPs}
- Paris green (​Copper(II) acetoarsenite)
DDT, Pyrethrum and Malathion
→ Anti-adult measure: nerve/contact poison - inhibits AChE
→ Anti-larval measure: stomach poison
3. ​Biological → ​Primary level of Prevention
- Larvivorous fishes - Gambusia (Highest affinity for Anopheles)
- ​Lebistes reticulatus
- ​Poecilia
- ​Bacillus thuringiensis serotype H14
- ​Coelomomyces - FUNGI
​ - Toxorhynchites - large Non-blood sucking mosquito
- their larvae prey on the larvae of other small mosquito
2) Air

Instruments
1. Kata thermometer - low air velocity
2. Hygrometer and psychrometer - air humidity
3. Anemometer - air velocity
4. Wind vane - air direction

Housing standards for Ventilation

1. Per capita requirement of air - 300-3000 ft​³​/hr
2. Recommended no.of air change - 2-3 Changes /hr in living room
- 4-6 changes /hr in work rooms and assemblies

Types of ventilation
1. Exhaust ventilation - air is extracted to outside by exhaust fans given by electricity
2. Plenum ventilation - fresh air is blown into rooms by centrifugal rooms
3. Balanced ventilation - combination of exhaust and plenum ventilation
4. Air conditioning - simultaneously controls of all factors specially temperature, humidity
and air movement

Indicator of air pollution

1. Biological indicator: Lichen (best)
2. Chemical indicators: S02 (best), C02, CO, N02
3. Air pollution index
4. Soiling index
5. Coefficient of haze
6. Suspended particulate matters

● Air pollution monitoring - Central Pollution Control Board (CPCB) of India

● global warming / green house effect: Major contributor - h20 vapour & C02
● Kyoto Protocol: - 187 countries took part on 16th Feb 2005.
- Targeted reductions in transmission
→ Carbon dioxide (C02)
→ Methane (Ch4)
→ Nitrous oxide (N20)
→ Chlorofluorocarbons (CFC)
→ Sulphur hexafluoride (SF6)
→ Perfluorocarbons (PFC)
● Predictable 4 hour sweat rate [P4SR]
- Comfort = 1-3 litre
- Max P4SR = < 4-5 litre [beyond this --> dehydration]
 3) Light

● Maximum illumination for satisfactory vision = 15-20 foot candles

● Day light factor (DLF) = compare with Daylight
1. Living room: ​≥ 8%
2. Kitchen:​ ​≥ 10%

​4)​ ​Sound

● Tolerable sound level to human ear: < 90 dB

● Auditory fatigue start: > 90 dB
● Permanent hearing loss: > 100 dB
● direct tympanic membrane rupture: > 150-160 dB
● Hospital ward, School (library, class), shop - least noise [permissible
sound level is 20-35 dB].
● Normal conversation: 60-70 dB

5) Housing

● Housing standards
1. Floor space per person > 50-100 ft² (avg. = 70-90 ft²)
2. Cubic space per person > 500 ft³
3. Door and window area ≥ 40% of floor area

● Overcrowding criteria
1. Number of person per area > 2
2. floor space per person <70-90 ft²
3. 2 persons > 9 years age (not husband-wife) sleep in same room.
→ If any one of the above is present → overcrowding
→ Hazards: increases risk of communicable diseases
6) Radiation

● Radiation exposure in Chernobyl tragedy - Cesium (Cs), Iodine (I), Strontium (Sr)
● Thickness of lead apron to prevent exposure: ​≥ 0.5 mm
● State receives highest solar radiation - Rajasthan
● Maximum utilisation of solar radiation - Gujarat
● Total natural radiation received = 0.1 rad/person/yr
● Maximum permissible radiation exposure
1. Man = 5 rad/ person /yr
2. Pregnant women = 0.5 rad/ person /yr

7) Waste Disposal

● Types of waste
1. Refuse - solid waste generated from living room, street, industry.
2. Garbage - solid waste from kitchen
3. Sewage - liquid waste containing human excreta (polio virus)
4. Sullage - liquid waste without human excreta
● Sewage contains 99% of water
● Strength of sewage
1. Biological oxygen demand [BEST indicator]
2. Chemical oxygen demand
3. Suspended solids
● Strong sewage: > 30 BOD
Ergonomics

Defn: Science where we study people efficiency in working environment.

1. Pre placement exam

a. right man in right job
b. fitting job to work
2. Post placement exam
a. regular periodic exam
b. annually → most occupational exposure
c. every 2 months → radiation
d. monthly - lead, dye, radium
e. daily - dichromate

Sickness absenteeism

1. Medical Cause
2. Non sickness cause
→ economic
→ social
→ others

Duration: 8-10 days/ person/ year

​Occupational health legislation

​The Factory act 1948

Factory - ​≥ 10 persons with power or electricity

- ≥ 20 persons without power

not applicable on 4 sector

a. Defence
b. Mines
c. Railways
d. eateries (food)

Child: 0-14 yrs

Adolescent: 15-18 yrs

● employment is prohibited below 14 years

● work hour duration - 9 hrs/day
 - 48 hrs/week
- 60 hrs/week (overtime)

1 safety officer = 1000 workers

1 welfare unit = 500 workers
1 canteen = 250 workers
1 creche = 30 workers

● There are Notifiable diseases in industry

The ESI (Employees State Insurance) Act 1948

● Union Ministry of labour covers ESI

Contribution to ESI
a. employer 4.75% of wages
b. employee 1.75% of wages
c. Central : State = 7:1

Coverage
a. all non seasonal factories ​≥ 10person
b. other factories ≥ 20 person

not applicable → defence, mines, Railways

Coverage: Income ​< ​₹ ​21k ​/ month

Benefits
1) Medical benefit - full medical care
2) Sickness benefit - 90% wages X 91 days
Extended sickness benefit - 80% wages X 2 years
Enhanced sickness benefit - 100% wages X 7 days {Vasectomy}
- 100% wages X 14 days {Tubectomy}
3) Temporary disablement benefit - 90% wages till recovery.
4) Permanent disablement benefit - 90% wages (medical board)
5) Maternity Benefit - 100% wages X 26 weeks
6) Dependence benefit 90% wages (pension)
7) Funeral expenses - ₹ 10k
Disaster management

Disaster: an occurrence that cause damage ecological disruption loss of human life or
deterioration of health or health services on a scale sufficient to warrant an extraordinary
response to outside region.

From Colin grant: disaster is Catastrophe causing injury and/or illness simultaneously.

Disaster mitigation:prevention of conversion of hazards or risk to disaster situation to minimise

the damage surge capacity ability of a health system to respond to disaster situation.

Search capacity: ability of a health system to respond to disaster situation.

types of disaster

Natural

geological Earthquake
volcanoes

hydrological Flood
tsunamis

climatological Drought
Fires

biological epidemic

extra terrestrial meteoroids

Man made

Wars

Accidents

Disaster cycle

(1) Disaster impact ​→​ (2) Health and Medical Relief ​→ (3) Rehabilitation →
(4) Disaster mitigation → (5) Disaster preparation → (1) Disaster impact
Health and medical relief
Primary 0-6 hrs first aid, medical care

secondary follow up 6-24 hrs Transportation, sanitation, immunization

tertiary cleanup 1-60 days food, clothing, shelter, employment, social

services, rehabilitation

Triage ​- consists of rapidly classifying the injured ‘on the basis of severity of the injuries and
likelihood of their survival’ with prompt medical interventions

Classification of victim of disease

basis of likelihood of survival
best done at site of survival

Triad system: most commonly uses 4 colour code system

Highest Red immediate resuscitation or life/limb saving surgery
Priority (0-6 hrs)

High yellow or blue possible resuscitation or life/limb saving surgery

priority (6-24 hrs)

Low green Minor injury - non life threatening

priority

Least black dad and Moribund patient

priority

Tagging: is the procedure where identification, age, place of origin, triage category, diagnosis
and initial treatment are tagged on to every victim of disaster through a colour coding.

Types of triage
1. START: simple triage and Rapid treatment
if disaster occurs in: remote inaccessible area of our country
triage done by lay person
2. Reverse triage - minor injuries are given highest priority (wars, battle)

Post disaster phase

1) Most common disease after disaster: gastroenteritis (acute) - typhoid, scabies
leishmaniasis, URI, Cholera, TB, leptospirosis.
2) Most common vitamin deficiency: vitamin A (also Vit B3 and Vit C).
3) Vaccine in post disaster: all vaccines are contraindicated (large incubation period)
exception - measles vaccine (short incubation period)
WHO vaccines are contraindicated
All vaccines are contraindicated especially a) typhoid, b) cholera, c) tetanus.
vaccine mandatory for health professional

4) Most important Preliminary step in post disaster phase

a. chlorination of water bodies
b. residual chlorine in PDP ​≥ 0.7 mg/L.

Disaster Management in India

National disaster management Prime Minister

authority

nodal ministry Home Affairs

nodal centre in disaster management district level

National Institute of disaster Union Home minister

management

national disaster response force CRPF, BSF, ITBP, CISF

Maximum mortality reported ---> hydrological.

Worst man made disaster ---> Bhopal gas tragedy (methyl isocyanate).
World disaster risk reduction day ---> 13th October.
Respiratory infections

Smallpox
● Causative agent: Chordopoxvirinae (Orthopoxvirus).
● Last case of Smallpox
a. World: 26th October 1977, Somalia
b. India: 24th May 1975
● WHO declared global eradication of Smallpox: 8th May 1980

Chickenpox
● Causative agent: Varicella zoster virus [Human alpha herpesvirus-3]
● Incubation period: 14-16 days
● Source of infection: Case
● Mode of transmission: Air droplets
● Specimen & Diagnosis - vesicle fluid → microscopy
● SAR - 90%
● Vaccine: live attenuated, OKA strain
● Late complication: Recrudescence → Shingles
● Period of communicability: 2 days <--- Rash appearance ---> 5 days
● Differential diagnosis
Chicken pox rash Smallpox rash

Dew drops on rose petal appearance ​—

Centripetal distribution Centrifugal distribution

Pleomorphic Non pleomorphic

Superficial and unilocular Deep seated and Multilocular

Effects flexor surfaces, involves axilla Effects extensor surfaces, spares axilla

Rapid evolution Slow evolution

Measles (Rubeola)
● Causative agent: RNA paramyxovirus
● Incubation period: 10-14 days
● Source of infection: Case [No carriers seen → No Iceberg phenomenon]
● Mode of transmission: Air droplets
● Period of communicability: 4 days <--- Rash appearance ---> 5 days
● SAR - 80%
● Clinical features
a. Pathognomonic: Koplik spots (opp. to lower 2nd molar).
b. Rash is of Retro-auricular origin.
 ● Complication
a. Most common: Otitis media
b. Rare: Subacute sclerosing panencephalitis (SSPE)
[affects 7/million after 7-10 yr]
● Vaccine
a. Active immunization
- Live attenuated
- Diluent: distilled h20
- Strain: Edmonston-Zagreb
- Administration: 0.5 ml s/c in R arm
- Dose:
1) 1st dose: given at 9-12 months
2) 2nd dose: given at 16-24 months
b. Passive immunization
- Measles Ig (0.25 ml/kg BW)

Mumps (Rubula)
● Causative agent: Myxovirus parotiditis
● Incubation period: 14-21 days
● Source of infection: Case (clinical & subclinical)
● Mode of transmission:Air droplets
● Period of communicability: 4 days <--- Symptom onset ---> 7 days
● SAR: > 86%
● Most common complication
a. Adult: Orchiditis
b. Child: Aseptic meningitis
● Vaccine: live attenuated, Jeryl Lynn strain.

Rubella
● Causative agent: RNA Togavirus
● Incubation period: 14-21 days
● Source of infection: Case [No carriers seen → No Iceberg phenomenon]
● Mode of transmission: Air droplets
● Period of communicability: 4 days <--- Symptom onset → Rash appearance ---> 7 days
● Vaccine
a. live attenuated
b. strain RA 27/3
c. C/I in Pregnant/Lactating mothers & not given to infants.
d. 1st priority: reproductive age group ​♀ (15-49 yrs).
 ● Congenital Rubella Syndrome
1. Syndromic triad
i) Sensorineural deafness
ii) Congenital heart defects (PDA)
iii) Cataracts
2. Time of transmission:​ 1st trimester [MOST DISASTROUS]
{if transmitted in 2ns trimester → only Sensorineural deafness
if transmitted in 3rd trimester → normal baby}

Influenza
● Causative agent: Orthomyxovirus
- Type A: epidemics every 2-3 yrs & pandemics every 10-15 yrs
[MC cause of Epidemic/outbreak]
- Type B: epidemics every 4-7 yr
● Currently circulating influenza virus
a. H​1​N1​ ​ (type A) → swine flu
b. H​3​N2​ ​ (type A) → swine flu
c. H​5​N1​ ​ (type A) → avian influenza
d. H​7​N9​ ​ (type A) → avian influenza
● Antigenic Variations in Influenza
Antigenic Shift Antigenic drift

Cause genetic reassortment point mutation

Nature sudden Nature - gradual

Lead to epidemic/pandemics sporadic cases

● Incubation period: 18-72 hrs
● Period of Communicability: 1-2 days <--- symptom onset ---> 1-2 days
● Pandemic H​1​N1​ ​ Influenza 2009, Mexico
1. IP: 1-4 days
2. Risk factors
a. Infants & Children < 2yr
b. Children in Aspirin therapy
c. Pregnant female
d. Old aged > 65 yr
e. COPD pt.
f. Chronic heart disease pt.
g. Hepatorenal disease pt.
3. Laboratory Diagnosis
a. Technique used - RT-PCR test
b. Samples - Nasopharyngeal + throat swabs
 4. Antiviral therapy
a. Oseltamivir: 75 mg X twice daily X 5 days
b. Zanamivir: 2 inhalation (2 X 5 mg) X twice daily X 5 days
[H​5​N1​ ​- Oseltamivir; H​7​N9​ ​-​ ​Oseltamivir → Zanamivir]
5. Vaccine
a. Live attenuated vaccine: nasal spray
b. Killed vaccine:
- A​7​ California/ 2009 strain
- 1st priority = pregnant women
6. Categorization
Category A Category B Category C

Clinical feature Mild fever High grade fever Breathlessness

Cough Severe sore throat Chest pain
Headache Hypotension
Diarrhea
Vomiting

Diagnostic test No test No test Test is done

TXT Symptomatic Oseltamivir Hospitalization

treatment Oseltamivir

Diphtheria
● Causative organism: Corynebacterium diphtheriae
● Source of Infection: Carrier >> Case
● Incubation period: 2-6 days
● Mode of transmission: air droplet
● Specimen & Diagnosis - Nasopharyngeal secretion
● Period of communicability: disease onset ---> 14-28 days
[POC = >2 culture done 24 hr apart → (+)ve → communicable]
● DPT Vaccine
a. Diphtheria toxoid + Tetanus toxoid + killed acellular Pertussis
b. DPT vaccine dosage = 0.5 ml
c. Site: anterolateral aspect of thigh, middle ⅓
d. Route - intramuscular (i/m)
e. NIS schedule (Vaccine vs when to give)
DPT-1 6 weeks of age

DPT-2 10 week of age

 DPT-3 14 week of age

DPT booster-1 16-24 months of age

DPT booster-2 5 year of age

● Schick test
a. Intradermal test of immune status to diphtheria toxin.
b. Dose administered:
1. 0.2ml of Schick test toxin in test arm.
2. 0.2ml of heat inactivated toxin in opposite control arm.
c. Interpretation after 4 days
Observation Reading Interpretation

Test arm Control arm

No reaction No reaction NEGATIVE Immune to diphtheria

Red flush No reaction POSITIVE Susceptible to diphtheria

Red flush fades by 4th day PSEUDO- Immune & Hypersensitive to

POSITIVE diphtheria

Test arm Control arm

Red flush pseudopositive COMBINED Susceptible & hypersensitive to

diphtheria

d. Action taken:
- Susceptible to diphtheria = vaccinate
- hypersensitive to diphtheria = desensitize
e. Schick test has been replaced by Hemagglutination Test
(it measures serum antitoxin level)

Pertussis
● Causative organism: Bordetella pertussis
● Source of Infection: Cases
● Incubation period: 7-14 days
● Period of communicability: pathogen exposure ---> 7-3 weeks
● SAR: > 90%
● Drug of choice: Erythromycin
● Vaccine: DPT vaccine
Meningococcal Meningitis
● Causative organism: N. meningitidis
● Source of Infection: Carrier > Case
● Incubation period: 3-4 days
● Period of communicability:
a. (​-​)ve → pathogen absent in nasal/throat discharge
b. (+)ve → pathogen present in nasal/throat discharge
● Mode of transmission: air droplets
● CFR: > 80%
● Drug of choice
a. TXT of Cases - penicillin
b. TXT of Carrier - rifampicin
c. Chemoprophylaxis of contacts - rifampicin
● Vaccine
1. Type: killed vaccine, cellular fraction
2. Contraindicated in
- Pregnant female
- Infant & children < 2 yr
3. Priority: early adolescents (10-13 yr)

Pneumonia
● New ARI guidelines, IMNCI 2017-18
Type of ARI Signs/Symptoms Management Colour code

No Pneumonia - Cough/Cold Home green

[Inhaled bronchodilator X 5 days
- If cough >14 days → assess ​TB
- If wheeze → assess Asthma
Follow up in 5 days].

Pneumonia - Chest indrawing PHC yellow

- Fast breathing [oral amoxicillin X 5 days and
a. RR >50 (2-12 month) inhaled bronchodilator
b. RR >40 (1-5 year) - If cough >14 days → assess ​TB
- If wheeze → assess Asthma
Follow up in 3 days].

Severe Pneumonia - Stridor when calm CHC pink

- Dangerous signs [1st dose of referral antibiotic
1. Inability to feed If convulsion - give Diazepam
2. vomit out food Treat any cause of
3. history of convulsion - Low sugar
 4. lethargic - hypothermia].
5. unconscious
[In case of young infant
(0-2 month age)
→ chest indrawing
→ RR > 60 per/min
→ fever > 37.5​°​C].

Tuberculosis
● Causative agent: Mycobacterium tuberculosis
● Source: cases
● Period of communicability: infective as long as cases remain untreated
● Mode of transmission: droplet infection
● IP: 4-12 weeks
● Specimen & Diagnosis - sputum smear
● Epidemiological Indices for TB
a. Incidence of TB infection (annual risk of infection): 1-2%
- Estimation → Tuberculin conversion index
b. Prevalence of TB infection: 30-40%
- Estimation → Tuberculin test
c. Incidence of disease: 167/100000
- Estimation → Sputum smear examination
d. Prevalence of disease: 195/100000
- Estimation → Sputum smear examination
● TB situation in India
1. Mortality = 17 per 1 lakh cases
2. Infectivity = 1 case of TB spread → 10-15 cases in 1 yr
3. MC age group: 25-34 year
[TB is the MC opportunistic infection of HIV
Diabetes mellitus is a risk factor for TB infection].
● Mantoux test (​tuberculin​ skin ​test)
a. Antigen: PPD (purified protein derivative)
b. Dose: 1 ​tuberculin unit(TU)​ in 0.1 ml [5000 TU/mg]
c. Site: intradermally on flexor surface of forearm
d. Strain: RT 23 with Tween 80
e. Readings - result read after 72 hrs:
- Induration > 9mm → POSITIVE [past/current infection]
- Induration 6-9mm → DOUBTFUL
- Induration < 6mm → NEGATIVE [never infected]
f. False reactions:
1. False (+)ve Mantoux test - prior BCG vaccine
2. False (-)ve Mantoux test - HIV/AIDS
● BCG ​(​Bacillus ​Calmette–Guérin​) ​Vaccine
 1. Nature: Live attenuated vaccine
2. Strain:
a. WHO recommended: DANISH 1331 strain
b. derived from Mycobacterium bovis
c. Produced by 239 subcultures over a period of 13 yr
3. Diluent: normal saline
4. Dose: 0.1 ml (for all ages)
5. Site: intradermally [i/d]
6. Protective efficacy against severe form of TB: 0-80%
7. Protection duration: 20 yr
● National reference labs for TB
a. National Tuberculosis Institute (NTI), Banglore
b. Tuberculosis Research Centre (TRC)
c. National Institute of TB and Respiratory Diseases (NITRD), Delhi
● The End TB Strategy 2016-2035
1. Vision - world free of TB
2. Goal - end the global TB epidemic
3. Target of End TB strategy
Indicators Target by 2035

↓ in TB deaths > 95%

↓ in TB incidence rate > 90%

TB affected families facing 0

catastrophic costs
● Transmission 2020
1. Goal - eliminate TB by 2020
2. Free diagnosis & treatment of TB
3. Ban on commercial serology
4. New Anti-TB drugs launched
5. Notification of TB cases
● Drug resistant TB
a. Multi drug-resistant TB (MDR-TB)
- Resistant to → isoniazid and rifampicin
b. Extensively drug-resistant TB (XDR-TB)
- Resistant to → isoniazid and rifampicin + 1 fluoroquinolone
+ 1 injectable drug (Kanamycin/ Amikacin/ Capreomycin)
● TB - propagated epidemic
(slowly ↑ in population overtime)
● Anti TB day: 24th March
Gastrointestinal infections

Poliomyelitis
● 3 Endemic countries - Pakistan, Afghanistan, Nigeria
● Poliomyelitis situation in India
- India declared ‘polio free’ by WHO on 27th March 2014
- last case of polio was detected on 13 January 2011 in Howrah, WB
● Causative agent: Poliovirus (serotype 1,2 & 3)
1. P1 → MCC of epidemics
2. P2 → MCC of ​Vaccine-derived poliovirus (​VDPV​)
→ Most antigenic & most easily eradicable
→ eradicated on 20 september 2015
3. P3 → MCC of ​Vaccine-associated paralytic polio (VAPP)
● Reservoir: Man
● Route of transmission: faeco-oral
● Incubation period: 7-14 days
● Period of communicability: 7-10 days <--- Symptom onset ---> 7-10 days
● Clinical presentations
Clinical spectrum Infections

Inapparent (subclinical) 95%

Abortive (minor illness) 4-8%

Non-paralytic polio 1%

Paralytic polio <1%

● Vaccine:
i) OPV (oral Sabin) - Bivalent [P​1​ & P​3​]
ii) IPV (inactivated Salk) - Trivalent [P​1​, P​2​ & P​3​]

Hepatitis
● Types of Viral hepatitis
Type Causative agent Incubation period Mode of POC
Transmission

Hepatitis A Enterovirus 72 15-45 days Fecal-oral (MC in 2 week <--- jaundice

(picornavirus) children) ---> 1 week

Hepatitis B Hepadnavirus 45-180 days Blood Disappearance of

HbsAg ---> appearance
 of anti Hbs Ab

Hepatitis C Hepacivirus 30-120 days Sexual & Parenteral

Hepatitis D Viroids like 30-90 days Sexual & Parenteral

Hepatitis E Calcivirus 21-45 days Fecal-oral (MC in

(alphavirus like) adult)
[↑ mortality in
pregnancy]
● Hep B vertical transmission - during 3rd trimester
● Hepatitis B serum Markers ​(in order of appearance)
1. HbsAg (Hepatitis B surface antigen)
a. 1st Ag to appear in serum → ‘Epidemiological marker’
b. aka ‘Australian antigen’
2. HbcAg (Hepatitis B core Antigen)
a. Rarely appears alone in serum
3. HbeAg (Hepatitis B envelope Antigen)
a. Marker of infectivity
b. Indicates active viral replication
4. Anti-Hbc Ab (Antibody to Hepatitis B core Antigen)
a. 1st Ag to appear in serum → IgM.
b. Indicates diagnosis of acute Hepatitis B
5. Anti-Hbe Ab (Antibody to Hepatitis B envelope Antigen)
a. Signals ‘stoppage of active viral replication’
6. Anti-Hbs Ab (Antibody to Hepatitis B surface Antigen)
a. Signals ‘end of period of communicability’

Cholera
● Causative agent: Vibrio Cholera
a. Serogroup - V. Cholera 01
b. El Tor biotype [Serotype: Ogawa → MC in India]
● Route of transmission: Faeco-oral
● Incubation period: 1-2 days
● Typical stool appearance: Rice-watery diarrhea
● Treatment of Cholera
1. Adults - Doxycycline
2. Children & Pregnancy - Azithromycin
● Chemoprophylaxis ​- Tetracycline
● In case of Epidemic → 1st step is Verification of diagnosis
- Identifying V.cholera in stools of few pt. is sufficient
- Not necessary to culture stool of all cases
● Most important Prophylactic measure - Health education
Typhoid
● Causative agent: Salmonella typhi
● Route of transmission: Feco-oral
● Incubation period: 10-14 days
● Clinical feature
a. Pea soup diarrhea
b. Coated tongue
c. Rose spot
d. Step ladder pyrexia

● Laboratory diagnosis ​[Mnemonic - BASU]

Diagnostic test Time of diagnosis

Blood culture 1st week

Antibody (Widal test) 2nd week

Stool culture 3rd week

Urine test 4th week

● Drug of choice:
a. Cases - Cephalosporins (ceftriaxone), Quinolones
b. Carrier - Ampicillin/Amoxicillin + Probenecid X 6 weeks
● Immunization for Typhoid:
a. TYPHORAL vaccine
b. TYPHIM Vi vaccine
c. TAB vaccine
● Oral Rehydration solution (ORS)
1. WHO recommended ‘Reduced osmolarity ORS (low Na ORS)’
Composition (gm) Osm conc. (mmol/l)

NaCl 2.6 Na+ 75

KCl 1.5 K+ 20

Na citrate 2.9 Cl- 65

Glucose 13.5 citrate 10

Total = 20.5 gm glucose 75
Total = 245 mmol/l
 1. ReSoMal (Rehydration solution for malnourished)
- WHO ORS packet + 2l h20 + 50gm sugar + 40gm electrolyte
- Na+ = 45 mmol/l (​X​½ of WHO ORS)
K+ = 40 mmol/l (​X2​ of WHO ORS)
1. Super ORS
- Composition instead of glucose
→ Amylase resistant starch (pectin)/ Glycine/ Alanine

Food poisoning
Staphylococcal Salmonella Botulism Perfirengens Cereus

Cause Staph. aureus 1) S. Typhimurium Cl. Botulinum Cl. Perfirengens Bacillus cereus
(Enterotoxin) 2) S. Enteritidis (Exotoxin)

IP 1—6 hrs 12—24 hrs 12—36 hrs 6—24 hrs a) Emetic form:
1—6 hr
b) Diarrheal form:
12—24 hr

Worm Infestations

Guineaworm
● Causative agent - Dracunculus Medinensis (nematode)
● Epidemiology in India
- Last case: july 1996 Jodhpur, Rajasthan
- Eliminated (WHO): february 2000
● Type of transmission - Cyclodevelopmental transmission
● Type of disease - Water based disease
● Drug of choice → Niridazole, Mebendazole, Metronidazole

Roundworm
● Causative agent - Ascaris lumbricoides
● IP: 2 months
● MOT: feco-oral

Hookworm
● Causative agent
- Ancyclostoma duodenale
- Necator americanus
● IP: 5 week-9 month
● MOT: penetration of skin
 ● Association
a. Iron deficiency anemia (blood loss = 0.03-0.2 ml/day)
b. Hypoalbuminemia
● Chandler’s index (CI)
1. description - No. of hookworm eggs /gm of stool
2. technique - Kato-katz technique
3. If CI > 300 → major public health problem

Tapeworm
● Causative agent
- Taenia solium
- Taenia saginata
● Host of infection
Definitive host Intermediate host

T.solium Man Pig

T.saginat Man Cow

a
● MOT
a. Ingestion of infective cysticerci in meat.
b. Ingestion of food/water contaminated with egg.
● IP: 8-14 weeks
● Drug of choice: Praziquantel, Niclosamide, Albendazole

Zoonotic infections

1. Classification of Zoonosis based on direction of transmission

a. Anthropozoonosis​ - infections transmitted from animals(zoo) to man(anthro).
Example → Rabies, Plague, Anthrax
b. Zooanthroponosis ​- infections transmitted from man(anthro) to animals(zoo).
Example → Human Bovine TB
c. Amphixenosis​ - infections transmitted in either direction
Example → T.cruzi, S.japonicum
2. Classification of Zoonosis based on life cycle of infected organism
a. Direct zoonosis​ - transmitted by direct contact/ fomite/ mechanical vector
Example - Rabies, Brucellosis, Trichinosis
b. Cyclozoonosis​ - its life cycle involves >1 vertebrate species
Example - teniasis, echinococcosis
c. Metazoonosis​ - its life cycle involves a invertebrate vector
Example - plague, arboviral infection
 d. Saprozoonosis​ - its life cycle involves a non-animal reservoir
Example - mycosis, larva migrans

Rabies
● Causative agent: Lyssavirus Type 1 (Rhabdovirus)
● IP: 20-60 days
● Clinical feature: Hydrophobia - difficulty in swallowing food/water
● Pathognomonic feature → Negri bodies
● MOT: infected Animal bite Except Rat & Human.
● Geographical barrier - water body
● Specimen & Diagnosis
living person biopsy of skin follicle on Nape of neck

Dead person brain biopsy

Living dog kill the dog → brain biopsy

Dead dog brain biopsy

● Local wound TXT
- Cleansing with soap water for 5-10 min.
- No suturing is done
● Vaccination for Rabies [from fixed virus]
1. PCECV (Purified chick embryo cell vaccine): i/m or i/d
Example - Rabipur, Vaxirab.
2. PVRV (Purified Vero cell Rabies vaccine): i/m or i/d
Example - Verorab, ​Abhayrab, Indira.
● Anti-rabies serum
1. ERIG (equine) - 40 IU/kg
2. HRIG (human) - 20 IU/kg

Plague
● Causative agent - Yersinia pestis
● Vector - Rat flea (Xenopsylla sp.)
● Reservoir - Wild rodents → Tatera indica in India
● Source - infected rats, flea & humans
● IP: 1-3 days
● MOT
- rat flea bite
- direct contact
- respiratory droplet
● Types of plague
Type IP
 Pneumonic plague 1-3 days

Bubonic plague 2-7 days

Septicemic plague 2-7days

● Drug of choice
a. Cases - Streptomycin
b. Chemoprophylaxis - tetracycline

Rickettsial disease
Disease Agent Vector Reservoir

Typhus group
Epidemic typhus Rickettsia prowazekii Louse Man

Murine typhus Rickettsia typhi Flea Rodent

(Endemic typhus)

Scrub typhus Rickettsia tsutsugamushi Trombiculid mite Rodent

Spotted Fever group

Indian tick typhus Rickettsia conorii Tick Rodent

Rocky mountain spotted Rickettsia rickettsii Tick Rodent

fever (RMSF)

Rickettsial pox Rickettsia akari Mite Mice

Non-Rickettsial group
Q fever Coxiella burnetii ​— Cattle

Trench fever Bartonella quintana louse Human

● Drug of choice - Tetracycline

● Brill​–Zinsser ​disease ​-​ ​Recrudescence of Epidemic typhus
Skin infections

Trachoma
● Causative agent: Chlamydia trachomatis (serotype A,B,C)
● Epidemiology - India was declared ‘free from Trachoma’ on 8th Dec 2017.
● Incubation period: 5-12 days
● Mode of transmission
- fomites (indirect contact)
- eye-seeking flies
- sexual contact
● Field diagnosis (DD): ≥ 2 criteria must be fulfilled in children (0-10 yr)
1. follicles on upper tarsal conjunctiva
2. limbal follicles
3. conjunctival scarring
4. vascular pannus
● WHO classification of Trachoma
a. Trachomatous inflammation follicular (TIF):​ presence of > 5 large follicles on
upper tarsal conjunctiva.
b. Trachomatous inflammation intense (TII):​ obscuration of > 50% of deep tarsal
vessels of upper tarsal conjunctiva.
● Drug of choice - Azithromycin.

Leprosy
● Aka Hansen’s disease
● It is probably disease known to Mankind
● Causative agent - Mycobacterium leprae
● Specimen & Diagnosis - None {purely clinical diagnosis}
● MOT
- Droplet infection
- Skin to Skin contact
- Transplacental
- Breast milk from lepromatous mother
- Insect bite
- Tattoo needles
- Organ transplantation
● Leprosy situation in India
a. Annual new case detection rate (ANCDR): 9.71 /100,000 pop
b. Prevalence: 0.66 /10,000 pop
c. Elimination level of Leprosy - <1 case/ 10,000 global pop.
 [India eliminated Leprosy in Dec 2005]
● Leprosy cannot be 100% Eradicated
1. long variable IP
2. multiple mode of transmission
3. no vaccine available
4. it has no culture media
● Classification of Leprosy
Paucibacillary leprosy Multibacillary leprosy

Ridley​—​Jopling 1. Tuberculoid leprosy (TT) 1. borderline borderline leprosy (BB)

classification 2. borderline tuberculoid leprosy (BT) 2. borderline lepromatous leprosy (BL)
(Immuno-histo) 3. Lepromatous leprosy (LL)

Bacteriological <2 >2

Index

Multi-drug a. Rifampicin: 600mg -1/30 day a. Rifampicin: 600mg -1/30 day

Therapy b. Dapsone: 100mg - 1/day b. Dapsone: 100mg - 1/day
c. Clofazimine: 300mg - 1/30 day
50mg -1/day

TXT time 6 months 12 months

- TT → Highest CMI, Strong lepromin test
- BT → most common in India.
- LL → highest bacillary load, least CMI, most infective
● Global Leprosy Strategy 2016-2020
1. Targets
- no. of children diagnosed with leprosy - 0
- rate of newly diagnosed leprosy pt w/ visible deformity - <1 /million
- No. of countries allowing discrimination based on leprosy - 0

Tetanus
● Causative agent: Clostridium tetani
● Source & Reservoir: Soil
● IP: 6-10 days
● POC: None
● Neonatal tetanus (NNT) elimination Criteria
1. Rate: < 0.1/1000 live birth
2. TT-2 coverage: > 90%
3. Attended deliveries: > 70%
● Prevention of Tetanus in Wounded
Immune Category Wounds < 6 hr old, clean, Wound > 6hr old, unclean
non penetrating, negligible Penetrating, noticeable
tissue damage tissue damage
 A​ [Complete dose of toxoid /booster Nothing required Nothing required
dose in previous 5 yrs]

B​ [Complete dose of toxoid /booster Toxoid 1 dose Toxoid 1 dose

dose in previous 5-10 yrs]

C​ [Complete dose of toxoid /booster Toxoid 1 dose 1. Toxoid 1 dose

dose in > 10 yrs ago] 2. Human tetanus Ig

D​ [Incomplete dose of toxoid Toxoid complete course 1. Toxoid complete course

/booster dose or status unknown] [follow NIS schedule] 2. Human tetanus Ig

Vector borne disease

Malaria
● Causative agent vs Incubation period
Cause IP [days]

Plasmodium vivax 8-17 (14)

Plasmodium falciparum 9-14 (12)

Plasmodium malariae 18-40 (28)

Plasmodium ovale 16-18 (17)

NB: ​P. falciparum​ is the most common type and only cause of death
● Vector​ a. Anopheles culicifacies [Rural]
b. Anopheles stephensi [Urban]
● Infective form - Sporozoite
● Specimen & Diagnosis - peripheral blood smear
● Life cycle of Plasmodium
Exogenous phase (in Mosquito) Endogenous phase (in Human)
Sexual cycle (Sporogony) Asexual cycle (Schizogony)
1. Sporozoite in mosquito saliva injected into human host → Exoerythrocytic cycle
multiplication in liver parenchymal cells → Merozoites → enter RBC → Ring
trophozoite ​→
a. Mature trophozoite → Immature Schizont → Mature Schizont →
Merozoite → enter RBC.
b. Micro/Macro-gametocyte → human blood enters mosquito →
Micro/Macro-gamete → Zygote → Ookinete (penetrates to reach outer
layer of stomach wall & encysts) → Oocyst → Sporozoites (pass through
body cavity to reach salivary gland).

Lymphatic Filariasis
 Bancroftian filariasis Brugian filariasis

Causative agent Wuchereria bancrofti Brugia malayi

Vector Culex quinquefasciatus Mansonia annulifera

Drug of choice Diethylcarbamazine [DEC] Diethylcarbamazine [DEC]

(6 mg/kg/day X 12 days) (3-6 mg/kg/day X 6-12 days)

Infective stage Microfilariae (Mf) Microfilariae (Mf)

● IP = 8-18 month

Dengue
● Causative agent:​ Dengue virus (4 serotypes) - ​‘Group B Arbovirus (Flavivirus)’
​— DENV-1, DENV-2, DENV-3, DENV-4, DENV-4
● Vector:​ Aedes aegypti
● Reservoir: Man, Mosquito
● IP: 5-6 days
● Diagnosis
Tourniquet test (spots = petechiae/sq inch) Serological test

a. >10 spots - Dengue Fever NS1 antigen

b. ​≥​20 spots - Dengue hemorrhagic fever
● Clinical features
Dengue fever (DF) Dengue hemorrhagic fever (DHF) Dengue shock syndrome (DSS)

- Breakbone fever - Fever - DHF + shock

- Haemorrhage
- Thrombocytopenia
- Hemoconcentration
● Global strategy for dengue prevention and control 2012-2020 (WHO)
1. Reduction of dengue mortality by 50% by 2020.
2. Reduction of dengue morbidity by 25% by 2020.
3. Estimation of true burden of disease by 2015.
● Dengue Vaccine = ​Dengvaxia
a. type: Live recombinant tetravalent
b. strain: CYD-TDV
c. age group: 9-45 yr living in Endemic areas
d. schedule: 3 injection in 1 yr (0, 6 & 12 months)
e. production: replacing the PrM (pre-membrane) and E (envelope) structural gene
of the Yellow fever virus [17D strain] with all 4 Dengue serotypes.
Yellow fever
● Causative agent:​ yellow fever virus ​‘Group B Arbovirus (Flavivirus)’
● Vector:​ Aedes aegypti
● Reservoir of infection
a. Forest cycle: monkeys & mosquitoes
b. Urban cycle: Man & mosquitoes
● IP: 2-6 days [Quarantine period - 6 days]
● CFR: 80%
● Vaccine = ​Yellow fever vaccine
a. live attenuated
b. strain: 17 Dakar
c. diluent: saline water
d. cold chain temp: -30°C to +5°C
e. immunity provided: 7 days to 35 yrs
f. validity for International travel (WHO): 10 days to life long
● Indices of surveillance of Aedes mosquito
1. Container index = ​Container showing breeding of Aedes Larva (​C+​​ )
Total containers surveyed (​C)​
2. House index = ​Houses showing breeding of Aedes Larva (​H+​​ )
Total house surveyed (​H​)
3. Breteau index = ​Container showing breeding of Aedes Larva (​C+​​ )
Total house surveyed (​H​)
● YF control measures
- Area around airports free of Aedes breeding - 400m
- Breteau index in town & seaports < 1%

Japanese Encephalitis
● Causative organism: ​‘Group B Arbovirus (Flavivirus)’
● Vector: ​Culex tritaeniorhynchus
● Host factors:
a. Amplifiers host - pigs
b. Mosquito attractant host - cattles & horses
c. Actual host - ​Ardeidae birds
d. Accidental dead-end host - human
● IP: 5-6 days
● CFR: 30%
● Epidemiology: 85% cases occur in children <15 yr
● Vaccine = JE vaccine
1. Type - live attenuated
2. Source - cell culture derived
3. Strain - SA 14-14-2
4. NIS schedule: → 1st does - 9th month
→ 2nd dose - 16-24 month
Kyasanur Forest Disease (KFD)
● aka Money disease
● Causative organism: Togavirus ​‘Group B Arbovirus (Flavivirus)’
● Vector: ​Haemaphysalis spinigera
● Reservoir: rats & squirrels
● Host factors
a. Amplifier host - Pigs
b. Accidental dead-end host - human
● IP: 3-6 days
● Vaccine: killed KFD vaccine

Leishmaniasis
Type Causative agent Vector (sandfly)

Visceral (Kala-azar) Leishmania donovani Phlebotomus argentipes

Cutaneous (oriental sore) Leishmania tropica Phlebotomus papatasi

Phlebotomus sergenti

Mucocutaneous Leishmania braziliensis

● IP: 10 days - 2 year [avg. = 1-4 month]
● Serology: rk39 Ag dipstick test & ELISA
● Immunity status test
a. Leishmanin (Montenegro) test
b. reading taken > 48-72 hr
● Vector control: DDT spray
● DOC - liposomal Amphotericin B

Sexually transmitted diseases

Classical STD Causative agent IP

Syphilis Treponema pallidum 9-90 days

Gonorrhea Neisseria gonorrhoea 3-12 days

Chancroid Haemophilus ducreyi 3-21 days

Lymphogranuloma Chlamydia trachomatis 3-5 days

venereum (LGV)

Donovanosis Klebsiella granulomatis 1-5 days

Treponematosis
 Disease Causative MOT Drug of Status Vertical transmission
agent choice

Syphilis Treponema Sexual Benzathine Not eliminated During 3rd trimester

pallidum penicillin G

Yaws Treponema direct contact Benzathine Eliminated

pallidum penicillin G
pertenue

Pinta Treponema direct contact Benzathine Not eliminated

carateum penicillin G

HIV/AIDS
● Causative agent: ​Human immunodeficiency virus (HIV)/ Human T-lymphotropic virus III
(HTLV-III)/ Lymphadenopathy virus (LAD).
● Period of communicability: Life long
● IP: few weeks to 10 yrs
● Specimen & Diagnosis - Blood → ELISA & Western blot
● Vertical transmission - during delivery
● MOT
- Sexual - {most common but least dangerous}
- Blood - {least common but most dangerous}
- Needles/ Syringe
- Vertical transmission
● Nobel prize winners - ​Robert gallo, Luc Montagnier, Françoise Barré-Sinoussi
● HIV situation in India
a. Prevalence - 0.26%
b. MC age group affected: 30-44 years
c. Mother to child transmission rate: 30%
d. Breastfeeding transmission rate: 12-16%
e. 1st case - Chennai
f. Highset case - Tamil nadu
g. Fastest ↑ prevalence - Andhra pradesh
h. ↑ prevalence among inj. drug users - Manipur
i. Moderate prevalence - Gujarat, Goa, Pondicherry
j. Categorization of districts
State District Prevalence

High prevalence A
 [Group I]
HRG ANC

> 5% >1% in last 3 years

Moderate prevalence B
[Group II]
HRG ANC

> 5% <1% in last 3 years

Low prevalence C
[Group III]
HRG ANC

< 5% with known <1% in last 3 years

hotspots

Low prevalence D
[Group III]
HRG ANC

< 5% / poor data with <1% in last 3 years

no known hot spots

1. ANC (Antenatal clinic) - PTCT (parent to child transmission)

2. HRG (high risk group)
- Commercial sex workers
- Men Who Have Sex with Men
- Intravenous drug users
- STD clinic attendees
3. Hotspots → migrants, truckers, factory workers, tourists
● MC opportunistic infection in AIDS
- World → Pneumocystis jiroveci pneumonia (PJP)
- India → Tuberculosis

Emerging & Re-Emerging diseases

Crimean Congo Fever (CCF)

 ● Causative agent: Nairovirus (Bunyavirus)
● Vector: Hyalomma ticks
● IP: 1-13 days
● CFR: 30%
● Drug of choice - Ribavirin

Severe acute respiratory syndrome (SARS)/ Middle East respiratory syndrome (MERS)
● Causative agent: Coronavirus

Zika Nipah Ebola

Causative agent: Zika virus Cause: ​Henipavirus Cause: Ebola virus

ROT: ROT: bat eaten ROT: contaminated body
a. Aedes sp. fruits fluids
b. Mother to child IP: 14-16 days IP: 2-21 days
(delivery not BF)
c. Blood transfusion
d. Sexual contact
Diagnosis: RT-PCR