DEPARTMENT OF PREVENTIVE AND SOCIAL MEDICINE

DEFENCE SERVICES MEDICAL ACADEMY

LECTURE NOTES

VOLUME – I
 CONTENTS

Page No.
1. Concept of Health 1

2. Concept of Wellbeing 3

3. Concept of Causation 4

4. Determinants of Health 7

5. Indicators of Health 11

6. Natural History of Disease 14

7. Levels of Prevention 17

8. History & Evolution of Preventive and Social Medicine 21

9. Definitions in Preventive and Social Medicine 23

10. Social Medicine 26

11. Environmental Health 28

12. Water Sanitation 29

13. Food Sanitation 33

14. Excreta Disposal 40

15. Refuse Disposal 46

16. Camp Hygiene 49

17. Air Pollution 51

18. Pest Control 53

19. Insecticides 61

20. Disinfection and Disinfectant 66

21. Management of fairs and festivals 70

22. Occupational Health 73

 THE CONCEPT OF HEALTH
Health is not perceived the same way by all members of the community including
various professional groups. (E.g., biomedical scientists, health administrators, ecologists.
etc).

Concepts of health are ever changing. Health has evolved over the centuries as a
concept from an individual concern to a world wide social goal and encompassed the whole
quality of life.

1. Biomedical concept

If one was free from disease then the person was considered health. The medical
profession views the human body as a mechanism, disease as a consequence of the break
down of the machine and one of the doctor’s task as repair of the machine.

2. Ecological concept

Ecologist viewed health as a dynamic equilibrium between man and his environment
and a disease as a maladjustment of the human to environment. Human adaptation and
adjustment to environment determine not only the occurrence of disease but also the
availability of food and the population explosion. Improvement in human adaptation to
natural environment can lead to longer life expectation and a better quality of life even in the
absence of modern health delivery services.

3. Psychosocial concept

Health is not only a biomedical phenomenon but one which is influenced by social
psychological cultural economic and political factors of the people concerned. These factors
must be taken into consideration in defining and measuring.

4. Holistic concept

It is a synthesis of all above concepts. It recognizes the strength of social economic

political and environmental influence on health. It corresponds to the view held by the
ancients that health implies a sound mind in a sound body in a sound family in sound
environment. The holistic approach implies that all sectors of society have an effect on
health in particular agriculture animal husbandry food industry education housing public
works and other sectors.

WHO DEFINITION OF HEALTH

Health is a state of complete physical, mental and social well-being and not merely
an absence of disease or infirmity. (1948)

New philosophy of health

 Health is a fundamental human right.

 Health is the essence of productive life, and not the result of ever increasing
expenditure on medical care.
 Health is an integral part of development.

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  Health is an intersectoral
 Health is central to the concept of quality of life.
 Health involves individual, state and international responsibility.
 Health and its maintenance is major social investment
 Health is world wide social goal.

DIMENSIONS OF HEALTH

1. Physical dimension

It conceptualizes health biologically as a state on which every cell and every organ is
functioning perfectly and is all within the range of normality for the individual’s age and
sex. Normality has fairly wide limits. Those limits are set by observation of a large number
of normal people who are evident of free from disease. E.g. BP, Heart rate, body temperature
Hb% etc.
Physical health can be measured by using biomedical methods.

2. Mental dimension

Mental health is not merely absence of mental illness more recently it has been
defined as “a state of balance between the individual and the surrounding world a state of
harmony between oneself and others a coexistence between the realities of the self and that
of other people and that of the environment.
Mind and body were not independent entities psychological factors can induce all
kinds of illness not simply mental ones.
Psychologists have mentioned the following characteristics as attributes of a mentally
healthy person:
• a mentally healthy person is free from internal conflicts he is not at war with himself.
• he is well adjusted i.e. he is able to get along well with others. He accepts criticism
and is not easily upset.
• he search for identity.
• he has a strong sense of self esteem.
• he knows himself: his needs, problems, and goals (self actualization)
• he has good self control
• he faces problems and tries to solve them intelligently i.e. coping with stress and
anxiety.

3. Social Dimension

In general social health takes into account that every individual is part of a family
and of wider community and focus on social and economic conditions and well being of the
whole person in the context of his social network.
Social health is rooted in positive material environment and positive human
environment, which is concerned with the social network of the individual.
Social health has been defined as the quantity and quality of an individual’s
interpersonal ties and the extent of involvement with the community.

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4. Spiritual Dimension

Spiritual health refers to that part of the individual, which reaches out and strives for
meaning and purpose in life. It is the intangible something that transcends physiology and
psychology.
It includes integrity principles and ethics the purpose in life commitment to some
higher being and belief in concepts that are not subject to state of art explanation.

5. Emotional Dimension

Mental health can be seen as knowing or cognition while emotional health relates to
feeling.

6. Vocational Dimension

When work is fully adapted to human goals capacities and limitations work often
plays a role in promoting both physical and mental health.
Physical work is usually associated with an improvement in physical capacity while
goal achievement and self-realization in work are a source of satisfaction and enhanced self-
esteem.

Positive Health

A person who enjoys all physical, mental and social health is said to be in a state of
positive health.
The state of positive health implies the notion of ‘perfect functioning’ of body and
mind perfect biologically, psychologically and socially.
Health is a relative concept. There is no proper yardstick to measure the standard of
health. Health standards vary among culture social classes, and age group. Each country will
decide on its own norms for a given set of prevailing conditions.

CONCEPT OF WELLBEING
Well-being of an individual or group of individual -- objective component and
subjective component.

Objective component-- standard of living or level of living

Subjective component-- quality of life

1) Standard of Living
Income and occupation, standard of housing, sanitation and nutrition, the level of
provision of health, educational, recreational and services may all be used individually
as measure of socioeconomic status and collectively as an index of standard of living.
Per capita GNP is a good indicator of standard of living (WHO).
2) Level of Living
It consists of nine components; health , food consumption, housing, education,
occupation and working conditions social security, clothing, recreation and leisure
and human right.

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3) Quality of Life
It is the subjective component of welling. Quality of life was defined by WHO as " the
conditions of life resulting from the combination of the effects of the complete range of
factors such as those determining health, happiness (including comfort on physical
environment and a satisfying occupation) , education, social and intellectual attainment,
freedom of action , justice and oppression."
It is a composite measure of physical, mental and social wellbeing as perceived by each
individual or group of individuals.
Quality of life can be evaluated by assessing a person's subjective feeling of happiness or
unhappiness about the various life concerns. Quality of life as perceived by each individual
varies.
Physical quality of life index (PQLI) is used as an approximate measurement of quality of
life. It consists of three indicators ; infant mortality, life expectancy at age one and literacy.
Each component has scale of 0-- 100
0--absolutely defined worst
100--absolutely defined best
PQLI has not taken per capita GNP into consideration showing thereby that " money is not
everything". It does not measure economic growth.. It measures the results of social,
economic and political policies. It is intended to complement not replace GPR. Oil rich
countries of middle east with high per capita incomes are not very high in PQLI. It suggested
that PQLI is influenced by many dimensions ; spiritual , emotional, vocational etc.

CONCEPT OF CAUSATION
Changing concepts of causation
1) Supernatural theory of disease
2) The theory of humors
3) Theory of contagion
4) Miasmatic theory of disease
5) Theory of spontaneous generation
6) Germ theory of disease
7) Epidemiological triad
8) Multi factorial causation
9) Web of causation

Germ theory of disease

• This theory said that microbes are sole cause of disease.

• The concept of cause embodies in the germ theory of disease is generally referred to
as a one- to- one relationship between causal agent and disease.

Disease agent Man Disease

• Germ theory led one- sided view of disease causation and it is now recognized that a
disease is rarely caused by a single agent alone, but rather depends upon a number of
factors which contribute to its occurrence.

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Epidemiological triad
• Germ theory of disease has many limitations. Not everyone exposed to tuberculosis
develops tuberculosis. Only an undernourished or otherwise susceptible person may
result in clinical disease. Similarly not every one exposed to β-haemolytic
streptococci develop acute rheumatic fever.
• So, in addition to agent, there are other factors relating to the host and environment
which are equally important to determine whether or not disease will occur in the
exposed host.
• This demanded a broader concept of disease causation that synthesized the basic
factors of agent, host and environment

Environment

Agent Host

• This model helps may epidemiologists to focus on different classes of factors,

especially with regard to infectious diseases

Multi factorial causation

• Both germ theory and epidemiological triad of causation can not explain the modern
diseases of civilization such as lung cancer, coronary heart disease, chronic
bronchitis, mental illnesses etc.
• So the realization began to dawn that the single cause idea was an oversimplification
and that there are other factors in the aetiology of disease such as social, economic,
cultural genetic and psychological which are equally important
• The doctrine of one-to-one relationship between cause and disease has been shown to
be untenable, even for microbial diseases. For example, tuberculosis is not merely
due to tubercle bacilli; factors such as poverty, overcrowding and malnutrition
contribute to its occurrence.
• It is now known that diseases such as coronary heart diseases and cancer are due to
multiple factors; excess of food intake, smoking, lack of physical exercise and
obesity are all involved in the pathogenesis of coronary heart disease.
• Epidemiology has contributed significantly to our present day understanding of
multifactorial causation of disease. Medical men are looking beyond the germ theory
of disease into the total life situation of the patient and the community in search of
multiple or risk factors of the disease.
• This multifactorial concept offers multiple approaches for the prevention and control
of disease.

Web of causation
• This model is ideally suited in the study of chronic disease, where the disease agent
is often not known, but is the outcome of interaction of multiple factors

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 • It considers all the predisposing factors of any type and their complex
interrelationship with each other.
• The web of causation does not imply that the disease cannot be controlled unless all
the multiple causes or chain of causation or at least a number of them are
appropriately controlled or removed. This is not the case. Sometime removal or
elimination of just only one link or chain may be sufficient to control disease
provided that link is sufficiently important in the pathogenetic process. The relative
importance of these factors may be expressed in terms of relative risk

Web of causation for myocardial infarction

Changes in life style Stress

Abundance of food Lack of physical Smoking Emotional

exercise disturbances

Aging and
other
factors

Obesity Hypertension

Hyperlipidaemia Increased catecholamines

Thrombotic tendency

Changes in walls of arteries

Coronary atherosclerosis

Coronary occlusion

Myocardial ischemia

Myocardial infarction

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 DETERMINANTS OF HEALTH
(FACTORS INFLUENCING HEALTH)
Health is multifactorial. The factors that influence health lie both within the
individual and externally in the society in which he or she lives. It is a truism to say that
what man is and to what disease he may fall victim depends on a combination of two sets of
factors-his genetic factors and the environmental factors to which he is exposed. These
factors interact and these interactions may be health promoting or deleterious. Thus,
conceptually, the health of individuals and whole communities may be considered to be the
result of many interactions. Only a brief indication of the more important determinants or
variables can be given here; they are:
1. Heredity (Human Biology)
2. Environment
3. Life-style
4. Socio-economic conditions
5. Health services
6. Other factors

1. Heredity
The physical and mental traits of every human being are to some extent determined
by the nature of his genes at the moment of conception. The genetic make-up is unique in
that it cannot be altered after conception. A number of diseases are now known to be of
genetic origin, e.g., chromosomal anomalies, errors of metabolism, mental retardation, some
types of diabetes, etc. The state of health therefore depends partly on the genetic constitution
of man.
Thus, from the genetic stand-point, health may be defined as that “state of the
individual which is based upon the absence from the genetic constitution of such genes as
correspond to characters that take the form of serious defect and derangement and to the
absence of any aberration in respect of the total amount of chromosome material in the
karyotype or state in positive terms, from the presence in the genetic constitution of the
genes that correspond to the normal, characterization and to the presence of a normal
karyotype.”
The “positive health” advocated by WHO implies that a person should be able to
express as completely as possible the potentialities of his genetic heritage. This is possible
only when the person is allowed to live in healthy relationship with his environment-an
environment that transforms genetic potentialities into phenotypic realities.

2. Environment
It was Hippocrates who first related disease to environment, e.g., climate, water, air,
etc. Centuries later, Pettenkofer in Germany revived the concept of disease environment
association.
Environment is classified as “internal” and “external”. The internal environment of
man pertains to “each and every component part of every tissue, organ and organ system and
their harmonious functioning within the system”. Internal environment is the domain of
internal medicine. The external or macro-environment consists of those things to which man

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is external to the individual human host”. It can be divided into physical, biological and
psychosocial components, any or all of which can affect the health of man and his
susceptibility to illness. Some epidemiologists have used the term “microenvironment” (or
domestic environment) to personal environment which includes the individual’s way of
living and lifestyle, e.g., eating habits, other personal habits (e.g., smoking or drinking), use
of drugs etc. It is also customary to speak about occupational environment, socioeconomic
environment and moral environment.
It is an established fact that environment has a direct impact on the physical, mental
and social well-being of those living in it. The environmental factors range from housing,
water supply, psychosocial stress and family structure through social and economic support
systems, to the organization of health and social welfare services in the community.
The environmental components (physical, biological and psychological) are not
watertight compartments. They are so inextricably linked with one another that it is realistic
and fruitful to view the human environment in ‘toto’ when we consider the influence of
environment on the health status of the population. If the environment is favorable to the
individual, he can environmental health is one of the major issues in the world today.

3. Lifestyle
The “term” lifestyle “is rather a diffuse concept often used to denote” the way people
live”, reflecting a whole range of social values, attitudes and activities. It is composed of
cultural and behavioural patterns and life-long personal, habits (e.g., smoking, alcoholism)
that have developed through processes of socialization. Lifestyles are learnt through social
interaction with parents, peer groups, friends and siblings and through school and mass
media.
Health requires the promotion of healthy lifestyles. In the last 20 years, a
considerable body of evidence has accumulated which indicates that there is an association
between health and lifestyle of individuals. Many current-day health problems especially in
the developed countries (e.g. coronary heart disease, obesity, lung cancer, drug addiction)
are associated with lifestyle changes. In developing countries such as India where traditional
lifestyles still persist, risks of illness and death are connected with lack of sanitation, poor
nutrition, personal hygiene, elementary human habits, customs and cultural patterns.
It may be noted that not all lifestyle factors are harmful. There are many that can
actually promote health. Examples include adequate nutrition, enough sleep, sufficient
physical activity, etc. In short, the achievement of optimum health demands adoption of
healthy lifestyles. Health is both a consequence of an individual’s lifestyle and a factor in
determining it.

4. Socio-economic Conditions
Socioeconomic conditions have long been to influence human health. For the
majority of the world’s people, primarily their level of socioeconomic development
determines health status, e.g., per capital GNP, education, nutrition, employment, housing,
the political system of the country, etc. Those of major importance are:

(I) Economic status: The per capita GNP is the most widely accepted measure
of general economic performance. They can be no doubt that in many
developing countries, it is the economic progress that has been the major
factor in reducing morbidity, increasing life expectancy and improving the
quality of life. The economic status determines the purchasing power,

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 standard of living, quality of life, family size and the pattern of disease and
deviant behaviour in the community. It is also an important factor in seeking
health care. Ironically, affluence may also be a contributory cause of illness as
exemplified by the high rates of coronary heart disease, diabetes and obesity
in the upper socioeconomic groups.
(II) Education: A second major factor influencing health status is educating
(especially female education). The world map of illiteracy closely coincides
with the maps of poverty, malnutrition, ill health, high infant and child
mortality rates. Studies indicate that education to some extent compensates
the effects of poverty on health irrespective of the availability of health
facilities.
The small state of Kerala in India is a striking example. Kerala has an
estimated infant mortality rate of 29 compared to 104 all India in 1984. A
major factor in the low infant mortality of Kerala is its highest female literacy
rate of 65.7 per cent compared to 24.8 per cent for all-India.
(III) Occupation: The very state of being employed in productive work promotes
health because the unemployment usually shows a higher incidence of ill
health and death. For many, loss of work many mean loss of income, and
status. It can cause psychological and social damage.
(IV) Political system: Health is also related to the country’s political system. Often
the main obstacles to the implementation of health technologies are not
technical, but rather political. Decisions concerning resource allocation,
manpower policy, choice of technology and the degree to which health
services are made available and accessible to different segments of the society
are examples of the manner in which the political system can shape
community health services. The percentage of GNP spent on health is a
quantitative indicator of political commitment. Available information shows
that India spends about 3 per cent of its GNP on health and family welfare.
To achieve the goal of health for all WHO has set the target of at least 5 per
cent expenditure on each country’s GNP on health care. What is needed is
political commitment and leadership, which is oriented towards social
development, and not merely economic development. If poor health patterns
are to be changed, then changes must be made in the entire sociopolitical
system in any given community. Social, economic and political actions are
required to eliminate health hazards in people’s working and living
environments.

5. Health Services
The term health and family welfare services cover a wide spectrum of personal and
community services for treatment of disease, prevention of illness and promotion of health.
The purpose of health services is to improve the health status of population. For example,
immunization of children can influence the incidence / prevalence of particular disease.
Provision of safe water can prevent mortality and morbidity from water-borne disease. The
care of pregnant women and children would contribute to the education of maternal and
child morbidity and mortality. To be effective the health services must reach the social
periphery, equitably distributed, accessible at a cost the country and community can afford
and socially acceptable. All these are ingredients of what is now termed “primary health
care” which is seen as the way to better health.

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 Health services can also be seen as essential for social and economic development. It
is well to remind ourselves that “health care dose not produce good health”. Whereas, there
is a strong correlation between GNP and expectation of life at birth, there is no significant
correlation between medical density and expectation of life at birth (the most we can expect
from an effective service is good care. The epidemiological perspective=emphasizes that
health services, no matter how technically elegant or cost-effective, are ultimately pertinent
only if they improve health.

6. Other Factors
Other contributions to the health of population derive from systems outside the
formal health care system. i.e., health related systems (e.g. food and agriculture education,
industry, social welfare, rural development) as well as adoption of policies in the economic
and social fields that would assist in raising the standards of living. This would include
employment opportunities, increased wages prepaid medical programme and family support
systems.
In short, medicine is not the sole contributor to the health and wellbeing of
population. The potential of intersectoral contributions to the health of communities is
increasingly recognized.

SPECTRUM OF HEALTH

Health and disease lie along a continue and there is no single cut-off point.
Lowest point-death
Highest point-positive health

Positive health
Better health
Freedom from disease

Unrecognized sickness
Mild sickness
Severe sickness
Death

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 INDICATORS OF HEALTH

Indicators are required not only to measure the health status of a community, but also
to compare the health status of one country with that of another: for assessment of health
care needs, for allocation of scarce resources; and for monitoring and evaluation of health
services activities and programme. Indicators help to measure the extent to which the
objectives and targets of a programme are being attained.

CHARACTERISTICS OF INDICATORS

Indicators have been given scientific respectability for example idea indicators:

a. should be valid i.e., they should actually measure what they are supposed to
measure.
b. should be reliable and objective i.e., the answered should be the same if
measure by different people in similar circumstances.
c. should be sensitive
d. should be specific

CLASSIFICATION OF HEALTH INDICATORS

1. Mortality indicators
2. Morbidity indicators
3. Disability rates
4. Nutritional status indicators
5. Health care delivery indicators
6. Utilization rates
7. Indicators of social and mental health
8. Environmental indicators
9. Socio-economic indicators
10. Health policy indicators
11. Indicators of quality of life
12. Other indicators

1. MORTALITY INDICATORS

(a) Crude death rate – This is considered in fair indicator of the comparative health of
the people. It is defined as the number of deaths per 1000 population per year in a
given community. It indicates the rate at which people are dying. But in many
countries, the crude death rate is restricted because it is influenced by the age-sex
composition of the population.

(b) Expectation of life (life expectancy) – Life expectancy is a good indicator of

socioeconomic development in general.

(c) Proportional mortality ratio – Number of deaths at age 50 and over as a percentage
of total deaths. If all persons survive up to 50 yrs of age the index would be 100; if
no one reaches this age, the index would be zero.

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(d) Infant mortality rate: Infant deaths under 1 year of age in a given year to the total
number of live births in the same year, usually expressed as a rate per 1000 live
births. It is one of the most universally accepted indicators of health status not only
of infants.

(e) Child mortality rate: Another indicator related to the overall health status is the
early childhood (1-4 years) mortality rate. 1-4 years in a given year, per 1000
children in that age group at the mid-point of the year concerned.

(f) Under-5 mortality rate: It is the proportion of total deaths occurring in the under 5-
age group. This rate can be used to reflect both infant and child mortality rates. In
communities with poor hygiene the proportion may exceed 60 per cent reflects high
birth rates, high child mortality rates and shorter life expectancy.

(g) Maternal (puerperal) mortality rate: Maternal (puerperal) mortality accounts for
the greatest proportion in most of the developing world.

(h) Disease-specific mortality:

(i) Proportional mortality rate: The simplest measure of estimating the burden of a
disease in the community is proportional mortality rate, i.e., the disease is the cause
of 25 to 30 percent of all deaths in most western countries. The proportional
mortality rate from communicable diseases has been suggested as a useful health
status indicator it indicates the magnitude of preventable mortality.

2. MORBIDITY INDICATORS

Therefore morbidity indicators are used to supplement mortality data to

describe the health status of a population.

The following morbidity rates are used for assessing ill health in the
community.

a. Incidence and prevalence

b. Notification rates
c. Attendance rates at outpatient departments, health centers, etc.
d. Admission, readmission and discharge rates
e. Duration of stay in hospital and
f. Spells of sickness or absence from work or school

3. DISABILITY RATES

Disability rates related to illness and injury have come into use to supplement
mortality and morbidity indicators.

(a) Event-type indicators

(i) Number of days of restricted activity
(ii) Bed disability days
(iii) Work-loss days (or school loss days) within a specified period

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 (b) Person-type indicators

( i) Limitation of mobility: For example confined to bed confined to the

house special aid in getting around either inside or outside the house.
( ii) Limitation of activity: For example limitation to perform the basic
activities of daily living (ADL) e.g. eating, wasting, dressing going to
toilet moving about etc.

4. NUTRITIONAL STATUS INDICATORS

Nutritional status is a positive health indicator. Three nutritional status

indicators are considered important as indicators of health status. They are:
(a) anthropometric measurements of preschool children, e.g. weight and height,
mid arm circumference.
(b) heights (and sometimes weights) of children at school entry and
(c) prevalence of low birth weight (less than 2.5 kg.)

5. HEALTH CARE DELIVERY INDICATORS

The frequently used indicators of health care delivery are:

(a) Doctor-population ratio
(b) Doctor-nurse ratio
(c) Population-bed ratio
(d) Population per health centre/sub-centre
(e) Population per traditional birth attendant. These indicator reflect the equity of
distribution of health resources in different parts of the country, and of the
provision of health care.

6. UTILIZATION RATES

Utilization of services or actual coverage is expressed as the proportion of people in

need of a service who actually receive it in a given period, usually a year. A few example of
utilization rates are cited below.
(a) proportion of infants who are fully immunized against the 6 EPI diseases
(b) proportion of pregnant women who receive antenatal care or have their
deliveries supervised by a trained birth attendant
(c) percentage of the population using the various methods of family planning
(d) bed-occupancy rate (i.e. average daily in patient census/average number of `
beds)
(e) average length of stay (i.e. days of care rendered/discharges)
(f) bed turn-over ratio (i.e. discharges/average beds)

7. INDICATORS OF SOCIAL AND MENTAL HEALTH

These include suicide, homicide, other acts of violence crime, road traffic
accident, juvenile delinquency, alcohol and drug abuse, smoking, consumption of
tranquilizers, obesity etc. To these may be added family violence battered baby
battered wife syndromes neglected and abandoned youth in the neighbourhood.
These social indicators provide a guide to social action for improving the health of
the people.

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8. ENVIRONMENTAL INDICATORS

Environmental indicators reflect the quality of physical and biological

environmental in which disease occurs and in which the people live. They include
indicators relating to pollution of air and water radiation, solid wastes noise exposure
to toxic substances in food or drink. Among these, the most useful indicators are
access to safe water and sanitation useful indicators are access to safe water and
sanitation facilities as for example percentages of households with safe water in the
home or with in 15 minutes walking distance from a water standpoint or protected
well adequate sanitary facilities in the home or immediate vicinity.

9. SOCIOECONOMIC INDICATORS

These indicators do not directly measure health. Nevertheless they are of

great importance in the interpretation of the indicators of health care. These include;

a. rate of population increase

b. per capital GNP
c. level of unemployment
d. dependency ratio
e. literacy rates, especially female literacy rates
f. family size
g. housing; the number of person room
h. per capital ''calorie'' availability.

10. HEALTH POLICY INDICATORS

11. INDICATOR OF QUALITY OF LIFE

Quality of life is difficult to define and even more difficult to measure. It

consolidates three indicators. Viz. infant mortality, life expectancy at age one, literacy.

NATURAL HISTORY OF DISEASE PROCESS

Health is never static. It varies continuously. The health of an individual is dynamic
phenomenon. It fluctuates within a range varying from optimum well being to extreme
illness. The lowest point on the health spectrum is the state of death and the highest point
being optimum health.
Every living thing had to adjust itself to external and internal stress; the degree to
which it succeeds in maintaining the integrity and functioning in the face of these stresses
measure the health and the degree to which it gives in, measures the disease.
Disease does not appear out of the blue without warning but it is a dynamic process,
which results when there is a disturbance in a delicate balance in the interaction between
agent, host and environment.
Disease is not a static entity. It is a process with a dramatic insidious onset of a short
or prolonged course and ending in recovery, disability or death.

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 The development of disease is often an irregularly evolving process, and the point at
which a person should be labeled as "diseased" or "not diseased" may be arbitrary.
Each disease has its own life history but for practical purposes it may be of some
help to understand if the natural history of a disease were pictured as the prepathogenesis,
pathogenesis and late pathogenesis stages. It may be easier to understand the preventive and
control measures instituted.

THE PROCESS OF INFECTION

Infection means the entry, lodgment, multiplication and/or development of an
infectious agent on a host. Epidemiologically, infection as disease is a process that involves
the interaction of the causal triad: agent, host and environment. The process of infection is
governed by an orderly sequence for a new infection in a new host to ensue. The sequence of
these systematic links in the chain of events is:
1. There should be an infectious agent.
2. The greatest majority of infectious agents are not capable of independent or
saprophytic life. They are naturally found and perpetuated from a reservoir of
infection. The reservoir may be human, animal (in zoonoses) or inanimate
(histoplasmosis). Human and animal reservoirs are either in the form of overt
cases or carriers of infectious disease.

The main portals of entry are: -

a. Digestive through ingestion
b. Respiratory through inhalation
c. Cutaneous or surface mucous membrane infections through implantation of agents.
d. Percutaneous through inoculation of disease agents through bites of animals or
arthropods, or with contaminated syringes and surgical instrument.

The mere entry of organisms into a new host does not mean infection. Many of
disease agents that enter the host are overcome by defensive and resistive mechanisms of the
host. Accordingly they do not lodge, develop and/or multiply. For infection to develop the
host should be susceptible.
We could not apply preventive action successfully for any infectious diseases unless
we understand each and every link in its strength and weakness. The strategy of
epidemiology is to attack and put barriers against the flow of this chain particularly at its
weakest link.

PRE PATHOGENESIS STAGE

This is period preliminary to the onset of disease in man. The disease process had not
developed but there are actors, the presence of which favors disease occurrence, e.g., high
serum cholesterol levels increase the likelihood that covert coronary heart disease will
develop or inadequate maternal nurturing predisposes to emotional illness.

15
 The disease process is initiated in man when the agent, host and environment factors
interact with each other. Under optimum conditions, the interaction between them results in
the occurrence of either isolated cases or epidemics.

PATHOGENESIS STAGE
a). Early Pathogenesis: Here the disease has entered into the human host but clinical
signs and symptoms are not demonstrable as yet. During this stage, the patient remains
apparently healthy but pathogenic changes are taking place due to the presence of the disease
agent, e.g., arthrosclerotic changes in the coronaries before overt clinical signs and
symptoms.
b). Late Pathogenesis: Here sufficient anatomic or functional changes had occurred
resulting in clear-cut recognizable clinical signs and symptoms. The end result of the disease
process may be complete recovery, disability or death.

PHASES OF THE PATHOGENESIS PERIOD

The pathogenesis period has four phases that go in the following sequence:
1. Exposure, i.e., circumstances that lead to the successful entry of disease agents.
Exposure could be single in case of individual causes and could be common in an outbreak
of an epidemic.
2. Incubation period of infectious disease or latent period of one-infectious diseases:
This period is defined as the interval of time that lapses between exposure of entry of disease
agents until the onset of disease signs and symptoms. This period is one fixed characteristic
for each disease within normal variation. We have to know the average and normal range for
each disease. In some diseases it is short as in chemical poisoning and in other diseases it is
very long and could be months or years as in serum hepatitis, TB, Leprosy and
arthrosclerosis and lung cancer. During the incubation period or latent period, the disease
agents multiply and/or develop in infectious disease or increase their increment in non-
infectious diseases. They start to interact with the tissues of the host resulting in pathological
and immunological reaction. At the end of this period if the resistive forces of the host
outweigh those of the agent, no clinical disease ensues and the host would be unaware of any
pathological or clinical reaction, e.g., in infectious diseases this would constitute unapparent
or sub clinical infection. Incase the aggressive forces of the agent outweigh the host
defensive mechanism, the third phase of pathogenesis develop.
3. Period of illness: This period starts with the onset of disease, i.e., the first
appearance of characteristics signs and symptoms and ends with the complete disappearance
of such specific symptoms. Like the incubation or latent period, this period has its
characteristics for each disease and has its normal variation. In some acute diseases this
period is short, i.e., in matter of hours or few days and other chronic diseases may extend for
many years.
In each and every disease whether infectious or non-infectious, the severity of illness
varies from the very mild to abortive to the very severe of fulminating. This is what we call
the clinical spectrum of disease severity, the textbook description of clinical expression
usually pertaining to the average of moderately severe cases. Unless we realize this concept
of biologic variation, the diagnostician may fail to diagnose mild cases and fulminating

16
cases. The latter may die quickly and so early before a diagnosis is arrived at, which may be
dangerous in infectious disease, e.g., smallpox and pneumonic plague.
It should be emphasized that in infectious diseases the agents start to gain a portal of
exit and become communicable late in the incubation period which continues through all or
part or period of illness.
4. Period of convalescence: This period starts with end of specific signs and
symptoms of the disease in question and ends by the resumption of the normal state of
health. The patient would be still weak and exhausted from his illness.
In some infectious disease, e.g., typhoid fever, poliomyelitis, infectious hepatitis,
diphtheria and streptococcosis, disease agents continue to gain exit during the period of
convalescence. In some diseases noted for the chronic carrier state, excretion of agents
continues even in the post-convalescence period, e.g., typhoid and diphtheria.

LEVELS OF PREVENTION
By prevention it means the inhibition of the development of a disease before it
occurs, including measures, which interrupt or slow the progress of disease. The three level
of prevention are primary, secondary and tertiary preventions.

PRIMORDIAL PREVENTION
The concept of primordial prevention is now being applied to the prevention of
chronic diseases such as coronary heart disease, hypertension and cancer, based on
elimination or modification of "risk factors”. The WHO has recommended the following
approaches for the primary prevention of chronic diseases where the risk factors are
established:

(a) Primordial prevention

(b) Population (Mass) strategy
(c) High risk strategy

Primordial prevention, a new concept, is receiving special attention in the prevention

of chronic diseases. This is primary prevention in its purest sense, that is, prevention of
emergence or development of risk factors in countries or populations in which they have not
yet appeared. For example, many adult health problems (e.g., obesity, hypertension) have
their origins in early childhood, because this is the time when lifestyles are formed (e.g.,
smoking, eating patterns, physical exercise). In primordial prevention, efforts are directed
towards discouraging children from adopting harmful lifestyles. The main intervention in
primordial prevention is through individual and mass education

17
PRIMARY PREVENTION
It is defined as ‘actions, which remove the possibility that a disease will occur', i.e., it
includes prevention of disease by altering susceptibility or by reducing exposure for
susceptible persons.
The three approaches to primary prevention are:
1. Removal of the noxious (infectious) agent
2. Preventing the contact between the agent and the host and
3. Strengthening the human host to increase his resistance to the noxious agent.
To whom should primary prevention be directed?
-> Towards the healthy components of the community.

When in the natural history period?

-> During the prepathogenesis period.

MEASURES OF PRIMARY PREVENTION

(A) Health promotion
It is not directed at any particular disease, but is intended to improve general
health and well being of individual and the community. The aim is to improve the general
status of health from healthier to healthiest.
The measures taken being: -
 Environment – safe water
 Sanitation in its totality for the total environment – safe water supplies, facilities for
the safe disposal of excreta and other wastes, healthful housing, control of insects and
rodents, provision of safe working conditions, provision of recreational facilities etc.
 Good standard nutrition adjusted to the developmental phases and needs.
 Sex education and pre-marital examination and genetic counseling.
 Personality development.
 Adequate medical care and health care facilities, qualitative and quantitative.
 Recreational facilities and services.
 Improving the standard of living in all its physical and economic aspects.
 Selective periodic medical examination for improvement of health and not for
disease.

(B) Specific measures

To all healthy individuals against a specific disease problem with the protective
objective of preventing its occurrence taken early in the natural history of the disease in
question as follows: -
1. Specific health education concerning the disease
2. Specific environmental health measures, e.g., potable water supply, sewage
disposal; fly control and prevention of breeding; food establishments as specific

18
 measures against gastro-intestinal diseases. Mosquito control and breeding are
measures against mosquito-borne diseases; destruction of non-economical animal
reservoirs, e.g., stray dogs in rabies and rats in plague. Sanitary housing of home
and work are specific measures against respiratory contact and occupational
disease.
3. Active immunization against infectious diseases
4. In some disease, chemoprophylaxis or antibiotic prophylaxis is given to
populations at risk. E.g., travelers to malarious areas and those with history of
rheumatic fever and against Venereal Diseases.
5. Specific health legislation and sanitary measures against introduction of specific
diseases into communities or nations free from it, e.g., International Health
Regulations against Internationally quarantinable diseases.
6. Accident protective measures, e.g., shielding of machines for occupational
accidents, safety measures in motor vehicles and road accidents (belts, helmets).
7. Food supplements against nutritional diseases: school programmes, milk and
vitamins and iron distribution to pregnant mothers, infants and children.
8. Radiation control as a carcinogen and mutagen against cancer and genetic diseases.
9. Genetic counseling before marriage for hereditary diseases and limitation of
consanguineous marriages in recessive disease, and blood grouping and Rh
typing before transfusions measures against genetic disease.

SECONDARY PREVENTION

It may be defined as " actions, which halts the progress of a disease at its incipient
stage and prevents complications". To whom? It is directed to finding the sick component of
the community. When in the natural history? During the early pathogenesis stage.
Nature of measures:
1. Early accurate diagnosis
2. Prompt and adequate treatment
3. Institution of measures to limit spread of infectious diseases

Types of measures
1. Early case finding and legislation concerning restrictive measures in notifiable
diseases, i.e., infectious diseases, occupational diseases and any other non-infectious
diseases that the health authorities require its notification or registration.
2. Provision of facilities required for accurate diagnosis, prompt adequate treatment
and administration of measures limiting spread of infectious diseases. These are:
(a) Adequate (quantitative and qualitative) and easily accessible hospital, clinic and
outpatient facilities of general or special nature.
(b) Adequate (quantitative and qualitative) and easily accessible laboratory,
radiological and other diagnostic facilities of general or special nature.

19
 (c) Continuous and adequate supply of all modern specific drugs and other
therapeutic, surgical and radiological facilities.
(d) Adequate (quantitative and qualitative), efficient and easily accessible facilities
required for the control, investigation and surveillance of community infections.
This requires efficient epidemiological machinery for:
(1) Early reporting of suspected cases to the local and higher health
authorities.
(2) Isolation of cases, their early diagnosis, specific treatment and
concurrent disinfections.
(3) Quarantine or surveillance of contacts, their immunization and
administration of chemoprophylaxis if applicable and their
investigations.
(4) Terminal disinfection, disinfection or cleaning of the immediate
environment of cases and contacts.
(5) Epidemiological investigation of cases, contacts and their
environment as the source of infection and mode of spread.
(6) Specific health education to cases and contacts.
(7) Efficiency in early diagnosis of epidemic situations at any time, their
proper investigation and institution of epidemic measures.
(8) Continuous and efficient epidemiological surveillance of a
community infection.
(9) Co-operation and co-ordination between health and veterinary
authorities in the field of zoonoses.

TERTIARY PREVENTION
To whom? Directed to the sick component of the community. When in the natural
history? During the late pathogenesis.
Nature of measures: as in secondary prevention
Types of measures: as in secondary prevention, plus:
1. Provision of special facilities for disabled or crippled conditions, e.g.,
physiotherapy, corrective appliances (artificial limb), visual or hearing aids, special
education, work education.
2. Rehabilitation: Physical, mental, psychological and social. The aim is to bring the
crippled individual back to his family and society as productive and independent member.

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 HISTORY AND EVOLUTION OF PREVENTIVE AND
SOCIAL MEDICINE

Preventive and social medicine has evolved through several stage developments and
was originated from the concept of Hygiene.

HYGIENE (1000 BC to 18th Century AD)

• Derived from Hygiea, the Greek Goddness of Health, daughter of Aesculapius
• Literally means rules for healthy living through cleanliness of person, environment,
food and water
• Originally concerned with the individual or his family and later expanded to cover
groups of people

PUBLIC HEALTH (FROM 19th CENTURY)

• Extension of the concept of Hygiene where organized efforts are made to protect the
health of the public (Community)
• Some more prefer the term community health to public health
• Birth of Public Health in England around 1840 was attributable to
• Industrial revolution
• Mass population movement to towns
• Slums
• Low standard of living
• Increased morbidity and mortality
• Cholera outbreaks
• Some advances of public health in England
• Johnna Peter Frank (1745 - 1821), a philosopher conceived PH as good
health law and that the State is responsible for the health of its people
• Edwin Chadwick (1800 - 1890), a lawyer focused attention on sanitary
reforms through his report "The sanitary conditions of the laboring
population" 1842. This lead to anti- filth crusades resulting in the great
sanitary awakening of the people and hence the legislation of the Public
Health Act of 1848 in England
• John Snow, a physician, in 1845 did epidemiological investigation on cholera
in London, pinpointed the water pump in Broad Street as the source of
infection
• William Budd in 1856 made similar investigations on typhoid
• Both investigations clinched the role of water in the transmission of cholera
and typhoid
• Sir John Simons (1816 - 1904) a noble man was the first medical officer of
health of London initiated and undertook man sanitary reforms in England
• Public Health (PH) in America
• The development of PH followed closely the English Pattern
• Shattuck (1793 - 1859) a book seller published his report on the conditions of
health in Massachusetts lead to sanitary reforms
• Other European and Scandinavian counties
• Followed suit and developed their PH systems
• By the end of 20th century, most countries in Europe has laid down broad
foundations of PH in their countries

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• Asia and Africa- The development of PH was slow while rapid strides were made in
the western world
• The establishment of WHO in 1948, providing the Health Charter for all people was
a great contribution to the public health movement in the developing countries
• During the course of its development, several conceptual changes took place within
the frame work of PH
• PH was originally concerned only with environmental sanitation and sanitary
legislation
• By the beginning of the 20th century, the concept that "the state has the
responsibility for the health of its people" emerged
• New emerging non- communicable diseases became integral components of
PH
• The concept of "Greatest Health for the greatest number of people" came into
being
• "Comprehensive Health Care" consisting of Preventive, Promotive, Curative
and Rehabilitative Health Care reflect the expanding scope of PH. Hence
some authorities suggested that community health was a more appropriate
term.

PREVENTIVE MEDICINE (FROM THE MID 19th CENTURY)

Some health philosophers viewed PH from the perspective of prevention at 3 levels
during the course of the natural history of diseases: primary secondary and tertiary
preventions. The science of prevention really dates back to the 18th century.
• James Lind (1753): fresh fruit for prevention of Scurvy
• Edward Jenner (1796): Small Pox vaccination
• Lewis Pasteur (1885): Anti- rabies sera
• Cholera vaccine (1892), diphtheria anti- toxin (1894), anti- typhoid vaccine (1898),
anti septic and disinfectants (1872 - 1912) after Germ theory of disease
• Tissue culture of virus lead to the development of the anti- viral vaccines:
• Polio vaccine (155 - 1960)
• The eradication of small pox (Last case in Somalia (1977)
• The search for new vaccines continues (against malaria, leprosy, HCV, HIV, SARS
etc.)
• Elucidation of the mode of transmission by
• Ross (1898): Malaria by the female Anopheles mosquitoes
• Walter Reed (1900): Yellow Fever by the Aedes mosquitoes
• The knowledge derived from bacteriology made possible to control diseases by
specific measures e.g. Quarantine, water purification, pasteurization, protection of
food, proper disposal of sewage, destruction of insects and disinfection. Later new
discoveries in the field of nutrition, synthetic organic insecticides, prophylactic and
therapeutic drugs, social hygiene, electronics etc. further enriched the knowledge
base of preventive medicine
• Originally, the focus of attention of preventive medicine was on the individual, later
it was expanded to cover groups of individuals. Preventive Medicine has become a
growing point in medicine. It has branched into newer areas such as
• Screening for the disease
• Population control
• Genetic counseling &
• Prevention of chronic disease

22
• Community prevention and primordial prevention are relatively new concepts. The
emergence of preventive pediatrics, preventive geriatrics and preventive cardiology
are new dimensions of prevention

SOCIAL MEDICINE (FROM EARLY 20th CENTURY)

Jules Guerin, French (1848), first introduced the term social medicine (SM). The
French revolution brought about a new order of society viz. Socialism, which sought equal
opportunities for all people in the country. Therefore SM and advocated the philosophy that
all national services, including health and education, should not be the monopoly of the few,
but should belong to the nation for the benefit of all people. This philosophy however did not
received wide recognition and thus faded away till the end of 19th century.
The concept of SM was revived by Alfred Grotijahn, in the book Social Pathology
(1911), advocated the importance of social and economic conditions in the causation of
health and disease. This idea spread through Europe. SM had achieved academic
respectability in England when John Ryle and Crew pioneered to establish SM department of
Oxford and Edinburg (1942).
SM should not be confused with Socialized Medicine. Although the basic philosophy
had a common origin, Socialized Medicine is concerned with State Medicine at one extreme
and with Compulsory Insurance for the sick, aged and poor, at the other end.

PREVENTIVE AND SOCIAL MEDICINE (FROM MID 20th CENTURY)

Myanmar and several developing countries had accepted the WHO recommendation
to combine the concepts of Preventive and Social Medicine and to call it P&SM.
The brand of P& SM varies from country to country, and even within the country,
because of the divergent conditions and the varying health needs of society. PSM is not
synonymous with Community Medicine.

DEFINITIONS IN PREVENTIVE AND SOCIAL MEDICINE

Hygiene
Hygiene has defined as "the science of health, and embraces all factors which
contribute to healthful living".

Public Health
The science and arts of preventing disease, prolonging life, and promoting health and
efficiency through organized community efforts for the sanitation of the environment, the
control of communicable disease, the organization of medical and nursing services for the
early diagnosis and preventive treatment of disease, and the development of social
machinery to ensure for every individual a standard of living adequate for the maintenance
of health, so organizing these benefits as to evoke every citizen to realize his birthright of
health an longevity. (C.E.A Winslow 1920)
With the adoption of the goal "Health for all", a new public health is now evident
world- wide which may be defined as: The organized application of local, state, national and
international resources to achieved "Health For All", i.e. Attainment by all people of the
world by the year 2000 of all level of health that will permit them to lead a socially and
economically productive life.

23
Preventive Medicine
• The science and arts of preventing disease, prolonging life and promoting physical
and mental health and efficiency. (Leavell & Clark)
• The art and science of health promotion, disease prevention, disability limitation, and
rehabilitation. (Clark Duncan & McMahon 1981)

Social Medicine
SM is concerned with the study of man as a total individual in all aspects of the
complex elements that make up a living man (B. N. Gosh).
SM is concerned with scientific disciplines and improvements of preventive and
remedial practice based there-on and with political planning (J.A. Ryle)
SM stands upon two pillars, medicine and sociology. Social medicine by derivation
is concerned with the health of groups of individuals and individuals within these groups
with a view to create promote, preserve and maintain optimum health.
The laboratory to practice social medicine is the whole community. The tools for
diagnosing community illness are Epidemiology and Biostatistics and social therapy does
not consist in administration of drugs but social and political action for the betterment of
conditions of life of man. Social medicine is one more link in the chain of social
organizations of a civilized community. (F. A. E. Crew)

Socialized Medicine
It means that Government, being persuaded that medicine has gifted of great value to
offer, takes much steps as it seems desirable to make those gifts freely available to all within
the population irrespective of age, sex, rank, income or of anything else. It implies provision
of free medical services to the people at the government expense.

PREVENTIVE MEDICINE
It is a branch of medical practice concerned with the development and employment
of measures capable of averting the onset of disease. LEAVELL and CLARK defined
preventive medicine as "the science and art of preventing disease prolonging life and
promoting physical and mental health and efficiency". In Preventive medicine; focus of
attention is on the individual with emphasis on individual responsibility and voluntary co-
operation to achieve optimum physical, mental and social well - being. Preventive medicine
is distinct from public health; it is applied to "healthy" people. Primary objective is
prevention of disease and promotion of health.

Progress of Preventive Medicine

1. Discovery of vaccines and anti sera in the prevention of communicable diseases
a. BCG, DPT, OPV & Measles vaccines for WHO EPI Immunization schedule.
b. VH, Rabies, Typhoid vaccines for immunoprophylasis
c. Small pox vaccine for eradication of small pox (Last case- 1977-Somalia)
d. Further search for vaccine continues
2. Discoveries in the field of nutrition for prevention of
a. Nutritional blindness
b. Iodine deficiency disorders (Goiters)
c. Vitamin deficiencies
d. Cancers: role of dietary fibers in prevention of Ca. Colon

24
 e. Dietary Approach to Stop Hypertension (DASH) diet for prevention of
hypertension etc.
3. Discoveries of synthetic insecticides (DDT, HCH, Malathion & others) for
prevention and control of:
a. Vector-borne diseases: malaria, D.H.F, filariasis and Japanese Encephalitis
b. Yellow fever
c. Plague
d. Leishmaniasis
e. Rickettsial diseases: Scrub Typhus
4. Discoveries of drugs for chemoprophylaxis and mass drug treatment such as
a. Antimalarials drugs
b. Antibiotics
c. Anti TB (Short Course Chemotherapy)
d. Anti leprosy (Multi-drug therapy)
5. Screening of diseases among apparently healthy persons such as
a. Serological test for syphilis
b. Chest x-ray for tuberculosis
c. Serological tests for Viral hepatitis & HIV
6. Screening for risk factors of disease and identification of high risk groups
a. Cervical Papanicolou smear (Pap Smear) for early detection of carcinoma of
cervix
b. Random Blood Sugar for diabetes
c. ASO titer for Rheumatism and
d. Serum cholesterol level for coronary and cardiovascular diseases
7. Prevention of Population Explosion in developing countries
a. Demography and population control for potential problems of
i. Economy
ii. Politics and
iii. Environment
8. Genetic counseling for preventable genetic disease
9. Newer aspects of preventive medicine
a. Preventive and social pediatrics
b. Preventive geriatrics and
c. Preventive cardiology

Three levels of prevention are now recognized

 Primary, intended to prevent disease among healthy people
 Secondary, directed towards those in whom the disease has already developed; and
 Tertiary, to reduce the prevalence of chronic disability consequent to disease

Modern preventive medicine has been defined as "the art and science of health
promotion, disease prevention, disability limitation and rehabilitation". It implies a more
personal encounter between the individual and health professional than public health.

25
 SOCIAL MEDICINE
Social medicine is the study of the social, economic, environmental cultural,
psychological and genetic factors which have a bearing on the health of groups of
individuals and individuals within these groups and at the same time with practical measures
within the social field than may be taken to promote health, to prevent disease and assist
recovery of the sick. In short, it is the study of man in his total environment – physical,
biological, psychological and socio-economic and deals with man in relation to society and
with health en masse.
Social medicine is also concerned with how medical care is organized within the
community and with the factors that influence its distribution, utilization and effectiveness.
The laboratory to practice SM is the whole community: the tools for diagnosing community
illnesses are epidemiology and biostatistics and social therapy does not consist in
administration of drugs but social and political action for the betterment of conditions of life
of man.

Objectives of Social Medicine

1. To access the health status of the population and its development
2. To access the sanitary conditions of the environment
3. To work out methods and means leading to promotion of the health of the people and
the prevention of disease, disability and infirmity
4. To organize medical care and rehabilitation for the whole population
5. To control sanitary conditions in the environment and
6. To control the birth rates in order to secure the harmonious development of the
population.

ASPECTS OF SOCIAL MEDICINE

Social Anatomy
It is the study of structure of a society or a particular community. It is concerned with-
1. Population structure – size, age and sex composition of the population
2. Population density
3. Social groups
4. Social class
5. Housing pattern
6. Industries
7. Sanitation conditions
8. Economic patterns
9. Per capita income and expenditure
10. Religious, cultural and recreational infrastructure
11. Geographical features- climate, temp, humidity, soil, irrigation etc. and
12. Availability of food
13. Villages, towns, cities, districts, states and divisions
Study of social anatomy provides background information for understanding health
and disease phenomenon in the community.

26
Social Physiology
Social Physiology deals with the way society function as an organized unit.
Physiological Functions
• Respiration - Air, ventilation, housing, urbanization, industrialization
• Digestion - Food production in the community, water supply
• Assimilation - Nutritional status of age and sex groups
• Excretion - disposal of wastes
• Reproduction - New generation of men and women
• Growth - Demography- births, deaths, population growth
• Coordination - Language, communication, festivals, customs, culture habits,
organization, administration

Social Pathology
Social Pathology deals with quantity and causes of diseases and assists in prevention.
It may be defined as the systematic study or inquiry into the relationship between human
disease and social conditions. It deals with dysfunction prevailing in the community as a
result of such factors as malnutrition, age and sex composition of the population, poverty,
accidents, illiteracy, standard of living etc.
It may be equated to reverse social physiological conditions as stated above such as
• Air pollution
• Poor housing conditions
• Inadequate food supply, Malnutrition & poor food sanitation
• Unsanitary conditions of excreta and refuse disposal
• Pest activity
• Uncontrolled reproduction
• Overcrowding
• Illiteracy
• Lack of health and social services
• Customs, culture and habits adverse to health, which prevail in the community

Social post mortems

Epidemiological and Medico-social surveys bring to light trends in morbidity and
mortality.
Example - Infant Mortality Rate in developed countries is 15/1000 LB (Live Births) but IMR
in developing countries is 100 / 1000 LB
Social Factors responsible for IMR are
• Occupation
• Income
• Social class
• Education, Marital status and
• Residence (Rural and Urban areas)
Cultural factors responsible for IMR are
• Traditions
• Misbelieves and
• Taboos

27
Social Therapy
Social and political action to improve social conditions for the betterment of
conditions of life of man is usually termed social therapy.
Suitable Legislation (Political Action): To prevent disease & to protect and promote health
of citizens
• Notification of communicable diseases
• Registration of Birth and Deaths
• Food & drug act
• Occupational Health
• Medical termination of pregnancy
• Social security - so on all aimed at protecting the health of the people

ENVIRONMENTAL HEALTH
The health status of an individual or a family or a community or a nation is
determined by the interaction between internal environment of man himself and external
environment, which surround him. In modern concept -disease is due to a disturbance in the
delicate balance between man and his environment. Agent, host & environment are
responsible for disease. Yet frequently, the key to the nature, occurrence, prevention and
control of disease lies in the environment.

Sanitation
The science of safeguarding health

ENVIRONMENTAL SANITATION (WHO)

The control of all those factors in man's physical environment, which exercises or
may, exercises a deleterious effect on his physical development, health and survival.

(USA)The way of life, the quality of living that is expressed in the clean home, clean farm,
clean business, clean neighborhood, and the clean community.

"Whole field of controlling the environment with a view to prevent disease and promote
health"
1. Water supply 7. Occupational Health
8. Urbanization
2 .Refuse disposal 9. Control of Atmospheric Protection
3. Excreta disposal 10. Radiologial Protection
4. Food sanitation 11. Accident Prevention
5. Pest control 12. Prevention of Public Nuisances
-Rodent control 13. Sanitation on Public Area
-Mosquito control --Swimming Pool
-Fly control --Recreation Area
6. Housing
-Ventilation
-Lighting
-Heat control
-Lighting

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 WATER SANITATION

1. Safe and wholesome water

(a)Free from pathogenic agent
(b)Free from harmful chemical substance
(c)Pleasant to the taste
(d)Usable for domestic purpose

2. Use of water
(a)Domestic purpose
(b)Public purpose
(c)Industrial purpose
(d)Agricultural purpose

3. Water needs 35 to 45 gallons / capita / day (gpcd)

Myanmar 20 gpcd in Urban,
12 gpcd in Rural
Minimum 7 gpcd is needed for personal hygiene

WATER SOURCE
1. Rain

2. Surface Water
Impounding reservoirs
Rivers and streams
Tanks, ponds and lakes

3. Ground water
Shallow Wells
Deep wells
Springs

SANITARY WELL

1. Location A higher level than latrine in the vicinity

At least 50 ft away from the latrines
Not more than 100 yards from the users
2. Lining build of bricks or stones set in cement up to 10 feet depth
Lower part should be line with perforation, so that water enters from the
bottom and not from the side of the walls.
3. Parapet wall up to a height of at least 2.5 feet above the ground
4. Plat form Cement concrete platform around the wall (3 feet) with gentle slope
5. Drain A pucca drain to carry of spilled water to a public drain or soakage pit
6. Covering The top of well should be closed especially with a cement cover

29
7. Hand pump A hand pump should be equipped for lifting water in a sanitary manner

8.Consumer responsibility Strict cleanliness should be enforce in the vicinity of the wall;
bathing, washing of cloths and animals, dumping of refuse and waste should be prohibited.
all this required health education.
9.Quality Physical, chemical and bacteriological quality of water should conform to
acceptable standards of quality of safe and wholesome water.
10.Disinfection should be done if necessary.

PURIFICATION OF WATER

Natural Purification
a. Evaporation and condensation (rain water)
b. Filtration through earth (ground water)
c. Dilution (rivers, stream)
d. Storage and sedimentation (lakes, ponds, reservoirs)
e. Ultraviolet rays and sunlight (rain and surface water)
f. Aeration- Oxidation (rain and surface water)
Artificial purification of water
a. Purification of water on small scale
b. Purification of water on large scale

A. Purification of water on small scale

1. Boiling
2. Chemical Disinfection: Cl solution, Cl tablets, Bleaching Power, Iodine tab, Potassium
permanganate
3. Filtration

Main sources of water supply in rural area

The most effective and cheapest method is disinfection by bleaching powder.

Chlorination of well (prepared from bleaching powder CaOCl2 )

1 Find the volume of water in the well.

(a) For circular well:
D=diameter, H=depth, (measure in feet)
Total gallons of water in the well = 5 D2 H
(b) For rectangular well:
L=length, B=breadth, h=height (depth)
Total gallons of water in the well =L x B x H x 6.25gallons
2 Find the amount of bleaching powder require for disinfection.
0.5 to 1 oz of bleaching powder is used for 1000 gallons of water.
To obtained 0.1 to 0.2 ppm of free residual chlorine.
3. Dissolve Bleaching powder in the water.

30
 Required bleaching powder is place in a bucket and made into a thin paste and then
mixed with water.
4. Delivery of chlorine solution into well.
The bucket containing the chlorine solution is lowered some distance below the water
surface. And moving the bucket violently both vertically and laterally agitates well
water.
5. Contact Period
A period of 30 minutes is allowed before the water is drawn for used.
6. Measurement of residual chlorine in water
The orthotolidine (OT) test to determined the free and combined chlorine in water to be
determined with speed and accuracy.

Principle of chlorination

1 Water should be clear / turbidity

2 Amount of chlorine should be estimated (to oxidize organic matter & ammonia
3 Contact period - required for reaction of chlorine substances & ammonia compounds,
until free residual chlorine appear.A contact time of at least half to one hour in essential to
kill bacteria and virus.
4 Free residual chlorine - the minimum recommended concentration is 0.1 to 1 ppm.
5 Chlorine Dosage - The sum of chlorine demand of water and the required level of free
residual chlorine. (The amount of chlorine to be added into water.)
6 Chlorine Residual - Amount of chlorine, left in water after the reaction of chlorine with
water during a contact period.

FACTORS INFLUENCING EFFECTIVENESS OF CHLORINATION

1 Type of chlorine used.

2 Amount of chlorine added (dosage)
3 Turbidity of water to be chlorinated.
4 Organic load, type and amount of bacteria contaminated.
5 Length of contact period.
6 Temperature of water.
7 PH of water.

B. Purification of water on a large scale

1. Storage
Water is drawn from natural sources and impounded in natural or artificial reservoirs.
It has the following actions.
(a) Physical: about 90% of the suspended impurities settle down in 24 hours period by
means of gravity.
(b) Chemical: oxidation of aerobic bacteria and reduction of the free ammonia contact.
(c) Biological: About 90% of bacteria will be reduced in the first 5 to 7 days of storage.

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2. Coagulation and Sedimentation

-Adding salts of trivalent metals such as Alum can bring coagulation.

-To remove coloring materials, colloidal gold and fine particles. Sedimentation precipitates
flocculent together with impurities and bacteria. It remove turbidity, reduces color and
bacteria count.
-The longer the period, the greater the effect.
-The detention period is about 2 to 6 hours.

3. Filtration

Important stage as it removes 98 to 99% of bacteria a/w/a turbidity and color. There are 2
types
3.a Biological or Slow sand filters
3.b Mechanical or Rapid sand filters

3.a Slow sand filters

It purify water by means of:
1 Sedimentation
2 Mechanical straining
3 Absorption of colloidal particles and bacteria
4 Oxidation of organic matters
5 Biochemical and bacterial changes
6 Electrolytic reactions
Algae, plankton, diatoms and bacteria form the Vital or Zoological layer. It holds
back bacteria and oxidizes ammonical nitrogen into nitrate and help in yielding bacteria free
water.

3.b Rapid Sand Filters:

The following steps are involved

1. Coagulation by addition of alum
2. Rapid mixing by violent agitation in a mixing chamber, which allows a quick and
thorough dissemination of alum throughout the bulk of water.
3. Flocculation by slow and gentle stirring of treated water in a "Flocculation
Chamber" for about 30 minutes; which results in formation of a thick, copious,
white flocculent precipitate of aluminum hydroxide.
4. Sedimentation to settle down bacteria and impurities with a detention period of 2
to 6 hours.
5. Filtration through filter bed.

4. Aeration

Aims
1 Removal of dissolved gasses such as CO2
2 Increase dissolved O2 content in water
3 Enhance precipitation and removal of Fe and Manganese in water

4 Render water less corrosive and acid in action

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5. Chlorination
It is the addition of chlorine into water to destroy bacteria causing disease.

The purpose is
a -disinfection of water
b -control of algae and other plants in reservoir
c -destroy taste and odour producing constituents
d -prevention of organic growth in pipe line, e.g. iron fixing bacteria.

FOOD SANITATION
Food
It is something we eat or drink, except water, medicine and the substances involved
in the process of making food, e.g. spices, coloured dyes. It is composite mixture of various
substances for provision of energy, body-building and repair and maintenance of tissue
function.

Food sanitation
Food sanitation in its widest sense implies sanitation in the production, handling, and
distribution of food till the time of serving food to the consumers. Its main aim is to make
food safe for consumption and to prevent food borne diseases and poisoning.

Types of Food
▫ Cereals
▫ Fish and fish products
▫ Ice and beverages (with or without alcohol)
▫ Fruits and vegetables
▫ Fat and oil
▫ Miscellaneous
Contamination of food may occur at any point, during its journey from the
PRODUCER to the CONSUMER.

Agents that can cause harmful effects through food

A. Living agents - Micro - organisms, toxins (produced by bacteria), animal parasites.

B. Non-living agents - Chemical substances, poisonous substances, plant toxicants:
mycotoxins.

Food - Borne Disease

1. Bacterial diseases - Typhoid and Paratyphoid fever, Staphylococcal food poisoning,
Salmonellosis, shigellosis, E. coil diarrhea, Streptococcal infections, Brucellosis.
2. Viral diseases - Viral hepatitis ,Gastroenteritis
3. Parasitic infections and infestations - Helminthiasis, Amoebiasis.
4. Chemical poisons - Pesticides, heavy metals (arsenic, lead, cadmium)
5. Food toxins - Aflatoxin, Lathyrism

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 Many food-borne diseases may initiate and intensify malnutrition, leading to
retardation of both mental and physical growth and development in children. In
adults, it severely reduces productivity.

SCHEMATIC DIAGRAM OF FOOD SANITATION PROCESS

Food Supply Processing Possible Contamination Areas

Raw Materials

Production Points
Production
Storage

Distribution

Food Handlers

Kitchen
Preparation
Cooking

Storage

Food Handlers

Utensils
Serving Food
Eating Places

Consumers

A. Food Production

(1). Raw materials

Meat should be fresh and free from disease agents. To ensure it, ante mortem
examination of animals should be dine in production of meat. Animals to be slaughtered are
placed under observation for a period of about a week prior, to slaughtering to see if they
develop any signs and symptoms of disease coughing, fever poor feeding etc. than after
slaughtering postmortem examination done. This is to observe if there is any haemorrhages
in the peritoneal cavity lymph node, cavities in lungs, cysts in the meat etc.
Milk is only taken form cows free from disease since milk borne tuberculosis is a
common zoonotic disease, milk should be taken from tuberculin negative animal only. The
outer should be healthy-free from ulcers or other lesions. It should contain as little
microorganism as possible.
Methylene blue reduction test is used to find out the amount of microorganisms as
present indirectly. When methylene blue is added to milk, the bacteria present break down
the blood colour and milk that remain blue the longest is considered to be the best quality.

34
(2). Production Plants
Hbs would be the slaughtering house (abattoir) in case of meat production and dairy
plants in case of milk.
Slaughtering houses (abattoirs)
1. Location: Preferably away from residential areas.
2. Structure: Floor and walls up to 3 ft should be impervious and easy to clean.
3. Disposal of waste: Blood, offal etc. should not be discharged into public sewers
but should be collected separately.
4. Water supply: should be independent, adequate and continuous.
5. Examination of animals: Ante mortem and postmortem examination to be
arranged. Animals or meat found unfit for human consumption should be
destroyed or denatured.
6. Miscellaneous: Animals other than those to be slaughtered should not be allowed
inside the shed.

Diary plants
The premises where the animal is housed and milked should be airy, well
ventilated, well illuminated and the floor and walls should be of imperious
materials. Lime washing of walls would be of impervious material. Lime washing
walls should be dime at least once a year. Floors washed alternate days if not
every day. Where possible, milking machine must be used. Milk vessels must be
sterile and kept concerned. There must be adequate supply of bacteriological sate
water.

Pasteurization of milk
Pasteurization may be defined as the heating of milk to such temperatures and
for such periods of times as are required to destroy any pathogens that may be
present while causing minimal changes in the composition, flavour and nutritive
value (WHO, 1970). There are several methods of pasteurization.
There are widely used:
1. Holder (vat) method: In this process, milk is kept at 63-66° C for at least 30
minutes and then quickly cooled to 5 ° C. Vat method is recommended for small
and rural communities. In larger cities, it is going out of use.
2. HTST Method- Also knows as "High temperature and short time method". Milk
is rapidly heated to a temperature of nearly 75° C is held at that temperature for
not less than 15 seconds, and is hen rapidly cooled to 4° C. This is now the most
widely used method. Very large quantities of milk per hour can be pasteurized by
this method.
3. UHT Method: also know as "ultra high temperature method". Milk is rapidly
heated usually in 2 stages (the second stage usually being under pressure) to
between125° C and 150° C, for a seconds only. It is then rapidly cooled and
bottled as quickly as possible.
Pasteurization is a preventive measure of public health importance and
corresponds in all respects to the modern principles of supplying sage water.
Pasteurization kills nearly 90 percent of the bacteria in milk including the more
heat resistant tubercle bacillus and the a ever organism. But it will not kill thermo
uric bacteria nor the bacterial spores. Therefore, despite pasteurization, with
subsequent rise in temperature, the bacteria are found to multiply. In order to
check the growth of microorganism, pasteurization milk is rapidly cooled to 4° C.
It should be kept cold until it reaches the consumer.

35
 Hygienically produced pasteurized milk has a keeping quality of not more than 8
to 12 hours at 18° C.

Tests of Pasteurized Milk

1. Phosphates test: Phosphates enzymes are present in raw milk. It is completely
destroyed by pasteurization. If any quantity is present, it shows that pasteurization
is not satisfactory.
2. Standard Plate Count: Should not be more than 30,000 bacteria per ml of
pasteurized milk.
3. Coliform Count: There should be no Coliform organisms in one ml of
pasteurized milk.

(3). Storage
Food should be stores in fly-proof and rat-proof rooms before distribution. The
temperature of the room should be maintained below 5° C if food is to be stored
overnight.

(4). Distribution
Meat and pasteurized milk should be distributed as soon as possible after
production. Along the way, they should be transported in fly-proof vans of if
possible in refrigerated vans.

B. Food Preparation and Serving

(1). Kitchen
a. Floor space minimum 60 sq.ft.
b. Window opening to be 25% of floor area.
c. Floor to be impervious, smooth, easy to keep clean and non slippery.
d. Doors and windows to be rat-proof, fly-proof and the self-closing type.
e. Ventilators 2% of the floor area in addition to smoke pipes.

(2). Cooking
The most important thing is for the temperature and duration of cooking should be
sufficient to kill pathogenic organisms. If the quality of raw materials should not be
vouched, meat especially, should be cooked well.

(3) Food Handlers

Food sanitation rests directly upon the state of personal hygiene and habits of the
personnel working in the food establishments. Proper handing of foods, utensils and dishes
together with emphasis upon the necessary for good personal hygiene are of great
importance.
The first essential is to have a complete medical examination carried out of all food
handlers at the time of employment. Any person with a history of typhoid fever, diphtheria,
chronic dysentry, tuberculosis or any other communicable disease should not be employed.
Persons with wounds, Otitis media or skin infections should not be permitted to handle food
or utensils. The day- to-day health appraisal of the food handlers is also equally important;
those who are ill should be excluded from food handling. It is also important that any illness
occurs in a food handler's family should at once be notified. Education of food handlers in
matters of personal hygiene, food handling, utensils, dishwashing. Many of the food

36
handlers have little educational background. Certain aspects of personal hygiene are
therefore required to be continually impressed upon them:
(a) Hands: The hands should be clean at all times. Hands should be scrubbed,
washed with soap and water immediately after visiting a lavatory and as often
as necessary at other times. Fingernails should be kept trimmed and free from
dirt.
(b) Hair: head coverings should be provided, particularly in the case of females to
prevent loss hairs obtaining entrance to food staffs.
(c) Overalls: all food handlers should wear clean white overalls.
(d) Habits: Coughing and sneezing the vanity of fool, licking the fingers before
picking up an article of food, smoking on food premises are to be avoided.

(4) Storage
Storage of cooked food: Separate room to be provided, for long storage, control of
temperature is necessary. Storage of uncooked foodstuffs; Perishable and non-perishable
articles temperature control should be adopted.

(5) Utensils
Utensils should be washed in got water and dried in a hot-air even or with a clean dry
cloth after every use. They should be put away in an area free from flies & rats.

(6) Eating places

1. Location: Shall not be near any accumulation of filth or open drain, stable, manure
pit and other sources of nuisances.
2. Floors: To be higher than the adjoining land, made with impervious materials and
easy to keep clean.
3. Rooms:
a. Rooms where meals are served shall not be less than 100 sq.ft and shall
provide accommodation for a maximum of 10 persons.
b. Wall up to 3 ft should be smooth, corners to be rounded; should be
impervious and easily washable.
c. Lighting and ventilation: ample natural lighting facilities aided by artificial
lighting with food circulation of air are necessary.
4. Furniture: should be reasonably strong and easy to keep clean and dry.
5. Disposal of Refuse: To be collected in covered, impervious bins and disposed
of twice a day.
6. Water supply: to be an independent source, adequate, continuous and safe.
7. Washing facilities: To be provided, cleaning of utensils and cookery to be dine
in hot water and followed by disinfection.

(7) Market Inspection

(A) Sanitation of market place (Bazaar-Sanitation)

Unsanitary bazaar may give rise to many food borne diseases, food poisoning out-
breaks, plague, rabies and leptospirosis etc.
1. Site/Location - must be in the leveled ground, with well-fenced compound to prevent
access of animals such as strayed dogs. No one is allowed to reside or sleep in the
bazaar.
2. Type of building - must be of Pucca type, impervious floor with proper drain, and
rat-proof.

37
3. Stalls-separate stalls for fish, meat, vegetables, and dry goods.
4. Water supply - must be safe and adequate.
5. Ventilation and lighting - must be proper and enough.
6. Excreta disposal - Sanitary fly-proof odor less public latrines must be provided.
7. Refuse disposal - Both putrifiable and non-putrifiable waste materials must be
properly stored in water-tight bins with covers to avoid strayed dogs and other
animals. Daily collection is the best, usually done by City Development Authorities.
8. Vector control - Fly control measures must be carried out effectively.
9. Rodent control - proper and strict rodent control measures are essential.
10. Sanitary status of food is checked.
11. Food handlers - Periodic and Regular Medical Check-up is necessary, by responsible
health personals.
Market sanitation is the responsibility of "bazaar sanitation committee", supervised
by Township Medical Officer. Daily cleansing service must be provided and regular
checking by health authorities must be done.

(B) Sanitation of a food-stall

Food stalls comprises of - meat stall, fish stall, Fruits, vegetables & dry goods (rice,
flour spices etc.)
(1) Food-meat (characteristics of good meat and unsound meat), fish, fruits,
vegetables and dry good (dried chilly, potatoes onion, dried noodles etc.) for
presence of fungus.
(2) Food handlers-Same as bazaar sanitation
(3) Food stall-Same as bazaar sanitation

(C) Sanitation of drinking, and eating establishments

- Include - restaurants, tea-house, cafeteria, confectionaries etc.
- Importance for prevention of Food - borne diseases and food-poisoning outbreaks,
- Responsible persons are Township Health Staff supervised by TMO, together with TDC
(Township Development Committee).

Five keys to safer food

1- Keep clean.
-Wash your hands before handling food and often during food preparation.
-Wash your hands after going to the toilet.
-Wash and sanitize all surfaces and equipment used for food preparation.
-Protect kitchen areas and food from insects, pests and other animals.
Why ?
While most microorganisms do not cause disease, dangerous microorganisms are
widely found in soil, water, animals and people. These microorganisms are carried on hands,
wiping cloths and utensils, especially cutting boards and the slightest contact can transfer
them to food and cause food borne diseases.
Why?
2- Separate raw and cooked.
-Separate raw meat, poultry and seafood from other foods.
-Use separate equipment and utensils such as knives and cutting boards for
handling raw foods.
-Store food in containers to avoid contact between raw and prepared foods.

38
Why ?
Raw food, especially meat, poultry and seafood, and their juices, can contain
dangerous microorganisms which may be transferred onto other foods during food
preparation and storage.

3- Cook thoroughly.
-Cook food thoroughly, especially meat, poultry, eggs and seafood.
-Bring foods like soups and stews to boiling to make sure that they have reached
70°C. For meat and poultry, make sure that juices are clear, not pink. Ideally, use
a thermometer.
-Reheat cooked food thoroughly.
Why ?
Proper cooking kills almost all dangerous microorganisms. Studies have shown that
cooking food to a temperature of 70°C can help ensure it is safe for consumption. Foods that
require special attention includes

4- Keep food at safe temperatures.

-Do not leave cooked food at room temperature for more than 2 hours.
-Refrigerate promptly all cooked and perishable food (preferably below 5°C).
-Keep cooked food piping hot (more than 60°C) prior to serving.
-Do not store food too long even in the refrigerator.
-Do not thaw frozen food at room temperature
Why ?
Microorganisms can multiply very quickly if food is stored at room temperature. By
holding at temperatures below 5°C or above 60°C, the growth of microorganisms is slowed
down or stopped. Some dangerous microorganisms still grow below 5°C.

5- Use safe water and raw materials.

-Use safe water or treat it to make it safe.
-Select fresh and wholesome foods.
-Choose foods processed for safety, such as pasteurized milk.
-Wash fruits and vegetables, especially if eaten raw.
-Do not use food beyond its expiry date
Why?
Raw materials, including water and ice, may be contaminated with dangerous
microorganisms and chemicals. Toxic chemicals may be formed in damaged and mouldy
foods. Care in selection of raw materials and simple measures such as washing and peeling
may reduce the risk.

39
 EXCRETA DISPOSAL

Human excreta [faeces and urine] are the potential source of infection in the
environment. Improper disposal of excreta may lead to occurrences of diseases spread by
faecal - oral route.

Public Health Hazards

(1) Soil pollution

(2) Water pollution
(3) Contamination of foods
(4) Propagation of flies
(5) Unsightly scene and public nuisance
Proper excreta disposal is one of the important components of "Environmental health
programme" in order to promote the health of the individuals, families and the community
(primary prevention).

Water

Finger

Host Faeces Food New

Flies

Soil

Figure - 1. Transmission of faecal - borne diseases

Water

Finger

Faeces Files Protected

Host
Soil

Food

Figure - 2. Sanitation Barriers of Transmission of Faecal - borne Diseases

40
Diseases due to improper excreta disposal (Excreta - borne diseases)

1. Diarrhoeal diseases
2. Dysentery
3. Typhoid and paratyphoid fever
4. Cholera
5. Viral Hepatitis
6. Poliomyelitis
7. Hook worm infestation, Ascariasis and other parasitic infections
8. other intestinal infections

Extent of problem in Myanmar

Acute diarrhoeal diseases constitute a very common syndrome of multiple aetiology

in Myanmar and are high prevalent in all ages, more so in children. Acute diarrhoeal
diseases next to malaria, took the leading role in both single leading causes as well as ten
leading causes of morbidity and mortality under national surveillance, 1997. According to
priority diseases of National health Plan (2006-2011) diarrhoea and dysentery took number 4
places among 42 priority diseases.
It is generally agreed that a latrine or other disposal methods should satisfy the following
requirements (Adapted from Ehlers & Steel)

1. The surface soil should not be contaminated.

2. There should be no contamination of ground water that may enters spring or wells.
3. There should be no contamination of surface water.
4. There should be no handling of fresh excreta.
5. There should be freedom from of ours of unsightly conditions.
6. The method should be simple and inexpensive in construction and operation.
7. Excreta should not be accessible to flies or animals.

METHODS OF EXCRETA DISPOSAL

I. Unsewered areas (no water carriage system)

A. Service type
1. Bucket latrine

B. Non-service type (sanitary latrines)

1. Pit latrine (direct pit and back pit)
2. Ventilated Improved Pit latrine
3. Water sealed type
4. Septic tank
5. Aqua privy
6. Bore hole latrine
7. Mound latrine
8. Overhung latrine
9. Compost privy
10. Chemical closet

C. Latrines suitable for temporary use (camps, fairs & festivals)

41
 1. Trench latrine (shallow & deep)
2. Pit latrine
3. Bore hole latrine

II. Sewered areas (Water - carriage system and sewage treatment)

Excreta disposal system with water carriage

- It is the method of choice in densely populated urban areas and industrialized areas.
- Used where there is an adequate water supply (piped - water)
- Carrying power of water is used to convey excreta from a house to a final
disposal plant.
- May or may not have a sewage treatment plant.
- Primary treatment (anaerobic)
- Secondary treatment (aerobic)
- Tertiary treatment
It consists of:
1. House fixture and drains
2. Sewerage system
3. Sewage treatment plant (+/-)
4. Receiving body of water (may be a lake, stream, river, or sea)

3. Sewage treatment
a. Primary treatment
 Screening
 Removal of grit
 Plain sedimentation
b. Secondary treatment
 Trickling filter
 Activated sludge process
 Digestion of sludge
c. Other methods
( i) Sea out fall
( ii) River out fall
(iii) Sewage farming
(iv) Oxidation ponds

Basic process of Sewage treatment

1. Primary treatment: Solids are separated from the liquid partly by screening and partly
by sedimentation, and are subjected to digestion by anaerobic bacteria. (Anaerobic
digestion)
2. Sediment solids (Sludge) are disposed sanitarily.
3. The remaining solids in suspension and solution (Effluent) are purified by biological
process manly (Aerobic digestion).

42
Selection of type of latrine depend on
1. Climate
2. Site - topography
- Seasonal water table fluctuations
- Geology
3. Ground water
4. Surface water
5. Population - urban (or) rural
6. Availability of water and other construction materials
7. Economic factor
8. Socio - cultural factor

Excreta disposal system without water carriage

A. Service type (bucket system) is no longer used
B. Non - service type

Pit latrine
 Selection - must be of at least 50 feet away from the source of water supply and on a
lower slope.

Eight components of a sanitary pit latrine

(1) Pit - direct (or) back pit
(2) Pit lining
(3) Base
(4) Floor
(5) Mound
(6) Hole cover
(7) Vent-pipe
(8) Super structure

Figure- 3. Conventional Unimproved Pit Latrine

43
A.1. Mound Latrine
 Suitable in flooded areas
 Mound must be of 2 to 3 feet higher from the water level

A.1. VIP Latrine

 Developed first in Zimbabwe
 Traditional pit latrines have 2 main disadvantages.
 Both these disadvantages are reduced in VIP latrines.
 Vent pipe plays a major role in odor control (usually painted black)
 The effect of sunrays is to heat up the vent pipe and thus the air inside it.
 This air become less dense and therefore rises up out of the vent-pipe and is
replaced by cooler air from below.
 Any odour may draw up the vent-pipe, leaving the super structure odour free.
 Hole cover and screen at the top of the vent pipe may reduce flies.
 Entry of flies is impossible because of the screen.
 If a few flies enter via the super structure, they will fly up the vent-pipe (as
the superstructure is dark) since the only light they can see is that at the top of
the in time, they fall back into the pit and die.

Structure - Consists of the concrete squatting slab, placed over the pit. The
slab has two openings squatting hole and a vent hole.

Water Sealed Type

The squatting plate of the pit latrine is fitted with a pan and water - seal. Water-seal
traps water. It sits right on top of the pit (direct pit latrine, water seals type) or the pan and
seal is connected with a connecting tube or ditch to the back pit (indirect pit latrine, water
sealed type). It is the trap, which prevents the access by flies, and the escape of odour. Once
the latrine is flushed, the faece is no longer visible it may also prevent children from falling
into the pit. Pour-flushed water-seal latrines are suitable for rural areas with ample amount of
water supply. The disadvantages are that it needs ample amount of water and it can be
blocked by material used for anal cleansing other that water.

Septic tank
 Suitable for housing complexes and also for individual household, with adequate
water supply.
 Appropriate in peri-urban areas.
 Not recommended for large communities.
 Watertight tank, single or double chambered.
 Its capacity depends on number of users.

The Main features of septic tank are

 Capacity - at least 500 gallons. (20-30 gallons for one person)
 Length - twice of the bread.
 Depth - 1.5- 2 m (5-7 ft).
 Liquid depth - 1.2 m (4 ft).
 Air space - 12 inches.
 Bottom - sloping toward the inlet end.
 Inlet and outlet - inlet is higher than outlet.

44
 Cover - concrete slab.
 Retention period - 24 hours.

Air space (1 Feet)

Inlet Outlet
Scum
Effluent

Liquid Depth (5-7 feet)

Figure-5. Septic tank

Working of a septic tank

The solids settle down in the tank, to form sludge, while the lighter solids including
grease and fat rise to the surface to form scum. The solids are attacked by the bacteria and
fungi and broken down into smaller chemical compounds. This is first stage of purification,
called anaerobic digestion. Due to anaerobic digestion, the volume of sludge is much
reduced and then stable and inoffensive. A portion of the solids is transferred into liquids
and gases (principally methane) that rise to the surface in the form of bubbles. Then the
liquid pass out of the outlet pipe from time to time is called effluent. It contains numerous
bacteria cysts, helminthes ova and organic matter in solution or fine suspension. The effluent
is allowed to percolate into the subsoil. It is dispersed covered with soil. The aerobic bacteria
in the upper layers of the soil attack the organic products. (i.e. nitrates. CO2 H2 O and is
called aerobic oxidation).

Operation and maintenance

 The use of soap water and disinfectants such as phenol should be avoided, as they are
injurious to the bacteria flora in the septic tank.
 Undue accumulation of sludge reduces the capacity of septic tank and interferes with
proper working.
 Newly build septic tanks are first filled with water up to the out let level.

Aqua privy
 Functions are same as septic tank.
 The privy consists of a watertight chamber filled with water.
 A short drop pope from the latrine floor drops into the water.
 Shape of tank may be circular or rectangular.
 Size of tank depends on the number of users.

45
 Capacity 35 cu. ft for small families and allowing 6 years or more.
 Aqua privies are designed for public use.
 Night soils are purified by anaerobic digestion of gases.
 Vent should be provided for escape of gases into atmosphere.

Bore hole latrine - It is a direct pit latrine in which pit is dugged by 'Auger'

Chemical closet
The closet consists of a metal tank containing a solution of caustic soda, or
formaldehyde, or other disinfectant fluid: Night soil is liquefied and sterilized by the
chemicals - used on boats and air crafts.

LATRINES SUITABLE FOR TEMPORARY USE

Shallow trench latrine: Width-1 feet; Depth-3 feet
Deep trench latrine: Width-2 ½ -3 feet; Depth 6-8 feet.
Trench latrines are suitable for temporary situation such as fairs and festivals, or
emergency conditions such as refugee camps or disasters aftermath. Open field defecation is
prohibited and trenched latrine encouraged.
Separate trenches should for separate sex. It is easy to construct but some co-
operation from the users and monitoring to make sure-that faeces are covered with soil after
each defecation, is needed. When the pits trenches are nearly filled, or at the end of the
festival it is covered with soil.

**Potential benefits of proper excreta disposal

1. Reduction of morbidity and mortality due to excreta borne diseases, which in turn
safe the direct medical care costs.
2. Promotion of state of well being in the population leading to social development.
3. Marked decrease in morbidity from other diseases with longer life expectancy.
4. Reduce absenteeism from schools and working places, which may then lead to
increase productivity and increase national in come.

REFUSE DISPOSAL(SOLID WASTE DISPOSAL)

Solid wastes (refuse or litter), are unwanted or discarded wastes from houses, street
sweeping, commercial and industrial wastes. They consist of dust, vegetable, paper and
others.
Sanitary disposal is needed since it can give rise to many health hazards.

HEALTH ASPECTS
1. The organic portion of solid wastes ferments and favour fly breeding.
2. The garbage in the refuse attracts rats.
3. The pathogens may be conveyed to man through flies and dust.
4. There are possibilities of water pollution if rainwater passes through deposits of
fermenting refuse.

46
5. There is risk of air pollution if there is accidental or spontaneous combustion of
refuse.
6. Piles of refuse are a nuisance from an aesthetic point of view.
Therefore, there should be an efficient collection removal and disposal of refuse
without the risk to health.

Objectives of sanitary refuse disposal

1. To control vectors of diseases
2. To prevent fire hazards
3. For aesthetic improvement

Sources of refuse
1. Street refuse: from street cleaning and contain leaves, papers, dust, straws, animal
droppings and litters of all kinds.
2. Marker refuses: It contains a large portion of putricible vegetable and animal matter.
3. Stable litter: animal droppings and left over of animal foods.
4. Industrial refuse: consists of inert matters to highly toxic and explosive compounds.
5. Domestic refuse:
Garbage - waste matter from consumption, cooking, and consumption of food.
Rubbish - paper, clothing, bits of wood, metal, glass, dirt and dust.
Ash - residue from fire used for cooking.
6. Dead animals

Storage of refuse: proper storage needed before collection.

Domestic - Closed fitting containers desirable: e.g. plastic bins with cover.
Public bins - Usually concrete platforms raised 2-3 inches above the ground
level with concrete walls or big plastic or galvanized steel bins
with close fitting lids placed at the corner of the street.

Collection
House to house collection is the best. Dumping at the nearest public bin and later
collected by vehicles with enclosed vans.

Methods of disposal
Dumping controlled tipping or sanitary trench filling, incineration, composting,
manure pits and burial.

Dumping
In low lying lands and areas partly for reclamation of land. Due to bacterial action,
refuse decreases in volume and is gradually converted into humor.
Drawback - being exposed to flies, rodents and other animals, source of nuisance from
its smell and appearance, pollution of surface and ground water.

Controlled tipping
Trench method, ramp method and area method

47
 1- Trench method
Refuse is dump into a trench or other prepared areas and covered with earth.
Level ground. A long trench is dug 6" - 10" deep, 12-36" wide and 6-10ft. Long:
refuse is compacted and covered with excavated earth.

2- Ramp Method
Sloping land. Some excavation is done to secure the covering material.

3- Area method
Used to fill land depressions, disused quarries, marshlands and clay pits. Refuse is
deposited packed and consolidated in uniform layers up to 6-8' deep. Each layer is
sealed with a mud or earth cover at least 12 inches deep. Due to chemical,
bacteriological pathogens are killed and decomposition is hastened. Usually takes 4-6
months for complete decomposition of organic matters.

Incineration
It is done where suitable land is not available. Burning is done with an incinerator.
E.g. Hospital refuses.

Composting
Combined disposal of refuse and night soil or sludge, Under bacteria action organic
matter breaks down with the formation of a relatively stable humus like material known as
compost. Heat produced is about 60' C for several days there by larvae and eggs of flies are
destroyed and pathogenic organisms are killed. It can also be used as manure.

Manure pit - refuse is dumped into a pit along with animal droppings (usually used in
rural areas)
Burial - refuse is buried under the ground

Information, Education and Communication to community regarding sanitary

disposal of solid wastes is important.

48
 CAMP HYGIENE
Field Service Regulations, Vol.1, 1930, Sec.145
The commander of every formation and unit in the field is responsible for the
sanitary condition of the area occupied by his command irrespective of the period for which
it may be occupied, and for the enforcement of all orders regarding health and sanitation.

Different from Barracks

Sanitation in the field differs from that in barracks to a great extent, because troops
are living under more adverse conditions of the hygienic principles are the same however
although their practical application may have to be varied and very often improvised.

Adverse conditions in the field

1. Necessarily crowded - greater opportunities for spread of communicable diseases.
2. Camp period is short. Sanitary methods and appliance have to be improvised, repeated
moves make careless of sanitary rules.
3. No special sanitary departments - carry out own sanitary measures.
4. Fatigue, exposure, scarcity or imperfectly cooked food and unaccustomed climates lower
the soldier's vitality and resistance.
5. Insects- more prevalent, especially when sanitary precautions are relaxed.
6. Water supplies- always liable to pollution, purification methods must be rapid, so
imperfect.

Orders
Orders dealing with sanitation should be published in the form of routing standing
orders and special local orders which should be brought to the notice of all concerned. Once
published, such orders must be enforced strictly, although the willing co-operation of all
ranks, based on knowledge gained from education in sanitary principles, is much more
effective than action enforced by orders.

Requirements for field hygiene

1. Adequate supply of safe drinking water and its protection from contamination, together
with good water discipline of the troops.
2. The protection of all food supplies from contamination, maintenance of the highest
possible standard of cooking and messing.
3. Ventilation of tents or other quarters.
4. Adequate arrangements for washing and disinfestations of the men and their clothing
5. The disposal of excreta, refuse manure and other waste products, also dead animals, in
such a manner as to prevent the introduction or spread of disease the breeding of insects and
the pollution of water supplies.
Diseases such as typhoid and dysentery are brought by the troops themselves and the extent
to which they spread depends more on the sanitation of the camp than on the ground on
which it is situated.

Selection of camp sites

Military necessity must take precedence over everything else in the selection of a
camp site although the proximity of water and the facilities for obtaining fuel and supplies
must be considered whenever possible the following points should be taken into accounts.

49
Points for selection of camps
1. Nature of surroundings- Neighbouring towns and villages may be sources of infection.
Broken ground is frequently an encouragement to bad sanitation and may harbour sand flies,
snakes or vermin. Swamps and the banks of streams may provide breeding grounds for
malaria carrying mosquitoes.
2. Water supply- A good water supply near at the hand is desirable, but, military
considerations of safety may necessitate the camp being placed at some distance from it.
3. Approach- The site should have easy approaches, preferably off the main line of traffic,
and be one that is not likely to become boggy in wet weather or dust tracks in dry.
4. Nature of ground- High ground with good drainage and covered with grass is to be
preferred. Steep slopes should be avoided, but gentle slopes facilitate drainage. Large woods
with undergrowth and low meadows with thick grass are unhealthy. The bottoms of narrow
valleys, ravines and watercourses are liable to flooding and are therefore dangerous. Newly
turned soil is apt to become a quagmire in wet weather or very dusty in dry weather.
Campsites, which have been occupied by other troops within the previous two months
should be avoided if possible.
5. Spaces- Sites should be selected as if for continued occupation, for a temporary camp may
become a permanent camp later. They should be large enough to permit ample spacing yet
not too large, as the difficulties in the sanitation of straggling camps are thereby increased.

The best site for camps

Gentle grassy slopes on fairly high ground with gravel soil, open to the wind but not too
exposed, with good approaches ample and a convenient water supply.
Who select?
By a staff officer in conjunction with an engineer and a medical officer.

Lay-out of camps
1. The front of a camp should face the prevailing wind.
2. The sleeping accommodation should be in front, with kitchens and messing
accommodation nearby at one side.
3. The transport lines for animals and vehicles should be concentrated in special areas in the
rear. This applies particularly to composite camps for several units, where the establishment
of one animal picketing ground for all units has a marked effect in reducing fly breeding.
4. Conservancy area should be concentrated to leeward but not too far away and not in a
situation likely to pollute the water supply.
5. The ablution area and water point should be at one side away from conservancy area and
with drainage so arranged as to prevent the water logging of the camp.
6. The camp roads, allowing easy transit should be so arranged that traffic through the camp
for watering horses and the delivery of supplies does not cover the cooking and messing
areas with manure-filled dust.
7. Surface drainage through the camp should be provided.

50
 AIR POLLUTION

Composition of air
▪ Nitrogen 78.1%
▪ Oxygen 20.93%
▪ Carbon dioxide 0.03%

Air pollution
Air pollution is the pollution of air by dust, smoke, toxic gases and chemical vapours
resulted in various sickness & death.
Foreign substances have been present in the air at all times and at all places. The term
air pollution is applied when there is an excess concentration of foreign matter in the outdoor
atmosphere which is harmful to man or his environment. Air pollution is a growing menace
to health throughout the world.

Sources of air pollution

1. Industrial process: chemical industries, metallurgical industries, oil refineries & fertilizer
factories etc.
2. Combustion: Industrial and domestic combustion of coal, oil and other fuel is another
source of smoke, dust and sulphur dioxide.
3. Motor vehicles: contribute to air pollution by emitting hydrocarbons, carbon monoxide,
lead, nitrogen oxides and particulate matter. In strong sunlight, certain of these hydrocarbons
and oxide of nitrogen may be converted in the atmosphere into a "Photochemical" pollutant
of oxidizing nature.
4. Miscellaneous: Burning of refuse, agricultural activities (Crop spraying, pest control) and
nuclear energy programs.

Pollutants of air
There are more than 100 contaminants. Important contaminants are-
1) Carbon monoxide
2) Sulphur dioxide
3) Lead
4) Carbon dioxide
5) Hydrocarbons
6) Cadmium
7) Hydrogen sulphide
8) Ozone
9) Carcinogenic agents such as Polycyclic Aromatic Hydrocarbons (PAH) etc.
Meteorological conditions such as wind and temperature play a major part in the
dissemination of air pollutants.

Indicators of air pollution

1) Sulphur dioxide
2) Smoke index or soiling index
3) Suspended particles

Other important parameters of air pollution

1) Carbon monoxide
2) Oxidants

51
3) Nitrogen dioxide
4) Lead

Health effects of air pollution

▪ Immediate effect- on respiratory system
▪ Delayed effect
▪ Chronic bronchitis
▪ Primary lung cancer
▪ Other effects
▪ Impairment of human, plant and animal health
▪ Corrosion of metals and building materials
▪ Costs of cleaning and repairing
▪ Cost of research and expenses to control pollution and
▪ Administrative expenses

Prevention and control

1) Containment: prevention of escape of toxic substances into the ambient air
2) Replacement: replacing a technological process causing air pollution by a new process
that does not e.g. Use of electricity and natural gas in place of coal and wood.
3) Dilution: e.g.some air pollutants are readily removed by vegetation the establishment of
green belts between industrial and residential areas is an attempt at dilution.
4) Legislation: many countries have adopted legislation for control of air pollution.
5) International action: to deal with air pollution on a world- wide scale, the WHO has
established an international network of Laboratories for the monitoring and study of air
pollution.
6) Disinfection of air by various methods such as
a. Mechanical ventalation
b. Ultraviolet radiation
c. Chemical mists (Triethlene glycol capors-dffective air bactericides, particularly
against droplet nuclei and dust) and
d. Dust control

52
 PEST CONTROL
PEST
A pest is a destructive or troublesome animal (or thing). Pest which consists of
Arthropods, Rodents, Weeds, Fungi, Herbs, etc, comprise the most numerous and varied of
the living things in the environment of man. Some of them live close to man and act as
vectors of carriers of disease.

INFESTATION
Infestation means the lodgment, development and reproduction of arthropods on the
surface of the body or clothing. E.g. Louse infestation.

ARTHROPODS
Arthropods are organisms having a hard, jointed exoskeleton, and pairs of jointed
legs. Some has wings, some wingless.
Class 1. Insecta
Class 2. Arachnida
Class 3. Crustacea

Class 1 Insecta
1) Mosquitoes, e.g. Anopheles, Aedes, Culex
2) Flies, e.g. House flies (Musca domestica), Sand flies, Tsetse flies, blackflies.
3) Human Lice, e.g. head lice and body lice
4) Fleas, e.g. Rat fleas, Sand fleas.
5) Bed bugs.

Class 2 Arachnida
1) Ticks.
a. Hard ticks
b. Soft ticks
2) Mite. E.g. Trombiculid mites, Itch mite.

Class 3 Crustacea
1) Cyclops

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 ARTHROPOD BORNE DISEASES

Class Arthropod Disease transmitted

I. Insecta
1) Mosquitoes Anopheles Malaria
Culex Filariasis, viral diseases, JE
Aedes Yellow fever, DHF
Mansonoides Malayan filariasis

2) Flies 1) House flies Enteric fever

Dysentery
Diarrhoea
Cholera
Gastroenteritis
Amoebiasis
Helminthic infestations
Poliomyelitis
Conjuctivitis
Trachoma
Anthrax
Yaws

2) Sand flies Kala-azar, sand fly fever

3) Tsetse flies Sleeping sickness

3) Human lice Head and body lice Epidemic typhus, relapsing

fever, trench fever

4) Fleas (Rat fleas) Rat fleas Bubonic plague, endemic

typhus

5) Reduviid bugs Small flat blood sucking Chagas disease

insects
II. Arachnida

1) Tick Hard ticks Tick-typhus,

viral encephalitis
Soft ticks Relapsing fever

2) Mite Trombiculic mite Scrub typhus

Itch mite scabies
III. Crustacea

1) Cyclops Fish tapeworm Fish tapeworm

Guinea worm Guines-worm

54
Types of transmission of Arthropods Borne diseases
Three types of transmission cycles are involves in the spread of Arthropod borne
diseases.
(1) Direct Contact
In this method of spread, the arthropods are directly transferred from man to man
through close contact e.g. Scabies, pediculosis.
(2) Mechanical transmission
The disease agent is transmitted mechanically by the arthropods. e.g. the
transmission of diarrhea, dysentery, typhoid, food poisoning, and trachoma by the house fly.
(3) Biological transmission
Here the disease agent undergoes either cyclical change e.g. filariasis; or multiples
but no cyclical changes e.g. plague bacilli in rat fleas, or undergoes both cyclical changes as
well as multiples in the body of the arthropod host. e.g. malaria parasite.

ARTHROPOD CONTROL
The general principles of arthropod control are:
1. Environmental control
2. Biological control, often refer as bio-environmental methods
3. Genetic control
4. Chemical control
5. Newer methods
1. Environmental control (Environmental Management)
Environmental modification
A form of environmental management consisting in any physical transformation that
is permanent or long lasting of land, water and vegetation aimed at preventing, eliminating
or reducing the habits of vectors without causing unduly adverse effects on the quality of the
human environment. e.g. Drainage, filling, land leveling, transformation and impounded
margins. Proper operation and adequate maintenance are essential for effective functioning.
Environmental manipulation
A form of environmental management consisting in any planned recurrent activity
aimed at producing temporary conditions unfavorable to breeding of vectors in their habits.
e.g. Water salinity changes, stream flushing, regulation of the water level in reservoirs,
dewatering or flooding of swamps or bogy areas, vegetation removal, shading and exposure
to sunlight, etc.

2. Biological control
It consists in the utilization of natural enemies and biological toxoids. It minimizes
environmental pollution.
▪ Larvivorous fish→ Gambusia afinis, Tilapia species, Poecilia reticularis
▪ Invertebrate predators→ Nematodes, Protozoa, Fungi
▪ Bacteria: Bacillus thuringiensis H-14 produces toxins lethal to larva

3. Genetic Control
Several methods are studied under laboratory conditions. e.g. Sterile male technique,
cytoplasmic incompatibility and chromosomal translocation.

4. Chemical Controls
It will be discussed according to specific vector control.

55
5. New Methods
▪ Insect growth regulator: Insect juvenile hormones (plant products, terpenoid;
Methoprene)
▪ Chemosterilants
▪ Sex attractants (Pheronomes)

MOSQUITOES
Two winged insects, more than 1500 species- two great division or tribes
▪ Anophelines→ smaller tribe and are vectors of human malaria
▪ Culicines → larger tribe and vectors of viral diseases and filariasis.
But not all are vectors.

ANOPHILINES
▪ A. minimus- slow running streams
▪ A. dirus- shady areas
▪ A. culicifacies- plains
▪ A. sundaicus- brakish water
▪ A. stephensi- wells (over head tanks)

CULICINES
▪ C. pipien fatigans- polluted water
▪ C. tritaeniorrinchus

AEDES
▪ Aedes aegypti
▪ Aedes albopictus

Life cycle of Mosquitoes

Mosquitoes develop in two different environment conditions.
1) Immature stages: (Eggs, Larva, Pupa) aquatic environment.
2) Adult mosquitoes: aerial and terrestrial environment.

MOSQUITO CONTROL MEASURES

І. Anti larval measures
П. Anti adult measures
Ш. Protection against mosquito bites
ІV. Health Education and community involvement

І. Anti larval measures

(A) Environmental control to eliminate their breeding places ( source reduction )
▪ Minor engineering methods
▪ Filling lands
▪ Leveling of ground
▪ Drainage
▪ Water management- intermittent irrigation
▪ Change salinity of water
CULEX
▪ Adequate collection, removal and disposal of sewage and waste water
▪ Town planning

56
AEDES
▪ Get rid of water holding containers; piped water supply

ANOPHELES
▪ Environmental control of breeding places
▪ Man made malaria (irrigation channels, garden pools, engineering projects, Dams
etc) leads to breeding of mosquitoes.

(B) Chemical control: larvicides

(1) Mineral oils-diesel, fuel, kerosene, crude oil

▪ Spread thin film, cut air supply, toxic action to larva and pupa
▪ Once a week on breeding places
▪ Disadvantages-unfit for drinking, kills fishes
(2) Paris green (copper acetoarsenite)
▪ Stomach poison for larvae
▪ Mainly kills anopheles larva
(3) Synthetic insecticides
▪ fenthion, chlorpyrifos, abate
▪ Organo chlorine compounds are not recommended to use

(C) Biological control

▪ Small fish feeds on larvae- Gambusia affinis, Poecilia reticularis

П. Anti adult measures

(A) Residual spray
Adult mosquitoes are most commonly controlled by spraying houses with residual
insecticides. DDT is used in the dosage of 1-2g per sq.m applied 1-3 times a year to walls
and other surfaces where mosquitoes rest. In area of DDT resistance malathion and propoxur
(OMS-33) and to a lesser extent gamma HCH (lindane) can be used. Resistance to
insecticides should be tested periodically.
(B) Space spray
Insecticides are sprayed into the atmosphere in the form of a mist of fog to kill
insects. Commonly used spaced sprays are;
(1) Pyrethrum extract: an extract of pyrethrum flowers, the active principle (pyrethrin) is a
nerve poison and kills insects instantly. It is sprayed using 1% solution at a dosage of 1oz
per 1000su.ft. of space. Doors and windows are kept closed for half an hour. For domestic
purpose, Flit fun with a fine nozzle can be used. For large-scale application, power sprayers
or “aerosol” dispensers can be used. Pyrethrum however has no residual action.
(2) Residual insecticides: Malathion and Fenitrothion can be used for ULV (ultra low
volume) space spraying using spraying machine, and fogging by fogging machine.

(C) Genetic Control

In recent years control of mosquitoes by genetic methods such as Sterile male
technique, Cytoplasmic incompatibility , Chromosomal translocation, Sex distortion, and
Gene replacement have been explored and their uses is still in the research phase.

57
Ш. Protection against mosquito bites
(A) Mosquito net
The size of the openings in the net is of utmost importance- the size should not
exceed 0.0457 inch in any diameter, a number of holes in one square inch is usually 150.
(B) Clothing- adequate
(C) Screening
Screening of buildings with copper or bronze or plastic gauze having 16 meshes to
the inch is recommended. The aperture should not be larger than 0.0457 inch.
(D) Repellents
Ethyltoluamide is an outstanding all purpose repellent. Other repellents are; Indalone,
Dimethyl phthalate, Dimethyl carbate, Ethyl hexanediol etc.

ІV. Health education and community involvement

It is only through health education that people can be motivated with a desire to get
rid of mosquitoes permanently.

HOUSE FLY CONTROL

Houseflies (Musca domestica) are commonest and the most familiar of all insects
which live close to man. They are regarded as sign of insanitation.
Life cycle of House fly:
There are 4 stages. Egg, larva, pupa and adult.
1) Eggs
▪ They lay eggs in moist decaying organic matter such as human and animal
excreta, manure heaps, garbage and vegetable refuses. The eggs hatch in 8-
24 hrs. During summer it may hatch within 3 hrs.
2) Larva
▪ They migrate to dry outer regions. It lasts 2-7 days.
3) Pupa
▪ Developed in 3-6 days.
4) The adult
▪ Egg to adult: It may take 5-6 days or 8-20 days. ( During winter ).

Habits of house fly

1. Breeding habits: The most important breeding places of flies are: (1) Fresh horse manure
(2) Human excreta (3) Manure of animals (4) Garbage (5) Decaying fruits & vegetables
(6) Rubbish damps containing organic matter (7) Ground where liquid wastes are spilled.
2. Feeding Habit: does not bite. It is attracted to food by sense of smell. Can not eat solid
foods, it vomits on solid food to make a solution of it and sucks in a liquid state.
3. Restlessness: moving activity between filth and food, and thus spread infection
mechanically.
4. Vomit drops: The fly vomits frequently.
5. Defecation: It defecates, constantly all the day.
6. Dispersal: It may fly up to 4 miles.
7. Resting habit: They have tendency to fly toward light.

Transmission of Diseases
Flies are potential vectors of many diseases by
1) Mechanical transmission
2) Vomit Drops: (Rich bacterial culture )
3) Defecation- deposits countless bacterial on exposed food.

58
GENERAL CONTROL OF HOUSE FLY
(1) Environmental control
The best way to control house flies is to eliminate their breeding places by improving
the environmental sanitation.
a. Proper storage or refuse in bins.
b. Efficient collection, removal and disposal of refuse by incineration
composting and sanitary land fill.
c. Provision of sanitary latrines. E.g. pit latrine, septic tanks, water seal
latrines and sanitary sewage system.
d. Stopping open air defecation
e. Sanitary disposal of animal excreta
f. Stepping up general sanitation.

(2) Insecticide Control

a. Residual spray-DDT
b. Baits
c. Cords and ribbons
d. Space sprays
e. Larvicides

a. Residual spray- DDT

Susceptible flies – may be killed by DDT (5%)
- Methoxychlorine (5%)
- Lindane (0.05%)
- Chlordane (2.5%) fenthion (2.5%) malation, (5%)- may be used.

b. Baits- poisoned baits containing 1-2% of malathion, (solid/ liquid) dichlorvos, runnel and
dimethoate.

c. Cords and ribbons runnel and dimethoate.

d. Space sprays- DDT or HCH

e. Larvicides (such as 0.5% diazin, 2% dichlorovos, 2% dimethoate)

(3) Fly papers- Sticky fly-papers are useful adjuvant to other methods.

(4) Protection against flies

▪ Screening of house, hospitals, food markets, etc.
▪ Screening is expensive for general use.

(5) Health Education

▪ Difficult to achieve control without community involvement.
▪ Require organized individual and community effort.
▪ It is only through Health Education that people can be motivated with a desire to get
rid of flies permanently.

59
 FLEAS

Fleas are small, bilaterally compressed wingless insects with a hard chitinous
exoskeleton and covered with backwardly directed strong bristles.
Rat fleas (a) Xenopsella Cheopis (b) Xenopsella Astia (c) Xenopsella brasiliensis

Life cycle: There are 4 stages. Egg, larva, Pupa and adult.

Fleas and Human Disease

(1) Plague (bubonic)
(2) Endemic or Murine typhus

Mode of transmission
Fleas conveys disease by:

Biting: the main method of transmission in the case of plague, is by the bite of hungry
blocked fleas. Some fleas which ingest plague bacilli become blacked due to the
multiplication of plague bacilli in their proventriculus (or) stomach. Fleas affected in their
way are called “blocked fleas”. The blocked of the food passage renders the flea unable to
obtain further blood feeds. Because of hunger, the flea begins to bite more ferociously and
makes frantic efforts to suck blood. Each time it bites, instead of sucking blood, it injects
plague bacilli, into the wound. Such blocked fleas play a great role in the spread of plague.

Mechanical transmission:
Mechanical transmission takes place from the proboscis of the fleas, which had recently fed
on an infected rodent.
Faeces: The fleas are apt to defecate while feeding. The faecal drop of infected flea may
contain numerous bacilli. When the host scratches over the flea bitten area, there in direct
inoculation of the infectious agent into the entry spot.
Flea Indices
The following indices are used in flea surveys.
1. General flea index- It is a average number of fleas of all species per rodent.
2. Specific flea index ( X-Cheopsis index, X-astia index etc )
It is percentage of flea of each species, found per rodent.
3. Percentage index of flea species.
It is percentage of flea of each species, found per rodent.
4. Rodent infestation rate
It is the percentage of rodent infested with various flea species.
Flea indices do not in themselves indicate an eminent plague epidemic. Situation should
plague outbreak over in an epidemic area. Specific flea indices are more significant than
overall flea indices.

Control of fleas
(1) Insecticide control- 10% DDT powder dusting over the rat runs and burrows to come into
contact with the furs of the rat and thus kills fleas. In DDT resistant areas, carbaryl or
diazenon (2%), or malathion (5%) is effective. Sprays should be applied to floors and walls
up to the height of 3 feet. Insecticide dust can also be blown into rodent’s burrows. Places of
dogs, cats should also be treated with insecticide dusting, spraying.
(2) Repellents- Diethyltoluamide repels fleas and Benzyl benzoate is also a good repellent.
(3) Flea control should be followed by rodent control.

60
 INSECTICIDES

Insecticides : Substances used to kill insects.

Pesticides : Chemicals used to kill pests including Insecticides, Rodenticides, Fungicides,
Herbicides and Germicides etc.

Classification
a) Contact Poisons- kill insects primarily by contact
i) Natural- Pyrethrum, nicotine, mineral oils
ii) Synthetic- Organo- chlorine, Organo- phosphorous and Carbamates
b) Stomach Poisons- kill insects when they ingest
i) Paris green
ii) Sodium fluoride
c) Fumigants- kill insects by emitting vapors
i) Hydrogen cyanide
ii) Sulphur dioxide
iii) Methyl bromide and
iv) Carbon disulphide
d) Repellents- repel insects by their smell
i) Benzyl benzoate
ii) Metadelphane ( Repito ) etc
This classification is by no means rigid. Contact poison can also be a stomach
poison.

Synthetic Insecticides
1) Organochlorine compounds- Nerve Poisons
▪ DDT
▪ HCH (BHC)
▪ Lindane (Gamma HCH )
▪ Dieldrine
▪ Aldrine
2) Organophosphorous compounds- Interfere nerve impulse transmission
▪ Malathion
▪ Fenthion
▪ Fenitrothion
▪ Abate (Temophose)
▪ Dichlorvos
▪ Chlorphoxim
3) Carbamates
▪ Carbaryl
▪ Propoxor
(1) D.D.T
Identification
DDT is a white, amorphous, waxy powder with an aromatic smell. It is insoluble in
water but soluble in most organic solvents and oils.
Action
Contact poison permeates through cuticle after dissolving in waxy covering of feet
leading to paralysis of legs, wings, convulsions and death. It takes several hours to kill by
acting on the nervous system (Slow action). It usually last about 6-18 months (Residual

61
action) and it varies with treated surface. Toxicity to LD50 is 113 mg/kg through oral and
2510 mg/kg through dermal. DDT is moderately hazardous.
Application
▪ Standard dose of indoor residual spray is 2 gm/m2 of the treated surface every 6
months.
▪ As dust (5-10%) for lice, fleas, ticks and bugs.
▪ DDT is first used in Myanmar since 1945. It is still most widely used insecticides.
Nowadays it is regarded as “Persistent Environmental Pollutant”. It persists in environment
and has adverse effect on animals. E.g. Disturb Carbon dioxide ,metabolism in Birds.

(2) HCH
Properties
Powder, white or grayish with musty smell which is not pleasant and is irritating to
eyes, nose and skin. Active ingredients is gamma isomer. Pure HCH contains 90% gamma-
isomer (i.e. Gamma HCH or Lindane)
Action
Contact poison. It is more insecticidal (dose 25-50 mg Gamma-HCH or 100 mg HCH
per sq. ft) but less residual (3-6 months) compared to DDT. Toxicity to LD50 is 88 mg/kg
through oral and 900 mg/kg through dermal. HCH is moderately hazardous.
Use
Vector control as well as agricultural use.

(3) Malathion
Whereas most of the organophosphates are very toxic to humans, the toxicity of
malathion is relatively low (slightly hazardous; LD50 2100 mg/kg)
Properties
Liquid, yellow or clear brown with an unpleasant smell.
Action
It has immediate knock- down action but has weak residual action (Dose
200mg/sq.ft. every 3-6 month)
Use
As ultra low volume spray to kill adult mosquitoes in Dengue Haemorrhagic Fever
and sometimes Japanese Encephalitis.

(4) Abate (Organophosphorous-Temphos)

Properties
Highly active against the aquatic larvae of mosquitoes and other insects. This
compound is highly effective against various species of mosquito larvae, including those
resistant to other insecticides. Liquid, brown and viscous, soluble in petroleum solvents or
mixed with sand
Action
Low toxicity thus applied in domestic water container.Its toxicity to fish, bird and
mammals is very low(unlikely to present acute hazard; LD50 8600 mg/kg).
Use
Larvicide in DHF control. This treatment can be repeated at intervals of 2-3months.
Dose
It is also used in liquid form as an emulsion at a rate of 37-100 ml per hectare and in
granular form of 2 percent concentration at between 5 kg and 20 kg per hectare, depending
on the type of water and the amount of aquatic vegetation.

62
(5) Fenthion (organophosphorous)
Properties
Liquid, brown with garlic smell.
Action
Effective, residual insecticide (Dose 100mg/sq.ft) Very powerful larvicide However
because of its toxic hazard to sprayers, fenthion is not suitable for routine indoor spraying.
(highly hazardous; LD50 330 mg/kg)
Use
Larvicide in Filariasis control (1ppm in polluted water) (Culex Fatigans)

(6) Pyrethrum
Properties
Kerosene extract of natural flower
Action
Never poison, contact poison, immediate knock-down effect, no residual effect.
(Moderately hazardous; LD50 500-1000 mg/kg)
Use
As space spray for mosquito and other insects
Pyre-D
Pyrethrum and DDT are added for synergistic action (Residual and Knock Down)

(7) Pyrethroid
The first useful synthetic pyrethroid came from the USA in 1969; it was the generic
name of allethrin. These compounds are more stable when exposed to sunlight. Their acute
toxicity to mammals is generally low. The insecticidal activity (knock-down and kill) of
synthetic pyrethroids is high.
As already mentioned, the pyrethroids are being used increasingly for the
impregnation of mosquito nets and curtins and the formulation available for residual
spraying.Permethrin, a safer pyrethroid (moderately hazardous; LD50 500 mg/kg). It is also
stainless and odorless.

(8) Carbaryl
It is used as agricultural insecticide. Dosage is 1-2 g/m2. It is classified as moderetely
hazardous, with an LD50 of 300 mg/kg.

(9) Mineral oils

Kerosene, crude oil and malarial oil had been used to kill mosquito larva and pupa.
By applying on the surface of the water, oil suffocates the aquatic stages of the mosquitoes,
but it also injured the vegetation and fish.

Stomach poison
(10) Paris green (Copper acetoarsenite)
Properties
Micro-crystalline, emerald green powder, insoluble in water
Action
A stomach poison

Uses
Spray on the surface of the water to kill surface feeders (Anophelines) and had been
used extensively before DDT was used.

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INSECTICIDES AND THEIR USES IN VECTOR CONTROL

The use of insecticides for the control of malaria and other vector-borne diseases
acquired great impetus with the advent of DDT and other organochlorine compounds in the
late 1940s. Their use in public health increased in extent and intensity with the worldwide
program of malaria eradication which was initiated in 1956/57. The residual insecticidal
effect of some of these chemicals made it possible to sustain and attack on the malaria
vectors by vectors by means of the periodic indoor spraying of houses.

Residual spraying
Residual spraying is still the most effective and feasible method for the chemical
control of mosquito vectors of malaria. For the control of other mosquito-borne diseases, the
use of this method is rather limited.
The technique consists in spraying insecticides that have 3 persistent effects on all
surfaces where mosquitoes are likely to rest the inside walls and ceilings of houses, barns.
The duration of the residual effect usually varies from a few weeks to over a year. The attack
is mainly directed to those endophilic mosquito vectors.
For eradication of malaria, which implies the interruption of transmission for a
sufficient number of years, the spraying coverage of the structures should aim at being total,
complete and sufficient.
Residual insecticides are usually applied by means of a hand compression sprayer.

Organochlorine compounds
The most common are DDT, dieldrin and HCH. They are applied in solution,
emulsion or suspension as a water-dispersible powder.
Water dispersible powders have proved to be the most convenient for field use as
they may be mixed with water in the rural areas immediately before application.
DDT was the insecticide most widely used in anti-malarial programs.
Dieldrin is a very effective insecticide but is more expensive than DDT and has
higher toxicity to man.
HCH is less toxic than dieldrin, the residual effect is shorter and it has an airborne
insecticidal effect.

Organophosphorous compounds
The development of vector resistance to organochlorine compounds left to the use of
the organophosohorus and carbamate groups as substitutes. They are more expensive and are
usually more toxic to man and often have a shorter residual effect than the organochlorine
compounds used in public health programs. These three factors contribute to higher
operationalcosts, more frequently cycles of applications, greater bulk to be transported and
more costly safety measures and equipment.
Among this group of compounds, alathion is the insecticide most widely used.
Fenitrothion is another organophosphorus compound of longer residual effect than malathion
but of higher cost and toxicity, its used in residual spraying is increasing.

Carbamate compounds
Propoxur is a carbamate compound that is highly toxic to mosquitoes and has an
airborne effect. Its high cost limits it’s used.

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Larvicide
Temephos (Abate) is a commonly used larvicide. It has
 Low mammalian and fish toxicity
 Lower cost compared to oils
 Efficient at lower dosage

Due to its properties, it is commonly used in Aedes control programs

Fenithion and chlorpyrinphos are also used as larvicides, particularly against
Culcines breeding in polluted waters. Their toxicity is higher and they must therefore be
used with care and caution.

Space spry application

The attack on the adult mosquito by applying atomized insecticide droplets in
indoors space where mosquitoes may be flying or resting is not new. The Flit gun has been a
household tool for mosquito control for over half a century.
The most recent household type of aerolol dispenser is a great improvement. The
mist produced contained minute droplets that remain airborne for perions long enough to dill
flying mosquitoes. Pyrethrum and pyrethroid compounds, dichlorvos and similar insecticides
are widely used as aerosols.
The application of insecticides to open spaces by the production of a mist or fog of
sufficient insecticidal efficacy to destroy adult mosquitoes in their resting and flying areas
require sophisticated equipment, skilled manpower and a high degree of organization and
managerial efficiency, they are appropriate only for urban areas, emergency situations due to
epidemic or places where other simpler methods are inadequate.
The ultra-low volume (ULV) technique of space application of insecticides consists
in applying highly concentrated or technical (undiluted) compounds to the air in the form of
minute liquid particles.
Malathion, pyrethrum compounds and haled are commonly used in mist for or ULV
application.

Dusting
Rondenticides and insecticides for rat fleas can be applied by dusting. Horn seeder
used to lay seeds on ground had been used for dusting insecticide granules. Hand duster,
bellows and knap sack duster are now used.

Personal protection (Chemical)

▪ Repellents used to repel insects by their smell lasting 1-2 hours. e.g. Benzyl
Benzoate, Methadelphene (Repito).
▪ Impregnated bed- nets: the new method using Permethrin to soak bed nets at a dose
of 200 mg per square meter of fabric (1 gm/ net) is an effective measure.
▪ Mosquoto coil: using Pyrethrum, pyrethroid and DDT may last for about 7-10
hours with over discarge of fumes whicg kill insects.
▪ Fumigation mat: on electric heating plate may last for 8 hours but have uneven
discharge, the more when the mats were first healed.
▪ Aerosol spray: in pressurized can or flit gun containing pyrethrum can be used for
personal protection.

65
 Disinfection and Disinfectant
Disinfection - is killing of infectious agent outside the body by direct exposure to chemical
or physical agent. Not necessarily kill all microorganisms, but reduce them to a level not
normally harmful to health. Disinfectant usually does not destroy bacteria spore.

Disinfestations- Any physical or chemical process serving to destroy or remove undesired

small animal forms, particularly arthropods or rodents, present upon the person, the clothing
or in the environment of individual or on domestic animals. Disinfection includes delousing
for infestation with body louse.

Detergents is surface cleaning agents, which acts by lowering surface tension

e.g. soap which removes bacteria along with dirt.

Antiseptic is a substance, which destroys or inhibits the growth of microorganisms.

Antiseptics are suitable or application to living tissues e.g. alcohol, hibitane.

Deodorant is a substance which suppresses or neutralizes bed odour e.g. lime and bleaching
powder.

Sterilization is the process of destroying all microbial life including spores.

Types of disinfections
1. Concurrent disinfection
Immediate destruction of micro-organisms present in the infectious material through
out the course of illness. it consist mainly of disinfection of urine, feces, vomits, infected
linen and clothes, hand etc.

2. Terminal disinfection
Disinfection of infectious materials after the recovery of or death of the patient. It
includes disinfection of the room, premises and articles that have been in contact with the
patients.
3 Precurrent (prophylatic) disinfection
Disinfection of water by chlorine, pasteurization of milk and hand washing may be
cited as example of precurrent disinfection.

Disinfectants
Disinfectant or germicide is a substance, which destroy harmful microbes to prevent
transmission of the disease. Disinfectants are suitable for application only to inanimate
objects.

Classification
1 Natural (a) Sunlight
(b) air
2 Physical
(a) Dry heat - burning, hot dry air.
(b) Moist heat - boiling, steam.
(c) Radiation - ionizing radiation, ultraviolet rays.

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3 Chemical
(a) Solids - lime, bleaching powder, potassium permanganate
(b) Liquids -Formalin, coal tar derivatives e.g. Phenol, lysol, cresol,
(c) Gases -formaldehyde
1. Natural
(a) Sunlight
Direct and continuous exposure to sunlight is destructive to many diseases producing
organisms. The Ultraviolet rays of sunlight (does not penetrate glass) are particularly lethal
to bacteria and some viruses. Articles such as linen, bedding and furniture may be
disinfected by exposure to direct sun light for several hours.
(b) Air
Exposure to open air (airing) act by drying or evaporation of moisture, which is lethal
to most bacteria.
Note - In general natural agents cannot be totally depended upon for disinfection.

2. Physical
(a) Dry heat
Burning
An excellent method of disinfection
Inexpensive articles such as dressings, rags and swabs can be disposed by burning;
by mixing with saw dust.
Hot dry air
Hot air has no powers of penetration. Its use is limited to disinfection of certain
articles such as glass ware ( syringe, petridishes ), sharp instruments ( as they may be
damaged by moist heat ), swabs and dressings. The air in the oven should be
maintained at 160'C for at least 60 minutes.

(b) Moist Heat

Boiling
an effective method
boiling for 5-10 minutes kill all germs but not spores or viruses.
to ensure destruction of bacterial spores, one needs T above 100'C
suitable for disinfection of small instruments, tools, linen and goods such as
gloves.
Drawback of boiling are, slow process, unsuitable for thick bedding and woolen
materials.
Autoclaving
Sterilizers which operate at high T' (in excess of 100C) and pressure are called
autoclaves. They generate steam under pressure (saturated steam), which is the most
effective sterilizing agent. Steam attains higher Temperature under pressure has
greater power of penetration. Absolute sterility can be obtained by Temperature over
133C and 13 lbs/ sq inch. The most effective method for sterilization of linen,
dressing, glove, syringe, certain instrument and culture media.
(c) Radiation
-have the advantage of combining great penetration power, with little or no heat
effect of object to be sterilized.
-bandages, catguts, dressings and surgical instruments can be sterilized by ionizing
radiation
-most effective, but very costly.

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3. Chemical
(a) Solids
lime
cheapest of all disinfectants
used in the form of fresh quick lime (or) 10 – 20 %
aqueous suspension as milk of lime
feces and urine can be disinfected by mixing 10 – 20 % aqueous suspension of
lime for 2 hours
Also used for white washing for disinfection of walls.
Bleaching powder
good disinfectant
good sample of bleaching powder contains 33% of available chlorine
draw back is unstable and loses active chlorine on storage
used for disinfection of feces, urine, sputum, pus, water and room.

Potassium permanganate
- weak solution of potassium permanganate can be used for disinfecting
contaminated vegetables and fruits

(b) Liquids
Formalin
Formalin (4% solution) can destroy all forms of micro-organisms including spores.
-may be used as 2% to 3% solution (20 – 30 ml of formalin in one litre of water) for
spraying rooms, walls and furniture.
It does not injure fabrics.
Phenol
Pure phenol (or) carbolic acids occurs in crystalline form pure phenol is effective
Crude phenol, which is a mixture of phenol and cresol is cheap and efficient
disinfectant. It may be used in not less than 10% strength for disinfection of faeces.
Cresol
An excellent coal-tar disinfection
-3 to 10 times powerful as phenol.
-used as 5 to 10% strength for disinfection of feces, sputum, etc.
Dettol
It is non-irritating when in contact with skin and mucous membrane but inactivated
by organic matter.
For disinfection of instrument and plastic equipment
Contact period is at least 15 minutes

(c) Gases
Formaldehyde
Most commonly used for disinfection
It is generated by pouring liquid formalin over crystals of potassium permanganate
placed in a deep pan or bucket.
About 300ml of formalin and 45 grams of potassium permanganate are required for
1000 cu ft of space.
The room is kept closed for 6 to 12 hours to allow disinfectant.

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RECOMMENDED DISINFECTION PROCEDURES

Faeces and urine

Faeces and urine should be collected in impervious vessels and treated with a
disinfectant for at least 2 hour. One of the following disinfection may be selected and added
to an equal amount of the faeces or urine.
Faeces should be broken up with a stick to allow the disinfectant to act.
If the following disinfectant are not available hot water to cover the mass of faeces
with about one four the total bulk of quicklime may be added, mixed together and left for 2
hours. If no other agent is available a bucket of boiling water may be added to a stool that is
then covered and allow standing until cool after disinfected the excreta matter may be into a
drain or buried in ground.

Sputum
This is best received in gauze or paper handkerchiefs and destroyed by burning. If the
amount is considerable (as in a large TB hospital) it is best disinfected by autoclaving for 20
minutes at 20 1bs pressure. Alternatively, 5 per cent cresol may be used.

Room
(a)The room and other hand surfaces should be washed copiously with soap and
water and left open for 48 hours. When possible, the room should be exposed to
direct sunlight for several hours.
(b) For chemical disinfection, floors and walls may be mopped with
2 1/2 per cent cresol, 4 per cent phenol or 10 per cent formalin and left for at least
4 hours before a final washing with water.
(c) When fumigation is practicable, rooms can be safely disinfected by exposure
to formaldehyde vapour for 6 hours. This can be accomplished by boiling commercial
formalin in tow volumes of water (500 ml of formalin plus, l liter of water per 30 cubic
meters of space) or by adding potassium permanganate to commercial formalin in large
jars (170 –200 g to 500 ml of formalin plus one liter of water for 30 cubic meters of
space)

Linen
Bedclothes, covers and towels should be boiled or steam disinfected. Linen soiled
with excreta should be soaked in a disinfectant (2 1/2 per cent cresol) for 12 hours before
being washed, otherwise a permanent stain will result.

Dead bodies
When there is a possibility of transmission of disease, dead bodies may be wrapped
in a bed sheet soaked in 10 % formalin or 5 % phenol while awaiting disposal.

Instruments
Cutting instruments like knives and scissors should received chemical sterilization by
keeping them soaked in Lysol or carbolic acid. Boiling in water or autoclaving should be
avoided, because such procedures blunt their edges and impair the utility.

69
 MANAGEMENT OF FAIRS AND FESTIVALS
Types of fairs and festival may be of two kinds. It may be-

1. Permanent: Through out the years and attracts large number of people,
E.g. Kyaik Hti Yo and Shwe Set Taw Pagoda festival.

2. Temporary: At certain time only where people gathered.

E.g. National day celebration: city pagoda festival.

In Myanmar, the land of pagoda, pagoda festivals are placed where people from all
over the country of different places gathered. Some of the pagoda festivals are "Gazetted
festival" which was held regularly each year. Some may be celebrated.

Whatever the type of) Fairs and Festivals), the Township Medical Officer of Health
officer concerned is called upon to manage the situation of festivals with the following
objectives:

1. To prevent the occurrence of outbreak of diseases at the site of F & F.

2. To prevent the spread of diseases, endemic in that area, to other parts of the
country after returning from the F & F.

In addition the F & F are places where health information and education can be
dispersed by exhibitions and displays.

Whatever the type of F & F, sanitary measures are important. Festivals vary in its
nature and character. So, it is not possible to lay down fixed rules for all F & F. Sanitary
measures to be carried out depend on local conditions.

In every festival, the plan of action should be drawn beforehand. For the effective
management of F & F regarding sanitation and prevention of spread of diseases the
following measures are done.

1. Organization

Arrangement must be done well and advanced. As health department alone can't do
all, it is necessary to have inter-department co-operation with other departments and
associations, such as local authorities, military and police officers, trustees of pagodas,
village elders and public welfare associations.

Plan of action includes allocation of responsibilities and arrangement for

emergencies. Adequate staff should be available for sanitary inspection and prevention of
disease. Besides the basic health service staff, such as HA, PHS I & II, LHV or MW's, labor
should be made available, as well as the NGO's such as members, concerning disease
prevention.

It is also important to have adequate funds to cover the expenditure during and after
the festival. Committee and subcommittee are formed to carry out various functions of the
festival.

70
2. Site selection

The site should have natural drainage; safe and adequate water supply; and well
shaded. Land should be cleared of jungle or dense vegetation. The area must not be water
logged. Craters and pools of water, if any, should be filled.

The location of the festival is usually placed on both sides of road. These from the
main road of the festival, and cross roads are made to from sections or blocks. Such blocks
are kept under supervision of one or more sanitary inspectors.

3. Accommodation

Both are allocated facing the main road. Behind the booths will be he blocks reserved
for residence of pilgrims.

Space should be arranged for the responsible departments such as health

departments, the dispensary, Red Cross, the police, etc.

Lodging house for the pilgrims should have good ventilation, lighting and drainage.
It should have some privacy and have access to safe and adequate water supply, sanitary
latrines and proper refuse disposal. The accommodation demand proper planning and regular
inspection to ensure the following standards; the room should have 10% of the floor area;
separate sanitary conservancies are provided for each lodging house, in ideal situations.

Waiting sheds for the non-residential pilgrims are to be constructed.

4. Sanitary arrangement

(a) Supervision: The whole area is divided into blocks and the sanitary
inspector, who will be HA or PHS I or II charges each bocks. The number of supervisor or
inspector and the sweepers and labor under their control should be calculated on the basic of
the approximate number of people likely to be present at the occasion.

Fund should be estimated for the necessary sanitary arrangements. The sanitary
facilities should be completed before the commencement of the festival.

(b) Safe, adequate and wholesome water must be provided to prevent the
occurrence and spread of water-borne diseases, for instance, cholera, viral hepatitis, etc, by
careful inspection and supervision.

In urban areas, water supply through pipes from the central water supply would
ensure safe and adequate water supply. In rural areas, water from the protected tanks and
wells can be used. However, river water should not be allowed to use. If require, all water
sources should be chlorinated, or super-chlorinated in emergency situations, Drinking water
can be chlorinated by using stock-solution of bleaching power.

(c) Sanitary disposal of excreta and refuse

For efficient conservancy, adequate number of sweepers and laborers should be

employed.
Latrines Should not be too far from the accommodations, but well lighted, and
separated for sex, -

71
 The seat user ratio should be 1:500 for day visitors or 1:100 for residential pilgrims.
Shallow trench latrines are suitable for temporary festivals in rural area, whereas, deep
trench latrines be installed for permanent pagoda festivals.

Urinals : are provided as a ratio of 1 for 500 people.

Refuse and garbage's should be collected regularly and disposed properly. Garbage from the
food stalls should be collected in covered bin. Refuse are disposed by burning or dumped in
a large pit, which is covered with earth every day. Liquid refuse are disposed in soakage pits.

(d) Pest control

Files should be completely wiped out. DDT, gammazine, malathion, and pyrethrum
should be used to eliminate the breeding places. Mosquitoes control measures are to be
carried out if require.

5. Pure and wholesome food

Inspectors in-charge of the block should examine all kinds of food including milk,
fish, meat, fruits and vegetables. Arrangement should be made for supply of pure and whole-
some food. Inspection and examination should be done concerning food storage,
transportation, processing, handling, and distribution. Care should be taken to ensure
protection of prepared food and cut fruits against dust and files. Garbage and refuses from
the food stall should be properly disposed.

6. Daily inspection

It is utmost important to inspect the sanitary conditions of the above facilities daily.
Latrines, urinals and refuse pits must be inspect at least twice a day. It should be disinfected
twice a day. Bleaching powder is the best. Stool and refuse in the pit can simply cover with a
layer of earth, sand and ashes at intervals and at the end of the day. It needs participation of
the people, but a paid manual worker should be kept and supervised to make sure
cleanliness. It is also necessary to look for any kind of sickness or cases of infectious
diseases and report to the medical officer concerned. Health officer should see that epidemic
disease like cholera, plague and others are brought to him without delay. Suspicious cases
should also be reported.

7. Medical facilities

Dispensary or clinic should be opened at convenient place for treatment of minor

illness and first treatment.

8. Preventive inoculation

It is advisable to continue and strengthen the vaccinations routinely practiced in the

locality. However, epidemiological monitoring, surveillance and reinforcement of sanitary
measures are more important. It is also need reassure the committee, political and local

72
authorities when there is demand for vaccination. Chemoprophylaxis can be arranged if
appropriate.

9. Health education

Health personal can disseminate health knowledge to visitors enjoying the festival by
exhibitions and display. Communication, information and assistance should be made at any
opportunity.

10. Post-festival sanitary supervision (Scavenging)

After the festival, refuse, excreta and other waste materials are carefully swept and
disposed (post festival sweeping). Drugs, sanitary equipment and funds are handed to
pagoda trustees.

OCCUPATIONAL HEALTH

Definition
Occupational Health is a state of the highest degree of physical mental and social
well being of workers in all occupations.

Aims and Objective of Occupational Health

1) Promotion and maintenance of highest degree of well being of workers
2) Prevention of departure from health of the workers.
3) Adaptation of work to man and of each man to his job

Ergonomics: It simply means fitting the job to the workers. The objective of ergonomic is to
achieve the best mutual adjustment of man and his work, for the improvement of human
efficiency and well-being

Occupational Environment
1) Man and physical, chemical and biological agents
2) Man and machine
3) Man and man

Environment acts as agent in causation of occupational diseases

Occupational Diseases: diseases that occur in workers due to their work

Occupational Hazards
An industrial worker may expose to hazards, depending upon his occupation.
The hazards or agents and the diseases caused by them are:

73
I. Physical Agents
1) Heat: burn, heat-exhaustion, heat cramps, heat syncope, heat stroke
2) Cold: immersion foot, trench foot, frost bite
3) Noise: Excessive noise over 90 dBA for more than 8 hrs per day as in weaving
factories, crushing processes may cause noise induced deafness
4) Light: poor illumination - acute affects: head ache, eye strain, eye pain,
lacrimation and eye fatigue, chronic effect: miner's nystagmus. Excessive
brightness are light from welding, welder's flash
5) Vibration: white finger
6) Ionizing radiation - genetic changes, cancer

II. Chemical Agents

1) Gases: CO2, CO, HCL, NH3, H2S, SO2 - gas poisoning: local irritant action
2) Dusts: Organic or inorganic. Pneumoconiosis
3) Metals: Lead poisoning, Mercury - Nephritis
4) Acid and alkalis: burns, occupational dermatitis
5) Pesticides: poisoning
6) Solvents: Benzene - Leukemia
7) Dyes: Aniline dyes - Ca. Bladder

III. Biological Agents

1) Virus: Rabies
2) Rickettsia: Scrub Typhus
3) Bacteria: Anthrax, Brucellosis, Leptosirosis, Tetanus
4) Fungus: Ring worm, favus
5) Protozoa: Malaria
6) Helminths: hook worm infestation
7) Arthropods: bee sting
8) Others: Snake and wild animals

IV. Mechanical Agents

1) Moving part: belts, rotating parts- laceration, amputation, descalping
2) Height: fall
3) Falling of objects

V. Psychological Agents
This may be due to
1) Lack of job satisfaction
2) Insecurity
3) Poor human relationship
Health effects are
(a) Psychological & Behavioral changes, hostility, aggressiveness depression,
anxiety; alcoholism, drug abuse, absenteeism, burnt out.
(b) Psychosomatic changes; fatigue, headache, PU, hypertension, Heart disease etc.

Function of an occupational health service in general

1. Advisory
(a) To advice the management regarding the hygiene of workplace, health of
workers, risk of occupational hazards, accident prevention and legislation.
(b) Advise workers regarding problems likely to be encountered.

74
2. Service
(a) Medical examination to fit work to man and man to work.
i. Pre- employment, pre placement medical examination: This examination is carried
out with the intention of placing the right man in the right job, so that the worker
can perform his duties efficiently without detriment to his health.
ii. Periodical examination: This examination is usually carried out in those
occupations which involve handling of toxic or poisonous substances by the
workers. By doing so early signs and symptoms of the disease will be recognized
which otherwise would go undetected.
iii. Reemployment examination: after sick leave or accident.
(b) Medical care of workers needing treatment.
(c) Medical supervision of canteens.
(d) Training of workers and management in first aid and nursing care
(e) Rehabilitation of workers
3. Research
(a) Epidemiology of illness peculiar to various occupations
(b) Prevention of occupational hazards
(c) Health promotion of workers. (Nutrition, physical fitness programs recreation
facilities).

Measures for the general health protection of workers

The following measures are recommended to achieve the aim of occupational health
i.e. to promote and maintain the highest degree of physical, mental and social well being of
workers in all occupation.

I. Nutrition Promotion: - the aim here is to establish a canteen where snacks and other
balanced diet could be bought by the workers at reasonable price and under sanitary
condition. At the same time, the workers are given health educational talks regarding the
value of a balanced diet and how to prepare nutritious diet under sanitary condition. If the
workers carry their own lunch to work, (cold storage and refrigerators) place to store them
should be provided, to prevent spoilage and contamination before consumption. Separate
room should be provided apart from working rooms where workers could have meals under
sanitary conditions.

II. Control of communicable disease: The objective here is to detect cases of

communicable diseases and render them non-infectious to other by treatment or by removal
from the work environment. Communicable diseases like tuberculosis, typhoid fever, viral
hepatitis, amoebiasis, diarrhoea and dysentery, venereal disease, etc. need special attention
so that they can be detected, prevented and controlled before getting out of hand. There
should also be an effective immunization program against some vaccine preventable
communicable diseases, e.g. Anthrax, Undulant fever and some communicable diseases of
occupational in origin.

III. Environmental Sanitation: To prevent spread of communicable diseases within the

work environment through food, drink, water etc. The following measures could be
undertaken.
1. Safe water supply
An adequate amount of safe and wholesome water supply should be supplied if possible
drinking water fountains should be installed at convenient points.

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2. Food Supplies
Food should be stored under sanitary conditions. Likewise, it should be handled, prepared
and sold under sanitary condition. Medical examination of food handlers is undertaken and
they are being given health education for proper handling of foodstuffs.
3. Toilet Facilities
Sufficient numbers of urinal and latrines should be provided for the workers: they should be
separated for the sexes. There should be at lest one sanitary convenience for every 25
workers for the first 100 employees and one for every 50 there after.
4. Waste Disposal
Garbage and waste disposal should be under sanitary conditions so as to avoid breading of
flies, vermin etc.
5. General Plant Cleanliness
A high standard of plant cleanliness is one of the fundamental of accidents prevention and
also contributes to the efficiency and high morale of the workers. The walls, ceilings and
passages should be painted every 3 years and white washed every 6 months. The dusts on the
floors and machines should be promptly removed be means of wet become etc. to prevent it
from redistribution.
6. Working Space
The recommended space is 500 cu feet/worker; space more than 14 feet above floor area is
not to be taken into consideration.
7. Lighting
There should be sufficient and suitable lighting, natural or artificial to see clearly without
effort. The results of poor lighting are worker's eye fatigue increased eyestrains, increased
accidents, decreased production and more rejects of finished product. For one-story factories
window space should be 300% of floor space.
* Stair - ways, passageway foot candles
* Assemble halls. 10 foot candles
* Regular working places. 6 to 12 foot candles
* Fine precision works. 50 to 75 candles.
8. Ventilation, Temperature and humidity
These should be regulated to obtain and maintain a comfort zone. Poor ventilation increases
the chances of spreading of infection. It also affects the mental and physical efficiency of the
workers. Proper ventilation is needed to control the accumulation of toxic fumes, dusts and
vapors.
9. Noise and Vibration
Noise level at or near 100 decibels is harmful to health especially after prolonged exposure
to dusts, fumes and other toxic hazards.

IV. Mental health promotion the objective being

(a) To promote the health and happiness of the workers.
(b) To detect signs of emotional stress and strain and to secure their relief wherever
possible.
(c) Treatment of workers suffering from mental illness and
(d) The rehabilitation of those who become ill

V. Health Education
Health education is to be given to all personal who are parts of the concerned occupation.
(Managers, staff, workers). The top9ics of health education will very from matters of
personal hygiene, family planning mental health etc.

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OCCUPATIONAL HEALTH IN AGRICULTURE
(AGRICULTURE AS AN OCCUPATION)

A joint ILO/ WHO committee on OH define Agriculture that; "Agriculture means all
forms of activities connected with growing, harvesting and primary processing of all
types of crop, with the breeding, raising and caring of animals, and with tending
gardens and nurseries".

CHARACTERISTICS OF AGRICULTURE WORK

Certain characteristics of agricultural works worth consideration for better understanding of
OH in agriculture, its hazards and prevention. Those are

A. Type of work
1) Irregularity of working hours
2) Temporary employment
3) Unorganized manpower
B. Place of work
1) Unpredictable changes of ambient environment
2) Contaminated soil and water
3) Dusty air
4) Too far away from health facilities
5) Sanitarily poor living places
C. The agricultural worker himself
1) Younger age due to deficiency of adult man power
2) Female also engaged in farm work
3) Mostly self- employed

OCCUPATIONAL HAZARDS IN AGRICULTURE

I. Physical agents
As most agricultural operations are conducted outdoor and vary during the year, the workers
can expected to be exposed to the extremes of heat and cold, to rain and dust, to bright
sunlight and darkness and often for long hours. Some physical agents are:

1. Heat & cold: excessive heat during the day, together with heavy manual labour in the field
may cause heat related disorders. E.g. heat exhaustion.

2. Light: Ultra-violet ray of the sun produce cancerous effect on the skin.

3. Electricity: During the monsoon, farmers working outdoor in erect position are prone to
be struck by thunder.

4. Sharp objects: Using sickles and other instruments may cause cuts and amputations.

5. Height: Falls from trees, such as toddy plant may cause serious injury and even death.
Overturning of bullock-carts on uneven tracks or roads is common causing fractures of the
limbs and spine.

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II. Chemical agents

1. Pesticides are used to control pests that destroy crops. Accidental or suicidal pesticide
poisoning of family members is not uncommon.

2. Fertilizers are known to cause allergic dermatitis to persons who handle it.

3. Dusts: cane (Bagassosis) cotton (Byssinosis) are organic dusts causing diseases of the
lungs.

III. Biological agents

Agricultural workers in our country usually work with animals and often live under the same
roof. Thus, they are exposed to zoonotic diseases. Other biological agents also harm them.
Among the most important biological agents and the disease caused by them in our country
are
1- Virus Rabies virus Rabies
2- Rickettsia R. tsutsugamushi Scrub Typhus
3- Bacteria B. Anthracis Anthrax
Brucella spp Brucellosis
Leptospira spp Leptospirosis
CL. tetani Tetanus
4- Fungus Micropolyspora faeni Farmer's lung
5- Protozoa Plasmodia spp Malaria
6- Helminthes A.duodenale Hook worm infestation
7-Arthropods Bees Bee sting
8- Others Snake Snake bites
Dogs and other wild animals bites

o Leptospirosis is seen among the jute cultivators, who immerse themselves in

ponds, contaminated with leptospira during the process of peeling the jute
fibers from the stalk of the plant.
o Hookworm infestation occurs in tea plantation workers who work bare-
footed on contaminated soil.
o Tetanus following minor cuts and injuries is common, since farmers work in
cow dung contaminated field.
o Those workers who handle animals or their hides or skin can get Anthrax.
o Snake bite which might be fatal.
o Machines may cause simple laceration to amputation of the fingers.
o Tractor overturning in the field or in the highway is common.

IV. Psychological agents

The agricultural workers are under stressful conditions. The weather is unpredictable.
Climatic condition may not be favorable for different stages of cultivation. Working hours

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are irregular. Some workers are temporary employed. Workers cannot be employed when
urgently needed on the part of the employer. Fertilizers and pesticides have to be used for
high yields, which mean higher investment. New methods of cultivation are being
introduced which they have to re-educated. Financial burden may be severe before the crops
reach the market. Outbreak of diseases among their cattle and other live-stocks may add new
stress to their life.
All of the above could cause emotional, psychosocial and psychosomatic problems of
serious consequences. The effect may be:
 Psychosocial- hostility aggressiveness, anxiety, depression, inferiority
complex, desire to escape from the land & alcoholism;
 Psychosomatic changes- such as headache, fatigue, backache, peptic ulcer,
hypertension etc.

PREVENTION AND CONTROL OF AGRICULTURAL HAZARDS

1. Agricultural Occupational Health care as part of General Health Care.

Agricultural workers form large part of economically active population in our country. OH
problems are more or less the same as public health problems in general. Therefore the same
health facilities that served the general population can and should serve the agricultural
workers and their family. Any comprehensive public health program should include OH
services for workers engaged in agriculture. Another fact is that the agricultural workers are
dispersed over wide expanse of land. Some work in remote areas. It is impossible to set up
special health services for the agricultural workers like factory workers. Thus, it is more
appropriate to render health care for them through primary health care and basic health
services.

2. Active immunization
Immunization agents: tetanus for farmers exposed to cow dung should be practiced
routinely. Active immunization agent Russell's viper bite with RV toxoid had been
developed and tested it's immunogenicity in monkeys and human volunteers. More
researches are under trial to produce more potent and stable RV toxoid.

3. Early Diagnosis and Treatment

PHC to the community is rendered by voluntary health workers and basic health service
staff. Control of locally endemic diseases, treatment of minor ailment, provision of essential
drug and so on are among the element of PHC. Thus occupational disease of the agricultural
workers like malaria can be diagnosed early, treated and referred to the first referral level of
health care system i.e.; township hospital. Minor ailments like heat exhaustion minor burns
cuts and abrasions can be cured at the work site in the community. First aid measure for
pesticide poisoning, burns, fractures and snake bites, if given timely and effectively before
referral would be life saving.

4. Health Education
The agricultural workers must have health knowledge of hazards imposed upon them. They
must be educated the essentials of healthy living safe use of pesticides and other agricultural
chemical as in storage handling and spraying safety in use of farm equipment safe ways of
driving tractors etc.

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5. Environmental measures
It include taking in the shade of the tree at noon, which can prevent heat related disorders
such as heat exhaustion, heat hyperpyrexia or heat stroke. They should avoid working in the
thunderous storm to prevent thunder strike.

6. Substitution of substances
Pesticides through potent and useful but harmful can be replaced with less harmful
substances (Malathion instead of Parathion)

7. Isolation
Animal should not be kept under the same roof with man, but kept apart in a separate
building or barn. That would prevent zoonosis. When spraying pesticides the operator should
take the lee side of the wind to be isolated or kept away from the droplets of insecticides.

8. Containment (Enclosure)
Dusts and fumes can be contained in an enclosed space. Grinding machines are enclosed.
Pesticides are blown into plastic enclosed bags to prevent infestation of seeds and grain and
are not allowed to escape into the surrounding.

9. Protective devices
Wearing hats, loose fitting clothing or sunscreen (Tha- nat- kha paste) can protect heat &
sunlight. Footwear can prevent hookworm infestation. Top boots cover the foot and ankles
the usual site of snakebite & envenomination.

10. Supportive measures

Ample amount of fluid with some salt is recommended to take during hot season.

About three- quarter of the working population in our country are engaged in
agriculture. Thus their hazards that are extensive and expanding should be considered
thoroughly and prevented.

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